Case Study – Unconscious Bias in Healthcare

This case study concerns a range of activities created for MCR8032 Clinical Research Delivery in Practice. The module leader, Fraser Birrell, put me in touch with his colleague, Associate Lecturer Ann Johnson, to assist in the development of a piece of learning about Unconscious Bias in Healthcare.

Ann Johnson has been a Patient and Public Involvement (PPI) Advocate, Lay tutor, and facilitator for twenty-five years, researching and creating a Patient Involvement Framework for Leicester University Medical School. She has conducted extensive community outreach in London, Leicester, and Florida USA with the goal of bridging communications between patients and practitioners. She is continuing her work as an Associate Lecturer and PPI Advocate at the School of Medicine.

As part of this module, it was important to ensure that a patient-centred approach to healthcare was highlighted. As such, Ann’s experience in the field allowed her to challenge students to look at healthcare – and clinical trials in particular – from the patients’ points of view.

One particular topic inspired Ann to focus on the topic of unconscious bias in more detail. In cases of hypertension, GPs had been trained to prescribe different drugs and treatment plans to people based on ethnicity, even though there is no evidence to support this course of action (Gopal, D.P. et al., 2022). This is an example of taught bias – but at the same time, GPs were making assumptions about patients’ ethnicities which could also be erroneous. Naturally, this is an area of concern for patients.

Equality, Diversity and Inclusion and Bias

The difference between EDI concerns and bias is important to clarify at this stage. While EDI principles are focused on actively working to improve outcomes, unconscious bias is present in all of us as a survival instinct and extends beyond those ‘protected characteristics’ formalised in EDI policies. Unconscious bias allows us to make quick decisions based on assumptions – for example choosing to cross the road to avoid encountering someone walking along with an unleashed Pitbull Terrier.

As a clinician, it is especially important to recognise one’s own potential for unconscious bias as it can affect decision-making, resulting in poorer outcomes for some patients. When this bias extends to choosing who to include in clinical trials, it is easy to see how misconceptions or omissions could be compounded.


Discussion

You have been asked to become involved with the recruitment for the trial of Nosuchximab, a targeted therapy for Paediatric Lymphoma. The research target group is children aged between 02 and 14. There is a significant disparity in survival rates of the South Asian population and white European population. You have been asked to recruit children from the target age range. However, the NHS Foundation Trust site for the Nosuchximab trial is located within in a region where this population is under-represented – however, it is present (although in minimal number).

  • How might Unconscious Bias impact the outcomes of this trial?
  • Is it important to strategically recruit this cohort?
  • How might you put in place a strategy for recruiting those particular subjects?
  • What attempts should be made to minimalize barriers to their inclusion?

The above activity challenges students to consider a range of complex factors and is designed to explore the recruitment process for clinical trials, which can be affected by unconscious bias. As such, we designed a range of scaffolding activities to lead up to students exploring this topic in a more confident and informed manner.

The learning was divided into three stages, supported by Canvas’ tools.

  1. An introduction to unconscious bias with a test-your-knowledge quiz. This built understanding of the basics, and used the quiz to instil confidence into the students that they had understood the basics. The introduction was also written in such a way to highlight that this was a supportive environment.
  2. An opportunity to explore the effect of unconscious bias through a key reading, and a test that students could try to identify their own potential biases, followed by reflection in one of a few ways.
  3. Attempt the activity in discussion with others. A webinar is also available for students to join and discuss the activity with Ann and the other students, as well as to explore the topic further if needed.

We understood that the topic of unconscious bias could be challenging for students to confront, as it is intensely personal and potentially triggering. To allow students to explore this area in a supportive way, we suggested a range of activities, from private reflection to group discussion, about the topic in general, to allow students to examine this in an environment where they felt comfortable. We felt that this was especially important as this meant students would not feel they may be judged or blamed for sharing their experiences and feelings about bias, and this would make the entire topic much more approachable, and the learning more effective.

Next Steps

The activities will soon be live for students to try out the materials and share feedback. Anything highlighted by the student feedback will be discussed, and appropriate changes made to the activities if necessary. These materials will then run as part of the module next year. Further distribution of this content can also be done via Canvas Commons, should other module leaders wish to incorporate them into their teaching.

References

Gopal, D.P., Okoli, G.N. & Rao, M. Re-thinking the inclusion of race in British hypertension guidance. J Hum Hypertens 36, 333–335 (2022). https://doi.org/10.1038/s41371-021-00601-9

Setting up different types of Discussions

The FMS TEL team recently delivered a webinar: Getting the most out of your discussion boards. If you can’t access the FMS TEL Canvas community, please enrol yourself before retrying the direct link.

As a follow up to that webinar we have created follow along video guides and step by step written instructions on how to make the ideas and suggestions a reality. Our guides cover:


Voting and Polls ✅

These can be set up in around 2 minutes and no external tools are required. Students can quickly share their opinions or provide feedback in a similar format to Social Media.

Discussion Folders ?

Is your modules area looking cluttered? Organise your discussions into folders so they are easy to navigate.

Sharing Group Discussions ?‍?‍?‍?

Group discussions in Canvas can be a great option however they have the disadvantage of only group members being able to see what was contributed. If your course would benefit from groups being able to share with other groups after the task then we have 2 solutions for you.

Multiple Posting Points ??

Some courses may require students to share personal experiences. In this guidance we offer a solution for student to choose if they post to the whole cohort or just to the Teachers on the course.

Anonymous Posts ft. Padlet ❔

Currently Canvas does not allow anonymous posts. To get around this limitation we can create boards using an External Tool Padlet and embed Anonymous Padlet Boards within Canvas and the MLE.


