Use of simulation-based education to mitigate race- and disease-based discrimination in sickle cell disease care

Abstract Introduction Patients living with sickle cell disease (SCD) have a life-threatening disease causing a decreased quality of life, shortened life span, and frequent vaso-occlusive pain episodes (Payne, Ann Emerg Med, 2009). In the US, the SCD population is disproportionately Black and often disenfranchised from high quality care, especially around pain management. As pain is a cardinal feature of SCD, it is important that learners entering the medical profession are equipped with the education and skills necessary to navigate pain in this demographic of people who often experience discrimination (Padmanabhan et al., Children (Basel), 2018). Methods The main study objective was the use of a simulation-based approach to mitigate race and SCD pain management-related discrimination and increase the interpersonal quality of medical attention to patients. The simulation scenario involved a young adult male patient with SCD presenting to the ED with an acute pain episode who is seen by the medical student learner. A pre-sim questionnaire preceded a brief didactic slide presentation on key learning points, followed by the simulated performance, post-sim debriefing, and the same item post-test. Chi-square or Fisher's exact tests were applied as appropriate to compare pre- and post-intervention responses. A Mann-Whitney U test assessed changes in the frequency of recognizing outward expressions of patient-generated pain-modifying behaviors post-intervention. The standardized patient (SP) also assessed student learner communication skills using the validated Communication & Interpersonal Skills Rating Scale (CIS)-Docs. Results To date, 26 learners have completed the simulation. Twenty were M3 students, with the remainder at the M4 level. Significant shifts occurred in clinical attitudes with fewer participants agreeing that vital signs should be used to assess pain in SCD patients (p = 0.002) and more endorsing the use of evidence-based guidelines for administering pain medication within 30 minutes of triage (p = 0.002) post-intervention. A significantly greater number of participants reported behaviors such as using personal devices, listening to music, avoiding eye contact, watching television, and darkening room lighting (all p < 0.005) post-intervention, showing an increased awareness of subtle behavioral cues that patients use to self-manage pain, which might have been previously overlooked. The SP actor rated all learners post-encounter on their ability to communicate and establish rapport. Our SP perceived learners' communication as friendly 92.3% of the time and their treatment as respectful 84.6% of the time. The SP also felt the learners were logically organized in their questioning 84.6% of the time and used appropriate language and vocabulary 69.2% of the time. Overall, this led the SP to express a desire to see the learner again as their physician 73.0% of the time. The SP also provided additional feedback, noting one student had a “really warm and inviting personality” and another made them feel “safe telling you my issues.” Additionally, the simulated encounter confronted learners with the drug-seeking bias by having a nurse enter the room as part of the encounter and remark that the opioid dose the patient himself verbalized as his usual ED IV dose was a “pretty high dose!” This part of the encounter was remarked upon by every student, with comments such as: “The nurse coming in threw me off,” and “The nurse's statement made it feel like there was an attitude.” This allowed expansion in the post-sim debriefing on the topic of approaches to bias interruption. Conclusion This study shows that simulation-based education on pain management in SCD may have a role in mitigating race- and disease-based discrimination and increasing the interpersonal quality of medical attention to patients. Learners verbalized the value of the sim in these statements: “The simulation really adds an extra dimension versus just learning about it in class,” and “This would be very beneficial for med students at all levels, even for residents and fellows. You can never be too good at communicating.”