Implicit bias refers to the unconscious, unintentional assumptions people make. It contributes to health disparities through provider medical decision making and interpersonal communication.1 Implicit bias is measured by the Implicit Association Test (IAT), a validated online test that measures reaction time to images and value-laden words.2 The difference in reaction times as test takers seek to match the images and value-laden words is used as a measure of implicit bias.2 Studies using the IAT to measure physician racial and/or ethnic implicit bias have demonstrated its influence on clinical decision making,3,4 health outcomes,5 doctor–patient communication,6,7 and patient perceptions of the clinical encounter.7,8 Given this evidence, a focus on implicit bias recognition and management has promise as a curricular approach to impact individual physician contributions to health disparities.
Curricula providing formal instruction for medical students on implicit bias have been reported in the literature9–15 and in MedEdPORTAL.16 We have demonstrated that formal and informal instruction influence each other and the development of student perspectives.17 Others have demonstrated the influence of informal instruction, including the hidden curriculum, on student perspectives related to implicit bias.18,19 The hidden curriculum encompasses the culture of an institution, interpersonal encounters, and what the students learn outside what they are taught in the formal curriculum.20 Medical students have resisted aspects of implicit bias instruction, including accepting the presence of bias in oneself and/or its potential influence on clinical practice behaviors.11,12,21
Published recommendations for implicit bias curricula expect faculty to instruct students in developing knowledge, attitudes, and skills in implicit bias recognition and management through both formal and informal instruction.22,23 However, curricula published to date do not always include opportunities for skills development and practice.9–16 Teal et al22 have proposed a framework to move individuals from absolute denial about implicit bias to development, practice, and integration of skills that will decrease the effect of implicit bias in their clinical practice behaviors. Student progression along this framework can be facilitated by instructional designs incorporating transformative learning theory.
Transformative learning theory is the conceptual framework guiding our instructional design; it has four main components.24 The first is an experience for the learner, followed by critical reflection, guided discourse, and action (behavior change).24 The experience must be powerful, a “disorienting dilemma.”25 Critical reflection and guided discourse must be profound and deeply moving.24 Behavior change is “growth enhancing and developmental.”24 Transformational learning requires a safe and supportive learning environment.24
The power of the facilitator on the learning environment in the context of multicultural discussions26 and the teacher in intercultural competence27 has been demonstrated. In our previous work, students felt the facilitator could “make or break” the session.17 However, there appears to be little in the medical education literature to guide faculty members in instructing implicit bias recognition and management. In addition, most faculty have not received such instruction themselves during their training. To address this gap, we conducted an exploratory study to understand faculty perceptions of challenges and opportunities related to facilitating instruction on racial and ethnic implicit bias recognition and management.
We conducted an in-depth interview study following a systematic qualitative research methodology using grounded theory. Grounded theory involves the discovery of theory through the analysis of data.28 Under this model, we employed an iterative process for recruitment, data collection, and analysis.
Setting and sample
Our study was conducted within a single institution, a research-intensive medical school located in a large urban setting and serving a racially and ethnically diverse population. At the time we held these faculty interviews, one 90-minute session in the third-year curriculum delivered instruction on implicit bias. This session was part of a yearlong course during which students returned to campus from their clerkships and participated in case-based discussions of topics including prevention, professionalism, and ethics, among others. The course occurred monthly and maintained continuity of small-group members and faculty cofacilitators. Prior to the session, students completed readings related to health disparities and implicit bias, and wrote a reflective narrative about a patient interaction they witnessed during which bias may have influenced the encounter. During the session, faculty delivered a multimedia presentation including slides, videos, and discussion prompts to raise awareness of implicit bias and identify strategies to mitigate its influence on clinical encounters. Subsequently, students took the Race IAT and wrote a reflective narrative on their experience with their results, and how they believed their results may influence their interactions with patients. Faculty gave feedback on student narratives, incorporating the IAT as a discussion-generating tool.
Faculty teaching the session received a facilitator guide and participated in a one-hour presession faculty development program and an optional 30-minute postsession debrief. During this debrief, faculty members could share successes and pitfalls that occurred during the session with other faculty facilitators. We expected to expand future instruction beyond one session; therefore, we sought the perspectives of faculty that taught in the existing session, as well as faculty interested in implicit bias instruction who taught in courses into which we anticipated integrating implicit bias instruction. We used typical case sampling, recruiting participants that are representative of a study’s focus within a given organization.29 Potential participants were contacted via e-mail, with one follow-up e-mail if there was no initial response. The Institutional Review Board of the Albert Einstein College of Medicine approved all aspects of the study.
