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Empathy and Implicit Bias: Can Empathy Training Improve Equity?

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Bias is everywhere. Explicit biases include conscious attitudes or intentional discrimination towards certain groups. In contrast, implicit biases include attitudes or behaviors that exert powerful influence over individuals outside their awareness. These implicit biases can perpetuate health disparities by widening inequities and decreasing trust between patients and health professionals. Among the interventions to reduce the adverse impact of implicit bias on healthcare is empathy training. The authors describe a program of research on implicit bias towards individuals with mental illness, highlighting how enhancing empathy may improve equity for marginalized and underserved populations.

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... Challenging implicit biases has become an important step to redress their effects within the medical curriculum and subsequent medical practice (Fallin-Bennett, 2015). Situating this challenge within a session focused on empathy in consultation skills offers an important micro level setting to improve equity for marginalized populations (Sukhera, 2019). Implicit biases need to be illuminated in a way that students can become sensitized to their existence and effects that in turn create an impact on their approach to practice. ...
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Introduction This paper discusses the design and impact of a clinical consultation skills session for undergraduate medical students in context of diverse sexual orientation, gender identity and expression, and sex characteristics. Existing teaching approaches omit opportunities for application and skills practice. This innovation seeks to address this gap. Methods Senior medical undergraduate students participated in actor-facilitated standardized simulated patient role-play. The scenarios utilized a structure akin to the end of year final observed objective structured clinical examination. Plan-do-study-act cycles involving facilitator observation, verbal and written feedback from students and actors, confidential student evaluations, and peer evaluation contributed to session modification and improvement. Findings The teaching session offered students the opportunity to practice exam-style simulated patient consultations, communication and empathy skills. Improvements made following the first iteration were reflected in positive student evaluations in the second iteration. Discussion and Conclusion Simulated consultations using standardised scenarios represent an accepted format for medical education. We demonstrated it is possible to include topics that frequently give rise to discrimination and stigma from medical professionals whilst maintaining expected learning outcomes. Student evaluations identify the acceptability and value of the topics for medical education. We present a viable option for integration into medical education.
... We suggest emphasizing that although bias is human nature and therefore not anyone's fault, we must engage in skill development and practice so that it does not influence our clinical practice behaviors. This call to action while avoiding blame can also enhance self-compassion and self-forgiveness (Sukhera 2018(Sukhera , 2019. ...
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Implicit biases describe mental associations that affect our actions in an unconscious manner. We can hold certain implicit biases regarding members of certain social groups. Such biases can perpetuate health disparities by widening inequity and decreasing trust in both healthcare and medical education. Despite the widespread discourse about bias in medical education, teaching and learning about the topic should be informed by empirical research and best practice. In this paper, the authors provide a series of twelve tips for teaching implicit bias recognition and management in medical education. Each tip provides a specific and practical strategy that is theoretically and empirically developed through research and evaluation. Ultimately, these twelve tips can assist educators to incorporate implicit bias instruction across the continuum of medical education to improve inequity and advance justice.
... Challenging implicit biases has become an important step to redress their effects within the medical curriculum and subsequent medical practice (Fallin-Bennett, 2015). Situating this challenge within a session focused on empathy in consultation skills offers an important micro level setting to improve equity for marginalized populations (Sukhera, 2019). Implicit biases need to be illuminated in a way that students can become sensitized to their existence and effects that in turn create an impact on their approach to practice. ...
Article
Introduction This paper discusses the design and impact of a clinical consultation skills session for undergraduate medical students in context of diverse sexual orientation, gender identity and expression, and sex characteristics. Existing teaching approaches omit opportunities for application and skills practice. This innovation seeks to address this gap. Methods Senior medical undergraduate students participated in actor-facilitated standardized simulated patient role-play. The scenarios utilized a structure akin to the end of year final observed objective structured clinical examination. Plan-do-study-act cycles involving facilitator observation, verbal and written feedback from students and actors, confidential student evaluations, and peer evaluation contributed to session modification and improvement. Findings The teaching session offered students the opportunity to practice exam-style simulated patient consultations, communication and empathy skills. Improvements made following the first iteration were reflected in positive student evaluations in the second iteration. Discussion and Conclusion Simulated consultations using standardised scenarios represent an accepted format for medical education. We demonstrated it is possible to include topics that frequently give rise to discrimination and stigma from medical professionals whilst maintaining expected learning outcomes. Student evaluations identify the acceptability and value of the topics for medical education. We present a viable option for integration into medical education.
