Making’the’ImplicitExplicit:’ Designing’and’Implemen6ng’a ... · PDF fileAsian 5% 8% Black 14% Hispanic 24% 2000 2050 2042. Changing’Demographics ... and’paent centered

Making the Implicit Explicit: Designing and Implemen6ng a

Curriculum on Implicit Bias, Cultural Humility and Racism for Pediatric

Residents, Faculty, and Interdisciplinary Care Teams

APPD Workshop | April 6, 2017

Kathleen BartleM, MD1, Stephanie Donatelli, MD2, Heather Hsu, MD MPH2, Kate Michelson, MD MMSc2, Ka6e Nash, MD2, Joanna

Perdomo, MD2, BeMy Staples, MD1, Bob Vinci, MD2 1Duke Pediatric Residency Program, 2Boston Combined Residency Program in Pediatrics

Welcome

Please text 22333 to BCRPCHIEFS to join poll everywhere

Please iden6fy your role as a medical educator

(text in the leMer corresponding to your response)

A.  Program director B.  Assistant program director C.  Instructor in the residency D.  Instructor in the medical school E.  Program administrator F.  Chief resident G.  Resident H.  Other

Why do you do what you do? What values drive your work? Please provide a one word response

Framework

•  Implicit bias increasingly recognized for its role in many disciplines, including medicine

•  Lack of exis6ng curricula to address the role of implicit bias in medicine

Mo6vated our ins6tu6ons to create novel programs

Outline

•  Introduc6on and background •  Implicit bias curriculum conceptual framework and examples

•  Small group work: – Ac6on planning – Curriculum evalua6on

•  Wrap-‐up

Workshop Objec6ves 1)  Describe tradi6onal cultural competency curricula and

their limita6ons 2)  Introduce the concept of implicit bias and its impact on

medical decision-‐making 3)  Provide a conceptual framework to develop curricula

aimed at reducing the impact of implicit bias in medicine –  Provide two examples of case-‐based curricula –  Demonstrate the role of perspec6ve-‐taking and the benefits of a case-‐based approach

–  Debrief lessons learned 4)  Use the new conceptual framework to help develop an

ac6on plan for your own ins6tu6on 5)  Brainstorm methods of curriculum evalua6on

Limita6ons of Tradi6onal Cultural Competency Curricula

Changing Demographics U.S. popula*on

White72%

Asian/PI4%

Native Am1%

Black12%

Hispanic11%

White49%

Other5%Asian

8%

Black14%

Hispanic24%

2050 2000

2042

Changing Demographics

71.3

212.9 217.1

187.9

7.4

Black Asian Other Hispanic White

% increase by ethnicity

12

Sandra Williams, 46, Chicago, Illinois Self-‐ID: biracial/“human being” Census Boxes Checked: black

13

Kelly Williams II, 17, Dallas, Texas Self-‐ID: African American and German/mul6racial Census Boxes Checked: black

14

Celeste Seda, 26, Brooklyn, New York Self-‐ID: Dominican and Korean Census boxes checked: Asian/some other race

Jordan Spencer, 18, Grand Prairie, Texas Self-‐ID: black/biracial Census box checked: black

Source: The Role & Rela6onship of Cultural Competence & Pa6ent-‐Centeredness in Health Care Quality (Mary Catherine Beach, Somnath Saha, & Lisa A. Cooper, October 2006, The Commonwealth Fund)

Early Models cross-cultural

immigrants, refugees, LEP,

non-Western

culture, language

interpersonal interactions

Recent Model cultural competence

all people of color (those affected by disparities)

prejudice, stereotyping, social determinants

of health

health care organizations

Newer Model CLAS/quality

everyone

safety, disparities

systems, communities

Curricular EvoluYonExpansion

How Do We Upgrade the Curriculum?

What is Implicit Bias? •  Bias: prejudice in favor of or against one thing, person, or group

compared with another, usually in a way considered to be unfair.

