[PPT] - Bias and Equity Implicit Bias & Health Care Disparities Two PowerPoint Presentation

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Implicit Bias, Race and Medical Care

Kate Lupton, MD Sarah Schaeffer, MD, MPH University of California, San Francisco

We have nothing to disclose

Bias and Equity

Two sides of the same coin

Quality of Health Care

Non Minority Minority

Clinical Appropriateness & Need Patient Preferences The Operation of Health Care Systems Discrimination: Biases, Stereotyping, and Uncertainty

Difference

Populations with Equal Access to Health Care

Disparity Gomes and McGuire, 2001.

Implicit Bias & Health Care Disparities

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Medicine is talking about it

Provider-Patient Encounter Patients’ Perception of Care

Healthcare Worker’s Attitudes & Beliefs Treatment Practices

Medical School Admission Graduate School Admission Faculty Hiring and Promotion

Trust in physician Perceptions & Experience

f Care

Trust in physician Perceptions & Experience

f Care

Healthcare Workforce

Communication

How Implicit Bias Impacts Healthcare

Provider-Patient Encounter Patients’ Perception of Care

Healthcare Worker’s Attitudes & Beliefs Treatment Practices

Medical School Admission Graduate School Admission Faculty Hiring and Promotio n

Trust in physician Perceptions & Experience

f Care

Trust in physician Perceptions & Experience

f Care

Healthcare Workforce

Communication

How Implicit Bias Impacts Healthcare

Objectives

Describe implicit racial bias and how it

develops

Recognize how implicit bias about race can

impact health care providers and patients

Identify strategies to reduce the impact of

implicit biases

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Development of Implicit Bias

– Evolutionary, Historical, and Structural Basis – Messaging that contributes to implicit bias

Examples of Implicit Bias and Patient Care

– Treatment decisions – Prevalence of bias among healthcare providers – Communication & experience of care

Tools to Counter Implicit Bias

– Reducing biased behavior – Reducing personal bias

Overview

Development of Implicit Bias

– Evolutionary, Historical, and Structural Basis – Messaging that contributes to implicit bias

Examples of Implicit Bias and Patient Care

– Treatment decisions – Prevalence of bias among healthcare providers – Communication & experience of care

Tools to Counter Implicit Bias

– Reducing biased behavior – Reducing personal bias

Overview Implicit Bias Defined

Bias - Prejudice in favor of or against one thing,

person, or group compared with another, usually in a way that is unfair. (Oxford Dictionary)

– Explicit (conscious) – Implicit (unconscious)

Implicit Bias - Social stereotypes about certain groups
f people that individuals form outside their own

conscious awareness (Fiske & Taylor, 1991; Valian, 1998)

How Implicit Bias Develops

1) Evolutionary Basis

Humans process huge amounts of

environmental stimuli  organize into categories with similar characteristics

Evolutionarily helpful to quickly categorize
Categorization is hard wired, even as

categories themselves evolve

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How Implicit Bias Develops

Frank, R. Trolley—New Orleans, 1955

How Implicit Bias Develops

2) Historical Basis

Specific to each environment: our country,

state, city, community

Long history of marginalization and injustice

3) Structural Basis

Systemic discrimination and oppression

We All Have Implicit Bias

Usually incompatible with our conscious values and

beliefs

“The result of mental associations that have formed

by direct and indirect messages we receive about different groups of people” (Staats 2016)

Origins of Implicit Bias - Race

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Origins of Implicit Bias - Gender

"There's the guy responsible for turning Katinka Hosszu, his wife, into a whole different swimmer” – NBC commentator on Olympic Gold medal swimmer’s coach

Origins of Implicit Bias Gender and Race

“Oh, say can you see … the Olympic gold medalist slouching during the playing of the U.S. national anthem? Her expression was blank and distant. By all means, do not use the podium to pout, and it seemed like Gabby Douglas was simply pouting.” "No apologies from [Lochte] or other athletes are needed…We have to understand that these kids were trying to have fun. Let's give these kids a break. Sometimes you make decisions that you later regret. They had fun, they made a mistake, life goes on."

