Objectives Review the impact of bias on clinical care Caring for - - PowerPoint PPT Presentation

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Nicole Rosendale, MD

Assistant Professor of Neurology UCSF/ZSFG Recent Advances in Neurology 2020

Caring for Patients with Diverse Backgrounds

No relevant financial disclosures

Objectives

• Review the impact of bias on clinical care
• Describe the current understanding of the neuroanatomy of

implicit bias

• Discuss strategies to combat bias in clinical care through

cultural humility and relationship centered communication

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Why is it important to be discussing this today?

• Research has consistently shown disparities in access to and
• utcomes in healthcare based on sociodemographic factors
• In a study of the 2006-2013 Medical Expenditure Panel Survey,

black patients were 30% less likely than white patients to see an

• utpatient neurologist; Hispanic patients were 40% less likely
• Example can be found across neurologic specialties, including

stroke, headache, epilepsy, and neuroimmunology

• Research has also suggested that clinician behavior can

contribute to these disparities

Hall WJ, et al. Am J Public Health 2015 Li CC, et al. LGBT Health 2015 Van Ryn M, et al. Am J Public Health 2003 White AA, et al. J Racial Ethn Health Disparities 2017 Saadi A, et al. Neurology 2017 Marulanda-Londoño ET, et al. Neurology 2019

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The neuroanatomy of implicit bias

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There are two types of bias: explicit and implicit

• Explicit bias = consciously held beliefs
• Implicit bias = unconscious beliefs
• Social stereotypes about certain groups of people that individuals

form outside their own conscious awareness

• Bias is prejudice in favor of or against one thing, person, or

group compared to another, usually in a way that is unfair

(Oxford Dictionary) Fiske & Taylor, 1991 Valian 1998

Neuroanatomy of bias involves a complex circuit

• The formation and regulation of implicit bias involves a

complex circuitry of neural networks

• The exact neural networks activated may be influenced by

the type of information input into the network

• Perception-based input (i.e. face, attire, etc.)
• Knowledge-based input (i.e. prior knowledge of social category

such as occupation)

• Perceiver characteristics (i.e. importance of appearing non-

biased, own social category, etc.)

Mattan BD, et al. Curr Opin Psych 2018

Network activated by perception-based input

Mattan BD, et al. Curr Opin Psych 2018

Network activated by knowledge-based input

Mattan BD, et al. Curr Opin Psych 2018 Zink CF, et al. Neuron. 2008

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Neural networks are influenced by perceiver characteristics

• Prior experiences can attenuate amygdala activation
• Neural networks are differentially activated based on internal

motivation to not appear biased

• Power increases racial implicit bias and racial stereotyping

Schmid PC, Amodio DM. Soc Neurosci. 2017.

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The environments in which implicit bias is triggered are…

• 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

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Neuro-disparities

12 1. Kimball MM, et al. J Stroke Cerebrovasc Dis 2014

• 2. McClelland S III, et al. Arch Neurol 20101
• 3. McQuistion K, et al. J Surg Res 2016
• 4. Befus DR, et al. Curr Pain & Headache Reports 2018

Stroke

• Less access to high-volume stroke centers & IV

thrombolysis for Black, Hispanic & Native American individuals1 Epilepsy

• African American race independently predicted a

lower likelihood of anterior temporal lobectomy for temporal lobe epilepsy2 TBI

• Lower rates of rehabilitation referrals for Hispanic,

Asian and uninsured patients3 Migraine

• African Americans are less likely to receive migraine

diagnosis and appropriate acute treatments for migraine4

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Language also plays role in health disparities

• Limited English proficiency has consistently been associated

with poor outcomes

• Increased risk of 30-day ED presentation / 30-day readmission for

COPD and HF, but not pneumonia or hip fracture1

• COPD and HF are chronic conditions requiring complex

management – similar to many neurologic conditions

• Race/ethnicity and language have a complex role in contributing

to disparities

• 2013 study showed that both race and limited English proficiency

contributed to disparities in surgical treatment for medically refractory epilepsy2

• Attention to English proficiency may highlight important, and

previously hidden, disparities3-4

• 1. Rawal S, et al. JAMA 2019
• 2. Betjemann JP, et al. Epilepsy Behav 2013
• 3. Sentell T, et al. JGIM 2007
• 4. Saha S, et al. JGIM 2007

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Center for Immigration Studies 2018 / US Census Data 2017

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LGBTQ+ individuals also experience unequal care

• 2015 U.S. Trans Survey1 found:
• 33% of respondents reported at least 1 negative experience in

accessing healthcare

• 31% of respondents reported that none of their health care

providers knew they were transgender

• 23% of respondents delayed or avoided accessing care out of

fear of discrimination or mistreatment

• 2017 nationally representative survey2 showed
• 8% of ~900 LGB respondents were refused care because of their

sexual orientation

• 9% who did see a clinician reported use of harsh or abusive

language during that encounter

• 1. National Center for Transgender Equality, 2016
• 2. Mirza SA & Rooney C, Center for American Progress 2018

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LGBTQ+ identity is relevant to neurology

• Transwomen taking gender-

affirming hormones may have a higher risk of stroke1 and higher risk of developing MS2

• Gender affirming hormones

may also

• interact with AEDs3
• influence prevalence,

severity, and treatment of

• ther hormone-sensitive

conditions like migraine4

• 1. Getahun D, et al. Ann Intern Med 2018
• 2. Pakpoor J, et al. Mult Scler J 2016
• 3. Johnson EL, Kaplan PW. Epilepsia 2017
• 4. Pringsheim T. Neurology 2004

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Providing patient-centered care

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Interventions for implicit bias

• Make the unconscious conscious
• Implicit Association Test
• Challenge automaticity
• Slow down decision making, use data, monitor outcomes/decisions
• Challenge stereotypes
• Individuation, increased intergroup experiences, etc.

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Practical tips for an inclusive practice

• Start with inclusive language
• In the first meeting, avoid assumptions about someone’s name

and relationships of others in the room

• Use gender-neutral terminology until the patient provides the

correct term (i.e. parents, spouse, significant other, siblings)

• Check in about need for interpreter
• Write this information down, so you don’t need to ask again and

consistently use chosen name in future interactions

• When using an interpreter
• Speak slowly and clearly, allow time for translation
• Avoid non-translated side conversations (or at least explain what

you are talking about if those happen)

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Practical tips for an inclusive practice

• Explore the individual’s perceptions and fears
• FIFE
• FEARS
• What worries do you have about the symptoms?
• IDEAS
• What do you think might be causing this?
• FUNCTION
• How has it affected your daily functioning?
• EXPECTATIONS
• What are you expectations for your hospitalization (or clinic appt)?

American Academy on Communication in Healthcare

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Practical tips for an inclusive practice

• Be aware of non-verbal communication
• Clinic posters / flyers
• TV in the waiting room
• Intake forms
• Positioning of you and the patient in the clinical space
• Clothing
• Ask – Teach – Ask when counseling about diagnosis or

treatment plan

• Written communication in the form of notes matters as well

Swayden KJ, et al. Patient Educ Couns 2012 Petrilli CM, et al. BMJ Open 2018

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Goddu AP, et al. JGIM 2019

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The effect of stigmatizing language

• Comfort in dosing pain

medications correlated with more aggressive pain management for the neutral language scenario but not for stigmatizing language scenario

• There was an inverse

relationship between year

• f training and PASS score

Goddu AP, et al. JGIM 2019

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The complexity of patient-centered communication in the clinical setting

Epstein RM, et al. Soc Science & Med 2005

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Thank you for your attention!

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