–  Conscious –  Self-‐reported –  Decline in

incidence over6me

Explicit Bias Implicit Bias –  Inherent to human

psychology –  Affect interpreta6on of

the world around us –  Exist for a wide range of

topics

–  Learned stereotypes and prejudices

–  Automa6c and unconscious

–  Difficult to change

Implicit Bias in Medicine: The Role of the Dual Processes Theory

Graphic source: hMp://upfrontanaly6cs.com/market-‐research-‐system-‐1-‐vs-‐system-‐2-‐decision-‐making/

Role of Implicit Bias in Medicine

•  All members of a medical interac6on come bearing biases

•  MDs have implicit bias1,2,3,4,5 •  Pediatricians have implicit bias2,6 •  Pediatricians’ implicit biases impact medical care and pa6ent outcomes and can lead to inequi6es6

•  Pa6ents perceive less pa6ent-‐centered care when seen by physicians with high levels of implicit bias7,8

1Blair and Steiner, et al, 2013; 2Sabin et al, 2008; 3Sabin et al, 2009; 4Sabin, Marini and Nosek, 2012; 5Schwartz et al, 2013; 6Sabin and Greenwald, 2012; 7Blair and Havranek, et al, 2013; 8Cooper et al, 2012

What Can We Do About Implicit Bias?

Internal mo6va6on to

respond without bias

Understand the

psychological basis of bias

Understand the historical context of racism

Enhancing provider

confidence

Regula6ng emo6onal responses

Increasing perspec6ve-‐taking and empathy

Building partnerships with pa6ents

Individuated impressions and pa6ent-‐centered

clinical care

MoYvaYon InformaYon EmoYon Skills Provider Judgment

Adapted from: Burgess, et al. J Gen Intern Med 2007

Theore6cal Framework to Tangible Curricula

Duke Curriculum Logis6cs

•  3-‐hour, interac6ve workshop •  Offered twice/year •  Facilitated by 2 faculty members •  Includes 8-‐12 residents pulled from elec6ve

–  Includes all levels –  Some residents do not aMend un6l 3rd year –  Only aMend once during training

•  Asked to read “The Silent Curriculum” prior to workshop

Theore6cal Framework in Prac6ce



Understand the



Enhancing provider

confidence





clinical care


Implicit Associa7on Test

Discussion of Health Dispari7es and role of physician biasd

Didac7c instruc7on

Create a safe space for self-‐reflec7on

“Replaying” cases from personal experience

Communica7on skills prac7ce Prepared cases with different perspec7ves Adapted from: Burgess, et al. J Gen Intern Med 2007

Cultural Competence Workshop

Duke Curriculum Content 1.  “Crossing the Line” Ice Breaker 2.  Discussion of changing demographics in the U.S. 3.  Introduc6on to implicit bias

•  Par6cipants take Implicit Associa6on Test in workshop

4.  Overview of Health Dispari6es and role of physician bias 5.  Discussion of prepared case where bias impacted care 6.  Summary of tools for providing pa6ent-‐centered care as a

means to mi6gate bias 7.  Video module from Worlds Apart Series with discussion 8.  Small group case discussions from trainees’ personal

experience

Layers of Diversity More than race & ethnicity

Source: Diverse Teams at Work, Gardenswartz & Rowe (Irwin, 1994) *Internal Dimensions & External Dimensions adapted from Marilyn Loden & Jody Rosener, Workforce America! (Business Irwin, 1991)

work content/field

functional level/classification

seniority work location

division/ department unit/group

management status

union affiliation

geographic location

recreational habits

income marital status

personal habits

religion

educational background

work experience

appearance

parental status

Personality

Characteristics we are born

with

Our experiences

Organizational dimensions

race gender

ethnicity sexual orientation

physical ability

age

personality

In reflec6ng on your self-‐iden6ty, which layer does your most important diversity characteris6c come from? (poll

everywhere)

1.  Personality (red) 2.  Characteris6c you were born with (green) 3.  Experien6al (grey) 4.  Organiza6onal (purple)

In reflec6ng on your self-‐iden6ty, which layer does your 2nd most important diversity characteris6c

come from? (poll everywhere)

1.  Personality (red) 2.  Characteris6c you were born with (green) 3.  Experien6al (grey) 4.  Organiza6onal (purple)

Case Discussions: 3 types

•  Prepared case of pa6ent with asthma –  3 perspec6ves: neutral, provider, and mother –  Conflict results as the unintended response to well-‐inten6oned behavior

