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The New Science of Unconscious Bias:
My name is Jin My name is Jean My name is Gene My name is Jeanne.
Do you know me? The New Science of Unconscious Bias: Workforce and
Patient Care Implications Presented by: David B. Hunt Jerry Benston
(612) Under Accreditation Council for Continuing Medical Education
guidelines disclosure must be made regarding relevant financial
relationships with commercial interests within the last 12 months.
David Hunt Commercial Interest Nature of Relevant Financial
Relationship What was received? For what role? Critical Measures
Payment Equity Owner Under Accreditation Council for Continuing
Medical Education guidelines disclosure must be made regarding
relevant financial relationships with commercial interests within
the last 12 months. Jerry Benston Commercial Interest Nature of
Relevant Financial Relationship What was received? For what role?
Critical Measures Consulting fees Consultant Disclosure Statement
David Hunt discloses that he is the sole equity owner of the
company Critical Measures and that Critical Measures is engaged in
the business of diversity-related, healthcare consulting. Critical
Measures does not offer any products or services that relate to the
clinical care of patients and will not make any clinical
recommendations during the course of this presentation. Critical
Measures does, however, offer various,
diversity-relatedorganizational assessment tools and CME-accredited
e-learning programs for doctors and nurses. Jerry Benston is an
independent consultant with a long-term, consulting and training
affiliation with Critical Measures. Learning Objectives Upon
completion of this session, participants will improve their
competence and performance by being able to: Explain how human
biology and sociology contribute to unconscious or implicit bias.
Identify their own unconscious biases by taking the Implicit
Association Test. Recognize the implications of implicit bias
research for the OU workforce and racial and ethnic disparities in
patient care. Use emerging best practices to overcome or minimize
the effects of unconscious bias both personally and
organizationally. Develop an organizational action agenda to
address the effects of implicit bias in the workforce and patient
care. Learning Objectives (contd)
Upon completion of this session, participants will improve their
competence and performance by being able to: Identify ten core
cross-cultural differences that can contribute to communication
problems and cross-cultural conflict. Utilize the Intercultural
Conflict Style Model as a framework for managing and resolving
cross-cultural conflict. Identify the leadership competencies that
managers and providers will need to manage a culturally diverse
workforce and care for culturally and linguistically diverse
patients. Agenda The Science of Unconscious Bias
Measuring Implicit Bias The Implicit Association Test Workplace and
Patient Care Implications Application: Racial and Ethnic
Disparities, Language Access, Caring for Immigrants and Refugees
Dealing With Cross-Cultural Differences BARNGA Dealing With
Cross-Cultural Conflict ICS Model Becoming Conscious of Unconscious
Biases Next Steps For Individuals and Organizations Understanding
the New Science of Bias
* 07/16/96 Understanding theNew Science of Bias * ## Know But Dont
Know I Know Think I Know
We may want to discuss a way to incorporate this with the
conversation about the important considerations listed below.
Awareness: New Research re: Bias
* 07/16/96 Awareness: New Research re: Bias In the past, bias was
regarded as aberrant, conscious and intentional. Today, we
understand that bias is normative, unconscious and largely
unintentional. Social Cognition Theory establishes that mental
categories and personal experiences become hard-wired into
cognitive functioning. 4. As a result, human biases can be seen as
evolutionarily adaptive behaviors. * ## Unconscious Bias: How Does
It Work?
The problem? Too much information to process. Scientists estimate
that we are exposed to as many as 11 million pieces of information
at any one time, but our brains can only functionally deal with
about 40. The solution? Mental short-cuts. The brain seeks to
conserve energy. Decision-making, ambiguity, novelty and problem
solving all take heavy cognitive reserve. Weve evolved to have
mental short cuts that save time and usually yield reliable
results. Our Brains at Work Seeks the simplest path to
conclusions
The brain asa prediction-machine Seeks the simplest path to
conclusions Wired for threat identification Perceptions of
Groupness Distort Perception and Behavior
Experiments by Tajfel and others showed that, as soon as people are
divided into groups even on trivial or random bases strong biases
resulted. Subjects perceived members of their group as more similar
to them and members of other groups as more different. Subjects saw
in-group members highly differentiated individuals and out-group
members as largely homogenous. Subjects were better able to recall
undesirable behavior of outgroup members than similar behavior of
ingroup members. Ingroup members failures were attributed to
situational factors while outgroup failures were attributed to
innate characteristics. Subjects permitted to allocate monetary
rewards maximized rewards to their own group and minimized rewards
to outgroups. Video -The Eye of the Storm
* 07/16/96 Video -The Eye of the Storm Reactions to film/video?
