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Bias is a ubiquitous problem in human functioning. It has plagued medical decision making, making physicians prone to errors of perception and judgment. Racial, gender, ethnic, and religious negative biases infest physicians' perception and cognition, causing errors of judgment and behavior that are damaging. In Part 1 of this series of 2 papers, the authors address the problem of harmful bias, the science of cognition, and what is known about how bias functions in human perception and information processing. They lay the groundwork for an approach to reducing negative bias through awareness, reflection, and bias mitigation, an approach in which negative biases can be transformed-by education, experience, practice, and relationships-into positive biases toward one another. The authors propose wisdom as a conceptual framework for imagining a different way of educating medical students. They discuss fundamental cognitive, affective, and reflective components of wisdom-based education. They also review the skills of awareness, using debiasing strategies, compassion, fostering positive emotion, and reflection that are inherent to a wisdom-based approach to eliminating the negative effects of bias in medical education. In Part 2, the authors answer a key question: How can medical educators do better? They describe the interpersonal, structural, and cultural elements supportive of a wisdom-based learning environment, a culture of respect and inclusion in medical education.

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In Part 1 of this 2-article series, the authors reviewed the problem of unmitigated bias in medical education and proposed a wisdom-based framework for a different way of educating medical students. In this article, Part 2, the authors answer a key question: How can medical educators do better? Is a bias-free environment possible? The answer to the latter question likely is "no." In fact, having a zero-bias goal in mind may blind educators and students to the implicit biases that affect physicians' decisions and actions. Biases appear to be a part of how the human brain works. This article explores ways to neutralize their destructive effects by: (1) increasing awareness of personal biases; (2) using mitigation strategies to protect against the undesirable effects of those biases; (3) working to change some negative biases, particularly learned biases; and (4) fostering positive biases toward others. The authors describe the concrete actions-interpersonal, structural, and cultural actions-that can be taken to reduce negative bias and its destructive effects.

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BACKGROUND: Resident duty hour restrictions have resulted in more frequent patient care handoffs, increasing the need for improved quality of residents' sign-out process. OBJECTIVE: To characterize resident sign-out process and identify effective strategies for quality improvement. DESIGN: Mixed methods analysis of resident sign-out, including a survey of resident views, prospective observation and characterization of 64 consecutive sign-out sessions, and an appreciative-inquiry approach for quality improvement. PARTICIPANTS: Internal medicine residents (n = 89). INTERVENTIONS: An appreciative inquiry process identified five exemplar residents and their peers' effective sign-out strategies. MAIN MEASURES: Surveys were analyzed and observations of sign-out sessions were characterized for duration and content. Common effective strategies were identified from the five exemplar residents using an appreciative inquiry approach. KEY RESULTS: The survey identified wide variations in the methodology of sign-out. Few residents reported that laboratory tests (13%) or medications (16%) were frequently accurate. The duration of observed sign-outs averaged 134 ±73 s per patient for the day shift (6 p.m.) sign-out compared with 59 ± 41 s for the subsequent night shift (8 p.m.) sign-out for the same patients (p = 0.0002). Active problems (89% vs 98%, p = 0.013), treatment plans (52% vs 73%, p = 0.004), and laboratory test results (56% vs 80%, p = 0.002) were discussed less commonly during night compared with day sign-out. The five residents voted best at sign-out (mean vote 11 ± 1.6 vs 1.7 ± 2.3) identified strategies for sign-out: (1) discussing acutely ill patients first, (2) minimizing discussion on straightforward patients, (3) limiting plans to active issues, (4) using a systematic approach, and (5) limiting error-prone chart duplication. CONCLUSIONS: Resident views toward sign-out are diverse, and accuracy of written records may be limited. Consecutive sign-outs are associated with degradation of information. An appreciative-inquiry approach capitalizing on exemplar residents was effective at creating standards for sign-out.

