Heartache or Bellyache? Epigastric Pain, Communication Skills, and Implicit Bias: Can We Uncover an Association in the Simulation Lab?
Heartache or Bellyache? Epigastric Pain, Communication Skills, and Implicit Bias: Can We Uncover an Association in the Simulation Lab?
复制标题
DOI：
10.1097/acm.0000000000004868
复制
发表时间：
2022-11-01
影响因子：
7.4
通讯作者：
Gonzalez, Cristina M
中科院分区：
文献类型：
--
作者：
Ark, Tavinder;Fisher, Marla;Milan, Felise;Kalet, Adina L;Marantz, Paul R;Burgess, Diana;Rodriguez, Carlos J;Burd-Orama, Lily;Samuel, Malika;Gonzalez, Cristina M
目的：隐性偏见通过医生沟通行为导致健康差异。 1 临床接触研究表明，某些非语言和语言交流与种族隐性偏见有关。 2 迄今为止，尚未发布可用于隐性偏见识别和管理 (IBRM) 教学或评估目的的模拟。我们开发了高保真模拟 3 并调整了现有的清单和全球评级量表，以纳入已知与种族隐性偏见相关的沟通行为。 2方法：本病例为一名 52 岁男性，因恶心、呕吐和上腹疼痛而到紧急护理中心就诊。鉴于急性冠状动脉综合征（ACS）中已证实的种族差异，选择上腹痛作为临床表现。 4 认知压力源包括时间限制、临床模糊性（上腹疼痛、心电图正常、检查无症状）以及标准化护士的打扰。我们拥有 N= 15 名医生志愿者 (PV) 超过 3 名飞行员的完整数据。我们采用探索性方法调查种族隐性偏见（通过种族和种族合规性隐性关联测试（IAT）测量）与内科/家庭医学 PV 的沟通技巧之间的关联。我们探索了 IAT 与内科/家庭医学 PV 沟通技巧之间的关联，并由训练有素的 SP 和监测员进行评分。对于每个通信域和子域，通过比较黑人与白人 SP 的分数来计算平均分数。沟通检查表项目按 3 分制评分，而委托项目按 4 分制评分。然后计算到达域和子域的平均分数，并以 SP 种族和医师种族（模型 1）作为自变量进行线性回归，然后是种族 IAT（模型 2）。还进行了相关性分析，以确定域/子域分数与 IAT 分数之间是否存在显着关系。结果：PV 的平均 IAT 分数处于中性范围内。共有 11 名黑人 SP/监测员和 9 名白人 SP/监测员对医生技能进行了评分。通过种族 IAT 收集的信息（r=− 0.68，P=. 01）和依从性 IAT（r=− 0.72，r= 0.02）中发现“引发所有患者的担忧”项目之间存在显着负相关。在 PV 种族和总体平均全球委托评分上发现了显着的主效应 (P=.01)，当不包括种族 IAT 时，非黑人医生的得分 (m=2.43，SD=0.35) 高于黑人医生 (m=1.82，SD=0.48)（模型 1）。当包括种族 IAT 时，没有发现显着差异。其他能力方面没有发现其他显着差异。意义：我们开发了高保真模拟以及随附的检查表和全局评级量表，能够得出练习 PV 之间沟通技能得分的差异。当不控制种族 IAT 时，黑人和非黑人医生的总体总体委托评分存在显着差异。当我们控制种族 IAT 分数（隐性偏见影响）时，差异不再存在，这表明隐性偏见的影响可以通过使用本案例和全球委托措施而不是沟通能力来衡量。这项研究表明，在小插图上使用高保真模拟可能会更好地理解隐性偏见对患者体验的影响。
Purpose:Implicit bias contributes to health disparities through physician communication behaviors. 1 Research in clinical encounters suggests certain nonverbal and verbal communication is associated with racial implicit bias. 2 To date, there are no published simulations that can be used for teaching or assessment purposes in implicit bias recognition and management (IBRM). We developed a high-fidelity simulation 3 and adapted existing checklists and global rating scales to include communication behaviors known to be associated with racial implicit bias. 2Approach:This case involved a 52-year-old man presenting to the urgent care center with nausea, vomiting, and epigastric pain. Epigastric pain was chosen as the clinical presentation given the demonstrated racial disparities in acute coronary syndrome (ACS). 4 Cognitive stressors included time constraints, clinical ambiguity (epigastric pain, a normal EKG, asymptomatic on exam), and an interruption from a standardized nurse. We have complete data for N= 15 physician volunteers (PV) over 3 pilots. We pursued an exploratory approach investigating the associations between racial implicit bias as measured on race and race-compliance implicit association tests (IAT) and communication skills of internal/family medicine PVs. We explored the associations between IATs and communication skills of internal/family medicine PV as rated by a highly trained SP and monitor. For each communication domain and subdomain, the mean score was computed comparing the scores on SPs that were Black vs White. Communication checklist items were rated on a 3-point scale, while the entrustment items were rated on a 4-point scale. A mean score was then computed for reach domain and subdomain, and linear regression was conducted with race of the SP and race of the Physician (model 1) as independent variables, followed by race IAT (model 2). Correlation analysis was also conducted to determine if significant relationship existed between the domain/subdomain scores and IAT scores.Outcomes:Mean IAT scores for PVs were in the neutral range. A total of 11 Black SPs/monitors and 9 White SPs/monitors rated physician skills. A significant negative relationship was found between “Elicits all patient’s concerns” item from information gathering with race IAT (r=− 0.68, P=. 01) and compliance IAT (r=− 0.72, r= 0.02). A significant main effect was found on PV race and overall mean global entrustment scores (P=. 01), with non-Black physicians receiving a higher score (m= 2.43, SD= 0.35) than Black physicians (m= 1.82, SD= 0.48) when race IAT was not included (model 1). When race IAT was included, no significant differences were found. No other significant differences were found in the other competencies.Significance:We developed a high-fidelity simulation and accompanying checklists and global rating scales that were able to elicit variability in communication skills scores among practicing PVs. A significant difference was found between the Black and non-Black physicians in their overall global entrustment scores when race IAT was not controlled for. When we controlled for race IAT scores (implicit bias impact), differences were no longer present suggesting the impact of implicit bias can be measured through the use of this case and global entrustment measures rather than communication competencies. This study suggests the use of high-fidelity simulations over vignettes may be better in understanding the impact of implicit bias in the patient experience.