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Am J Perinatol 2024; 41(12): 1634-1644
DOI: 10.1055/a-2240-1979
Original Article

Implicit Bias and Health Disparities Education in the Neonatal Intensive Care Unit

Nicolle Fernández Dyess  ‡   *
1   Section of Neonatology, Department of Pediatrics, University of Colorado, Aurora, Colorado
,
Cara Beth Carr‡   *
2   Division of Neonatology, Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
,
Stephanie C. Mavis
3   Division of Neonatal Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
,
Catherine G. Caruso 
4   Division of Neonatology, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
,
Susan Izatt
5   Division of Neonatology, Department of Pediatrics, Duke University, Durham, North Carolina
,
Heather French
6   Division of Neonatology, Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania
,
Rita Dadiz
7   Division of Neonatology, Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
,
Elizabeth M. Bonachea
8   Division of Neonatology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio
,
Megan M. Gray 
9   Division of Neonatology, Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
› Author Affiliations Funding This work was supported by a 2020 American Academy of Pediatrics Section of Neonatal-Perinatal Medicine Strategic Grant. The funding agency had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.
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Abstract

Objective This study aimed to characterize implicit bias (IB) and health disparities (HD) education in neonatal–perinatal medicine (NPM), including current educational opportunities, resources, and barriers.

Study Design A national web-based survey was sent to NPM fellows, neonatologists, and frontline providers after iterative review by education experts from the National Neonatology Curriculum Committee. Quantitative data were analyzed with chi-square and Fisher's exact tests. Qualitative data were evaluated using thematic analysis.

Results Of the 452 NPM survey respondents, most desired additional IB (76%) and HD (83%) education. A greater proportion of neonatologists than fellows received IB (83 vs. 57%) and HD (87 vs. 74%) education. Only 41% of neonatologists reported that their institution requires IB training. A greater proportion of fellows than neonatologists expressed dissatisfaction with the current approaches for IB (51 vs. 25%, p < 0.001) and HD (43 vs. 25%, p = 0.015) education. The leading drivers of dissatisfaction included insufficient time spent on the topics, lack of specificity to NPM, inadequate curricular scope or depth, and lack of local educator expertise. A minority of faculty who were tasked to educate others have received specific educator training on IB (21%) and HD (16%). Thematic analysis of survey free-text responses identified three main themes on the facilitators and barriers to successful IB and HD education: individual, environmental, and curricular design variables.

Conclusion NPM trainees and neonatologists desire tailored, active, and expert-guided IB and HD education. Identified barriers are important to address in developing an effective IB/HD curriculum for the NPM community.

Key Points

  • There is a gap between the current delivery of IB/HD education and the needs of the NPM community.

  • NPM trainees and neonatologists desire tailored, active, and expert-guided IB and HD education.

  • A successful curriculum should be widely accessible, NPM-specific, and include facilitator training.

Keywords

implicit bias - health disparities - neonatal–perinatal medicine - curriculum development

Data Availability Statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.


Authors' Contributions

N.F.D. and C.B.C. contributed to the methodology, investigation, data curation, visualization, formal analysis, and writing (of the original draft) of the study. As corresponding author, N.F.D. has full access to the data in the study and final responsibility for the decision to submit for publication. S.C.M. and C.G.C. contributed to the study's methodology, investigation, formal analysis, and writing (review and editing). S.I., H.F., R.D., and E.M.B. contributed to the study's conceptualization, methodology, review, and editing. M.M.G. contributed to the study's conceptualization, methodology, supervision, formal analysis, and writing (review and editing). All authors approved the final manuscript as submitted and agreed to be accountable for all aspects of the work.


* These authors contributed equally to this work as cofirst authors.


Supplementary Material



Publication History

Received: 04 November 2023

Accepted: 05 January 2024

Accepted Manuscript online:
08 January 2024

Article published online:
06 February 2024

© 2024. Thieme. All rights reserved.