Interview guide development
We developed open-ended questions to create a semistructured interview guide (Appendix 1) based on a review of the available literature and our experiences teaching about implicit bias. We recognized that participants would have varying levels of experience with implicit bias instruction. To ensure uniform understanding and use of terms across participants, the interview guide began with definitions and background information about implicit bias. We probed participants’ perspectives on implicit bias, its potential role in medical education, and preferences and concerns regarding faculty development and facilitating instruction. Additional probes (e.g., “tell me more”) allowed participants to elaborate on their experiences.
The principal investigator (C.M.G.) conducted individual interviews scheduled at a time and location convenient to the participant. Written, informed consent was obtained from all participants. Interviews were conducted until we reached thematic saturation based on analysis of interview transcripts30—that is, when no new concepts or themes emerged from subsequent interviews. Interviews were digitally recorded and professionally transcribed, with accuracy checked by investigators cross-referencing the audio recordings with the transcripts.
Initial coding of interview transcripts was performed by two investigators (A.R.L. and C.M.G.), who independently read two transcripts and applied codes to the text. We agreed on a list of codes by consensus to create the preliminary codebook, which was tested and refined by application to two additional transcripts. Three investigators (A.R.L., C.M.G., and R.G.) then coded the remaining transcripts independently. We met to perform further analysis on the coded transcripts using a constant comparative method, a technique which transforms the data into larger theoretical categories.31 Starting with low inference codes, we discussed their meaning and potential ways of grouping the codes to develop themes. Finally, we identified relationships between themes, reaching consensus on themes and representative quotes through discussion. To ensure accurate representation of their perspectives, we presented themes and quotes to select participants as a method of member checking.
We conducted 21 interviews, each 45 to 70 minutes in length. Demographic data are listed in Table 1. Twelve participants were women. Five self-identified as Hispanic, one as Asian, and 15 as white. There were 15 clinicians and 6 basic scientists/medical educators. Participant experience ranged from less than 10 years to more than 40. Seven participants had prior experience teaching in our existing session on implicit bias, each having facilitated the session at least three times. They attended a 1-hour faculty development program preceding the session and the subsequent 30-minute debrief; the remainder had no prior experience teaching in the current curriculum and had not attended the faculty development session. The participants with prior experience facilitating implicit bias instruction felt more comfortable than participants without previous experience; otherwise, perspectives did not differ according to demographic data. Participants discussed the role of facilitator identities and institutional values on ability to instruct students, the impact of the resistant learner and faculty, and strategies for institutions to enhance instructional opportunities. The following paragraphs discuss the four main themes outlined.
Theme 1: Role of facilitator identity
Participants identified personal challenges to their perceived ability to facilitate instruction on implicit bias. These included perceptions of faculty based on their clinical “status,” clinical expertise, and/or self-identified race. They represent barriers to faculty facilitating discussions related to implicit bias and clinical practice behaviors.
Some faculty sensed disparate perceptions of themselves by medical students if they were nonclinicians, compared with clinical colleagues. Perceived prestige and preconceptions about specialty choice, such as assumptions of being liberal if in primary care and subsequently being discredited by the students, plagued some participants. Self-identified race or ethnicity came up frequently in both majority and minority participants: “The other concern is that people do not take me seriously because they are like, ‘Who is this privileged white guy talking about racism?’” (P13).
Participants secure in their own area of expertise and who are viewed as excellent teachers nevertheless expressed high levels of discomfort because of their inexperience teaching about implicit bias. Most participants had not received training in implicit bias themselves and were not teaching it in the curriculum. Some dreaded broaching the subject with their students: “People are afraid to appear racist. It feels extremely uncomfortable. Either because of our own backgrounds or own sensitivities … it is all fear” (P07). Anticipating significant emotional reactions from students might preclude faculty participation.
Participants predicted discomfort when faced with powerful emotions, including defensiveness, shame, and fear, leading to further facilitation challenges. Sometimes this anticipatory discomfort was influenced by previous anxiety when discussing race in medicine within clinical contexts.
As the speaker who wants to say African Americans have more burden of “whatever,” you can feel awkward using the wrong word. Then as the speaker you are so anxious that you are going to say something wrong, that you may not want to talk about it at all. (P15)
Power differentials related to age—“a generational gap” (P03)—and qualifications, among other factors, were also highlighted as a challenge when cofacilitating a session; they presented disproportionate challenges to self-efficacy for some participants when facilitating as a member of a cofacilitator dyad: “If I say this, what might happen? I will be dismissed and I’ll be corrected like, well, ‘I’m a physician; you’re not.’ It is that inner, nagging voice that gets at me” (P03).
