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Unconscious Bias in Medicine

• Dr. Brian E. Gittens

Disclaimer

The following presentation is for the purposes of professional development and education. I have no conflict of interest or commercial bias with regard to the content found herein.

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Course Objectives

Participants will

• Examine their own background and identities, so that

they can interact more authentically with colleagues, clients and the community.

• Explore how the brain functions, so that they can

recognize unconscious bias as a natural function of the human mind.

• Be exposed to patterns of unconscious bias so that they

can navigate their impact on their inclusion and decision- making

• Be introduced to strategies and tools that can create

transformational intrapersonal change

What are your associations with bias?

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The McGurk Effect

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The Stolen Idea

FedEx Commercial

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As you look at each slide, note the feelings, judgments and reactions that emerge.

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Gender Skin tone Setting Body type Body posture Clothing Facial expression Ethnicity Age

What patterns do you notice?

John Fetterman

• Mayor of Braddock, PA (a suburb of Pittsburgh) – the tattoo on his arm is the

zip code!

• Has a Master’s degree in Public Policy from Harvard
• Served in the Americorps
• Received international media attention for the economic revitalization

programming he started in his community

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Pratibha Patil

• Economist,

attorney, and first female president of India 2007- 2012 Ted Bundy

• American

serial killer and rapist.

• Confessed

to killing 30 women

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Mae Jemison

• Physician
• Professor
• U.S.

Astronaut Jamison Green

• Educator,

Author, Speaker, Advocate

• Internationally

recognized expert

• Assigned

female at birth

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What is bias?

A tendency or inclination that results in judgment without question. A shortcut to interact with our world An automatic response

Mental associations without:

• Awareness
• Intention
• Control

These often conflict with our conscious attitudes, behaviors, and intentions.

What is Unconscious Bias?

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What function does bias serve?

• Helps us to create meaning out
• f what we observe
• Provides mental shortcuts
• Screens out information so that

we can concentrate on what we choose to focus on

• Keeps us alive

Impact of Bias Research

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Trends in Underrepresented Minority (URM) Faculty Compared to U.S. Population

Census data: The U.S. population between 2000 and 2008

• 3.5% decrease of Whites (69.1%

vs 65.6%)

• 3% increase in Hispanic/Latinos

(12.5% vs 15.4%)

• 0.2% increase in Black population

(12% vs 12.2%) AAMC Faculty Roster:

• The percent of medical school

faculty has not changed between 1990 and 2008 (for blacks 3% or Hispanics 4%), reflecting poorly compared to the U.S. population distribution

• For all groups, except Black

faculty, the total percentage of male outnumber female faculty by 2-fold

Merchant et al. (2010) University of Michigan Medical School

• 15% More likely to be shorter
• 24% At least one doubt raiser
• 3% Referred by title
• More references to personal life
• Hedges, faint praise, and

irrelevances

• It’s amazing how much she’s

accomplished

• It appears her health is

stable

• She’s close to my wife

Letters for Recommendation for Successful Medical School Faculty Applicants

Letters for Men Letters for Women

• 16% More likely to be longer
• 12% At least one doubt raiser
• 97% Referred by title
• 62% Were referred once as

“researcher”

• More references to
• CV
• Publications
• Patients
• Colleagues

Trix and Psenka (2003) Wayne State University

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SCIENCE FACULTY'S SUBTLE GENDER BIASES

FAVOR MALE STUDENTS.

• “John” was rated an average of 4 on a 7 point scale;

“Jennifer” was rated an average of 3.3

• The average starting salary offered to “John” was

$30,328; to “Jennifer” was $26,508

• John was also seen more favorably as someone

they might hire for their laboratories or would be willing to mentor.

• Female professors were just as biased as male

professors

• Dr. Jo Handelsman,

Yale University, 2012

Women and Minorities White Men

Experiences of Women and Minorities compared to White Men in Academic Medicine

Cropsey et al. (2008) Medical College of Virginia

• Lower academic ranking
• Less opportunities for advancement

and promotion

• Lower salary
• More reported incidents of

harassment and discrimination

• More likely to leave for personal

reasons

• Higher academic ranking
• More opportunities for advancement

and promotion

• Higher salary
• Less reported incidents of

harassment and discrimination

• More likely to leave for retirement

Women and minorities reported different experiences leaving faculty position compared to white men

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Implicit Bias in Medical Education

• Completing the race IAT alone significantly predicted a decrease in

implicit racial bias

• Hearing negative comment about African American patients from

an attending physician or resident and having an unfavorable experience with African American physicians were statistically significant predictors of increased implicit racial bias

3,547 medical students completed a web-based questionnaire and race preference Implicit Association Test (IAT)during first and last semester

• f medical school

Ryn et al. (2015) Mayo Clinic College of Medicine

Are Doctors Fattists?

Research testing 2284 medical doctors found that overall doctors show a strong implicit bias against overweight

• people. Men’s bias was

stronger than women’s, and bias was strongest among those tested who were the thinnest.

University of Washington, University of Virginia, University of Modena

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Conceptual Model of Medical Mistrust Describe the Experience

• f African American Men
• 65% of men reported at least one discriminatory experience while seeking healthcare
• 42% reported rarely receiving parental encouragement to engage with healthcare
• rganizations and older men had higher levels of medical mistrust
• Higher mistrust was reported when men expected differential treatment because of

their race, when reported more discrimination from their environment, and when men held more masculine role identity

• African American men reported having more trust in healthcare organization after a

recent high quality (patient centered) physician interaction Hammond (2010) University of North Carolina at Chapel Hill 216 men where recruited from the Midwest and Southwest area of the US and reported on background factors, identity and socialization factors, recent healthcare experience, recent socio-environmental experience, and care outcome expectations

Anterior Cingulate Cortex Amygdala Pre- Frontal Neocortex

System Two Thinking “Slow Brain” System One Thinking “Fast Brain”

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SLB CFLTK CFLTK SPRND HLMG CFLTK SLB SPRND SLB SPRND HLMG CFLTK HLMG SPRND CFLTK

John Ridley Stroop, 1935

RED GREEN YELLOW BLUE GREEN BROWN PURPLE YELLOW BLUE BROWN BROWN BLUE YELLOW GREEN RED

John Ridley Stroop, 1935

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Selective Attention

Awareness Test

36

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From Background to Bias to Impact

Background Bias Micro-behaviors Micro-messages Advantages Disadvantages Inequities/exclusion Equity/inclusion

The Unconscious is Malleable

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6 Ways to Mitigate Your Biases

Recognize and accept that you have bias

6 Ways to Mitigate Your Biases

Develop the capacity to use a flashlight on yourself

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6 Ways to Mitigate Your Biases

Practice “Constructive Uncertainty”

Take a P.A.U.S.E. A quick way to check your reaction.

• Pay attention to what’s actually happening, beneath

the judgments and assessments

P

• Acknowledge your own reactions, interpretations and

judgments

A

• Understand the other possible reactions,

interpretations and judgments that may be possible

U

• Search for the most empowering, productive way to

deal with the situation

S

• Execute your action plan

E

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6 Ways to Mitigate Your Biases

Explore awkwardness, and discomfort

6 Ways to Mitigate Your Biases

Engage with people you consider “others” and expose yourself to positive role models in that group

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6 Ways to Mitigate Your Biases

Get feedback

“You can out-distance that which is running after you, but not what is running inside you.”

Rwandan Proverb

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“Between stimulus and response, there is a space. In that space is

• ur power to choose our
• response. In our response lies our

growth and freedom.” Victor Frankl