... Knowledge of these health disparities, and their outcomes, is essential to developing effective interventions to improve the health of this vulnerable population (Fredriksen-Goldsen & Kim, 2014;IOM, 2011;Sukhera, 2020). The outcomes of these disparities and contributing barriers affect sexual minorities across the lifespan (Dorsen, 2014;Hollenbach et al., 2014;IOM, 2011;McEwing, 2017). ...
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Recognizing sexual minorities continue to experience discrimination and social, institutional, and health disparities, this study explored implicit and explicit sexual attitude among nursing students. Knowledge of these attitudes is an important step to improve the care provided to this vulnerable population. Yet, there remains little research of implicit sexual attitude among nurses and no research among nursing students. This study addressed this gap in the current literature by comparing measurements of implicit and explicit attitude and identifying demographic attributes that predict these attitudes. Critical cosmopolitan theory (Delanty, 2006), informed this non-experimental, descriptive, correlational study. Implicit attitude wasmeasured using the sexuality Implicit Association Test (IAT) (Greenwald, McGhee, & Schwartz, 1998). Explicit attitude of homophobia was measured using the Attitudes Toward Lesbians and Gay Men Scale (ATLG) (Herek, 1988). The IAT had acceptable (α = 0.73) reliability and the ATLG good (α = 0.89) reliability with this study sample. A demographic questionnaire of relevant predictor variables was drawn from the literature attitudes toward sexual minorities. A large sample (n = 1,348) of United States baccalaureate nursing students, drawn from a convenience sample, participated in the study. The majority of participants were female (n = 1,164, 86%), White (n = 990, 73%), self-identified as heterosexual (n = 1,044, 77%), and were enrolled in a registered nurse (RN) to bachelor of science in nursing (BSN) program (n = 790, 59%). The average age of participants was 28 years. Analysis of the results demonstrated a moderate implicit preference favoring heterosexuals over lesbian women and gay men (D-score = 0.22) that was more negative than the general public who took the IAT in 2018 (D-score = 0.15). Explicit attitude results indicated a low level of homophobia (ATLG = 17.52) in contrast to earlier studies, which reported moderate to high levels of this negative explicit attitude. The difference in implicit and explicit scores were found to be statistically significant, consistent with previous research that reported more positive explicit compared to implicit attitude. Among demographic variables, identifying as male, heterosexual, somewhat or very religious, enrolled in a RN to BSN nursing program predicted more negative implicit and explicit attitude. The implications of these findings for nursing education were discussed and recommendations for nursing academic leadership, faculty, and students were presented.
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Existing literature on implicit bias is fragmented and comes from a variety of fields like cognitive psychology, business ethics, and higher education, but implicit-bias-informed educational approaches have been underexplored in health professions education and are difficult to evaluate using existing tools. Despite increasing attention to implicit bias recognition and management in health professions education, many programs struggle to meaningfully integrate these topics into curricula. The authors propose a six-point actionable framework for integrating implicit bias recognition and management into health professions education that draws on the work of previous researchers and includes practical tools to guide curriculum developers. The six key features of this framework are creating a safe and nonthreatening learning context, increasing knowledge about the science of implicit bias, emphasizing how implicit bias influences behaviors and patient outcomes, increasing self-awareness of existing implicit biases, improving conscious efforts to overcome implicit bias, and enhancing awareness of how implicit bias influences others. Important considerations for designing implicit-bias-informed curricula-such as individual and contextual variables, as well as formal and informal cultural influences-are discussed. The authors also outline assessment and evaluation approaches that consider outcomes at individual, organizational, community, and societal levels. The proposed framework may facilitate future research and exploration regarding the use of implicit bias in health professions education.