Theme 2: Role of Institutional Values
Institutional climate and values related to organizational culture, as well as allocation of curriculum time, affected participants’ perceptions of their ability to facilitate implicit bias instruction: “There’s this acculturation [in academia] where we tend to not want to call anybody out. You never know when you’re going to need somebody’s support for an initiative” (P02). An institutional climate with a pervasive culture of silence could inhibit discussion about the topic and growth as an academic community around it.
If the organizational culture does not support instruction of clinical faculty in the discussion and role modeling of implicit bias during routine patient care, students could perceive it as irrelevant to their future clinical practice, adding an additional challenge during formal instruction: “I am worried about how we inoculate our students against the potentially prevailing thought, ‘That was just touchy-feely stuff we learned; no one does this in real life’” (P07).
In addition to challenges related to organizational culture, participants identified consequences of current instruction. They emphasized the dangers of teaching about a problem and then not providing any tangible skills: “The challenge is that I still don’t think we give them those strategies to move past awareness into action. I found myself not as secure in those conversations” (P19). These observations demonstrate the potential consequences of institutional values that shape the compulsory curriculum to include only one stand-alone session for implicit bias instruction.
Participants noted that instruction evolving from a stand-alone session to integration across the curriculum presented another challenge. Institutional values could affect successful integration of implicit-bias-related content into the existing curriculum: “So much importance is placed on the course evaluation. How much am I going to risk as a course leader having very awkward conversations [about bias] that may lead to poor evaluations for my overall course?” (P10). Course directors supportive of implicit bias instruction in general might still hesitate to integrate it into their own courses for fear of ramifications.
Theme 3: Role of the Resistant Learner and Faculty
Participants encountered and anticipated obstacles to instruction stemming from faculty and student perceptions and resistance to the topic, as well as using the IAT during instruction.
I think the acceptance of implicit bias is a big challenge in teaching and developing a curriculum. I’ve been faced with this challenge [in related content areas]. Even among faculty there are people who don’t think that there really are health disparities and think cultural competency is “foo foo juice” in the curriculum. (P20)
Concerns about buy-in were based on previous experiences on related topics of instruction. Participants discussed that the lack of buy-in predicted future challenges for implicit bias instruction.
Participants anticipated that some learners would be more resistant than others: “You get pushback from the students. There’s nothing more threatening, I think, to a medical student whose heart is in the right place about taking care of patients than grappling with the fact that they may be biased. Many are in denial” (P09). Participants described another “resistant learner” as one who intentionally comes to an institution to learn from and serve an underserved population.
It is a little bit of “I am here because these are the poor people who are biased against and I am here to help them. Are you telling me I am one of the bad guys? No, I am one of the good guys trying to help the people who are at the mercy of the bad guys.” (P11)
These varied types and degrees of resistance add another layer of challenges within an instructional setting.
Resistance from students related to the IAT was noted by participants with experience using the IAT during instruction. Participants described resistance in the form of anger, denial, and trying to game the system (by taking the test over and over to try to get a neutral score).
One student did a whole analysis and did research behind the IAT and pulled up articles that brought out the flaws and the shortcomings and used that as a justification for why we really should not ask students to do this exercise because the system is flawed. I had not anticipated that level of upset. (P18)
The arguments some students make about the IAT in response to their own results could overwhelm faculty, leading to further challenges to their perceived ability to facilitate.
Theme 4: Enhancing Instructional Opportunities
Participants identified opportunities to enhance the faculty experience during facilitation, combat the hidden curriculum, and improve the organizational climate, and made suggestions to overcome the perceived obstacles to instruction. They believed that faculty would have to go through a process similar to the students to recognize and begin managing their own biases to be able to facilitate sessions about implicit bias.
The easiest way to approach faculty is by saying, “We need to teach this to our students.” You speak to the educator in them, more than you speak to the clinician in them because that is where you get a little more dangerous. By virtue of the topic, they are going to be thinking about themselves in the clinical setting. (P11)
Approaching identified facilitators as educators, whether they are clinicians or not, potentially enhances buy-in to participate in faculty development programs. This approach would eliminate the confounding of clinical practice behaviors with the approach one needs to address implicit bias recognition and management.