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  • References

  • 1 Dasgupta N. Mechanisms underlying the malleability of implicit prejudice and stereotypes: the role of automaticity and cognitive control. In: Nelson T. ed. Handbook of Prejudice, Stereotyping, and Discrimination. New York, NY: Psychology Press; 2009: 267-284
    Google Scholar
  • 2 Braveman P. What are health disparities and health equity? We need to be clear. Public Health Rep 2014; 129 (Suppl. 02) 5-8
    CrossrefPubMedGoogle Scholar
  • 3 Accreditation Council for Graduate Medical Education. ACGME Common Program Requirements (Residency). Accessed on February 10, 2023 at: https://www.acgme.org/globalassets/pfassets/programrequirements/cprresidency_2022v3.pdf
    PubMedGoogle Scholar
  • 4 Accreditation Council for Graduate Medical Education. ACGME Common Program Requirements for Graduate Medical Education in Neonatal-Perinatal Medicine. Accessed on January 31, 2021 at: https://www.acgme.org/Portals/0/PFAssets/ProgramRequirements/329_NeonatalPerinatalMedicine_2020.pdf?ver=2020-06-29-162707-410
    PubMedGoogle Scholar
  • 5 CLER Evaluation Committee. CLER Pathway to Excellence: Expectations for an Optimal Clinical Learning Environment to Achieve Safe and High-Quality Patient Care, Version 2.0. Accessed on August 29, 2022 at: https://www.acgme.org/Portals/0/PDFs/CLER/1079ACGME-CLER2019PTE-BrochDigital.pdf
    PubMedGoogle Scholar
  • 6 Trent M, Dooley DG, Dougé J. Section on Adolescent Health, Council on Community Pediatrics, Committee on Adolescence. The impact of racism on child and adolescent health. Pediatrics 2019; 144 (02) e20191765
    CrossrefPubMedGoogle Scholar
  • 7 Skorton DA. AAMC Statemetn on Police Brutality and Racism in America and Their Impact on Health. Accessed on August 29, 2022 at: https://www.aamc.org/news-insights/press-releases/aamc-statement-police-brutality-and-racism-america-and-their-impact-health
    PubMedGoogle Scholar
  • 8 Sundermeier J. Racial disparity in the NICU: position statement #3070. Adv Neonatal Care 2021; 21 (06) 431
    CrossrefPubMedGoogle Scholar
  • 9 Sukhera J, Watling C. A framework for integrating implicit bias recognition into health professions education. Acad Med 2018; 93 (01) 35-40
    CrossrefPubMedGoogle Scholar
  • 10 Mavis SC, Caruso CG, Dyess NF, Carr CB, Gerberi D, Dadiz R. Implicit bias training in health professions education: a scoping review. Med Sci Educ 2022; 32 (06) 1541-1552
    CrossrefPubMedGoogle Scholar
  • 11 Witt RE, Malcolm M, Colvin BN. et al. Racism and quality of neonatal intensive care: voices of black mothers. Pediatrics 2022; 150 (03) e2022056971
    CrossrefPubMedGoogle Scholar
  • 12 Matthews TJ, MacDorman MF, Thoma ME. Infant mortality statistics from the 2013 period linked birth/infant death data set. Natl Vital Stat Rep 2015; 64 (09) 1-30
    PubMedGoogle Scholar
  • 13 Howell EA, Hebert P, Chatterjee S, Kleinman LC, Chassin MR. Black/white differences in very low birth weight neonatal mortality rates among New York City hospitals. Pediatrics 2008; 121 (03) e407-e415
    CrossrefPubMedGoogle Scholar
  • 14 Lee HC, Lyndon A, Blumenfeld YJ, Dudley RA, Gould JB. Antenatal steroid administration for premature neonates in California. Obstet Gynecol 2011; 117 (03) 603-609
    CrossrefPubMedGoogle Scholar
  • 15 Natarajan G, Mathur A, Zaniletti I. et al; Children's Hospitals Neonatal Consortium (CHNC). Withdrawal of life-support in neonatal hypoxic-ischemic encephalopathy. Pediatr Neurol 2019; 91: 20-26