Origins of Implicit Bias Gender and Race Measuring Implicit Bias

Implicit Association Test (IAT)

Introduced in 1998: >15 million participants
Used widely to measure implicit bias
Measures time to match representatives of social

groups (age, gender, race, others) to particular attributes (good, bad)

Quicker matching = strong unconscious linkage
Relatively resistant to social desirability concerns

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implicit.harvard.edu Measuring Implicit Bias

Development of Implicit Bias

– Evolutionary, Historical, and Structural Basis – Messaging that contributes to implicit bias

Examples of Implicit Bias and Patient Care

– Treatment decisions – Prevalence of bias among healthcare providers – Communication & experience of care

Tools to Counter Implicit Bias

– Reducing biased behavior – Reducing personal bias

Overview Race and Pediatric Pain Management

Goyal et al, JAMA Pediatrics. 2015

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Race and Pediatric Pain Management

Goyal et al, JAMA Pediatrics. 2015

Race and Pediatric Pain Management

Goyal et al, JAMA Pediatrics. 2015

Sabin & Greenwald, AJPH. 2012

Race and Pediatric Pain Management

As pediatricians implicit pro-white bias increased

Less likely to recommend opioid

treatment for African American children

Recommendations for white children

did not change

Race and Thrombolysis

Green et al., JGIM. 2007

Black Patients White Patients Patient likely to have CAD 40.1% 29.8% Very likely to offer thrombolysis 42.7% 58.2%

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Race and Thrombolysis

Green et al., JGIM. 2007

Healthcare providers across disciplines and

training levels have implicit racial biases

Variable association between provider implicit

bias and patient treatment recommendations and outcomes

Consistent association between implicit bias

and poorer provider-patient communication

Maina et al., Soc Sci & Med. 2017

Implicit Bias in Healthcare Providers Race, Bias and Communication

Explicit attitudes → objecve rangs of verbal

friendliness

Explicit attitudes → self-perceived friendliness
Implicit attitudes → objecve rang of non-

verbal friendliness

Implicit attitudes → partner’s perception of

friendliness

Dovidio et al., J Personality and Social Psychology. 2002 Blair et al., Ann Fam Med. 2013

Implicit Bias and Communication

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Implicit Bias and Communication

Black Patients White Patients Objective

bservations

Patient perceptions

Cooper et al., AJPH, 2012

PCPs with high levels of pro-white implicit bias

↑ verbal dominance
↓ pt positive affect
↑ verbal dominance
↓ respect for paent
↓ like clinician
↓ confidence in

clinician

↓ recommend to
thers
↑ respect for paent
↑ clinician likes

patient

↓ clinician is

participatory

Implicit Bias and Communication

Black Patients White Patients Objective

bservation

Patient perception

Cooper et al., AJPH, 2012

PCPs with high levels of stereotypes of Blacks as non-adherent

longer visits
slower speech
↓ pt-centered

dialogue

shorter visits
faster dialogue
↓ clinician verbal

dominance

↑ clinician posive

affect

↑ pt-centered dialogue
↓ involvement in

decisions

↓ likelihood of

recommending

↓ trust
↓ confidence in

provider

↓ involvement in

decisions

Development of Implicit Bias

– Evolutionary, Historical, and Structural Basis – Messaging that contributes to implicit bias

Examples of Implicit Bias and Patient Care

– Treatment decisions – Prevalence of bias among healthcare providers – Communication & experience of care

Tools to Counter Implicit Bias

– Reducing biased behavior – Reducing personal bias

Overview When Implicit Bias is Triggered

Busy
Have competing responsibilities
Multi-tasking
Under high pressure
Have less personal experience with other

group members

Need to fill in information gaps
Asked to use pattern recognition

Environments where we are…

36

CLINICAL MEDICINE!!

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Making the Unconscious Conscious

Recognize and identify our biases
Understand the cognitive and structural

foundations of our implicit biases

Having implicit/unconscious biases ≠ being a

“bad” person

Addressing Implicit Bias implicit.harvard.edu

Response to the IAT - We All Carry Biases

"I took [an implicit association test] the first time, and it told me that I had a moderate preference for White people… I was biased - slightly biased - against Black people, toward White people, which horrified me because my mom’s Jamaican. The person in my life who I love more than almost anyone else is Black, and here I was taking a test, which said, frankly, I wasn’t too crazy about Black people, you know? So, I did what anyone else would do: I took the test again! Maybe it was an error, right? Same result. Again, same result, and it was this creepy, dispiriting, devastating moment."

Malcolm Gladwell in 2007, speaking to Oprah Winfrey

Addressing Implicit Bias

Decrease biased behavior

Improve decision making conditions

Slow down, be mindful and objective

Counting

Use objective data to notice patterns

Brewer, 1988. Fiske & Neuberg, 1990. Monteith, 1993. Burgess et al., 2007 Godsil et al, 2014

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Individuation

Learn individual stories and characteristics

Stereotype replacement

Recognize responses based on stereotypes

Increase opportunities for contact

Who has a voice - personally and professionally

Brewer, 1988. Fiske & Neuberg, 1990. Monteith, 1993. Burgess et al., 2007 Godsil et al, 2014

Addressing Implicit Bias

Decrease personal bias

Conclusions

Unconscious creation of stereotypes and bias is

unavoidable

Implicit bias plays a role in health disparities
Implicit bias worsens communication with

patients

Awareness of personal biases is an important

first step

Strategies to mitigate personal bias exist and