The CONSULT-BP Educational Intervention
Core Educational Elements
The core elements of the educational intervention are: 1. National Institute of Minority Health and Health Disparities-funded e-learning modules to build knowledge about health disparities, implicit bias, and patient-centered communication skills;14 2. Implicit Association Tests (IAT)15 with results feedback to develop personal bias awareness, along with strategies to mitigate bias developed by Devine et al16; 3. high-fidelity simulated clinical encounters with standardized patients (SPs) from the community for skills practice17; and 4. evidence-based practice knowledge about hypertension management. We focused on implicit bias given the evidence of its impact on interpersonal communication7 and patient outcomes,2,5 particularly in hypertension where it contributes to a complex interaction of suboptimal clinical decision making and unsatisfactory patient experience of care.18 (Figure 1)
Theoretical Framework
The educational intervention and its delivery were designed to reflect key features of an adaptation of Bennett’s intercultural competency framework.19,20 (Figure 2) In this theoretical model, to overcome denial about ones’ own implicit biases, learners need to first acquire knowledge and understanding about implicit bias. Then, to help learners develop acceptance of the effect of implicit bias on healthcare disparities, learners need to move toward integration and recognition of implicit bias within themselves and their clinical encounters. The ultimate goal is to motivate learners to acquire and apply effective skills in situations where implicit bias is likely to arise.
Applying the simulation-based model of repeated practice and feedback for skills acquisition and progression to skill mastery21, the CONSULT training featured “mock” clinical encounters designed to “activate” trainee biases in the clinical care setting. To replicate the “authentic” experience of implicit bias in clinical care, the CONSULT intervention developed face-to-face simulated clinical encounters with “acting” SPs recruited from local racial and ethnic communities as a foundational component of the program. These face-to-face interactions provided a “contact-based educational intervention.”20 Contact with groups for which one may hold biased attitudes may help reduce such bias.22,23 For those diverse individuals participating as trained CONSULT SP’s, the simulation intervention created an opportunity for empowerment and equity, as community SP’s provided direct skills feedback to healthcare trainees and contributed their “voice” as equal partners in the team effort to develop and refine the simulation scenarios. We sought to understand whether this creative and novel approach to communication skills training of healthcare professionals catalyzed the motivation of our learners to take their patient communication skills to a higher level of mastery through direct, objective, and specific feedback from individuals of color trained as SPs.20,24,25
PAR Stakeholder Engagement
To adapt the core educational elements and strategies into a feasible and acceptable educational intervention, we used a PAR approach in which investigators collaboratively partnered with stakeholder participants. The goal was to work together to address system-specific issues affecting program operationalization.13 Community stakeholder partners for educational design and delivery were racial/ethnic and socioeconomically diverse community leaders representing our local patient population. A local community health organization served as the community member recruitment liaison. Key academic stakeholder partners for educational design were School of Medicine and Graduate School of Nursing faculty from our target healthcare system. A separate community-based transformational change organization, with extensive experience in staff bias training, was engaged to help design in-person facilitation around implicit bias. These partners worked together to design case simulation scenarios, a trainee performance evaluation checklist, and SP training protocols that were integrated into a cohesive, replicable training program. Community advisors also assisted with recruiting community members representing the demographics of the medical center’s local service population to work as community SPs. During the design process, we recruited faculty and trainees from the participating clinical training programs to pilot test the program in order to assess acceptability and clinical training relevance.
Structure and Delivery of Educational Program - CONSULT 1.0
Our stakeholder-engaged design process resulted in an intervention that applies a blended learning format to deliver information about implicit bias, communication skills, and hypertension management via online modules, all of which precede clinical simulation practice. At the recommendation of faculty stakeholders, program delivery occurred over two, in-person sessions, five weeks apart, to leverage a spaced learning design.26 The sessions were designed to minimize the time burden of the intervention on trainees outside of the classroom. As such, the in-person training sessions combined multiple components that trainees completed individually, but as part of an onsite group session. In each educational session, components included: “individual” online didactic modules, online IATs, face-to-face clinical practice simulation with SPs; and “group-based” facilitated debriefing sessions. Skills to mitigate the effects of implicit bias detailed by Devine et al16 were addressed as part of the group-based IAT debriefings. Each of the two, in-person sessions lasted three to four hours.