Moving Lab Health & Safety Online

In September 2020, the School of Biomedical, Nutritional and Sport Sciences launched their new Laboratory Health and Safety Module.  This online package was designed to give Stage 1 students an induction into key areas of laboratory health and safety, but also as a revision resource for Stages 2 and 3. Future content development will look at additional resources specific to the later stages of study.

Development of this module required a complete redesign of laboratory health and safety resources, moving from paper-based module handbooks to interactive, online blended materials. We had to establish an infrastructure to support both staff and students with this change. We also used key design principles and frameworks to facilitate user engagement with interactive resources.

A collaborative team was formed between the Faculty of Medical Sciences Technology Enhanced Learning team (FMS-TEL) and the school of Biomedical, Nutrition and Sport Sciences (BNS) to amalgamate technological, pedagogical and content knowledge.

Our Goals

Student engagement: Academic staff were finding it difficult to monitor student engagement with the paper-based module handbook and laboratory code of conduct and wanted to have a more standardised approach to ensure that all students are aware of and complying with health and safety requirements in the laboratory.

Blended Learning: We did not want to simply replicate the paper materials into a digital format, so a lot of time was spent thinking about blended learning pedagogy.

New and interactive Resources: Access to the new VLE, Canvas, provided us with a more sophisticated platform to produce an interactive module with new approaches to learning.

Staff Autonomy: We did not want to rely on external tools and specialist software otherwise upkeep and editing would be a challenge once staff handover was completed.

The Project Roadmap below summarises key milestones from the project:

An overview of the project roadmap including project brief, design process and consultations.
Click on image to enlarge

Achievements

Clear Signposting and Navigation

The intention is that students can dip in and out of sections in whichever order they prefer. However, the laboratory safety section was divided into three ordered segments:

  • Arriving at the lab
  • During the lab practical
  • At the end of the lab practical

Multi-disciplinary

Some resources cover all three strands of Biomedicine, Sport and Nutrition so we decided to host one course for all. Subject specific materials are clearly labelled. We attempted to introduce lock and release and mastery pathways so that students would only access their own subject areas, however some students are multi-disciplinary so this did not work. Also, there was too much of a time delay with the Canvas mastery pathways function that we felt this was not appealing to students.

Humanising/Personalisation

We felt it important that students could connect with key staff members and that video welcomes would achieve this.

  • Videos from a laboratory demonstrator
  • Welcome video from Head of School and H+S Officer

Interactive Resources

It was always planned that we would use 360⁰ images to allow students the opportunity to become familiar with the laboratory environment before attending in person. This is to help alleviate some of the anxiety that our students experience when first entering a large laboratory space.

  • 360⁰ lab walkthrough tours
  • 360⁰ interactive images

Innovative assessments

Canvas enabled us the opportunity to embed and host new online interactive assessments.  

(i) 360⁰ hotspots hazard identification

We wanted to create a hazard identification exercise in a safe environment. 360⁰ images allowed us to create an interactive digital version of the laboratory with a number of hazards included. This would not have been safe or possible to do in a physical laboratory space.

The 360⁰ materials were hosted externally on theasys.io There are many tools which allow you to add hotspots to 360⁰ images but the problem is that they are never hidden. However, with the ability to upload custom hotspots in theasys we were able to create and upload a transparent image to use as an invisible hotspot.

(ii) Branching Scenarios

Branching scenarios allow students to make decisions in a safe online environment, helping them to understand the consequences of their choices.

Self-management of learning

We added features to encourage students to monitor their own progress:

  • Standalone units to encourage self managed learning and flexibility
  • Colour-coded and branded sections for ease of navigation
  • Clear learning objectives for each section
  • Section progress bars
  • Content release based on complete action e.g. minimum score in Health and Safety quiz

For future developments, we are considering how we may be able to generate course completion certificates or Digital Badges.

Student Feedback and Canvas Analytics

The new course went live in September 2020 for the start of the academic year with 1176 students enrolled. Canvas analytics indicates good interaction at appropriate times.

  • 21st Sept 28,230 page views
  • 12th October 40, 676
  • January access showed a peak of 26, 997
A data image showing a large proportion of students agreeing the module is user friendly.
A data image showing a large proportion of students agreeing the module is easy to navigate with appropriate images and accessible on all device types.
A data image showing a large proportion of students agreeing the interactive resources were helpful.
A data image showing a large proportion of students agreeing they were taught something new. And 50% of students agreeing having all three subject strands together was useful.

Planning Learning

As part of my own research to pass on to colleagues, I recently attended a Future Learn course “How to Teach Online” where this planning tool was demonstrated. I thought colleagues may find it to be of interest.

Learning Designer helps you plan different types of activities for your students. It allows you to organise a blend of online and face to face activity. These are called TLAs, or Teaching and Learning Activities. There are 6 different types to choose from

  • Read, watch, listen
  • Collaborate
  • Discuss
  • Investigate
  • Practice
  • Produce

You can add resources such as links to videos and websites.

It produces a helpful pie chart showing the proportion of activities the students will experience.

You can download your plan as a word document or share it with a link.

Have a go with the Learning Designer Tool yourself at https://www.ucl.ac.uk/learning-designer/designer.php (Links to an external site.)  The video below talks you through how to use it.

More information is available on the Learning Designer Website https://www.ucl.ac.uk/learning-designer/index.php (Links to an external site.) 

A User Guide is also available at https://www.ucl.ac.uk/learning-designer/guide/