    CrossrefPubMedGoogle Scholar
  • 16 Profit J, Gould JB, Bennett M. et al. Racial/ethnic disparity in NICU quality of care delivery. Pediatrics 2017; 140 (03) e20170918
    CrossrefPubMedGoogle Scholar
  • 17 Sigurdson K, Morton C, Mitchell B, Profit J. Correction: Disparities in NICU quality of care: a qualitative study of family and clinician accounts. J Perinatol 2018; 38 (08) 1123
    CrossrefPubMedGoogle Scholar
  • 18 Sigurdson K, Mitchell B, Liu J. et al. Racial/ethnic disparities in neonatal intensive care: a systematic review. Pediatrics 2019; 144 (02) e20183114
    CrossrefPubMedGoogle Scholar
  • 19 Shapiro N, Wachtel EV, Bailey SM, Espiritu MM. Implicit physician biases in periviability counseling. J Pediatr 2018; 197: 109-115.e1
    CrossrefPubMedGoogle Scholar
  • 20 Davis B, Baggett KM, Patterson AL, Feil EG, Landry SH, Leve C. Power and efficacy of maternal voice in neonatal intensive care units: implicit bias and family-centered care. Matern Child Health J 2022; 26 (04) 905-912
    CrossrefPubMedGoogle Scholar
  • 21 Shaikh H, Billimoria Z, Vandeleur D, Weiss EM, Batra M, Hedstrom AB. Transmission of negative biases through social commentary included in neonatal intensive care unit progress notes. J Perinatol 2023; 43 (07) 903-908
    CrossrefPubMedGoogle Scholar
  • 22 Sukhera J, Milne A, Teunissen PW, Lingard L, Watling C. The actual versus idealized self: exploring responses to feedback about implicit bias in health professionals. Acad Med 2018; 93 (04) 623-629
    CrossrefPubMedGoogle Scholar
  • 23 McClinton A, Laurencin CT. Just in TIME: trauma-informed medical education. J Racial Ethn Health Disparities 2020; 7 (06) 1046-1052
    CrossrefPubMedGoogle Scholar
  • 24 Project Implicit. Accessed in November 2021 at: https://implicit.harvard.edu/implicit/takeatest.html
    PubMedGoogle Scholar
  • 25 Tsai JW, Michelson CD. Attitudes toward implicit bias and implicit bias training among pediatric residency program directors: a national survey. J Pediatr 2020; 221: 4-6.e1
    CrossrefPubMedGoogle Scholar
  • 26 Smith WR, Betancourt JR, Wynia MK. et al. Recommendations for teaching about racial and ethnic disparities in health and health care. Ann Intern Med 2007; 147 (09) 654-665
    CrossrefPubMedGoogle Scholar
  • 27 Mavis SC, Caruso CG, Carr CB. et al. Consensus on an implicit bias and health disparities curriculum in neonatal medicine: a Delphi study. J Perinatol 2022; 42 (11) 1519-1526
    CrossrefPubMedGoogle Scholar
  • 28 Gray MM, Dadiz R, Izatt S. et al. Value, strengths, and challenges of e-learning modules paired with the flipped classroom for graduate medical education: a survey from the National Neonatology Curriculum. Am J Perinatol 2021; 38 (S 01): e187-e192
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Rickards G, Magee C, Artino Jr AR. You can't fix by analysis what you've spoiled by design: developing survey instruments and collecting validity evidence. J Grad Med Educ 2012; 4 (04) 407-410
    CrossrefPubMedGoogle Scholar
  • 30 Dillman DA, Smyth JD, Christian LM. Internet, Phone, Mail, and Mixed-Mode Surveys: The Tailored Design Method. 4th ed.. Indianapolis, IN: John Wiley & Sons, Inc; 2014
    CrossrefGoogle Scholar
  • 31 Ruel E, Wagner III WE, Gillespie BJ. The Practice of Survey Research Theory and Applications. Thousand Oaks, California: SAGE Publications, Inc; 2016
    CrossrefGoogle Scholar
