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4/3/2019 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. 1

4/3/2019 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 Course recognize unconscious bias as a natural function of the human mind. Objectives • 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? 2

4/3/2019 The McGurk Effect 3

4/3/2019 The Stolen Idea FedEx Commercial 4

4/3/2019 As you look at each slide, note the feelings, judgments and reactions that emerge. 5

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4/3/2019 Gender Ethnicity Skin tone Age What Setting patterns Facial expression do you notice? Body Body type posture Clothing 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 8

4/3/2019 Pratibha Patil • Economist, attorney, and first female president of India 2007- 2012 Ted Bundy • American serial killer and rapist. • Confessed to killing 30 women 9

4/3/2019 Mae Jemison • Physician • Professor • U.S. Astronaut Jamison Green • Educator, Author, Speaker, Advocate • Internationally recognized expert • Assigned female at birth 10

4/3/2019 What is bias? A tendency or inclination that results in judgment without question. An automatic A shortcut to response interact with our world What is Unconscious Bias? Mental associations without: • Awareness • Intention • Control These often conflict with our conscious attitudes, behaviors, and intentions. 11

4/3/2019 What function does bias serve? • Helps us to create meaning out of 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 12

4/3/2019 Trends in Underrepresented Minority (URM) Faculty Compared to U.S. Population Census data: AAMC Faculty Roster: • The percent of medical school The U.S. population between 2000 faculty has not changed between and 2008 1990 and 2008 (for blacks 3% or • 3.5% decrease of Whites (69.1% Hispanics 4%), reflecting poorly vs 65.6%) compared to the U.S. population • 3% increase in Hispanic/Latinos distribution (12.5% vs 15.4%) • For all groups, except Black • 0.2% increase in Black population faculty, the total percentage of (12% vs 12.2%) male outnumber female faculty by 2-fold Merchant et al. (2010) University of Michigan Medical School Letters for Recommendation for Successful Medical School Faculty Applicants Letters for Men Letters for Women • 15% More likely to be shorter • 16% More likely to be longer • 24% At least one doubt raiser • 12% At least one doubt raiser • 3% Referred by title • 97% Referred by title • More references to personal life • 62% Were referred once as • Hedges, faint praise, and “researcher” irrelevances • More references to o It’s amazing how much she’s o CV accomplished o Publications o It appears her health is o Patients stable o Colleagues o She’s close to my wife Trix and Psenka (2003) Wayne State University 13

4/3/2019 S CIENCE 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 Experiences of Women and Minorities compared to White Men in Academic Medicine Women and minorities reported different experiences leaving faculty position compared to white men Women and Minorities White Men • • Lower academic ranking Higher academic ranking • • Less opportunities for advancement More opportunities for advancement and promotion and promotion • • Lower salary Higher salary • • More reported incidents of Less reported incidents of harassment and discrimination harassment and discrimination • • More likely to leave for personal More likely to leave for retirement reasons Cropsey et al. (2008) Medical College of Virginia 14

4/3/2019 Implicit Bias in Medical Education 3,547 medical students completed a web-based questionnaire and race preference Implicit Association Test (IAT)during first and last semester of medical school • 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 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 15

4/3/2019 Conceptual Model of Medical Mistrust Describe the Experience of African American Men 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 • 65% of men reported at least one discriminatory experience while seeking healthcare • 42% reported rarely receiving parental encouragement to engage with healthcare organizations 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 Anterior Cingulate System System Two Cortex One Pre- Thinking Thinking Frontal “Slow Neocortex “Fast Brain” Brain” Amygdala 16

4/3/2019 John Ridley Stroop, 1935 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 17

4/3/2019 Selective Attention Awareness Test 36 18

4/3/2019 From Background to Bias to Impact Background Bias Micro-behaviors Micro-messages Advantages Disadvantages Inequities/exclusion Equity/inclusion The Unconscious is Malleable 19

4/3/2019 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 20

4/3/2019 6 Ways to Mitigate Your Biases Practice “Constructive Uncertainty” Take a P.A.U.S.E. A quick way to check your reaction. P • Pay attention to what’s actually happening, beneath the judgments and assessments A • Acknowledge your own reactions, interpretations and judgments U • Understand the other possible reactions, interpretations and judgments that may be possible S • Search for the most empowering, productive way to deal with the situation E • Execute your action plan 21

4/3/2019 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 22

4/3/2019 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 23

4/3/2019 Victor Frankl “Between stimulus and response, there is a space. In that space is our power to choose our response. In our response lies our growth and freedom.” 24