•  Video Case and discussion: Jus6ne Chitsena from World’s Apart Series – Mother as “in-‐between” genera6on

•  Pair and share discussion of real cases from par6cipant’s experiences – Most valuable based on feedback; hardest to facilitate

Brief Overview of Boston Medical Center Curriculum

Boston Medical Center (BMC) Health Equity Rounds Logis6cs

•  One-‐hour, interac6ve morning conference •  Offered quarterly •  Led by residents and selected faculty moderator(s)

•  Interdisciplinary and interdepartmental •  Complementary to intern racial jus6ce training workshop

Goals BMC Health Equity Rounds

•  Increase par6cipants' awareness of personal implicit bias and structural bias, including its impact on pa6ent care

•  Challenge par6cipants to consider their personal biases when working with pa6ents

Objec6ves BMC Health Equity Rounds

•  Explore the psychological basis of bias •  Self-‐reflect on personal bias through cases •  Examine the historical context of structural bias

•  Examine how structural bias impacts personal interac6ons and ins6tu6onal systems

•  Iden6fy and apply strategies to mi6gate ins6tu6onal, interpersonal, and structural bias

Theore6cal Framework in Prac6ce



Understand the



Enhancing provider

confidence





clinical care


Provide evidence for adverse impact of

bias d

Mo7vate aOen7on by using real cases

Didac7c instruc7on

Create a safe space for self-‐reflec7on

d

End on a high note: Emphasize concrete

next steps

Provide opportunity for low-‐stakes skill building


Health Equity Rounds

Example Case Presenta6on

You are in the ED…

•  It is 11:00 PM on a Monday in early Spring •  11 year old boy •  Name: Mar6n Hernandez •  Chief complaint: abdominal pain •  Vital signs: T 37.5, HR 88, RR 20, BP 98/58 •  BMI: 98th percen6le

You walk into the room… •  Mar6n is smiling and watching TV •  There is a doughnut box on the exam table and white powdered sugar on his face

•  He is lying down and rubbing his abdomen in a circular mo6on

•  He is with his mother Gloria •  She is overweight •  She is tapping her right leg and holding his hand •  She is speaking to Mar6n in Spanish and English •  They greet you in English

Reflec6on

History of Present Illness

•  Characteriza6on of abdominal pain – Started 3 days ago; epigastric, burning – Decreased appe6te, but normal PO intake – No nausea or vomi6ng; daily stooling, no melena

Addi6onal History

•  Mom is worried he eats too fast •  Mom cannot control the amount of junk food he eats when he is home with his brother while she is at work

•  Mom is specifically concerned about cancer due to family history of maternal great aunt with gastric cancer, maternal aunt with breast cancer, and maternal grandfather with prostate cancer

•  He has not aMended school since abdominal pain started

Social History

•  Born in Boston •  Parents born in DR; living in Boston for 15 years •  Family is bilingual •  Parents divorced, but in a friendly rela6onship •  Mostly lives with mom and mom’s boyfriend •  Mom works as retail clerk M-‐F from 10am-‐8pm •  Home alone with brother auer school •  6th grade: good grades and aMendance record

Physical Exam

•  Heart & Lung: normal •  Abdomen: sou with mild tenderness in the epigastric area; no hepatomegaly, and no masses

•  Skin: acanthosis nigricans on the nape of neck and axilla

Perspec6ve Taking Exercise

Imagine yourself

in this mother’s shoes

Case Wrap-‐up

•  At the first ED visit, the pa6ent was given a “GI cocktail” and discharged with plan to trial famo6dine and follow-‐up with PMD

•  Within the next 10 days, the pa6ent returned to the ED twice and addi6onally visits his PCP

•  He was ul6mately referred to GI clinic where profound weight loss was noted and abdominal imaging revealed a large mass, which was later confirmed to be malignancy

Small Group/Individual Reflec6on •  With the guided imagery and the case unfolding over 6me, how does who you pictured evolve?

•  How did the perspec6ve-‐taking exercises make you feel?

•  Iden6fy the implicit biases that may have impacted the case

•  What are the risk factors for discrimina6on or bias?