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Empathy is a key element of patient-physician communication; it is relevant to and positively influences patients' health. The authors systematically reviewed the literature to investigate changes in trainee empathy and reasons for those changes during medical school and residency. The authors conducted a systematic search of studies concerning trainee empathy published from January 1990 to January 2010, using manual methods and the PubMed, EMBASE, and PsycINFO databases. They independently reviewed and selected quantitative and qualitative studies for inclusion. Intervention studies, those that evaluated psychometric properties of self-assessment tools, and those with a sample size <30 were excluded. Eighteen studies met the inclusion criteria: 11 on medical students and 7 on residents. Three longitudinal and six cross-sectional studies of medical students demonstrated a significant decrease in empathy during medical school; one cross-sectional study found a tendency toward a decrease, and another suggested stable scores. The five longitudinal and two cross-sectional studies of residents showed a decrease in empathy during residency. The studies pointed to the clinical practice phase of training and the distress produced by aspects of the "hidden," "formal," and "informal" curricula as main reasons for empathy decline. The results of the reviewed studies, especially those with longitudinal data, suggest that empathy decline during medical school and residency compromises striving toward professionalism and may threaten health care quality. Theory-based investigations of the factors that contribute to empathy decline among trainees and improvement of the validity of self-assessment methods are necessary for further research.
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There have been long-term concerns regarding discriminatory discipline practices used with culturally and linguistically diverse students, with little research on the impact teacher-centered empathy interventions may have on this population. This randomized pretest–posttest control group design investigates the ability of a brief empathy-inducing intervention to improve the implicit bias of pre-service teachers, as measured by the Implicit Association Test. We found the empathy intervention statistically significant at decreasing the implicit bias of White female pre-service teachers toward Black individuals (F = 7.55, η² = 0.22, p = 0.01). Implications and future research are discussed, including extended intervention periods.
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Recent interest in the implicit self-esteem construct has led to the creation and use of several new assessment tools whose psychometric properties have not been fully explored. In this article, the authors investigated the reliability and validity of seven implicit self-esteem measures. The different implicit measures did not correlate with each other, and they correlated only weakly with measures of explicit self-esteem. Only some of the implicit measures demonstrated good test–retest reliabilities, and overall, the implicit measures were limited in their ability to predict our criterion variables. Finally, there was some evidence that implicit self-esteem measures are sensitive to context. The implications of these findings for the future of implicit self-esteem research are discussed.
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To facilitate a multidimensional approach to empathy the Interpersonal Reactivity Index (IRI) includes 4 subscales: Perspective-Taking (PT) Fantasy (FS) Empathic Concern (EC) and Personal Distress (PD). The aim of the present study was to establish the convergent and discriminant validity of these 4 subscales. Hypothesized relationships among the IRI subscales between the subscales and measures of other psychological constructs (social functioning self-esteem emotionality and sensitivity to others) and between the subscales and extant empathy measures were examined. Study subjects included 677 male and 667 female students enrolled in undergraduate psychology classes at the University of Texas. The IRI scales not only exhibited the predicted relationships among themselves but also were related in the expected manner to other measures. Higher PT scores were consistently associated with better social functioning and higher self-esteem; in contrast Fantasy scores were unrelated to these 2 characteristics. High EC scores were positively associated with shyness and anxiety but negatively linked to egotism. The most substantial relationships in the study involved the PD scale. PD scores were strongly linked with low self-esteem and poor interpersonal functioning as well as a constellation of vulnerability uncertainty and fearfulness. These findings support a multidimensional approach to empathy by providing evidence that the 4 qualities tapped by the IRI are indeed separate constructs each related in specific ways to other psychological measures.
