Teaching Health Professional Students to Manage Patient Bias

by Allison Wadlow, PharmD, PGY1 Pharmacy Practice Resident, G.V. (Sonny) Montgomery VA Medical Center

Health disparities based on race have been a long-standing problem in the United States. Much light was shed on this matter in recent years prompted by numerous murders of minorities and the Black Lives Matter advocacy movement. It is well known that racial disparities exist within the healthcare system of this country. Even when patients have comparable incomes, similar education, and live in the same geographic location, minority populations sadly do not always receive the same standards of care as their white counterparts.¹

Many health professions programs offer training to learners on addressing bias and improving care delivery for all patients. Over the past decade, some popular training programs include Trauma Informed Care, Adverse Childhood Experiences training, and Multicultural Training. These programs have included materials to serve patients better, with the primary focus on patients, not the providers of care.

Bias towards healthcare professionals from underrepresented and marginalized groups is, unfortunately, commonplace. A recent study “Harassment and Discrimination in Medical Training” found that most health professional trainees have experienced bias at some point in their career, most often based on their race, gender, or sexuality.² 

To address this problem, medical students and faculty at multiple institutions in Northern Virginia and Washington, DC created a training program for medical students to manage patient bias.³ The goal of this program was to prepare students for the biases they may encounter in practice.  The investigators created a simulation exercise whereby participants learned, in a safe environment, to navigate these situations.³

The simulations involved encounters with standardized patients. During the encounter, the student was instructed to tell the patient about a follow-up appointment that had been scheduled with a provider who had a foreign-sounding name. The standardized patient was instructed to either accept this appointment or request an alternative provider. The student was then instructed to use motivational interviewing techniques to understand where the request to change providers stemmed from. The possible reasons for the patient’s request were:

• An untreated hearing loss made it difficult for the patient to understand accents
• A belief that “foreigners shouldn’t be taking American jobs”
• A preference to receive treatment from a physician who shares a similar cultural background due to the patient’s previous experiences of intolerance or disrespect

During the encounter, it was up to the student to determine the root cause of the request. In some instances, the request might lead to better patient care, and it should be honored. For example, in the case of a patient with hearing loss, switching to a provider without an accent, the patient might be able to better distinguish words spoken during the encounter. Of course, if the provider did not have an accent, the student should provide reassurance to the patient.  However, in some cases, the request to change providers was racially motivated. Of course, a surname does not always indicate the race of the provider. The point of this training experience was to allow students the opportunity, in a safe and controlled environment, to navigate through a patient request that, on the surface, may be motivated by racial bias. The goal is to develop the skills to uncover the root of these requests, rather than assuming that racism is the problem.

At the beginning and end of the course, students were surveyed to measure their growth. After completing the activities, students reported an increase in their confidence to explore intentions and beliefs, navigate a conversation with a patient exhibiting bias, and use nonverbal skills to demonstrate empathy.³

Addressing bias directed towards providers is not taught in most health professions' curricula or residency training programs. I think health-professional programs should begin to include this type of training so that students and residents are better equipped to manage patient bias.

The first step would be to give students exposure to patients who express a bias toward certain (commonly marginalized) groups. Nearly all students who participated in this simulation exercise stated they were very uncomfortable, but that it was a positive experience to be able to interact in a safe environment. The students stated they felt more prepared to manage these situations with real patients in practice.  Because learners should never be intentionally required to interact with people who have racial animus, they would learn how to assess patients’ requests, how to act in the face of bias, and how to move forward with patients who are explicitly or implicitly biased towards them or others. 

The next step would be to teach learners how to address patients who have explicit biases based on race, gender identity, and sexual preferences. Students must first be taught how to approach patients and uncover the rationale behind their biases. Once the student has uncovered the reasoning for the bias, there will be times when patients are explicitly racist, and students will need to be prepared (mentally) to manage the situation. Do they simply ignore and endure the bias? Do they refer the patient to alternative providers? Do they know when it is safe to speak up and say something to the patient? While there are no easy answers to these questions, the least we could do is provide students the opportunity to experience this type of conversation with patients before having to deal with it in the real world.

As with the implementation of any new training, cost becomes a factor to consider. The cost of hiring standardized patients may not be feasible for many programs. One workaround is to have volunteers serve as standardized patients, which could include faculty, upperclassmen, or alumni. Another way to mitigate the costs could be to have recordings of patient encounters, pausing the recording at various times to discuss with the class what they are observing. This option could open a rich class discussion on the negative consequences of bias toward marginalized patients as well as providers.

Bias in healthcare is not something we can eliminate, but we can build our skills to recognize and mitigate it.  We can prepare our students to uncover and address the biases they may encounter, including the bias that patients may express toward them or their professional colleagues. It is not ethical to know a problem exists, one that can mentally harm our learners, and do nothing to prepare them. It’s time to talk about patient bias and teach health professional students how to manage it.

