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

Canvas Booster for Interactivity

We recently delivered a quick Canvas Booster session for Population Health Sciences Institute, which covered Quizzes, Discussion Boards, Accessibility and H5P. You can find the recording and resources for this session in our Canvas Community.

FMS TEL recently delivered a quick Canvas Booster session for Population Health Sciences Institute, which covered the themes below. You can find the recording for this session in our Canvas Community. Other resources are shared below – you may need to log in to Canvas to access these.

Quizzes

Discussion Boards

Accessibility

H5P

What does that mean again? Glossary Building

Why use a glossary?

“A glossary is a great reference tool for a student, especially when they’re studying material which is quite technical and contains a vocabulary which is specific to the subject.”

David McGeeney, MCR8019 Module Leader

“Well, our students come from a diverse range of professional backgrounds, are based in different countries and have different experiences.  And when you’re dealing with clinical scenarios you really can’t afford to allow confusion and misinterpretation to happen, especially where the subject material is quite technical.  Adding a glossary to ONC8004: Developments in Diagnostic Imaging in Oncology allows us to focus the webpage content on teaching and learning whilst linking to explanatory terms for those who need it.”

Victoria Hewitt, ONC8004 Module Leader

Benefits of using a Glossary

  • Ensures all students are familiar with discipline specific vocabulary
  • Provides a reliable reference tool students can use throughout their studies
  • Content can be more concise
  • Easy to create
  • Can be rolled over year after year

Making your own Glossary

It could be as simple as having a dedicated page located near the start of the content which students can reference throughout the course.

screenshot of a glossary in canvas

You can view example glossaries in the FMS Community, along with instructions on how to add navigation options such as an A-Z menu at the top and ‘Back to top’ links.

Branching Activities

Following a request to create branching activities for the BMS Health and Safety Course, we have added an example of a branching activity to the FMS Community so that others can try these out. These activities can be used to present a scenario with a range of options for students to follow, like a choose-your-own-adventure book.

A branching activity was included in the Health and Safety course this year to guide students through a scenario where a fellow student becomes unwell. At each stage, some information and a set of choices is presented. The student clicks through to discover the consequences of their choices, and finally, an outcome is presented. Students can run through the activity multiple times to try out different paths through the scenario.

These activities are built by setting up pages in Canvas to represent each stage and adding buttons that link pages together in the right order depending on the choices.

You can try out an example branching activity in the FMS Community. This example has 13 different pages, including a landing page where students start the activity. The number of pages you need to create will depend on how complex you want your scenario to be.

If you’d like to try making your own branching activity, you can find instructions here: https://ncl.instructure.com/courses/30988/pages/creating-branching-activities.