User’s Guide

Purpose of the Toolkit:

Many physicians and patients face bias in the hospital environment due to distinct aspects of their identities. National initiatives, academic study, and social media have all made salient the ways stereotypes regarding race/ethnicity, gender, sexual orientation, ability etc. shape interactions among medical professionals and towards patients. However, while the medical community may acknowledge that such events are common, we often fail to respond effectively to these incidents.

To close this gap, we have created a Cultural Complications Curriculum and case series designed to be periodically integrated into Morbidity and Mortality conferences. We have targeted M&M, because it is a familiar and widely accepted framework to address errors or complications. By leveraging the foundational principles of M&M (case presentations, didactic teaching, and expert feedback) we will identify knowledge gaps and build consensus around best practices.

What Does the Cultural Complications curriculum entail?

The curriculum consists of 12 (and growing) PowerPoint-based modules, each focused on a different theme. The curriculum is designed to build a strong conceptual foundation both longitudinally across themes and within each module. The goal is to introduce key concepts in disparity research (e.g. implicit bias, stereotype threat, gender schemas, etc.) review the scientific basis of these phenomena, and develop best practices in responding to them. To do this, each module has a highly data-driven didactic session that can be delivered in under 10 minutes, and sample cases with discussion prompts aimed to elicit audience suggestions regarding how to prevent these events or improve the response.

Logistics 

Institutional customization

We recognize that there may be great variability in given institutions’ receptiveness to Diversity, Equity and Inclusion (DEI) content, audiences’ existing knowledge base, and tolerance for change in existing M&M format. To accommodate this reality, we have striven to make the curriculum customizable to each department’s unique needs. For example, one of our pilot sites already had robust DEI education, so organizers truncated the didactic portion of the curriculum to allow for more time in case discussion. Similarly, to account for the belief that M&M should focus on complications as they affect patients rather than providers, we offer a patient-centered didactic option, as well as patient-centered sample cases, in addition to the original provider focused material. As the curriculum continues to evolve, we welcome feedback regarding how the better meet users’ needs.

Accessing the curriculum

If you would like to start this program at your institution, we ask that you request the curriculum through our website, and we will give you access to the full patient- and provider-centered curricula. Per University of Maryland regulations, access to the ShareDrive lasts for 30 days, so we recommend downloading the full curriculum. However, if its times out and you need access again, please feel free to email us (CulturalComplications@Gmail.com) and we will be happy to renew access.

Who should deliver this curriculum?

As some institutions may not have designated DEI leaders, each module includes a complete script in the slide notes so that even relative novices will be able to deliver the presentation. Additionally, the Research and Resources section of the website includes links to every study referenced throughout the curriculum as well supplemental videos and podcasts that go into more detail.

For optimal implementation, we encourage departmental leadership to identify champions to lead this effort to ensure consistency and quality. Additionally, a local expert base will likely be integral in adapting curricula to local conditions, addressing follow-up questions, and cultivating a grassroots feel. Finally, if the people implementing the curriculum are not the same as those who normally run M&M, we recommend face-to-face meetings to explore the curriculum and generate consensus

Establishing & Introducing the Curriculum

Issues surrounding identity, bias, and discrimination are notoriously thorny. They may be politically charged, highly personal, or seen as fluffy; thus, establishing that departmental leadership takes the topic seriously is mission essential. This may mean meeting and addressing the concerns of stakeholders well before delivering the first session. Be wary that a lack of response from various parties may not be the same as acceptance of the initiative, and you should have had face-to-face meetings with anyone related to the conference.

We have also found having department leaders (ideally the chair) introduce the first session reinforces the curriculum’s importance. Some skepticism may be inevitable, but having a well-respected member of the department lend the initiative credence will help prevent broad suppression of any discussion.

How do we identify cases to discuss? 

For each topic, our website includes sample provider- or patient-centered cases (and we are always looking for new ones!). The cases are based on the study team’s personal experiences, existing literature, and social media. The advantage of a standardized case bank is that it can mitigate any tendencies audience members may have to try and suss out who was involved in the case or assign blame. To date, our experience has been that these sample cases closely mirror many audience members’ actual experiences and often serve as a jumping off point for participants to reference similar anecdotes. This grounding in real world events may help overcome any skepticism that the issues described actually happen at a given institution.

If you wish to to build local cases, we suggest establishing a survey (google, survey monkey, redcap etc.) where respondents can anonymously submit the event and their response (suggested format below). Respondents should be furnished with an option to present their case if they feel comfortable or have it presented on their behalf. It will be important to explicitly state that although names will not be used, if the circumstances of the event are highly specific, anonymity may be impossible to preserve. We suggest that entry forms include language explicitly detailing the hospital’s harassment policies with appropriate offices and contact numbers stated so that affected individuals can pursue further action as necessary. Finally, if you found a case generated a particularly helpful discussion, we would very much appreciate you sharing that with the research team.

Do cases have to match the content exactly?

No. Some content areas such as Microaggressions may have abundant content, whereas others such as Understanding the Business Case for Diversity may have few. As much as possible, submitted cases should be organized into the modules that best match their content, but as the purpose of this curriculum to improve culture, discussing local issues may be more effective.

How can we ensure good discussion?

For the first few sessions, we have found it helpful to make audience members aware of the sample cases or prompts beforehand, which help jumpstart discussion. This may be particularly important at places where institutional culture dictates only senior members speak during M&M. The intent is not to create a propaganda machine, or to create scripted responses, but rather to avoid putting individuals on the spot, and allowing them time to collect their thoughts. Furthermore, at more homogenous institutions, individuals representing minority groups may be unfairly or frequently called upon to speak for their entire group. Organizers should be very sensitive to this possibility and may want to touch-base beforehand to gauge individuals’ willingness to participate, particularly if the person who may be called upon is junior. Finally, individuals may not be comfortable discussing certain aspects of their identity in public, and this should be respected at all levels.

It may also be helpful to appoint a designated ‘devil’s advocate’ to tackle some of the more difficult aspects of these topics. Inevitably some audience members may be skeptical about the data or legitimacy of the topics, but may fear voicing these ‘unpopular’ opinions. By allowing the devil’s advocate to take these positions, you may be able to address thornier topics in a less adversarial way.

Emotional distress with few solutions?

Each module is designed to be delivered in under 20 minutes, which necessarily limits discussion. A possible result is that discussion will open up painful topics but may be short on solutions. Another unintended consequence may be that out-group physicians may be disproportionately asked to shoulder the emotional labor of these sessions. Identifying faculty members who are willing to offer additional support, periodic after-hours events to continue discussion, and links to institutional supports such as Employee Assistance Programs may help alleviate stress participants feel.

How do I generate buy-in or cope with skeptics?

Some individuals may dismiss Diversity, Equity & Inclusion efforts as politically correct nonsense. The curriculum is specifically designed to minimize this reaction by building a scientific case for these efforts rather than taking a social justice approach (e.g. diversity is the morally right thing to do). Each module also contains a section directly addressing the limitation of the scholarship or contexts where effort to change may fail. Finally, we hope that the discussion of local cases and their ramifications will overcome the cognitive bias that “these things are not an issue at our institution.” Identifying clinical champions to help this work translate into daily practice will also be key.