Managing Our Implicit Bias Kimberly Curseen, MD Associate Professor - - PowerPoint PPT Presentation

Managing Our Implicit Bias

Kimberly Curseen, MD Associate Professor of Internal Medicine Emory School of Medicine Director of Emory Outpatient Supportive Care Clinic kacurseen@emory.edu

January, 17 2017

Join us for upcoming CAPC events

➔

Webinar:

– How to Use CAPC Membership: Wednesday, January 25, 2017 | 12:00-1:00 pm ET – The Effective and Efficient ED-Palliative Care Consult: Tuesday, February 7, 2017 | 1:30 - 2:30 pm ET

➔

Virtual Office Hours:

– Palliative Care models in the Community with John Morris, MD, FAAHPM: TODAY | 4:00 pm ET – Team Health and Wellness with Phil Higgins, PhD, LICSW: Thursday, January 19, 2017 12:00 pm ET – Palliative Care in Long Term Care Settings with Katy Lanz, DNP, ANP, GNP: Monday, January 23, 2017 | 12:00 pm ET – Ask Dr. Diane Meier: Open Topics: Monday, January 23, 2017 | 3:00 pm ET – Home Health Agencies Delivering Palliative Care in the Community with Bob Parker, DNP, RN, CENP, CHPN: Tuesday, January 24, 2017 | 2:00 pm ET – Ask a Program Leader: Open Topics with Andrew Esch, MD, MBA: Wednesday, January 25, 2017 | 2:00 pm ET (30 minute session)

2

Visit www.capc.org/providers/webinars-and-virtual-office-hours/

Managing Our Implicit Bias

Kimberly Curseen, MD Associate Professor of Internal Medicine Emory School of Medicine Director of Emory Outpatient Supportive Care Clinic kacurseen@emory.edu

January, 17 2017

➔I have no relevant disclosures

4

Objectives

➔ The learner will be able to define and identify

implicit bias

➔ The learner will be able to evaluate how culture can

affect interactions with patients

➔ The learner will be able to implement tools to

• vercome implicit bias to improve care given to

patients

5

Common language

6

➔ Implicit bias is the bias in judgment and/or behavior

that results from subtle cognitive processes (e.g., implicit attitudes and implicit stereotypes) that often

• perate at a level below conscious awareness and

without intentional control

➔ Ethnocentrism is the belief that one’s own cultural

view is the only correct view

➔ Prejudice is unreasonable feelings, opinions, or

attitudes, especially of a hostile nature, regarding an ethnic, racial, social, or religious group

➔ Racism is prejudice or discrimination directed against

someone of a different race based on such a belief

7

Implicit Bias: Kirwan Institute

➔ Implicit biases are pervasive. Everyone possesses them, even people with

avowed commitments to impartiality such as doctors.

➔ Implicit and explicit biases are related but distinct mental

• constructs. They are not mutually exclusive and may even reinforce each
• ther.

➔ The implicit associations we hold do not necessarily align with our

declared beliefs or even reflect stances we would explicitly endorse.

➔ We generally tend to hold implicit biases that favor our own in-group,

though research has shown that we can still hold implicit biases against our in-group.

➔ Implicit biases are malleable. Our brains are incredibly complex, and the

implicit associations that we have formed can be gradually unlearned through a variety of de-biasing techniques.

http://kirwaninstitute.osu.edu/research/understanding-implicit-bias/ 8

Implicit Bias

➔ Not recognizing the impact of implicit bias can prevent

palliative care providers from providing the type of care that our patient’s need and deserve

➔ Implicit bias can rob the palliative care provider of the

patient interactions along with the type of care that we find fulfilling, leading to frustration and contributing to burnout

➔ “I came here to help and I’m not helping, can’t they

see I am looking out for them”

Butler M et al. Improving Cultural Competence to Reduce Health Disparities; Agency for HealthCare Research and Quality; Mar 2016

9

Implicit Bias Impact

➔ A literature search performed by Partners in Equity &

Inclusion/Michelle Van Ryn revealed > 1000 studies detailing the inequalities and disparities and healthcare