  • 32 Artino Jr AR, Phillips AW, Utrankar A, Ta AQ, Durning SJ. “The Questions Shape the Answers”: assessing the quality of published survey instruments in health professions education research. Acad Med 2018; 93 (03) 456-463
    CrossrefPubMedGoogle Scholar
  • 33 Kiger ME, Varpio L. Thematic analysis of qualitative data: AMEE Guide No. 131. Med Teach 2020; 42 (08) 846-854
    CrossrefPubMedGoogle Scholar
  • 34 Saldana J. The Coding Manual for Qualitative Researchers. 3rd ed.. Thousand Oaks, California: SAGE Publications Inc; 2016
    Google Scholar
  • 35 York M, Langford K, Davidson M. et al. Becoming active bystanders and advocates: teaching medical students to respond to bias in the clinical setting. MedEdPORTAL 2021; 17: 11175
    CrossrefPubMedGoogle Scholar
  • 36 Altman MR, Kantrowitz-Gordon I, Moise E. et al. Addressing positionality within case-based learning to mitigate systemic racism in health care. Nurse Educ 2021; 46 (05) 284-289
    CrossrefPubMedGoogle Scholar
  • 37 Wu D, Saint-Hilaire L, Pineda A. et al. The efficacy of an antioppression curriculum for health professionals. Fam Med 2019; 51 (01) 22-30
    CrossrefPubMedGoogle Scholar
  • 38 Acosta D, Ackerman-Barger K. Breaking the silence: time to talk about race and racism. Acad Med 2017; 92 (03) 285-288
    CrossrefPubMedGoogle Scholar
  • 39 Capers IV Q, Bond DA, Nori US. Bias and racism teaching rounds at an academic medical center. Chest 2020; 158 (06) 2688-2694
    CrossrefPubMedGoogle Scholar
  • 40 Rodríguez JE, Campbell KM, Pololi LH. Addressing disparities in academic medicine: what of the minority tax?. BMC Med Educ 2015; 15: 6
    CrossrefPubMedGoogle Scholar
  • 41 Medlock M, Weissman A, Wong SS. et al. Racism as a unique social determinant of mental health: development of a didactic curriculum for psychiatry residents. MedEdPORTAL 2017; 13: 10618
    CrossrefPubMedGoogle Scholar
  • 42 Sherman MD, Ricco J, Nelson SC, Nezhad SJ, Prasad S. Implicit bias training in a residency program: aiming for enduring effects. Fam Med 2019; 51 (08) 677-681
    CrossrefPubMedGoogle Scholar
  • 43 Zeidan A, Tiballi A, Woodward M, Di Bartolo IM. Targeting implicit bias in medicine: lessons from art and archaeology. West J Emerg Med 2019; 21 (01) 1-3
    CrossrefPubMedGoogle Scholar
  • 44 Zeidan AJ, Khatri UG, Aysola J. et al. Implicit bias education and emergency medicine training: step one? Awareness. AEM Educ Train 2018; 3 (01) 81-85
    CrossrefPubMedGoogle Scholar
  • 45 Kirkpatrick D. Great ideas revisited: revisiting Kirkpatrick's four-level model. Train Dev 1996; 50 (01) 54-57
    PubMedGoogle Scholar
  • 46 Shepperd JA, Waters E, Weinstein ND, Klein WM. A primer on unrealistic optimism. Curr Dir Psychol Sci 2015; 24 (03) 232-237
    CrossrefPubMedGoogle Scholar
  • 47 Nayak B, Moon JY, Kim M, Fischhoff B, Haward MF. Optimism bias in understanding neonatal prognoses. J Perinatol 2021; 41 (03) 445-452
    CrossrefPubMedGoogle Scholar
  • 48 FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics 2017; 18 (01) 19
    CrossrefPubMedGoogle Scholar
  • 49 Freire P. Pedagogy of the oppressed. In: Toward a Sociology of Education. New York, NY: Routledge; 2020: 374-386
    Google Scholar
  • 50 Hagiwara N, Kron FW, Scerbo MW, Watson GS. A call for grounding implicit bias training in clinical and translational frameworks. Lancet 2020; 395 (10234): 1457-1460
    CrossrefPubMedGoogle Scholar
  • 51 French H, Arias-Shah A, Gisondo C, Gray MM. Perspectives: the flipped classroom in graduate medical education. Neoreviews 2020; 21 (03) e150-e156
    CrossrefPubMedGoogle Scholar