Virtual Communication Across Differences: Development of a Workshop on Managing Patient Bias

Abstract

Problem 

Despite the prevalence and detrimental effects of racial discrimination in American society and its health care systems, few medical schools have designed and implemented curricula to prepare medical students to respond to patient bias and racism.

Approach 

During the summer of 2020, a virtual communication class was designed that focused on training medical students in how to respond to patient bias and racism. Following brief didactics at the start of the session, students practiced scenarios with actors in small groups and received direct feedback from faculty. For each scenario, students were instructed to briefly gather a patient’s history and schedule an appointment with the attending whose name triggered the patient to request an “American” provider. In one scenario, the patient’s request was motivated by untreated hearing loss and difficulty understanding accents. In another, it was motivated by racist views toward foreign physicians. Students were to use motivational interviewing (MI) to uncover the reasoning behind the request and respond appropriately. Students assessed their presession and postsession confidence on 5 learning objectives that reflect successful communication modeled after MI techniques.

Outcomes 

Following the session, student skills confidence increased in exploring intentions and beliefs (P = .026), navigating a conversation with a patient exhibiting bias (P = .019) and using nonverbal skills to demonstrate empathy (P = .031). Several students noted that this was their first exposure to the topic in a medical school course and first opportunity to practice these skills under supervision.

Next Steps 

The experience designing and implementing this module preparing students in responding to patient bias and racism suggests that such an effort is feasible, affordable, and effective. With the clear need for such a program and positive impact on student confidence navigating these discussions, including such training in medical school programs appears feasible and is strongly encouraged.

Problem

Racial inequities have long been a significant issue in American society and health care systems. Following the murders of George Floyd and Breonna Taylor in 2020, Black Lives Matter (BLM) protests swept the world, highlighting the urgent need for change and forcing many institutions to examine systemic racism in their communities. Medical students and educators were vocal throughout the movement, and chapters of White Coats for Black Lives and the Student National Medical Association across the country have demanded antiracist curricula at their institutions. ¹

The impact of physician and trainee bias on patient experiences and outcomes has been well documented, and the medical education community has responded with training and initiatives to address this concern. While a 2014 meta-analysis found that nearly 60% of medical trainees experience some form of discrimination, ² few initiatives describe efforts to help medical students manage discriminatory behavior from patients. ³ A 2015 study noted that 50% of pediatric residents experiencing mistreatment indicated they did not know how to respond. ⁴ A 2019 study identified significantly higher rates of medical student mistreatment based on one’s race/ethnicity and sexual identity status versus white and heterosexual students. ³

We are aware of just 2 initiatives to provide support and training in how to deal with discrimination from patients, both pilot workshops using practice with standardized patients (SPs) to increase medical student confidence in managing a discriminatory encounter. ^3,5 In response to the current climate, the painful effects of discrimination on confidence and performance, ⁶ and specific requests from medical students for training to manage bias toward them as clinicians, we chose to include a module on responding to bias as 1 of the 5 classes in our clinical communication course for medical students. We focused on training second-year medical students how to navigate discrimination presenting as the use of suggestive language and microaggressions reflecting a patient’s bias in a communication course. Because the COVID-19 pandemic necessitated a move to online learning, we designed, piloted, and evaluated a virtual session for medical students to discuss and practice communication techniques for managing potentially biased patients. The hospital institutional review board approved this research as an exempt study of standard educational practices.

Approach

In June 2020, we spent 1 month developing a patient-centered communication curriculum for second-year medical students from 2 local medical schools in Virginia and the District of Columbia; 23 of 254 second-year students volunteered to participate after receiving an email describing the class that featured 5 simulation-based sessions and occurred on Wednesday afternoons in July 2020 using Zoom technology (San Jose, California). Each session featured a unique communication-related challenge; session 3 focused on managing patient bias. We recognized that the exercise in this session could be uncomfortable and distressing for the students and that it would be difficult for all participants to approach the subject with the integrity, impartiality, and dignity it deserved. While the literature offered suggestions for how a trainee or physician could respond to bias directed at them by patients, few resources were available to guide the teaching of medical students in this area. We developed the module presented here using a combination of published frameworks, hospital discrimination policies, legal considerations, and basic communication skills founded on respect, empathy, and an open-minded approach. ^2–7

The module that we developed for session 3 begins with a 30-minute interactive lecture that addressed patient versus provider rights, arguments regarding accommodating bias, and a framework for managing a patient’s request for physician reassignment based on gender, race, or ethnicity using a motivational interviewing (MI) framework. ⁷ We classified a “legitimate” request as one known to improve health outcomes in several quality-of-care measurements; examples included a Muslim woman requesting a female doctor for religious reasons and an African American patient requesting an African American doctor. ⁶ We emphasized that while some institutions have guidelines that clarify standards for accommodating requests for alternate caregivers, most do not.