To help faculty role model in real time, some participants suggested providing faculty with a list of key phrases to highlight the assumptions they make during routine clinical care: “A brief comment of ours on rounds, a brief respect for biases, an acknowledgment of biases along with information about pathophysiology, a sentence here and a sentence there I think is very instructive” (P17). Additional suggestions from participants included formal instruction for students during clinical rotations to counter the influences of the hidden curriculum: “The treatment of patients in front of students is sometimes hideous. We could debrief with students about it, do a time out. We do debriefs for hemorrhage. Why can’t we do debriefs for [bias]?” (P20).
Some participants identified benefits to implicit bias instruction by making discussing race mandatory. Participants with previous experience teaching about racial bias noted the potential for avoidance whenever discussing race issues was made optional. “We changed the assignment to force them to do the race IAT. That made a huge difference. It enriched the conversations in the classroom” (P18).
There are three main findings of our research. First, faculty’s ability to facilitate implicit bias instruction is influenced by individual factors such as their own background, identity, and past personal experiences discussing race-related topics. Second, the culture and values of the institution influence implicit bias instruction and how the curriculum is received at the institution. Third, faculty development programs can impact the faculty’s ability to teach. Figure 1 provides a summary of the factors that interact to augment or diminish faculty expectations of their own abilities to facilitate and have potential implications for faculty development and program-level decision making.
Implications for faculty development
Sukhera and Watling23 acknowledge that teaching about implicit bias can be risky. They suggest choosing faculty who are “approachable, inclusive, nonthreatening, inspiring, open-minded, encouraging, and knowledgeable” for implicit bias instruction to maximize the safety of the learning environment.23 Our participants volunteered to participate in a study for medical education and are known at our institution to embody many of those qualities, yet they still recognized the riskiness of implicit bias instruction. The in-depth qualitative approach of our study revealed challenges and opportunities for facilitating instruction in implicit bias recognition and management that can inform faculty development efforts to diminish the risk and maximize the success of efforts to implement existing recommendations. Gaining insight into faculty members’ perspectives and ability to discuss race and discrimination has been recommended as a way to inform the design and implementation of related faculty development efforts.32 Incorporating participants’ perspectives identified from our study into faculty development programs in implicit bias should enhance faculty perceptions of their facilitation abilities.
Allowing for exploration of aspects of self-identities, expression of emotions, and reflecting and debriefing on these concerns could be useful to faculty members. Freire’s33 theory of problem-posing education states that “through dialogue, the teacher-of-the-students and the students-of-the-teacher cease to exist and a new term emerges: teacher-student and student-teacher…. They become jointly responsible for a process in which all grow.” This perspective would alleviate some of the pressure to role model, be a content expert, and navigate unforeseen obstacles under which faculty may be struggling. Faculty can empower students to participate actively and set expectations that everyone is a learner in this topic. This model of facilitation could influence utilization of transformative learning theory.
Curriculum developers can create the experience for the learners, but then the group becomes responsible for making the critical reflection and guided discourse deeply moving, taking the onus off the facilitator.33 Successfully facilitating and participating in such instruction can be transformational for faculty members themselves, as others have demonstrated in cross-cultural education settings34 and while facilitating discussions about psychosocial topics.35 Curriculum developers writing the facilitator guides could include facilitator tips, if–then statements, and other guidance, creating a “safety net” for facilitators. Allowing facilitators the option to debrief after each instructional session, sharing new obstacles and opportunities discovered as instruction progresses, could improve facilitators’ experiences and the curriculum itself.
Implications for program-level decision making
Our participants highlight opportunities for program-level decision making to optimize the success of implicit bias curricula. Providing multiple sessions of implicit bias instruction within the compulsory, longitudinal curriculum addresses several of these insights. A multisession curriculum would enable students to move beyond the initial experience and engage in critical reflection and meaningful guided discourse before moving to the behavior change component of transformative learning theory.24 Multiple sessions also facilitate progression along the framework from Denial to Integration.22 Being part of the compulsory curriculum would eliminate dependence on collegial relationships for curricular time and might send the message that implicit bias instruction is valued. In addition, inclusion is potentially an important counter to the hidden curriculum. Multiple positive experiences within the compulsory curriculum could help draw in resistant students and faculty. Balance of new implicit bias content within the existing curricular load can be achieved through integration with existing health disparities instruction and explicitly connecting bias instruction with instruction that also fosters reflective practice.23 Integration through multiple courses including history-taking and organ systems courses, in addition to their clinical rotations, could diminish the anticipated negative effects on course evaluations.
