Skin Tone and Gender of High-Fidelity Simulation Manikins in Emergency Medicine Residency Training and their Use in Cultural Humility Training

INTRODUCTION: It is important for physicians to learn how to provide culturally sensitive care. Cultural humility is defined as a lifelong process with a goal of fixing power imbalances and creating institutional accountability through learning about another’s culture as well as performing self-exploration about one’s own beliefs, identities, and biases. One way to teach cultural humility in medicine is simulation. However, there are no peer-reviewed published studies that examine whether the skin tone or gender of the high-fidelity simulation manikins (HFSM) used by emergency medicine (EM) residency programs reflects the US population nor whether high-fidelity simulation is used to teach cultural humility. We aimed to address that gap in the literature. Our primary objective was to evaluate what proportion of EM residency programs use HFS to teach cultural humility. Our secondary objective was to evaluate whether the skin tone and gender breakdown of the EM residency program HFSM is representative of the US population. METHODS: We conducted a simple random sample of 80 EM residency programs to characterize HFSM and cultural humility training. Selected programs were emailed a questionnaire. Key outcomes included HFSM skin tone and gender and whether cultural humility was taught via HFSM. We calculated point and interval estimates for the proportion of dark-, medium-, and light-toned skin and the proportion of female and male manikins. Confidence intervals were employed to test the null hypothesis that dark/medium/light skin tone was 20/20/60 and that the female/male ratio was 50/50. Both ratios were extrapolated from the US Census data. RESULTS: Our response rate was 74% (59/80). Fifty-five of 59 EM residency programs that had manikins (0.93, 95% confidence interval [CI] 0.88–0.99) reported data on a total of 348 manikins. Thirty-nine of the 55 programs with manikins reported using HFS to teach cultural humility (0.71, 95% CI 0.60–0.82). Proportions of light-, medium-, and dark-toned manikins were 0.52 (0.43–0.62), 0.38 (0.29–0.47), and 0.10 (0.07–0.14), respectively. Proportions of male and female HFSM were 0.69 (0.64–0.76) and 0.31 (0.24–0.36), respectively. The null hypotheses that skin tone follows a 60/20/20 split and gender follows a 50/50 split were rejected, as not all confidence intervals contained these hypothesized values. CONCLUSION: While most EM residency programs surveyed use high-fidelity simulation to teach cultural humility, the manikins do not reflect either the skin tone or gender of the US population.