We chose to have students use MI as the practice approach when addressing patient bias because it offers a nonjudgmental yet inquisitive engagement technique; we instructed students to (1) employ reflective listening using NURSE (a mnemonic summarizing how to respond to patient emotions: N = naming; U = understanding; R = respecting; S = supporting; E = exploring ⁸); (2) explore the goals of the patient to understand the basis of the displayed behavior; and (3) adjust to, rather than oppose, resistance from patients.

Students were then separated into groups of 4 to 6 students plus 1 faculty facilitator and SPs from a team of simulation-trained patient volunteers and patient experience staff. One student and SP pair engaged in a 10-minute simulation followed by a 5-minute faculty-guided debriefing and feedback session; this process was repeated with a different student using the second scenario. A “lifeline” student was identified for each scenario to support or assist the primary student as needed. Students assigned to this role were available for consultation or to assume the primary role if requested. Facilitation instructions had been reviewed with faculty before class (see Supplemental Digital Appendix 1 at https://links.lww.com/ACADMED/B348). All students then returned to the main room for a 30-minute discussion and facilitated reflection. A model schematic for how this works on Zoom appears in Figure 1.

Figure 1: Model schematic for using Zoom breakout rooms for the session 3 simulation on bias. After initially meeting in the main Zoom room for a 30-minute lecture, students are separated into breakout rooms in groups of 4–6 with 1 faculty facilitator and SPs from a team of simulation-trained patient volunteers and patient experience staff. One student/SP pair engages in a 10-minute simulation followed by a 5-minute faculty-guided debriefing and feedback session; this process is repeated with a different student using the second scenario. After completion of the simulation, all students then return to the main room for a 30-minute discussion and facilitated reflection. Abbreviation: SP, standardized patient.

Students were instructed to take a brief history with a SP complaining of ear pain and to schedule an appointment with a primary care physician (see Supplemental Digital Appendix 2 at https://links.lww.com/ACADMED/B348). When the student indicates the appointment will be with “Dr. Kanumba,” the White SP asks to be seen by an “American” provider instead. In the first scenario, the patient’s request stems from untreated hearing loss and a difficulty understanding unfamiliar accents. In the second scenario, the request from the White SP stems from a belief that “foreigners shouldn’t be taking American jobs” and the request from African American/Latino SP stems from a preference for a physician who shares their cultural background due to previous experiences of systemic racism and a desire for more culturally sensitive care. The patient scenarios are wholly fictional.

All SPs were instructed to allow the students to practice MI and to guide the conversation toward their reveal of the underlying reason for the patient’s request so it may be addressed (see Supplemental Digital Appendix 3 at https://links.lww.com/ACADMED/B348). To maximize cultural perspectives during curriculum development, our team included medical students, attendings, researchers, and communication experts ranging in age from 23 to 55 years with approximately half identifying with an ethnic group other than non-Hispanic White.

Students rated their presession and postsession confidence levels on 5 learning objectives that reflect successful communication modeled after MI techniques ⁷: (1) exploring patients’ intentions and beliefs, (2) using reflective listening, (3) navigating conversations with patients exhibiting bias, (4) using open-ended questions to explore fears and concerns, and (5) using nonverbal skills to demonstrate empathy. Qualitative data were obtained from recordings of the 5-minute faculty-guided debriefing and feedback session immediately following the scenarios and from the recordings of SP and faculty discussions at the conclusion of the class; these were transcribed for analysis. In addition, students offered written reflections on the class in postclass surveys (see Supplemental Digital Appendix 4 at https://links.lww.com/ACADMED/B348). Two of the authors (M.Z. and M.D.) transcribed the class recordings and created initial categories of student, SP, and faculty reflections; one of the authors (A.N.) reviewed coded data for discrepancies. Themes were refined through team-negotiated consensus. Coding fragments relevant to each theme were extracted and compiled into a dataset; one author (M.Z.) identified quotes for the article. Statistical analyses were conducted in R 3.3.2 (R Core Team, Vienna, Austria). Medians and interquartile ranges were reported for confidence scores and compared using Wilcoxon signed-rank test. P values < .05 were considered statistically significant.

Implementation costs were minimized by engaging volunteer SPs and relying on medical student teaching assistants to design first drafts of all materials and manage all administrative activities. The institution incurred no additional costs associated with hosting the course.

Outcomes

Twenty students, 7 faculty, and 10 SPs participated in this particular session. Our scenarios required each student to engage in respectful inquiry to determine the motivation for the request for a different physician, and many students were able to identify the “hard of hearing” patient from the patient exhibiting racial bias. Faculty-guided student debriefings following each scenario enabled students to reflect on their own willingness to explore the patient’s request and the importance of considering all resources available to them, including communication tools and clues from the patient’s medical history, to appropriately navigate challenging scenarios. Based on the results of the surveys administered, student skills confidence increased in 3 areas following the session: exploring intentions and beliefs before developing a plan (P = .026), navigating a conversation with a patient exhibiting bias (P = .019), and using paralinguistic tools to demonstrate empathy (P = .031; Figure 2). Students noted this was their first opportunity to practice these skills and their first exposure to the topic in a medical school course. Although skill confidence ratings do not equate to proficiency, it is encouraging that the students generally identified that after the session, they were both more familiar with the tasks of addressing bias and more comfortable performing those tasks.

