"It's Kind of a Hidden Code": An Exploratory Study of Residents’ Experiences Caring for People with Sickle Cell Disease on the Internal Medicine Wards

introduction: Sickle cell disease (SCD) hospitalizations are rising in Canada. Painful vaso-occlusive episodes (VOEs) are responsible for 90% of acute health care visits for patients with SCD and are often recurrent with more than 50% of patients being re-admitted in the first month after discharge. Yet, there is little medical education literature on SCD and pain management. Also, while it is known that anti-black racism leads to poorer healthcare outcomes for SCD patients, there is no literature on how this impacts medical education, particularly when it comes to internal medicine residents.

Objectives: To determine the training experiences and gaps in knowledge, skills, and attitudes of internal medicine residents who care for patients with SCD suffering from VOEs.

Methods: We conducted a qualitative study using in-depth, one-on-one interviews with internal medicine residents at the University of Toronto. A semi-structured interview guide was iteratively developed by the study team to explore topics around experiences caring for patients with SCD, the perception of bias in in-patient care for SCD, and training and education around SCD and VOEs. Participant demographics were also collected (post-graduate year, gender, race, and number of patients with SCD cared for). Both purposive and snowball sampling were used for recruitment. All interviews were recorded and professionally transcribed. Qualitative content analysis guided the analysis phase. Codes were developed inductively and discussed between three coders (FK, WY, JZ) until consensus was reached. Interview memo notes were also incorporated in the analysis to capture body language and context that may be missed in the transcription. After four interviews, coders began reading transcribed interviews to conduct analysis. Concurrent analysis allowed the research team to look for thematic saturation. Research ethics approval was obtained.

Results: Twelve interviews were completed. Five participants identified as female, and seven as male. Most participants (5/12) were in their post-graduate year 2, and 10/12 participants described having significant exposure to patients with SCD (>3 patients per year). Participants self-reported race included 3/12 South Asian, 3/12 Arab, 2/12 Caucasian, 1 Asian, 1 Black, amongst others. Preliminary findings after analyzing 5 transcriptions are summarized in Table 1. Patients with SCD are treated differently than other in-patients for their care, whether this is operationalized through an unspoken hidden code within healthcare providers or through racial biases. For many internal medicine residents, trust between them and their patient with SCD is paramount: patients with SCD have historically distrusted physicians and the healthcare system. Some patients, however, are still willing to listen to their counselling physicians and allow residents to change their care plan. There is little SCD and pain education taught during residency and much of pain management is learned from cancer or palliative pain. Residents remain feeling uncomfortable managing the pain of patients with VOEs.

Conclusion: While these are preliminary findings, they support a wider literature that demonstrates inadequate SCD education during medical training. This study was completed in the largest SCD centre in Canada and yet, educational deficiencies were still noted amongst rotating internal medicine residents suggesting that they are widespread. We hope to use these findings to develop curricular recommendations for training in the management of VOEs, implicit bias training of internal medicine residents, as well as develop teaching moments around health care disparities and societal inequities regarding delivery of care to individuals with SCD.

Liederman:SOBI: Membership on an entity's Board of Directors or advisory committees.