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Introduction: Mindful clinicians are resilient and more likely to provide patient-centered care. We aimed to enhance clinicians' well-being by offering a Mindfulness-Based Stress Reduction (MBSR) course that teaches mindfulness and stress management and then determine whether this impacted their subsequent medical encounters. Methods: In a longitudinal cohort study with 27 clinicians, MBSR was taught by a certified instructor. Pre-MBSR and post-MBSR online questionnaires assessed burnout, depression, stress, meaningfulness, and mindfulness. Patients independently rated their clinicians using the Rochester Communication Rating Scale (RCRS) after a clinical encounter before and after their clinician took the MBSR course. Nine medical doctors audiorecorded the consultations before and after MBSR; the tapes were coded and analyzed by an independent team using the Roter interaction analyses system. Results: Significant reductions in stress and burnout were found, and increases in mindfulness and meaningfulness. The decrease in stress was correlated with less judgmental attitudes and less reactivity-facets of mindfulness. The decrease in emotional exhaustion was correlated with more acting with awareness and less judgmental attitudes-facets of mindfulness. Patients' perceptions of the clinical encounter suggested that patient-centered care improved after MBSR. Decreased depersonalization was significantly associated with the RCRS subscale, "understanding of the patient's experience of illness." At both time points, doctors dominated the exchange and were patient-centered. Discussion: Mindfulness has a direct and positive impact on clinicians' well-being. When clinicians' experienced less depersonalization, their patients reported being better understood.
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Abstract Introduction This exercise is a small-group discussion about bias for medical students who have had at least some clinical experience. It is designed to cultivate awareness that bias is inherent in all humans, including physicians, and can impact patient care. The aim is to foster self-reflection through an exercise that challenges assumptions about personal bias. Methods The Implicit Association Test (IAT) is used as a trigger, and a small-group discussion format is used to create reflection about personal biases and their effects on clinical decisions. Students discuss what it was like to take the IAT, how they felt when they got their results, if their results were expected, when bias can be helpful, clinical experiences with bias, and what they will do with their results. The content is presented as a set of guidelines and features materials for training facilitators and conducting the discussion. These materials comprise an outline of the exercise, advance preparation assignments, instructions for students, and a small-group facilitator guide. The materials also include evaluation tools consisting of pre- and postdiscussion student surveys and facilitator postdiscussion surveys. Results As evidence that the IAT does generate meaningful discussion in a facilitated small group, we report the analysis of our pilot data (n = 72). Our exercise resulted in an increase in the perception that personal bias could have an impact on patient relationships (p < .001) among students reporting a lower belief that bias can have impact (n = 6). Among students who rated themselves as having a lower self-awareness prior to the exercise (n = 14), there was an increase in self-awareness of personal bias after the exercise (p < .001). Finally, students reported significant increases (p < .01) in the perception that the IAT was an effective tool for generating small-group discussion about personal bias (p < .001) and that the reflection exercises and small-group discussions were effective tools for raising awareness about personal bias (p < .001) after attending the session. Discussion Our results suggest that the primary value of this exercise lies not simply in taking the IAT but rather in the cognitive processing of the IAT and other potential biases that takes place during the small-group session. The IAT in conjunction with the discussion appears to be what leads to increased self-awareness and self-reflection.
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Experiment 1 used the Implicit Association Test (IAT; A. G. Greenwald, D. E. McGhee, Be J. L. K. Schwartz, 1998) to measure self-esteem by assessing automatic associations of self with positive or negative valence. Confirmatory factor analysis (CFA) showed that two IAT measures defined a factor that was distinct from, but weakly correlated with, a factor defined by standard explicit (self-report) measures of self-esteem. Experiment 2 tested known-groups validity of two IAT gender self-concept measures. Compared with well-established explicit measures, the IAT measures revealed triple the difference in measured masculinity-femininity between men and women. Again, CFA revealed construct divergence between implicit and explicit measures. Experiment 3 assessed the self-esteem IAT's validity in predicting cognitive reactions to success and failure. High implicit self-esteem was associated in the predicted fashion with buffering against adverse effects of failure on two of four measures.