Trial Design
The educational intervention was integrated into the residency programs in Internal Medicine (IM) and Family Medicine (FM), and into the curriculum for Doctor of Nursing Practice (DNP) students at our institution. The impact of the CONSULT-BP training model is being tested through a stepped-wedge cluster randomized trial. This trial design allows for all trainees in any given year to be assigned to the intervention, which was a pre-condition for training program participation. The training intervention is a program requirement. This design is statistically advantageous as all trainees have both control and intervention periods, such that each individual serves as his/her own control, faciliating comparisons both within and across participants. Our model randomizes training times to one of five start dates within each academic year to accommodate pre-existing training schedules and to mitigate the effect of temporal trends in clinical skill proficiency.
Trainee Enrollment and Data Collection
Training programs assign their own trainees to participate in the intervention. Eligibility criteria for inclusion of trainee measures in the trial’s outcomes analysis are: 1. practice at a clinical site supported by the medical center’s electronic medical record (EMR) to allow data collection for BP outcome measurement; 2. a 10-week clinical look-back period; and 3. no prior completion of the CONSULT-BP intervention. Trainees are provided a fact sheet and asked to opt-out of the study if they do not want their data used for outcomes analysis.
Trainee Measures
Trainee Implicit Association Tests (IAT), Explicit Bias Measures, Bias Awareness, and Reaction to the IAT. In addition to completing online Race/Ethnicity IATs [Black/White, Latino/White]36 and Race/Ethnicity-Medical Compliance IATs [Black/White, Latino/White]37, corresponding explicit questions are presented as part of the online intervention. Trainees are asked about their own explicit beliefs and perceptions of what “other health professionals” believe about race/ethnicity and race/ethnicity-related medical compliance in order to assess trainees’ perception of their own bias as being “better than average".27 To assess trainees’ reaction to the IAT, three questions are included from Howell & Ratliff, 2016,27 using a 4-point scale (Strongly disagree, Disagree, Agree, Strongly Agree) to measure the trainees’ degree of defensiveness to the IAT. Trainees also complete a 7-item Bias Awareness Scale, with items assessed on a 6-point scale (strongly agree to strongly disagree) and higher scores indicating greater bias awareness.28
Trainee Assessments by SPs. Community SPs complete standardized checklists of trainee performance measuring communication skills, emotional response/concern, BP measurement technique, and global performance.
Patient Measures
The primary trial outcome is the change in BP as reported in the EMR. Secondary outcomes include self-reported adherence to visits, diet modification and antihypertensive medication use as measured by the BP Self-Care Scale,29 and quality of communication and trust measured in the Health Care Climate Questionnaire30 and the trust sub-scale of the Primary Care Assessment Survey.31 These surveys are administered in clinic offices of participating trainees in the 10-weeks before and after the educational intervention. Following the stepped wedge design, all comparisons are before and after the intervention within patients nested within trainee and across trainees.
Qualitative Feedback about the Educational Program
We planned for ongoing early feedback from community SPs and faculty through periodic informal debriefing sessions, and from trainees via formal post-program online surveys. We also captured real-time observations and comments in fieldnotes maintained by research staff. Further, we conducted formal, individualized feedback meetings with groups of trainee representatives from the IM, FM and DNP programs, CONSULT-BP program faculty, and community SPs in June and July 2019. Invitations for individualized feedback was extended to all program faculty and SPs, and the 125 trainees who completed the first-year CONSULT-BP program. A Masters’ level educational curriculum specialist conducted all feedback sessions and took extensive fieldnotes to capture respondents’ comments.
The study protocol was reviewed and approved by the University of Massachusetts Medical School Institutional Review Board (IRB).