Simulation has become an educational gold standard in emergency medicine. The beauty of it is that EPs get the full Danger Room experience, an unbridled opportunity to rehearse critical skill sets in a low impact environment.
PEs can gain confidence through repetition and episodes of constructive commentary for everything from megacodes and procedures to difficult patient management. Even the oral board exams and family of advanced life support certifications (like ACLS, ATLS, and PALS) incorporate some degree of simulation. Basic simulation is simply a tool to explore and improve our clinical insecurities in vitro. We must recognize the immense untapped potential of simulation to navigate complex racial equity issues as we work to improve our understanding of diversity, equity and inclusion.
We have already started to use simulation to explore concepts of health equity; cases now concern transgender patients, patients with housing insecurity and patients with limited English proficiency. The goal of simulating cases like these is to help learners develop language and soft skills that honor the patient’s identity while accessing appropriate resources (or performing clinical tasks) to provide care. optimal. However, cases that tackle racism head-on are not only rare, but often dismissed. The big question is why.
One of the biggest concerns and counterpoints to its use is that of psychological safety. “In the field of medical education, psychological safety describes how a learning environment mitigates or exacerbates the risks that learners must take to learn medicine, ”wrote Bynum and Haque a few years ago. (J Grad Med Educ. 2016; 8: 780; https://bit.ly/3n5n1Dl.) Reinterpreted, a non-judgmental environment must be prioritized and ensured to optimize learning (in this case, on the systemic and structural effects of racism). Variables such as self-discovery, exposing prejudices, activating race and racism-related triggers and traumas, and retaliatory actions need to be controlled to honor the psychological safety of learners.
Unwrapping the premise further reveals a deeper question of fairness: Do all learners inherently benefit from psychological safety in their given environment (in this case, the emergency department)? Specifically, do learners from historically excluded backgrounds, also known as underrepresented minorities (MUR), enjoy psychological safety? The plethora of evidence on implicit and explicit biases and microaggressions suggests not.
Convenience is not always positive
Psychological safety has conceptual meaning until the lived experiences of URM (or historically excluded) learners are taken into account. Studies by Peterson, et al., And Nunez-Smith, et al., Suggest that non-majority physicians experience significant racial discrimination and prejudice in the workplace. (J Gen Med Intern. 2004; 19: 259; https://bit.ly/2YDEedT; 2009; 24: 1198; https://bit.ly/3c44u4b.)
Another study by Dyrbye et al. reported that symptoms of burnout were associated with greater implicit and explicit racial biases encountered throughout residency training. (JAMA Netw Open. 2019; 2: e197457; https://bit.ly/2YGre7i.) Even medical students identify racial prejudice as a barrier to their personal and professional success in medicine. (Acad Med. 2007; 82: 146; https://bit.ly/3nbDnL2.) These risks are very real, have good data, and disturb fairness in the learning environment. The psychological safety of URM learners across the medical education arc is by and large treated as an afterthought, and this is where the problem lies.
Interestingly, psychological safety may be appropriate when anti-racism is the topic of discussion. Ironically, simulation owes part of its popularity to this notion of learning in a protected space. The conditions of the case are meant to appear as close to reality as possible as the learner spontaneously resolves issues as they arise. Racism, xenophobia, sexism, ageism and other -isms exist. Conversely, the URMs have used this approach of encountering less than favorable conditions and traveling through them without knowing it and in rarely protected areas. The simulation that approaches racial equity issues intelligently and with clear goals honors the lived experiences of marginalized communities. It also sheds light on the daily life of URM colleagues.
Psychological safety should not be applied at the right time, simply as a means of discouraging the process of uncovering personal biases and combating systemic and structural racism. Simulation marketed as a guilt-free learning and practice method should be avoided so as not to limit growth parameters to pure clinical or procedural mastery.
Instead, we should challenge ourselves to seek new applications of this learning model, especially in becoming anti-racist. Psychological safety, when applied broadly, aligns with the goals of diversity, equity and inclusion. Our learning environments are becoming safer places for everyone as we become more diverse, equitable and inclusive. It doesn’t have to be one or the other, and all learners can benefit from practical ways to honor the diverse experiences of our diverse patient population.
Dr Brownis an emergency physician and assistant professor of social emergency medicine at Stanford Hospital. He is also the Impact Manager of TRAP Medicine, a salon-based wellness initiative that leverages the cultural capital of barber shops to address the physical and emotional health of men and boys. black. He has also served with the ABC News medical unit and contributed to articles on health equity and wellness for The New York Times, USA Today, GQ, and The root. Follow him on twitter@ gr8vision. Read his past articles onhttps://bit.ly/DiversityMatters-EMN.