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Given that understanding the sociocultural dimensions underlying a patient's health values, beliefs, and behaviors is critical to a successful clinical encounter, cross-cultural curricula have been incorporated into undergraduate medical education. The goal of these curricula is to prepare students to care for patients from diverse social and cultural backgrounds, and to recognize and appropriately address racial, cultural, and gender biases in health care delivery. Despite progress in the field of cross-cultural medical education, several challenges exist. Foremost among these is the need to develop strategies to evaluate the impact of these curricular interventions. This article provides conceptual approaches for cross-cultural medical education, and describes a framework for student evaluation that focuses on strategies to assess attitudes, knowledge, and skills, and the impact of curricular interventions on health outcomes.
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Implicit bias is an unconscious preference for a specific social group that can have adverse consequences for patient care. Acute care clinical vignettes were used to examine whether implicit race or class biases among registered nurses (RNs) impacted patient-management decisions. In a prospective study conducted among surgical RNs at the Johns Hopkins Hospital, participants were presented 8 multi-stage clinical vignettes in which patients' race or social class were randomly altered. Registered nurses were administered implicit association tests (IATs) for social class and race. Ordered logistic regression was then used to examine associations among treatment differences, race, or social class, and RN's IAT scores. Spearman's rank coefficients comparing RN's implicit (IAT) and explicit (stated) preferences were also investigated. Two hundred and forty-five RNs participated. The majority were female (n = 217 [88.5%]) and white (n = 203 [82.9%]). Most reported that they had no explicit race or class preferences (n = 174 [71.0%] and n = 108 [44.1%], respectively). However, only 36 nurses (14.7%) demonstrated no implicit race preference as measured by race IAT, and only 16 nurses (6.53%) displayed no implicit class preference on the class IAT. Implicit association tests scores did not statistically correlate with vignette-based clinical decision making. Spearman's rank coefficients comparing implicit (IAT) and explicit preferences also demonstrated no statistically significant correlation (r = -0.06; p = 0.340 and r = -0.06; p = 0.342, respectively). The majority of RNs displayed implicit preferences toward white race and upper social class patients on IAT assessment. However, unlike published data on physicians, implicit biases among RNs did not correlate with clinical decision making. Copyright © 2015 American College of Surgeons. Published by Elsevier Inc. All rights reserved.
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A recent Institute of Medicine report concluded that lesbian and gay individuals face discrimination from health care providers and called for research on provider attitudes. Medical school is a critical juncture for improving future providers' treatment of sexual minorities. This study examined both explicit bias and implicit bias against lesbian women and gay men among first-year medical students, focusing on two predictors of such bias, contact and empathy. This study included the 4,441 heterosexual first-year medical students who participated in the baseline survey of the Medical Student Cognitive Habits and Growth Evaluation Study, which employed a stratified random sample of 49 U.S. medical schools in fall 2010. The researchers measured explicit attitudes toward gay and lesbian people using feeling thermometer self-assessments, implicit attitudes using the Implicit Association Test, amount and favorability of contact using self-report items, and empathy using subscales of the Interpersonal Reactivity Index. Nearly half (45.79%; 956/2,088) of respondents with complete data on both bias measures expressed at least some explicit bias, and most (81.51%; 1,702/2,088) exhibited at least some implicit bias against gay and lesbian individuals. Both amount and favorability of contact predicted positive implicit and explicit attitudes. Both cognitive and emotional empathy predicted positive explicit attitudes, but not implicit attitudes. The prevalence of negative attitudes presents an important challenge for medical education, highlighting the need for more research on possible causes of bias. Findings on contact and empathy point to possible curriculum-based interventions aimed at ensuring high-quality care for sexual minorities.
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Despite many recent advances in rights for sexual and gender minorities in the United States, bias against lesbian, gay, bisexual, and transgender (LGBT) people still exists. In this Commentary, the author briefly reviews disparities with regard to LGBT health, in both health care and medical education, and discusses the implications of Burke and colleagues' study of implicit and explicit biases against lesbian and gay people among heterosexual first-year medical students, published in this issue of Academic Medicine.Emphasis is placed on the ways in which physicians' implicit bias against LGBT people can create a cycle that perpetuates a professional climate reinforcing the bias. The hidden curriculum in academic health centers is discussed as both a cause of this cycle and as a starting point for a research and intervention agenda. The findings from Burke and colleagues' study, as well as other evidence, support raising awareness of LGBT discrimination, increasing exposure to LGBT individuals as colleagues and role models in academic health centers, and modifying medical education curricula as methods to break the cycle of implicit bias in medicine.
