Mayo Clinic doctors seek to eliminate bias in medical education

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The clinical learning environment for medical trainees is the foundation of medical education programs.

The clinical learning environment for medical trainees is the foundation of medical education programs. However, discrimination and bias during medical education is a pervasive and harmful reality, especially for women and underrepresented minority groups. Not only are such experiences detrimental to the trainee, but they can also negatively affect patient care and the learning environment as a whole.

Several years ago at our facility, we both noticed an increase in discriminatory patient comments directed at our hematology/oncology fellows at the Mayo Clinic School of Graduate Medical Education. We both interact with Fellows on a regular basis, so we were privileged to hear about these patient encounters firsthand.

Instead of normalizing fellows’ experiences, we chose to listen to what was happening in the learning environment, lean in, and be curious about what we were told. From this choice – the choice to not shy away from tackling difficult questions – the idea for our research study titled “Evaluating Discrimination, Bias, and Inclusion in a Hematology and Oncology Fellowship Program in the United States- United” was born organically.1

The qualitative study was an in-depth examination of our interns’ experiences of discrimination, bias and inclusion. We wanted to understand at a granular level what discrimination or bias they encountered during their clinical training, how these events were handled, whether they were reported, who was discriminating, and how trainees coped with such experiences. . We also chose to ask about inclusion, as well as factors in the clinical learning environment that were supportive and welcoming, with the idea that a learning environment is the collective outcome of the negative and positive.

We originally intended to conduct our study in the form of semi-structured face-to-face interviews, but we quickly learned that under Title VII and Title IX laws, we would be required to report any discrimination based on gender or personal characteristics, which could subject our participants to further surveys. Because we wanted our trainees to be able to speak freely and without fear of reprisal, we modified our study design to an anonymous telephone interview conducted by a qualitative research partner with no interaction or knowledge of hematology/oncology fellows or the training program. . During the interviews, no identifying information of either party was exchanged. This method has been very effective in creating a safe environment for trainees to share their experiences of discrimination, prejudice and inclusion.

Several key themes emerged regarding discrimination and prejudice. Many of our comrades of diverse ethnic and racial backgrounds felt unwanted or “outsiders at home,” even though they were American citizens. Prior to the publication of our work, descriptions of the feeling of “outsider at home” had not yet appeared in the body of medical literature surrounding discrimination in medical education. Another related theme was that of trainees born outside the United States being treated as foreigners, even though they had spent much of their lives in the country.

Gender bias against women was also extremely common. Worse still, most interns did not report these events because they thought it would be futile and not result in any substantial change.

An intuitive but notable conclusion was that diversity itself breeds inclusion. At Mayo Clinic, we are fortunate to recruit talented interns from around the world, and we’ve learned that having people from diverse backgrounds makes interns feel welcome. The inherent diversity of the program combined with other factors has created a culture of inclusion, even though 100% of trainees surveyed witnessed or experienced discrimination or prejudice. In a nutshell, the positive experiences outweighed the negative ones.

We learned several valuable lessons from this study that can be directly translated into action. Most episodes of discrimination were microaggressions, which are subtle comments or actions as opposed to overt racism or discrimination. Most of the incidents were not of malicious intent, but represent ingrained societal perceptions. In other words, the unconscious biases of patients, and sometimes staff, would manifest in words or actions towards trainees.

Unconscious bias training has been shown to be effective in highlighting the subconscious judgments we all make when interacting with the world. We would advocate that everyone involved in medical education, ideally including patients, undergo an unconscious bias training program.

We also advocate for bystander or “participant” training for all medical staff to provide practical tools and approaches to support medical trainees who experience discrimination or bias. We cannot prevent such events from occurring, but we can control our reactions and lessen the impact on trainees’ well-being.

In response to our findings, the Mayo Clinic has established ongoing efforts to combat discrimination. Dr. Warsame hosted a department-wide retreat on diversity and inclusion. We have developed an annual anonymous online learning climate assessment survey as part of the Fellowship Program to track the learning environment and changes that occur over time.

We’ve conducted bystander training and rolled out unconscious bias training. We continue to promote our facility’s Patient and Visitor Misconduct Policy which provides protection and validation to our trainees and employees who speak out against discriminatory patient and visitor behavior.

Although we conducted this study under a single fellowship program in 2018, as an organization, the Mayo Clinic is applying lessons learned beyond the hematology/oncology department. We have developed and delivered facility-wide faculty development training on topics such as unconscious bias, microaggressions in the learning environment, supporting trainees who encounter patient bias and what to do when a patient refuses care due to factors such as gender. , religion or race.

The Mayo Clinic now requires additional bystander intervention training for all staff, residents, and fellows. Additionally, in 2020, over 1,800 residents and fellows participated in a survey about our learning climate. Administrators shared school-wide and program-specific anonymous results to stimulate conversations and drive improvement initiatives in other programs and departments.

The message we would most like to share may not be new, but in our current polarized society it has never been more important: talking about sensitive topics is part of the solution, not the problem. Identifying and naming a problem does not create a problem or make it a reality, but rather is the first step in helping to solve it.

We have learned a great deal about ourselves, our interns, and our program during this process, and we strongly suggest that each institution and program take steps to learn more about discrimination, bias, and inclusion, as well as on how it affects their medical trainees. Together, we can take action for more equitable and discrimination-free medical education.

Reference

Warsame RM, Asiedu GB, Kumbamu A, et al. Assessing discrimination, bias, and inclusion in a hematology and oncology fellowship program in the United States. JAMA Netw Open. 2021;4(11):e2133199. doi: 10.1001/jamanetworkopen.2021.33199

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