A fourth-year medical student presents his patient, a 44-year-old African American man with frequent asthma exacerbations requiring emergency room care. When you ask why the asthma is not well controlled, the student states dismissively, “I don’t know, probably crack.” Your evaluation reveals a forthcoming patient with no history or physical stigmata of drug use whose asthma is treated with a short-acting beta-agonist alone. While talking with the patient about the need for inhaled corticosteroids, you find yourself becoming angry with the student and unsure how, or even if, you should discuss his remark with him.
Physicians often rely on pattern recognition to simplify decision making in clinical situations, particularly when pressed for time, fatigued or overloaded with information.31,33
While often useful, pattern recognition may involve stereotypes or cognitive shortcuts to obtain, process and recall information about others.33
Cognitive shortcuts involving race, ethnicity or gender may contribute to health care disparities and prevent physicians from treating diverse patient populations effectively, particularly when these shortcuts are combined with bias, defined as unjustifiable negative beliefs about others.34
Bias is often unconscious and may differ from consciously expressed views.32,35–37
In the example above, the student equated inadequate asthma control in an African American patient with the use of inhaled cocaine. Though inhaled cocaine can exacerbate asthma, the cognitive shortcut prevented the student from thinking through other etiologies for the patient’s poor asthma control. Bias may, or may not, have played a role in the student’s remark. It is often neither possible nor necessarily desirable to attempt to establish the role of bias.38,39
However, the student should be made aware of the shortcoming associated with his cognitive short cut and of the literature that shows physicians often underestimate asthma severity in African Americans, and are therefore less likely to prescribe appropriate therapy.40,41
Physician behavior may contribute to the longstanding observation that African American patients with asthma are more likely to require visits to the Emergency Department and hospitalization for their illness than white patients.42–46
Feedback proves a useful strategy for addressing inappropriate stereotyping or bias. Feedback allows learners to gain insight into their performance so that it may be further modified and refined. It should be a regular and expected component of the education process. Feedback should be specific, focused, objective, and offered in a timely manner.28,47,48
The context in which feedback is delivered should be considered carefully as feedback is most likely to be successfully incorporated when delivered in a direct, yet supportive, manner. Because situations with the potential to cause health care disparities are emotionally charged for both faculty and learners, teachers may benefit from a brief time out to organize their own thoughts and feelings before providing feedback.
Feedback may be used to promote reflection, especially when it is corrective and discordant with the learner’s self-perception.49
Reflection provides an opportunity for critical thinking and review.50
Teachers stimulate reflection by asking learners to share their insights about a particular experience or articulate what they have learned. Adding additional probes such as “tell me more” encourages learners to engage in deeper reflection. Through reflection, learners explore the larger meaning of their actions and experiences, which leads to individual growth.51
Reflection can be accomplished in a group setting or individually.
Attending: What led you to believe the patient’s frequent asthma exacerbations were due to drug use?
Student: I guess he reminded me of so many other patients I’ve seen this year with asthma. A lot of them were using cocaine.
Attending: (Calmly giving feedback.) While cocaine use can certainly worsen asthma, many other etiologies are more likely in this patient who denies drug use and has no suggestion of drug use by history or physical examination. There is literature showing that when doctors are busy and under stress, we take cognitive shortcuts. I know that I certainly do. These shortcuts or stereotypes can be useful, but they can also lead to disparities in care by affecting the way we interpret clinical information. In this case, the stereotype you used was not accurate or helpful and masked the real problem — failure to prescribe inhaled corticosteroids for inadequately controlled asthma. Next time, a more careful history will help us avoid jumping to conclusions.
Putting it all Together: The TEST Model and Health Care Disparities Education
On post-call rounds, your intern presents a 68-year-old white man with hypertension, hypercholesterolemia, and congestive heart failure with exacerbation who has required admission twice this month. The intern notes that once again, the CHF exacerbation is due to non-adherence. As the intern presents the case, his frustration is evident. You have several immediate concerns: determining the cause of the patient’s non-adherence, figuring out how to target teaching to the intern, and addressing the intern’s frustration.
You decide to perform a two-minute observation to simultaneously “diagnose” the patient and the intern. You explain to the intern that you would like to watch him assess the patient’s use of medication.
Intern: Are you taking the lisinopril every day?
Patient: Is that the blue one or the white one? I take the blue pill every day.
Intern: The blue pill is the furosemide. You need to take the lisinopril every day.
You suspect the patient has low health literacy and diagnose the learner as unfamiliar with this problem and established skills to address it. Outside the room, you teach a general rule.
Attending: This situation is frustrating, isn’t it? I suspect this patient has low health literacy. In the US, low health literacy is particularly common in older patients and in those with chronic disease, low socioeconomic status and low educational attainment.52
In fact, two-thirds of adults age 60 and older have inadequate or marginal health literacy.53
Patients with low health literacy often fail to understand medication instructions and are at increased risk for hospitalization.54,55
Failing to recognize and respond effectively to patients with low health literacy is common and may lead to disparities in health care. The “teach-back” method is used to assess patients’ understanding of medication instructions.56,57
Have you had a chance to use this skill before?
Intern: I have heard about the teach-back method, but do not really know what it is.
Attending: (Initiating an activated demonstration.) When we return to the room, I would like you to pay attention to how I explain the medications to the patient and ask him to show me — teach me — how he will use them at home.
After the demonstration, the attending seeks to activate the intern by asking questions about his observations.
Attending: Tell me what you observed about the use of the teach-back method.
Intern: You used simple language to explain the purpose of the medications and how to use them and then you asked the patient to show you how he would take the medication at home. When he didn’t get it quite right, you showed him again and then had him show you another time until he got it right.
Attending: (Giving feedback.) You just summarized the teach-back method for patients with low health literacy beautifully. (Promoting reflection.) How do you think the patient perceived us?
Intern: Well, I was pretty exasperated with this patient and I bet he knew it. I mean, I have spent hours taking care of him and then he goes home and is right back to square one again. After a while, it just seems so futile. I feel more optimistic at this point.
Attending: I’m glad to hear that. How do you think the patient feels now?
Intern: I think he feels more like we’re on the same team instead of rivals. I know I do.
In this scenario, the attending selects a two-minute observation, to “diagnose” the patient and the learner. The attending learns the intern possesses gaps in both knowledge and skill. The attending teaches a general rule about low health literacy to strengthen the intern’s knowledge base and then uses an activated demonstration to improve the intern’s skill set. Finally, brief feedback and an invitation to reflect on the patient’s perspective allow the intern to give voice to his emotions and recognize that he has entered a partnership with the patient.