Background: Discrimination towards trainees is a pervasive problem and surveys show that it is often perpetrated by patients (1,2). Trainees are especially vulnerable to discriminatory behavior, with negative impacts on their education and wellbeing (3,4). Fellow clinicians, including faculty and advanced practice providers (APPs), play an important role in managing these issues and ensuring a safe and inclusive learning environment. Clinicians who are new to an institution, however, have heterogenous training and lack experience and familiarity with local resources and policies.
Purpose: As part of an overarching initiative to prepare clinicians to respond to discrimination, we targeted new internal medicine (IM) providers participating in an annual onboarding simulation program. Both inpatient and outpatient providers were given the opportunity to practice responding to a trainee who has experienced discrimination.
Description: Our IM residency program has established curriculum on how to respond to discrimination by patients and we recently developed Objective Structured Clinical Exam (OSCE) cases to reinforce these skills. Medical students, residents, and chief residents participate in these simulations, and this year we targeted new IM clinicians to ensure all provider levels are engaged in supporting a safe and inclusive learning environment. A simulation case was adapted to the faculty context and incorporated into the 3-station virtual OSCE onboarding program. Participants meet an intern, a standardized trainee (ST), who appears to be struggling on the wards/in clinic. Participants learn the intern has experienced multiple episodes of discrimination from patients, resulting in burnout. They are then expected to address the discrimination and its impact, as well as provide counseling and a plan for follow-up. Following the 10-minute encounter, STs completed a 32-item behaviorally anchored checklist to evaluate skills on a scale of not, partly, or well done (WD), and delivered verbal feedback to the clinician. Clinicians debriefed with facilitators and received an institutional resource guide with programs and resources specific to this case, then completed a program evaluation survey. 63 new clinicians (within 24 months of hire) participated in the program and data was gathered from 53 checklists. Participants scored highly on information gathering (70% WD) and relationship development (72% WD) but scored lower on education/counseling (49% WD) and most case-specific skills, which included explicitly acknowledging incidents as discrimination (30% WD), communicating concern about the impact of discrimination (38% WD) and sharing resources for continued support (36% WD). In the post-program evaluation survey (n=42), 100% of respondents agreed that the onboarding program helped them feel more confident about supporting a colleague experiencing discrimination and that the program improved their ability to recognize, respond to and provide resources for a colleague experiencing discrimination.
Conclusions: This simulation experience showed the heterogeneity of skill and comfort level among new clinicians when responding to discrimination against trainees. Through a targeted simulation experience coupled with debriefing and a resource guide, clinicians reported improvement in their ability to respond to these situations. This case, as part of a required onboarding experience, established that a safe and inclusive learning environment is a priority at our institution.