➔ In systematic review published in the American Journal of Public

Health in 2015 it concluded that: “Although some associations between implicit bias and healthcare outcomes were nonsignificant, results showed that implicit bias was significantly related to patient– provider interactions, treatment decisions, treatment adherence, and patient outcomes”

➔ A study showed that racial bias reduces empathic sensorimotor

responses to patients complaints of pain

Avenanti et al. Racial bias reduces empathic sensorimotor resonance with other race pain. Current Biology 2010 Hall W. et al. Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. Amer J of Pub Health; 2015 http://www.p-e-i.org/

Implicit Bias Impact

➔ Beyond race: We should think

about implicit bias in a broader sense, looking beyond race to factors such as: gender, generation/age, transgender, women, children, social economic status, language, disability, LGBQ, political affiliation, prisoner, religion, etc

➔ “Basically if you are looking at

someone who is not you, you should consider if or how implicit bias maybe affecting your actions”

11

Strategies to managing implicit bias

Mindfulness Deliberate Behavior Perspective Taking Skills Shared Decision Making Self awareness

12

Self awareness

➔ “In order to fix a problem it is necessary to be

aware that there is a problem and be willing to work on it”

13

Self awareness

➔ Study by Michelle Van Ryn published in 2016 concluded that

– “most physicians were unaware of their own biases” – “research shows that unintentional bias on the part of physicians can influence the way they treat patient’s from certain ethnic and racial groups”

➔ Study in Journal of General Internal Medicine in 2013

reviewed literature on implicit bias pertaining to physicians which concluded:

– “The contribution of implicit bias to healthcare disparities could decrease if all physicians acknowledge their susceptibility to it, and deliberately practice perspective taking and individuation when providing patient care”

Chapman EN et al. Physicians and implicit Bias; How Doctors May unwittingly perpetuate healthcare disparities. J Gen Intern Med. 2013 Van Ryn M. Minn med. 2016 Mar-Apr

14

How do you become self aware?

➔First we need to understand us. Why do

we struggle with this?

http://www.sensanalysis.com/news/implicit-vs-explicit-product-research-which-one-should-be-conducted/

15

Affective Flash

➔ We can develop cognitive beliefs that are consistent with our

first emotional response

➔ This could influence our nonverbal behavior and set up

essentially a negative feedback loop that reinforces our cognitive belief Example: I’m going out to do a home visit and when I drive up I see a very large Confederate flag hanging over-the-door. What do you suppose my Affective Flash could be?

16

Self awareness

➔Implicit-Association Test (IAT) is

designed to detect the strength of a person's automatic association between mental representations of

• bjects/concepts in memory

17

Self Reflection

I’m going out to do a home visit and when I drive up, I see a very large Confederate flag hanging over-the-door. There are couple of very large dogs barking at me while I am sitting in my car. The husband of my dying patient

• pens the door and waves me in. When I walk in the

house none of the several family members acknowledge my presence. I see a Rebel Yell poster on the wall. The floor has parts that are rotted and I have to step over them to get to my patient’s bedside. There is a space heater in the corner.

18

Self Reflection

My patient’s husband offered to take my bag and

• ffer me a glass of water. I decline and said I’m okay.

I ask to examine her and discuss my concerns with him and afterwards he expressed his fear that he thinks she is dying. I develop a plan to immediately take her to inpatient because a storm is coming and they frequently experience power outages. I return to my car with his son following at a distance behind me.

19

Self Reflection

I get in my car and lock my door. I ask him through the window is there something I can do or answer for him. He says no but asks if the doctor is coming. I explain I am the doctor but Kelly her nurse is on her way. “She knows your mom really well.” I get a little nervous and call Kelly “Hey I think she needs to go to inpatient, but not sure they can handle it especially if they lose power. Her husbands says yes but I am worried that he may change his mind. Maybe if you tell them they will hear from you. They really trust you.”

20

Self Reflection

➔What did you see in my reflection of

events?

➔What implicit bias could you identify? ➔How did I express my bias? ➔Did my bias affect the outcome? ➔What do I do now?