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ABSTRACT This study tested the hypothesis that empathizing with out-group members is beneficial outside of, but not within, intergroup-contact situations. We predicted that in the context of intergroup interaction, the potential for evaluation would lead individuals' perspective-taking efforts to take on an egocentric and counterproductive flavor. As predicted, when empathy was instantiated during an intergroup exchange, it failed to exert its usual positive effect on intergroup attitudes and led higher-prejudice individuals to derogate an out-group member who was an interaction partner; empathy also blocked the prejudice-reducing influence of intergroup contact. Mediation analyses indicated that activation of negative metastereotypes regarding the out-group's view of the in-group accounted for these effects. The findings, which demonstrate ironic effects of empathy in intergroup interaction, indicate that interventions based on studies of individuals' reactions to out-group members in the abstract might have dramatically different consequences when put into practice in real exchanges between members of different groups.
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A significant proportion of physicians and medical trainees experience stress-related anxiety and burnout resulting in increased absenteeism and disability, decreased patient satisfaction, and increased rates of medical errors. A review and meta-analysis was conducted to examine the effectiveness of interventions aimed at addressing stress, anxiety, and burnout in physicians and medical trainees. Twelve studies involving 1034 participants were included in three meta-analyses. Cognitive, behavioral, and mindfulness interventions were associated with decreased symptoms of anxiety in physicians (standard differences in means [SDM], -1.07; 95% confidence interval [CI], -1.39 to -0.74) and medical students (SDM, -0.55; 95% CI, -0.74 to -0.36). Interventions incorporating psychoeducation, interpersonal communication, and mindfulness meditation were associated with decreased burnout in physicians (SDM, -0.38; 95% CI, -0.49 to -0.26). Results from this review and meta-analysis provide support that cognitive, behavioral, and mindfulness-based approaches are effective in reducing stress in medical students and practicing physicians. There is emerging evidence that these models may also contribute to lower levels of burnout in physicians.
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Currently, a relatively small number of studies have employed qualitative methods to rigorously examine the experiences of health care professionals enrolled in mindfulness-based stress reduction (MBSR). This study developed a working model of how participants may experience change during an adapted MBSR program for health care professionals. The model derived from the data demonstrated that participants echoed themes similar to those described by clinical populations engaged in MBSR, such as the salience of the group experience and support, discovery of acceptance as well as the realization that some degree of frustration and/or distress is part of learning and establishing a mindfulness practice. Unique themes highlighted included becoming aware of perfectionism, the automaticity of “other focus” and the “helping or fixing mode”. Findings illustrated the nuanced change processes undertaken by participants and the implications such change held across professional and personal domains.
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This monograph provides a philosophical framework and practical ideas for improving service delivery to children of color who are severely emotionally disturbed. The monograph targets four sociocultural groups (African Americans, Asian Americans, Hispanic Americans, and Native Americans). The document emphasizes the cultural strengths inherent in all cultures and examines how the system of care can more effectively deal with cultural differences and related treatment issues. In dealing with cultural differences, there is a need to clarify policy, training, resources, practice, and research issues, and cultural competence should be viewed as a developmental process. Five elements contributing to a system's, institution's, or agency's ability to become more culturally competent are identified: value diversity, cultural self-assessment, consciousness of the dynamics of cultural interaction, institutionalization of cultural knowledge, and development of adaptations to diversity. Cultural competence must be developed at the policymaking, administrative, practitioner, and consumer levels. Service adaptations developed in response to cultural diversity may impact on intake and client identification, assessment and treatment, communication and interviewing, case management, out-of-home care, and guiding principles. Planning for cultural competence involves assessment, support building, facilitating leadership, including the minority family and community, developing resources, training and technical assistance, setting goals, and outlining action steps. (Approximately 170 references) (JDD)
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This article describes our collaborative research on aversive racism and a strategy we developed to combat it, the Common Ingroup Identity Model. In addition, we reveal some details about our personal and professional relationship in pursuit of our scientific agenda. We begin by discussing evidence for the existence of aversive racism, a subtle, unintentional form bias that can have pernicious effects. Then we review research concerning how a common ingroup identity can combat aversive racism by redirecting the forces of social categorization and social identity, such that "Us" and "Them" are regarded as "We." We conclude with a brief discussion of where we may look next for clues toward helping to achieve a fairer, more just society.