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OBJECTIVE: To compare patient demographics and Rapid Estimate of Adult Literacy in Medicine (REALM) scores with respect to their ability to predict medication comprehension. METHODS: A survey was conducted of 100 patients presenting for follow-up at an academic primary care clinic serving a low socio-economic status population. The Medication Knowledge Score (MKS) consisted of knowledge of drug name, dose, indication, and a potential side effect for each of their medications and then averaged. The REALM (Rapid Estimate of Adult Literacy in Medicine) was administered and socio-demographic characteristics were recorded. The association of REALM score and patient characteristics with MKS was evaluated by univariate and multivariable regression analysis. RESULTS: The subjects' mean age was 62 with an average of 9.8 years of schooling and 5.9 prescription medications. Participants identified a correct indication for 78.8% of their medications and correct dosage for 93.4%. However, they could provide the name for only 55.8% of medications and a known side effect for only 11.7%. On multivariate analysis without including REALM score, younger age (p=.01), highest grade completed (p=.001), and female sex (p=.004) remained positively associated with MKS. When the model included REALM, REALM (p<.0001), age (p=.001), and sex (p=.04) remained independently associated with MKS. CONCLUSION: REALM score predicts medication knowledge as assessed by the MKS. However, age, last grade completed, and sex were also independently associated with mean MKS with a similar strength of association to that of REALM. This suggests that simpler cues to screen for medication knowledge deficits may also be useful. Since the MKS incorporates knowledge of medication indications and side effects, it may also be useful for quality and safety purposes.

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BACKGROUND: Despite increased attention to patient safety in recent years, physician involvement in hospital safety activities appears to have remained limited. METHODS: An anonymous survey of internal medicine housestaff and faculty physicians at an academic medical center assessed safety reporting behavior and witnessed adverse events or near misses. RESULTS: Although 65% of the 120 physicians responding (56% response rate) had not made any adverse event or near miss reports in the prior year, 60% had witnessed at least three adverse events or near misses. Uncertainty about reporting needs and mechanisms, concern about time required, perceived clinical import of the event in question, and lack of physician involvement in the system were all important reasons for failure to report. Concern about being blamed or judged less competent or similar consequences to others were considered less important barriers to reporting. The perceived degree of reporting barriers (p = .01) and number of witnessed adverse events or near misses (p = .005) were independently negatively associated with respondents' perception of safety. Most (58%) physicians expressed willingness to participate in the hospital safety process actively if requested. DISCUSSION: Physicians' barriers to safety reporting in an academic medical center are negatively associated with their perception of hospital safety. These barriers are remediable, and most physicians appear amenable to increased participation in the hospital safety process.

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BACKGROUND: Voluntary reporting of near misses/adverse events is an important but underutilized source of information on errors in medicine. To date, there is very little information on errors in the ambulatory setting and physicians have not traditionally participated actively in their reporting or analysis. OBJECTIVES: To determine the feasibility and effectiveness of clinician-based near miss/adverse event voluntary reporting coupled with systems analysis and redesign as a model for continuous quality improvement in the ambulatory setting. DESIGN: We report the initial 1-year experience of voluntary reporting by clinicians in the ambulatory setting, coupled with root cause analysis and system redesign by a patient safety committee made up of clinicians from the practice. SETTING: Internal medicine practice site of a large teaching hospital with 25,000 visits per year. MEASUREMENTS AND MAIN RESULTS: There were 100 reports in the 1-year period, increased from 5 in the previous year. Faculty physicians reported 44% of the events versus 22% by residents, 31% by nurses, and 3% by managers. Eighty-three percent were near misses and 17% were adverse events. Errors involved medication (47%), lab or x-rays (22%), office administration (21%), and communication (10%) processes. Seventy-two interventions were recommended with 75% implemented during the study period. CONCLUSION: This model of clinician-based voluntary reporting, systems analysis, and redesign was effective in increasing error reporting, particularly among physicians, and in promoting system changes to improve care and prevent errors. This process can be a powerful tool for incorporating error reporting and analysis into the culture of medicine.

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