Figure 2: Results of presession and postsession survey of medical student participants. The survey assessed confidence on 5 learning objectives that reflect successful communication. Each objective was scored on a scale of 1 to 5 (1 = no confidence; 2–4 = somewhat confident; and 5 = completely confident).

During small group debriefing immediately following the scenarios, students expressed discomfort navigating the role play, including feelings of inexperience, anxiety, and emotional distress (Table 1). Reflections of these themes among ethnically diverse student participants included, “I’m multiracial and … people feel like they have the right to interrogate and probe,” and, “it was a difficult class and situation, but those are the ones that you learn the most … it’s good to hear how to best handle those conversations.” Similarly, several SPs expressed discomfort with their roles and surprise at how challenging it was to portray a racist patient. One reported that he “needed to get outside and go for a long walk to settle my anxiety and … shame.” While faculty did not express the same anxiety and stress as those engaged in simulation, several themes arose from physician feedback to students following the scenarios. Physicians conveyed the importance of recognizing and managing one’s own triggers to decode the patient’s intentions without judgment and emotional engagement. In response to several students’ question on how to respond to patients’ inquiries about the students’ own nationality or ethnicity, physicians suggested tactics such as “stealing the narrative” by succinctly answering a patient’s question and immediately following with relevant clinical discussions.

Table 1: Summary of the Participants’ Experiences and Recommendations Based on Debriefing Sessions and With Example Quotes in Italics

Next Steps

This module prepares students to respond to racial bias and serves as groundwork for students to draw upon when confronting other uncomfortable situations, such as those involving gender and sexual orientation bias. We hope our students’ high level of interest in participating in these training simulations will encourage the implementation of similar activities in other medical schools. During a time when convening in-person classes and adding cost and risk by employing actors is infeasible, our low-cost, high-impact module focused on providing medical students with tools and practice responding to biased and racist patients offers a feasible way to meet the increased demand for such training sessions.

Medical schools, hospital administrators, and curriculum developers can further improve our module based on the feedback and recommendations from the participants (Table 1). First, because many of the students requested mentorship from facilitators with similar backgrounds, facilitators should be prepared to share stories regarding their own experiences engaging biased patients. Second, faculty should be provided with specific debriefing instructions, including standardized feedback and “buzz phrases” that can be used to diffuse uncomfortable situations like the one in our scenario. During our pilot class, the advice that faculty offered during the debriefing varied depending on their personal experiences and comfort with the topic. Third, the module should incorporate bystander/upstander training as well as instructions for reporting safety events involving racism to create a more robust culture of antiracism in the training program. Finally, because the session was emotionally taxing for many participants, we offer these recommendations to better ensure psychological safety for students, SPs, and staff:

• Include a small group discussion identifying students’ cultural perspectives, beliefs, and prejudices, alerting the student to their own biases and expectations.
• Schedule time for SP debriefing to ensure actors’ well-being.
• Ensure faculty are available to the students after class for ad hoc discussions as needed.
• Provide explicit “trigger warnings” regarding the potentially upsetting scenario content, encouraging students to request an alternate educational approach if needed.
• Encourage the active participation of the “lifeline” student as a supportive back-up during practice and reminder to students that they do not have to handle difficult situations alone.
• Assemble a diverse group of faculty and SPs to include a range of viewpoints from various cultures, races, religions, genders, and sexual identities during discussions.

Other improvement that faculty and students identified to improve the learning experience included: (1) add a demonstration by an experienced clinician showcasing the target skills, (2) encourage the use of “stop action” during simulation to invite support and consultation, and (3) increase small group discussion time before and after role-plays. In addition, we strongly recommend hospital clinical and administrative leadership adopt institution-approved statements when responding to requests for a different care provider. For instance, “Our institution accommodates for beliefs and improvements in care but not for discrimination” may offer a uniform and fair approach, providing the backbone of a conversation with patients regarding a request for a different care provider. This phrase could create a shared mental model for all members of an institution, an essential tool for students and those vulnerable to biased comments. Students and faculty alike noted feeling “blindsided” with a biased or racist comment in the past; having an “approved” response provides confidence that they are supported by their supervisors and institution.

We successfully hosted a second group of students in July 2021 in our 5-session communication series, including the third session on bias, and we anticipate continuing to offer the series annually. We plan to distribute a follow-up survey to both the 2020 and 2021 cohorts in their fourth year of medical school to understand how they were able to practice the communication skills that they learned during the course in real situations. The survey will also ask whether they believe the class was successful in preparing them for their clinical rotations and what additional communication-related topics might have better prepared them for clinical work.

Acknowledgments:

The authors would like to acknowledge the volunteer actors and patients who made this module possible, including Bob Baldassari, Melissa Blazic, Kelvin Centeno, Jane Harrison, Heather Hunn, Kelly Lang, Hugh Newcomb, John Opitz, Leon Ransome, and Richard Schiller.