References:

1. Williams DR, Rucker TD. Understanding and addressing racial disparities in health care. Health Care Financ Rev 2000;21(4):75-90.
2. Fnais N, Soobiah C, Chen MH, et al. Harassment and discrimination in medical training: a systematic review and meta-analysis. Acad Med 2014;89(5):817-27.
3. Zewdie M, Duval M, Liu C, et al. Virtual Communication Across Differences: Development of a Workshop on Managing Patient Bias. Acad Med 2023;98(2):209-213.

Professional Identity Formation (PIF) in Health Professions Education: Doing is Different from Being

by Lauren C. McConnell, PharmD, PGY1 Pharmacy Practice Resident, Baptist North Mississippi Hospital

Professional identity formation, or PIF, is the process through which a person becomes a professional — typically from student to practicing professional. The progression of PIF is uniquely individualized and superimposed on each student’s personal identity, values, morals, and beliefs.¹ The goal of forming a professional identity is to develop a resilient sense of belonging within a health profession.² PIF goes beyond students acquiring knowledge (‘thinking’) and demonstrating professionalism (‘acting’) to support one’s perception of self (‘feeling’).

Professionalism, as defined by The White Paper on Pharmacy Student Professionalism, is “the active demonstration of the traits of a professional”.³ Health professions students are intrinsically and extrinsically motivated to join a professional community and are willing to uphold certain professional expectations, such as wearing a white coat, communicating respectfully, and being accountable.^4,5 However, acting like a professional and being a professional are two different phenomena.

Interrelationship Between Professional Identity and Professionalism

Professionalism and professional identity are distinct yet related concepts, which makes the fluid relationship between the two challenging to describe (see Figure 1). Professionalism is an outward display of the conduct of a professional, while a professional identity is the internal perception of one’s role as a professional.⁶ Professional traits and behaviors are crucial for PIF, as ‘acting’ like a professional encourages assimilation to that role.⁷ Similarly, self-awareness of a professional identity is essential for developing a professional demeanor. Several stepwise models exist that have attempted to describe this relationship. Acts of professionalism are observable signs which indicate the concurrent development of professional identity.⁶ Therefore, my professors at Auburn University and I recently proposed a model to illustrate the infinite and undirected interplay between PIF and professionalism, the Möbius Strip.⁷

Figure 1: Professionalism-Professional Identity Möbius Strip

According to Moseley et al., “as the internalization process of PIF occurs, outward professional behaviors are displayed, and as one chooses to behave as a professional, their sense of identity blossoms”.⁷ This model aligns with the proposal that the end goal of health professions education should not just focus on ‘doing’ but also on ‘being’.⁸ As with all educational goals, methods for teaching and evaluating progress are essential. The conundrum is how this fluid process can be measured and supported.

PIF-Friendly Pedagogy

Obtaining a professional identity is the desired outcome in health professions education, as it is the backbone of all decisions students will make as professionals.⁸ However, many students (and admittedly, myself included) fail to recognize themselves as professionals early in their health education journey. For this reason, PIF has long been an elusive target amongst health professions educators. Furthermore, PIF is a non-linear process, and each student progresses toward their professional identity at a different pace, which makes it challenging to foster and evaluate progress.⁹ For this reason, health professions educators should incorporate PIF-friendly teaching strategies into curricula.

PIF pedagogy is the practice of teaching, facilitating, and coaching students through their PIF journey — teaching methods that support the development of an identity that aligns with the values of their profession. Educators are a fundamental component of the student’s journey. The formation of a professional identity is influenced by external factors, such as curricula, learning environments, expectations, mentorship, and feedback.⁵ I distinctly remember key preceptors who created positive learning environments and served as role models that positively impacted how I perceived myself as a future pharmacist. Therefore, it is important for educators to foster relationships and create experiences that are meaningful to students, as PIF is facilitated, not taught.

Self-assessment and self-reflection are two PIF-friendly strategies that educators can use in curricula to help students become more aware of their professional strengths and weakness.¹⁰ The ability of the student to be self-aware of their presence and growth within a professional community increases PIF and creates a sense of belongingness.⁹ Other meaningful relationships outside the formal education environment (e.g., with preceptors, other health professionals, and patients) play a similar and equally important role. To me, there is no replacing the feeling you get the first time a patient mistakenly refers to you as a pharmacist or when a physician shows appreciation by stating ‘good catch.’ Through these interactions, students gain recognition for their place on the healthcare team. Situated learning theory suggests that “learning should take place in a setting the same as where the knowledge will be used”.¹¹ Therefore, it is no surprise that students report early introduction to their profession, direct interaction with patients, and frequent collaboration with other health professionals as key drivers of identity construction.¹²

Because educators are facilitators of PIF, structured evaluations (e.g., exams or performance-based assessments) are not helpful measures of student progression, particularly given that PIF does not occur at a single point in time. Experts recommend that assessments of PIF should occur longitudinally to ensure that the student’s professional identity is progressively developing over time.¹³ Unfortunately, there are no standardized methods for measuring PIF, and assessments rely on student understanding of who they are within a profession. I remember creating short- and long-term career goals as a first-year student pharmacist, thinking I knew exactly who I was and what pharmacy career path I wanted to pursue. But with each semester, I revisited these goals and was honestly embarrassed by what I thought I knew about who I wanted to be. 

