Fostering students' reflection about bias in healthcare: Cognitive dissonance and the role of personal and normative standards

Background: To reduce cognitive dissonance about one's beliefs or behavior, individuals may compare their behavior to personal and/or normative standards. The details of this reflection process are unclear. Aims: We examined how medical students compare their behavior or beliefs to standards in discussions about implicit bias, and explored if and how different reflective pathways (preserving vs. reconciling) are associated with each standard. Methods: Third-year students engaged in a small-group discussion about bias. Some students and group facilitators also participated in a debriefing about the experience. Using qualitative methods, the transcripts from these 11 sessions were analyzed for evidence of student comparison to a standard and of reflection pathways. Results: Of 557 text units, 75.8% could be coded with a standard and/or a path of reflection. Students referenced personal and normative standards about equally, and preserved or reconciled existing beliefs about equally. Uses of normative standards were associated with preservation-type reflection, and uses of personal standards with reconciliation-type reflection. Conclusions: Normative expectations of physicians are sometimes used to provoke students' consideration of implicit biases about patients. To encourage critical reflection and reconciliation of biased beliefs or behavior, educators should frame reflective activities as a personal exercise rather than as a requirement.