As an institutional priority, role modeling by the leadership and efforts to normalize implicit bias recognition and management could be made more visible. Increased visibility and standardized faculty development programs would combat the culture of silence that our participants believe stifles growth, simultaneously affecting the clinical climate leading to open, honest, and safe discussions among students and faculty.36 Culture change would facilitate visibility of faculty champions from undergraduate medical education, through graduate and continuing medical education.
The American College of Physicians released a position paper supporting implicit bias trainings by organizations employing physicians.37 Increasing the number of physicians who have awareness of the potential influence of implicit bias on clinical encounters can help normalize the topic on rounds and throughout the patient care experience, and can increase the number of faculty who are able to positively role model behaviors to recognize and manage implicit bias in clinical encounters. Positive role models are essential, as negative role models can contradict the efforts of formal instruction and negatively affect professional identity formation for students.38 These efforts could maintain buy-in to the relevance of implicit bias achieved through preclinical instruction as students advance to the clinical setting and address nonclinician educators’ concerns about their credibility in teaching about implicit bias, if students start to see the “real doctors” recognizing and discussing it during clinical rotations. Such positive experiences within the hidden curriculum would be expected to positively influence students’ professional behaviors and identity formation.39
In addition to the overarching potential benefits of institutions declaring implicit bias recognition and management a priority, our themes inform specific program-level decisions. Incorporating instruction into existing learning communities would increase cohesion and trust among the students and facilitators,40 potentially overcoming some anticipated obstacles to instruction when implicit bias content is introduced. If learning communities do not exist at an institution, maintaining continuity of small groups could be beneficial as well, as continuity should foster the comfort necessary for deeply critical reflection.41 After initial instruction, providing clinical experiences earlier in the curriculum would enhance the relevance of the instruction to students,42 as they might observe bias in clinical encounters and then build skills to recognize and manage it before they have the responsibility of patient care during their clerkships.
We conducted interviews at a single institution, which serves a racially and ethnically diverse population. Faculty elsewhere may have different perspectives. In addition, the participants agreed to participate and are committed to medical education; therefore, their views may not be generalizable. It should be noted, however, that this was an exploratory study.
We engaged faculty in an in-depth exploration of their perceived challenges and opportunities related to facilitating instruction in racial and ethnic implicit bias recognition and management. Themes we identified provide novel insights into opportunities to enhance faculty perceptions of their ability to facilitate instruction, guide programmatic decision making, and overcome perceived obstacles to instruction. The potential implications could inform faculty development programs designed to deliver instruction using transformative learning theory and facilitate progression of learners along the continuum from Denial to Integration of behaviors in implicit bias recognition and management. The potential implications have informed our own instructional design and could inform curriculum development at other institutions.
The authors wish to thank Drs. Clarence Braddock III, A. Hal Strelnick, and William Southern for their thoughtful feedback from study inception to completion; Ms. Veronica Aviles and Ms. Natalia Rodriguez for their generous assistance; and Dr. Paula Ross for her invaluable contributions to the revision.
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Appendix 1 Interview Guide
After definition and background information:
We are interested in learning about faculty members’ perspectives regarding the issues about implicit bias and learning about how to recognize and manage it in clinical encounters. We want to know what you are worried about, as well as opportunities you see to make the discussions in class safe and productive. We want to incorporate your perspectives when creating the instructional design for any eventual curriculum as well as for future faculty development efforts.
- Do you ever think doctors treat patients differently based on race or ethnicity?
- Do you think we should be teaching our medical students about implicit bias and its potential impact on clinical encounters?
- Do you think that your implicit biases have the potential to impact your patient care?
- What are the challenges to discussing implicit bias in class?
- How would you feel facilitating a discussion about race in medicine?
- Do you have any concerns?
- Do you have any suggestions for enhancing the discussion?
- What are some concerns you have about discussing racial prejudice in medicine?
- Personal subconscious racial bias?
- Other’s racial bias?
- Racial bias you have witnessed?
- Systemic racism?
- What are your preferred methods for providing instruction about implicit bias?
- What do you suggest to enhance the safety of the environment when discussing implicit bias?
- What are the barriers to incorporating implicit bias instruction into the curriculum?
- How should we address these barriers?
- Have you ever provided instruction on implicit bias? What worked, what didn’t?
- How should we assess implicit bias recognition and management in our students?
- How can we evaluate the effectiveness of the curriculum?
- What, if any, obstacles do you foresee for faculty development in this area?
- What, if any, opportunities do you foresee for faculty development?
General prompts will include “Tell me more,” “How did that make you feel?” “What did (or would) you do next?” etc.