21

Self Awareness

➔ Self awareness: (what is the real problem?) – When I drove up and began to have emotions – Took time to sit in my car (can’t deal with my emotions in the patient’s house) spent a few minutes identifying those emotions (naming the emotion)

• Fear: am I safe here
• Anger: how can someone still think this is okay
• Resentment: after everything I have achieved, I still have to

walk in that house with a smile and perform a service to people who probably don’t recognize my basic humanity or may not care, and act like it is okay

• Uncertainty: they may not listen to me or understand me, what

if I make it worse for them

• Shame: I may have to call my partner if they won’t listen to me,

they will hear it from him and everyone will know why, they will look at me with pity at IDT

22

Self awareness

So what was the real problem? The problem was looking back at me in my review mirror. In that moment I was the problem. I had no frame of reference for who I was actually going to meet in the house. The symbol of that flag caused me to experience affective flash allowing me to create an unconscious narrative. In reality, if I am not aware of my real feelings, I could pass them

• ff as being tired, busy, distracted or feeling disconnected from

work today. My feelings become manifested, even if subtlety, in the way I interact with my patient’s family.

23

Self awareness

➔ A study examining 3rd year medical students engaged

in small group discussion about bias

➔ Students split into groups either using normative

standards for reflection or personal standards for reflection

– Normative standards: Reflecting on what is appropriate and what good clinicians should do & think in situations – Personal standards: Reflection on how they feel and respond in situations and what is their personal standard

➔ Students who reflected based on personal standards

were better able to reconcile personal biases

Hernandez R. et al. Fostering student Reflections about bias in healthcare: Cognitive dissonance and the role of personal and normative standards: 2012

24

Mindfulness

➔ Mindfulness training: a mental state achieved by

focusing one's awareness on the present moment, while calmly acknowledging and accepting one's feelings, thoughts, and bodily sensations, used as a therapeutic technique.

– Focuses on development through practice – Promotes a non judgement approach – Promotes a holistic approach to promoting providers well being – Implicit bias affects behavior through a two phase process: activated and applied

Burgress D. et al. Mindfulness practice: A promising approach to reducing the effects of clinician implicit bias on patient. Patient Educ Couns: 2016

25

Mindfulness

➔ Mindfulness:

– Reduce the likelihood that implicit biases will be activated in the mind – Increase provider awareness

• f implicit biases

– Increase ability of providers to control implicit bias – Increase compassion/empathy towards patient – Increase self-compassion – Reduces stress, burnout, compassion fatigue

Burgress D. et al. Mindfulness practice: A promising approach to reducing the effects of clinician implicit bias on patient. Patient Educ Couns: 2016

26

Mindfulness

➔ I can practice some general mindfulness/meditation in the car

– Set aside some time – Observe the present moment as it is – Let your judgements roll by – Return to observing the present moment as it is – Allow mind to wander

➔ This allows me to calm myself internally because even if I am aware

• f the emotions, I have to learn to deal with them so I can walk in the

house as openly as I possibly can or the “Get your mind right and fix your face technique”

➔ Better to take a time out, or even come back another time vs forging

ahead when you are internally not prepared; stakes can be to high at times

27

Deliberate behavior

➔ Many physicians and palliative care practitioners possess natural

abilities that make them good communicators

➔ Skills that are learned in workshops and fellowships should be mastered.

When communication is difficult natural skills may become unreliable, because we are uncomfortable

➔ Rely on deliberate behaviors such as: greetings, sitting with open

posture, therapeutic silence, I am concerned/wish statements, empathic statements etc…

➔ Monitoring & discouraging bias amongst teams (you can support &

reframe a team member’s frustration without cosigning a bias point of view) – Ex: “I hate seeing fibromyalgia they are all nuts” response “How is it going today? Is there something I can do to help? I haven’t found that but managing chronic pain is a beast.”