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Developing diagnostic competence in students is a major goal of medical education, but there is little empirical evidence on instructional strategies that foster the acquisition of this competence. The aim of this study was to investigate the effects of structured reflection compared with the generation of immediate or differential diagnosis while practising with clinical cases on learning clinical diagnosis. This was a three-phase experimental study. During a learning phase, 46 Year 4 students diagnosed six clinical cases under different experimental conditions: structured reflection, immediate diagnosis, or differential diagnosis. This was followed by an immediate test and a delayed test administered 1 week later. Each test consisted of diagnosing four different cases of diseases presented in the learning phase. Performance in diagnosing these new cases was used as a measure of learning. Repeated-measures analysis of variance on the mean diagnostic accuracy scores (range: 0-1) showed a significant interaction between performance moment (i.e. performance in the learning phase and on each test) and instructions followed during the learning phase (p=0.003). Follow-up analyses of this interaction showed that diagnostic performance did not differ between conditions in the learning phase. On the immediate test, scores in the reflection condition (mean=0.48, 95% confidence interval [CI] 0.38-0.58) were significantly lower than scores in the differential diagnosis condition (mean=0.62, 95% CI 0.54-0.70; p=0.012) and marginally lower than those in the immediate diagnosis condition (mean=0.61, 95% CI 0.52-0.70; p=0.04). One week later, however, scores in the reflection condition (mean=0.66, 95% CI 0.56-0.76) significantly outperformed those in the other conditions (differential diagnosis: mean=0.48, 95% CI 0.37-0.58 [p<0.01]; immediate diagnosis: mean=0.52, 95% CI 0.43-0.60 [p=0.01]). Comparisons within experimental conditions showed that performance from the immediate to the delayed test decreased in the immediate and differential diagnosis conditions (immediate diagnosis: p=0.042; differential diagnosis: p=0.012), but increased in the reflection condition (p=0.003). Structured reflection while practising with cases appears to foster the learning of clinical knowledge more effectively than the generation of immediate or differential diagnoses and therefore seems to be an effective instructional approach to developing diagnostic competence in students.
Article
We examined the association between pediatricians' attitudes about race and treatment recommendations by patients' race. We conducted an online survey of academic pediatricians (n = 86). We used 3 Implicit Association Tests to measure implicit attitudes and stereotypes about race. Dependent variables were recommendations for pain management, urinary tract infections, attention deficit hyperactivity disorder, and asthma, measured by case vignettes. We used correlational analysis to assess associations among measures and hierarchical multiple regression to measure the interactive effect of the attitude measures and patients' race on treatment recommendations. Pediatricians' implicit (unconscious) attitudes and stereotypes were associated with treatment recommendations. The association between unconscious bias and patient's race was statistically significant for prescribing a narcotic medication for pain following surgery. As pediatricians' implicit pro-White bias increased, prescribing narcotic medication decreased for African American patients but not for the White patients. Self-reported attitudes about race were associated with some treatment recommendations. Pediatricians' implicit attitudes about race affect pain management. There is a need to better understand the influence of physicians' unconscious beliefs about race on pain and other areas of care.