In one study, investigators designed a Professional Self Identity Questionnaire (PSIQ) that attempts to measure the degree to which health professions students identify as a member of their profession.¹⁴ Building on this notion, faculty at Auburn University Harrison College of Pharmacy recently created a PIF instrument to encourage students to reflect on their professional identity. This instrument asks students to self-assess fourteen qualities/behaviors, such as confidence, knowledge, personality, professionalism, and communication.¹⁰ These PIF-friendly exercises, using a combination of self-assessment and self-reflection, attempt to measure what educators cannot see: how students see themselves in relation to their profession.

There are several other activities and instructional strategies that can be used to promote PIF, such as feedback, experiential education, co-curricular activities (e.g., health fairs), mentoring/role modeling, student well-being groups, and white coat ceremonies.^7,15 Of course, most professional curricula already incorporate many of these pedagogical methods, but require active effort by educators to intentionally foster PIF. Reflecting on my time as a student, I now know why I have always appreciated professors who were passionate about what they taught, preceptors who encouraged autonomous work, and mentors who led by example – they intentionally helped create my professional identity. Educators should continue to purposefully use and prioritize PIF-friendly pedagogical methods, particularly early in curricula, to support the process of professional identity formation amongst their students.

References

1. Cruess RL, Cruess SR, Steinert Y. Amending Miller's pyramid to include professional identity formation.Acad Med. 2016;91(2):180-5.
2. Kellar J and Austin Z. The only way round is through: Professional identity in pharmacy education and practice. Can Pharm J (Ott). 2022 Aug 13;155(5):238-240.
3. Roth MT and Zlatic TD. American College of Clinical Pharmacy. Development of student professionalism. Pharmacotherapy. 2009 Jun;29(6):749-756.
4. Holden M, Buck E, Clark M, Szauter K, Trumble J. Professional identity formation in medical education: The convergence of multiple domains. HEC Forum. 2012 Dec;24(4):245-255.
5. Findyartini A, Greviana N, Felaza E, et al. Professional identity formation of medical students: A mixed-methods study in a hierarchical and collectivist culture. BMC Med Educ. 2022 Jun 8;22(1):443.
6. Forouzadeh M, Kiani M, Bazmi S. Professionalism and its role in the formation of medical professional identity. Med J Islam Repub Iran. 2018;32(1):765-8.
7. Moseley LE, McConnell L, Garza KB, Ford CR. Exploring the evolution of professional identity formation in health professions education. New Dir Teach Learn. 2021 Dec 6;168:11-27.
8. Snell R, Fyfe S, Fyfe G, Blackwood D, Itsiopoulos C. Development of professional identity and professional socialisation in allied health students: A scoping review. Focus on Health Prof Educ. 2020 Apr 30;21(1):29-56.
9. Cruess SR, Cruess RL, Steinert Y. Supporting the development of a professional identity: General principles. Med Teach. 2019 Jun;41(6):641-9.
10. Ford CR, Astle KN, Kleppinger EL, Sewell J, Hutchison A, Garza KB.Developing a self-assessment instrument to evaluate practice-readiness among student pharmacists. New Dir Teach Learn. 2021 Dec 6;168:133-145.
11. Li LC, Grimshaw JM, Nielsen C, Judd M, Coyte PC, Graham, ID. Use of communities of practice in business and health care sectors: A systematic review. Implement Sci. 2009 May 17;4:27.
12. Wald HS. Professional identity (trans)formation in medical education: Reflection, relationship, resilience.Acad Med. 2015 Jun;90(6):701–6.
13. Garza KB,Moseley LE, Ford CR.Assessment of professional identity formation: Challenges and opportunities.New Dir Teach Learn. 2021 Dec 6;168:147-151.
14. Crossley J and Vivekananda-Schmidt P. The development and evaluation of a Professional Self Identity Questionnaire to measure evolving professional self-identity in health and social care students. Med Teach. 2021 Dec;31(12):e603-7.
15. Chandran L, Iuli RJ, Strano-Paul L, Post SG. Developing "a Way of Being": Deliberate approaches to professional identity formation in medical education.Acad Psychiatry. 2019 Oct;43(5):521–7.