•  What bothered you about this case?

What can we take away from these experiences?

Shared Challenges

•  Choosing appropriate cases •  Gevng people to talk about implicit bias rather than medical aspects of case

•  Addressing the needs of different learners: – Those who need evidence – Those who “grew up” in a 6me where race-‐blindness = an6-‐racism

•  Talking about race and bias is uncomfortable

Shared Lessons Learned

•  Role of the moderator(s) – Guiding discussion – Every session will be different; requires flexibility

•  Trainees are ahead of faculty •  Current events may influence discussion •  Approach with curiosity and not judgment •  Format drives what you are able to accomplish

Ac6on Planning

•  Small group breakout – Group 1

•  No exis6ng curriculum on implicit bias •  OR have a curriculum, but want to workshop something new

– Group 2 •  Have exis6ng implicit bias curriculum

•  Use worksheets provided

Theore6cal Framework



Understand the



Enhancing provider

confidence





clinical care



Building an Assessment

Using Kirkpatrick’s model to assess medical curricula

Result

Transfer

Learning

Reac6on How did the par6cipants react to the training?

Did the training result in an increase in knowledge, skills or avtudes

Did par6cipants change behavior in the workplace as a result of the training?

Did the training impact processes or pa6ent outcomes?

Duke Assessment Experience

•  Most exis6ng assessment tools are aligned with knowledge-‐based curriculum – specific cultural norms and values

•  Tool designed to measure resident preparedness and skillfulness to deliver cross-‐cultural care – Relies on self-‐assessment –  Inherently flawed given that most bias is unconscious

Duke Assessment Experience

•  Pre-‐ and post-‐workshop assessment of 52 trainees –  92% found the workshop useful. –  At baseline, 92% of trainees felt prepared to care for pa6ents from different cultures; did not change significantly auer the workshop

–  Increased skillfulness in assessing the pa6ent’s understanding of illness, iden6fying cultural customs that might affect clinical care and nego6a6ng a realis6c treatment plan.

•  Raises ques6on of “post-‐pre-‐” survey: “in hindsight, prior to the workshop, how prepared were you…”

BMC Assessment Experience

NEGATIVE POSITIVE

ACTIVATED

DEACTIVATED

excited

enthusias-c

pleased

content

calm

relaxed

angry

tense

anxious

fa-gued

sad

bored

Small Group Assessment Exercise What are the barriers? Can we collaborate?

How do we get to Level 1?

Result

Transfer

Learning

Reac6on How did the par6cipants react to the training?

Did the training result in an increase in knowledge, skills or avtudes

Did par6cipants change behavior in the workplace as a result of the training?

Did the training impact processes or pa6ent outcomes?

Using Kirkpatrick’s

Model

Workshop Objec6ves 1)  Describe tradi6onal cultural competency curricula and its

poten6al drawbacks 2)  Introduce the concept of implicit bias and its impact on

medical decision-‐making 3)  Provide a conceptual framework to develop curricula

aimed at reducing the impact of implicit bias in medicine –  Provide two examples of case-‐based curricula –  Demonstrate the role of perspec6ve-‐taking and the benefits of a case-‐based approach

–  Debrief lessons learned 4)  Use the new conceptual framework to help develop an

ac6on plan for your own ins6tu6on 5)  Brainstorm methods of curriculum evalua6on

Conclusions & Wrap Up

•  Take home materials – Cases and discussion ques6ons – Guided imagery instruc6ons – Glossary – Key readings