28

Deliberate behaviors

➔Other Race effect and implicit bias

– Other race training reduces implicit bias – Having Caucasian participants exposed to African American faces until they were able to make distinctions which resulted in identification of individuals – This correlated with decrease in racial bias – Implicit bias is pervasive in humans but biases are malleable and can be modified with training

Lebrect S. Perceptual Other-Race Training Reduces Implicit Racial Bias. PLoS One: 2009

29

Deliberate behaviors

➔ Behaviors I could have employed

– Took time to introduce myself and my role to her family – Ask to sit with her husband and any other family members who had questions – Accepted the offer of water or holding my bag (this would have been culturally appropriate) – Once I realized the son was following me, stop introduce myself and inquire if he had questions or concerns

30

Deliberate behaviors

➔Taking time to understand the culture of your

patient helps to fill your tool box with deliberate behaviors

➔Understanding can take you from deliberate

behavior to true empathy

➔“Feel how you feel but it matters what you do”

31

Perspective Taking

➔ Perspective Taking is the cognitive component of

empathy

➔ Perspective Taking has been shown to inhibit

activation of implicit bias

➔ Employing perspective taking as a skill will help

• ur communications seem less threatening when

interacting with people with different values systems

Galinsky AD. The effect of perspective taking on prejudice; the moderate role of self evaluation. Pers. Soc Pyschol Bull : 2004 Van Ryn M. Partners in Equity & Inclusion: 2016

Perspective Taking

➔ Step 1: As soon as two people share a common

space, they have a thought about each other

➔ Step 2: Consideration of the other person's intentions

and motives

➔ Step 3: Each person considers what the other may be

thinking about them

➔ Step 4: Monitor and possibly modify behavior to keep

the other person thinking about them the way they want to be thought of

Cynthia W. et al. Perspective-Taking Increases Willingness to Engage in Intergroup Contact. Plos Once: 2014 https://www.socialthinking.com/Articles?name=Social%20Behavior%20Starts%20with%20Social%20Thought%204%20steps%20PT

33

Perspective Taking

➔ If you are concerned whether or

not a question or an action is appropriate ask:

– In order to best understand how to help you could you please help me to better understand your culture? – We are recommending….how has this been handled by other doctors in your community in the past? – Was my explanation clear and could you share with me what you understood?

34

Perspective Taking

➔ I could have stopped to consider whether I was

misinterpreting signals I thought I was receiving

➔ Could they have been mirroring my discomfort?

– Was I warm? – Did I smile? – Was I formal or folkies?

➔ “If I was in their shoes” what could the flag mean? ➔ How did it make him feel when I refused his offer?

What did he think I was thinking?

35

Decision-making process

36

Shared Decision Making

➔ Develop a partnership with a

patient

➔ Establish or review the patient's

preferences for information

➔ Establish or review the patient's

preferences for his or her role in decision-making (e.g., risk taking and degree of involvement of self and others) and the existence and nature of any uncertainty

➔ Ascertain and respond to the

patient's ideas, concerns and expectation

➔ Identify choices (including ideas

and information the patient may have) and evaluate the research evidence in relation to the patient

➔ Present evidence, taking into

account patient preferences; help the patient to reflect upon and assess the impact of alternative decisions with regard to his or her values and lifestyles

➔ Negotiate a decision in

partnership and resolve conflict

➔ Agree upon an action plan and

complete arrangements for follow up

Edwards, A. et al. Evidence-based Patient Choice (1st ed.). Oxford, England: Oxford University Press: 2001 Elwyn, G. et al. "Shared Decision Making: Developing the OPTION Scale for Measuring Patient Involvement." Quality and Safety in Health Care : 2003 Makoul G. et al An Inegrative Model of Shared decision making in medical Encounters. Patient Education and Counseling: 2004

Shared Decision Making

➔ I became nervous (lack confidence) about my plan because in

retrospect it was my plan and it satisfied my concerns about what was best for my patient and family

➔ Did my implicit bias concerning educational level &

socioeconomic status cause me not to engage in shared decision making? Hey maybe they had a generator … how would I know?

➔ Did my implicit bias cause me not to engage more than I had

to?

➔ “I completed my task but not sure if I did my job.”

38

Culture

➔ Culture: learned patterns of behaviors, beliefs, and

values shared by individuals in a social group

➔ Culture is a strong factor in determining how

people make health care decisions and view the nature of death and dying

➔ Death and dying is a culturally specific experience

as well as a universal one

39

Culture

➔ Culture influences health care provider’s thought

processes and behaviors just as much as it influences their patients

➔ Understanding how our own cultural beliefs effect us is

a necessary first start to understanding our patients

➔ Why is this true?

