Heartache or Bellyache? Epigastric Pain, Communication Skills, and Implicit Bias: Can We Uncover an Association in the Simulation Lab?

Abstract

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. 2 Approach: 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. Medical educators implementing curricula in IBRM infrequently provide learners opportunities for skill development and practice, or assessment of those skills. 5 Our simulation provides a model for skill development in IBRM as it relates to ACS. In addition, given the racial disparities treatment decisions in ACS, this simulation is timely and relevant both for its assessment of communication behaviors associated with IBRM and for its clinical content. Next steps include finalizing simulations with community member input, revisions as informed by data analysis, and assessing medical decision making.