•  Contact Informa6on – Crea6ng a network for sharing implicit bias curricula

Thank you

References Baron AS, Banaji MR. The Development of Implicit Avtudes. Evidence of Race Evalua6ons From Ages 6 and 10 and Adulthood. Psychological Science. 2006;17(1):53-‐58. Blair IV, Havranek EP, Price DW, HanraMy R, Fairclough DL, Farley T, Hirsh H, Steiner J. Assessment of Biases against La6nos and Americans Among Primary Care Providers and Community Members. American Journal of Public Health. 2013;103(1):92-‐8. Blair IV, Steiner JF, Fairclough DL, HanraMy R, Price DW, Hirsh HK, Wright LA, Bronsert M, Karimkhani E, Magid DJ, Havranek EP. Clinician’s Implicit Ethnic/Racial Bias and Percep6ons of Care Among Black and La6no Pa6ents. Annals of Family Medicine. 2013;(11)1:43-‐52. Brooks KC. A piece of my mind. A silent curriculum. JAMA. 2015;313(19):1909-‐1910. Burgess D, Van Ryn M, Dovidio J, Saha S. Reducing racial bias among health care providers: lessons from social-‐cogni6ve psychology. Journal of General Internal Medicine. 2007;22(6):882-‐7. Chapman EN, Kaatz A, Carnes M. Physicians and Implicit Bias: How Doctors May Unwivngly Perpetuate Health Care Dispari6es. J GEN INTERN MED. 2013;28(11):1504-‐1510. Cooper LA, Roter DL, Carson KA, et al. The Associa6ons of Clinicians’ Implicit Avtudes About Race With Medical Visit Communica6on and Pa6ent Ra6ngs of Interpersonal Care. Am J Public Health 2012;102(5):979-‐987. Devine PG, Forscher PS, Aus6n AJ, Cox WT. Long-‐term reduc6on in implicit race bias: A prejudice habit-‐breaking interven6on. Journal of Experimental Social Psychology. 2012;48(6):1267-‐1278. Dunn AM. Culture competence and the primary care provider. J Pediatr Health Care. 2002;16(3):105-‐111. Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its predic6on of thrombolysis decisions for black and white pa6ents. Journal of general internal medicine. 2007;22(9):1231-‐1238.

References Kahneman, Daniel (2011). Thinking, fast and slow (1st ed.). New York: Farrar, Straus and Giroux. Park ER, Chun MB, Betancourt JR, Green AR, Weissman JS. Measuring residents' perceived preparedness and skillfulness to deliver cross-‐cultural care. Journal of general internal medicine. 2009;24(9):1053-‐1056. Sabin JA, Rivara FP, Greenwald AG. Physician Implicit Avtudes and Stereotypes About Race and Quality of Medical Care. Medical Care. 2008;46(7):678-‐685. Sabin JA, Nosek BA, Greenwald AG, Rivara FP. Physicians’ Implicit and Explicit Avtudes About Race by MD Race, Ethnicity, and Gender. Journal of Health Care for the Poor and Underserved. 2009;20(3):896-‐913. Sabin JA, Greenwald AG. The Influence of Implicit Bias on Treatment Recommenda6ons for 4 Common Pediatric Condi6ons: Pain, Urinary Tract Infec6on, AMen6on Deficit Hyperac6vity Disorder, and Asthma. Am J Public Health. 2012;102(5):988-‐995. Sabin JA, Marini M, Nosek BA. Implicit and Explicit An6-‐Fat Bias among a Large Sample of Medical Doctors by BMI, Race/Ethnicity and Gender. Fielding R, ed. PLoS ONE. 2012;7(11):e48448. doi:10.1371/journal.pone.0048448. Schwartz M, O’Neal Chambliss H, Brownell KD, Blair SN, Billington C. Weight Bias among Health Professionals Specializing in Obesity. Obesity Research. 2003;11(9)1033-‐9. Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians' recommenda6ons for cardiac catheteriza6on. The New England journal of medicine. 1999;340(8):618-‐626. Smedley BD, S6th AY, Nelson AR, Ins6tute of Medicine (U.S.). CommiMee on Understanding and Elimina6ng Racial and Ethnic Dispari6es in Health Care. Unequal treatment : confron7ng racial and ethnic dispari7es in health care. Washington, D.C.: Na6onal Academy Press; 2003. Stone J, Moskowitz GB. Non-‐conscious bias in medical decision making: what can be done to reduce it? Medical educa7on. 2011;45(8):768-‐776. Worlds Apart. hMps://med.stanford.edu/medethicsfilms/films/worldsapart.html.

Documents

Making’the’ImplicitExplicit:’ Designing’and’Implemen6ng’a ... · PDF fileAsian 5% 8% Black 14% Hispanic 24% 2000 2050 2042. Changing’Demographics ... and’paent centered