40

Culture: Name 3 cultures you belong to

➔ Awareness of cultural diversity can

enhance your communication but do not use it as a substitute for exploration of an individual patient’s background

➔ People are more than their ethnicity

and we need to start by understanding how they define themselves

➔ Communities of people are not

homogenous; the root of many

• ffenses stems from assumptions

– (Religion, education, age, geography, political affiliation, etc)

41

Culture

➔Western

– Individualism – autonomy

➔Non Western

– Interdependency – Hierarchy

42

Case study

➔78 yro female with stage 4 breast cancer tells

you that she is tired of chemotherapy and she wants to be comfortable. Her chemotherapy has been painful and unsuccessful. You believe she is dying. She says “I just want to live out the rest of my time pain free.”

➔ You as her doctor agree and you both make

a plan for her comfort. The next morning her husband and children ask you when is her next round of chemo.

43

➔ You look at the patient and she is looking at her

bed sheets. You explain that chemo is not likely to be helpful and that you recommend comfort and you thought that would be acceptable.

➔ Her son states “We don’t give up.” Your patients

looks at you and says “yes doctor when do we get started”.

➔ You ask her later when she is alone “I thought you

did not want more chemo?” She says “ I know it is not going to…we are going to have to.”

44

➔How do you feel about this scenario? ➔What do you think is the right thing to do

now?

➔How do you best honor her wishes? ➔What may be influencing how she makes a

decision? Can you accept her decision?

45

Culture

Depending on a patient’s value system, they may see themselves as “whole entity unto themselves” connected but separate vs. seeing themselves although independent, but first and foremost as a part of a larger body “having self but not fully belonging to self”

46

Culture

Western

➔ Communication

– Right to know – Direct communication is most ethical approach

➔ Social structure

– Equality

➔ Timing of death

– Controlled, respect for autonomous choices – Avoidance of suffering

➔ Nonverbal

Communication

– Direct communication

Non Western

➔ Communication

– Family decision making – Patient protection

➔ Social structure

– Hierarchy

➔ Timing of death

– Preordained, fate – Suffering may hold meaning

➔ Nonverbal

Communication

– Respect rituals silences, body language

47

Culture

➔ Awareness of value systems that are different from yours will

not change you views but will instead assist you in understanding the choices your patients may make while fostering the empathy needed for establishing trust and the intimate connections we need to do our job properly

➔ Be mindful that although autonomy is important to you, it is

not a universal value

➔ Remember that one of our palliative care goals is:

– Treatment is congruent with the values, beliefs, and concerns of the patient and family ( we are reaching their goals not our goals) vs “I want you to have what I want you to have because it is so awesome”

48

Culture

➔ As palliative care providers we represent a

culture which is new to our patients

➔ In some cases our patients are not only

adjusting to their illness but this new culture they are entering

– Palliative care – Healthcare culture

➔ We are ambassadors of our society

49

Should we be color blind? Identifying the other

➔ Why when you present are you telling me this is a “22 yr. old

Latino male with a Pmhx of……” anyway?

– Information concerning a patient’s ethnicity should add to the patient’s clinical picture – Telling me a patient is an elderly Caucasian male with depression and possible SI is helpful because of the link between suicide and this group (I would not ignore RF in other groups)

➔ “Seeing my differences does not make you biased; not respecting my

differences or allowing your fear of my differences to affect how you treat me does”

50

Summary

➔ Being self aware of how your culture and implicit biases influences you, can

help you communicate with your patients and recognize why interactions may be going poorly or well

➔ Mindfulness training can be an added benefit to palliative care training by

helping us manage implicit bias

➔ Being deliberate in our communication will not change our implicit biases

but can help minimize their adverse affects

➔ Perspective taking can open us up to true empathy which promotes

acceptance and support of our patients and their decisions as they are and not as we wish them to be

➔ If you are not able to create a trusting interaction with a patient or family it is

• kay to admit this and help them find a provider who can meet their needs

51

Summary

➔ Trust is built everyday across ethnic and cultural lines ➔ Creating an environment of mutual respect ➔ Listening and validation ➔ Consistency and willingness to provide help ➔ Cultural awareness is a useful tool for optimizing our interactions by

allowing us to improve patient care and access to care

52

Questions and Comments?

Please type your question into the questions pane

• n your webinar control panel.