Article
We examined the associations of clinicians' implicit attitudes about race with visit communication and patient ratings of care. In a cross-sectional study of 40 primary care clinicians and 269 patients in urban community-based practices, we measured clinicians' implicit general race bias and race and compliance stereotyping with 2 implicit association tests and related them to audiotape measures of visit communication and patient ratings. Among Black patients, general race bias was associated with more clinician verbal dominance, lower patient positive affect, and poorer ratings of interpersonal care; race and compliance stereotyping was associated with longer visits, slower speech, less patient centeredness, and poorer ratings of interpersonal care. Among White patients, bias was associated with more verbal dominance and better ratings of interpersonal care; race and compliance stereotyping was associated with less verbal dominance, shorter visits, faster speech, more patient centeredness, higher clinician positive affect, and lower ratings of some aspects of interpersonal care. Clinician implicit race bias and race and compliance stereotyping are associated with markers of poor visit communication and poor ratings of care, particularly among Black patients.
Article
Clinicians are believed to use two predominant reasoning strategies: system 1 based pattern recognition, and system 2 based analytical reasoning. Balancing these cognitive reasoning strategies is widely believed to reduce diagnostic error. However, clinicians approach different problems with different reasoning strategies. This study explores whether clinicians have insight into their problem specific reasoning strategy, and whether this insight can be used to balance their reasoning and reduce diagnostic error. In Experiment 1, six medical residents interpreted eight ECGs and self-reported their predominant reasoning strategy using a four point scale (4S). Self-assessed reasoning strategy correlated with objective assessment by two clinical experts using a post hoc talk-aloud protocol (ρ = 0.69, p < 0.0001). Reporting an analytic strategy was also associated with 40% longer interpretation times (p = 0.01). In Experiment 2, twenty-four residents were asked to reinterpret eight ECGs with instructions customized to their 4S. Half of the ECGs were reinterpreted with instructions to use the opposite reasoning strategy to that reported, and half with instructions to use the same reasoning strategy. ECG reinterpretation scores did not differ with potentiating compared to balancing reasoning instructions (F(1,188) = 0.22, p = 0.64). However, analytic instructions were associated with improved scores (F(1,188) = 15, p < 0.0001). These data suggest that clinicians are able to recognize their reasoning strategies. However, attempting to balance reasoning strategies through customizable instructions did not result in a reduction in diagnostic errors. This suggests important limitations to the widespread belief in balancing reasoning strategies to reduce diagnostic error.
Article
Medical Education 2011: 45: 768–776 Context Non-conscious stereotyping and prejudice contribute to racial and ethnic disparities in health care. Contemporary training in cultural competence is insufficient to reduce these problems because even educated, culturally sensitive, egalitarian individuals can activate and use their biases without being aware they are doing so. However, these problems can be reduced by workshops and learning modules that focus on the psychology of non-conscious bias. The Psychology of NON-Conscious Bias Research in social psychology shows that over time stereotypes and prejudices become invisible to those who rely on them. Automatic categorisation of an individual as a member of a social group can unconsciously trigger the thoughts (stereotypes) and feelings (prejudices) associated with that group, even if these reactions are explicitly denied and rejected. This implies that, when activated, implicit negative attitudes and stereotypes shape how medical professionals evaluate and interact with minority group patients. This creates differential diagnosis and treatment, makes minority group patients uncomfortable and discourages them from seeking or complying with treatment. Pitfalls in Cultural Competence Training Cultural competence training involves teaching students to use race and ethnicity to diagnose and treat minority group patients, but to avoid stereotyping them by over-generalising cultural knowledge to individuals. However, the Culturally and Linguistically Appropriate Services (CLAS) standards do not specify how these goals should be accomplished and psychological research shows that common approaches like stereotype suppression are ineffective for reducing non-conscious bias. To effectively address bias in health care, training in cultural competence should incorporate research on the psychology of non-conscious stereotyping and prejudice. Training in Implicit Bias Enhances Cultural Competence Workshops or other learning modules that help medical professionals learn about non-conscious processes can provide them with skills that reduce bias when they interact with minority group patients. Examples of such skills in action include automatically activating egalitarian goals, looking for common identities and counter-stereotypical information, and taking the perspective of the minority group patient.