Simulation has become an educational reference in emergency medicine. The beauty of this is that EPs benefit from the full Danger Room experience, an unbridled opportunity to practice critical skill sets in a low-impact environment.
EPs can gain confidence through repetition and bouts of constructive feedback for everything from megacodes and procedures to handling difficult patients. Even the oral board exams and family of advanced life support certifications (such as ACLS, ATLS, and PALS) incorporate some degree of simulation. Simulation at its core 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 issues of racial equity as we work to improve our understanding of diversity, equity and inclusion.
We have already started using simulation to explore concepts of health equity; cases now include transgender patients, housing insecure patients, and patients with limited English proficiency. The goal of simulating cases like these is to help learners develop language and soft skills that honor patient 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, about the systemic and structural effects of racism). Variables such as self-discovery, uncovering of biases, activation of race and racism-related triggers and trauma, and retaliatory actions must be controlled to honor learners’ psychological safety.
Unpacking the premise further reveals a deeper question of fairness: do all learners inherently enjoy psychological safety in their given environment (in this case, the emergency department)? Specifically, do learners from historically excluded backgrounds, also known as underrepresented minorities (URMs), enjoy psychological safety? The plethora of evidence on implicit and explicit biases and microaggressions suggests not.
Convenience is not always positive
Psychological safety conceptually makes sense 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 racial bias 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 burnout symptoms were associated with greater implicit and explicit racial bias experienced throughout residency training. (JAMA Netw Open. 2019;2:e197457; https://bit.ly/2YGre7i.) Even medical students identify racial bias as a barrier to their personal and professional success in medicine. (AcadMed. 2007;82:146; https://bit.ly/3nbDnL2.) These risks are very real, have good data, and disrupt fairness in the learning environment. The psychological safety of MRU learners across the entire arc of medical training is usually treated as an afterthought, and therein lies the problem.
Interestingly, psychological safety can 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. Case conditions are meant to appear as close to reality as possible while the learner spontaneously solves problems as they arise. Racism, xenophobia, sexism, ageism and other -isms exist. Conversely, URMs have used this approach of encountering less than favorable conditions and navigating through them unknowingly and into spaces that are rarely protected. The simulation that addresses issues of racial equity intelligently and with clear goals honors the lived experiences of marginalized communities. It also sheds light on the day-to-day experiences of URM colleagues.
Psychological safety should not be applied at the opportune moment, simply as a means to deter the process of uncovering personal biases and addressing systemic and structural racism. Simulation marketed as a method of guilt-free learning and practice should be avoided so as not to limit growth parameters to pure clinical or procedural mastery.
Instead, we should challenge ourselves to pursue new applications of this model of learning, especially to become anti-racist. Psychological safety, when applied broadly, aligns with diversity, equity and inclusion goals. Our learning environments are becoming safer places for all 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 lived 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 Director of TRAP Medicine, a salon-based wellness initiative that leverages the cultural capital of barbershops to address the physical and emotional health of men and boys. black. He has also worked with ABC News’ medical unit and contributed articles on health equity and wellness. The New York Times, USA Today, GQ, and The root. Follow him on Twitter@gr8vision. Read his past articles onhttps://bit.ly/DiversityMatters-EMN.