Impact of the collars on students socially & academically. Who
wears collars at OU Medicine? Take-aways for you: -Professionally
-Personally * ## The Implicit Association Test
* 07/16/96 The Implicit Association Test * ## YouTube Video: Do the
Test
* 07/16/96 YouTube Video: Do the Test * ## SLB CFLTK SPRND HLMG
John Ridley Stroop, 1935
Copyright Cook Ross Inc. - Unconscious Bias Learning Lab RED GREEN
YELLOW BLUE BROWN
John Ridley Stroop, 1935 Copyright Cook Ross Inc. - Unconscious
Bias Learning Lab What Activates Our Biases?
* 07/16/96 What Activates Our Biases? Our biases are most likely to
be activated by four key conditions. They are: stress time
constraints multi-tasking need for closure * ##
https://implicit.harvard.edu YouTube Video: How Biased Are
You?
* 07/16/96 YouTube Video: How Biased Are You? * ## * 07/16/96 Key
IAT Findings - Age Age: Around ninety percent of Americans mentally
associate negative concepts with the social group "elderly"; only
about ten percent show the opposite effect associating elderly with
positive concepts. Older people do not, show an automatic
preference for their own group. Remarkably, the preference for
young is just as strong in those in the over-60 age group as it is
among 20-year-olds. * ## Key IAT Findings - Gender
* 07/16/96 Key IAT Findings - Gender Gender: Seventy-five percent
of men and women do not associate female with career as easily as
they associate female with family. (Women show an implicit
attitudinal preference for females over males, but they nonetheless
show an implicit stereotype linking females closer to family than
career.) * ## * 07/16/96 Key IAT Findings - Race Race:
Whiteparticipants consistently show a preference for White over
Black on the IAT a substantial majority of White IAT respondents
(75% to 80%) show an automatic preference for White over Black.
Data collected from this website consistently reveal approximately
even numbers of Black respondents showing a pro-White bias as show
a pro-Black bias. Other key race findings: younger people are just
as likely to display an implicit race bias as older adults, women
are as likely to display an implicit race bias as men and
educational attainment appears to make no difference with respect
to implicit race bias. * ## Summary: Key IAT Trends
* 07/16/96 Summary: Key IAT Trends Implicit biases are pervasive.
People are often unaware of their implicit biases. Implicit biases
predict behavior. People differ in levels of implicit bias.
Educational attainment makes no difference with respect to implicit
biases. * ## Workplace Implications
* 07/16/96 Workplace Implications * ## Biases Impact
Decision-Making
* 07/16/96 Biases Impact Decision-Making Unconscious bias can
infect management decisions throughout the employment life cycle:
a.Interviewing. Recruitment, hiring & retention. b.Expectations
of and interactions with employees. (Micro-inequities) c.Employee
evaluations. (Set Up to Fail Syndrome Harvard Business Review)
d.Decisions about promotions, training and other job benefits.
e.Termination and discharge decisions. * ## The Big Five
Orchestras
Chicago and Boston None of the Big Five employed more than 12%
women until the 1980s Blind auditions Improved the chances that a
woman would ultimately be hired Female musicians in the Big Five
increased five-fold from 1970 to 2000 Orchestrating Impartiality:
the Impact of Blind Auditions on Female Musicians, 94 Am. Econ.
Rev. 715 (2000). Susan Boyle Britains Got Talent
Great talent often doesnt look and act like you Can you spot great
talent no matter how it is packaged? Selection/Signing of
Professional Athletes Are Emily & Greg More Employable than
Lakisha & Jamal?
Study of actual racial hiring bias in Chicago and Boston Resumes
sent to actual want ads 4 resumesper position 2 high quality and 2
low quality African American sounding names assigned to one high
quality and one low quality Primary measurement was the callback
rate Results: people with "white-sounding" names are 50 percent
more likely to get a response to their resume than are those with
"black-sounding" names. Marianne Bertrand and Sendhil Mullainathan,
Are Emily and Greg More Employable Than Lakisha and Jamal?Field
Experiment on Labor Market Discrimination, 94 Am. Econ. Rev. 991
(2004). Racial Disparities in Medical Education
In 2012, there were just 517 black men among the more than 20,000
graduating students among the more than 20,000 graduating students
at U.S. medical students. Only 2.9% of all faculty members at U.S.
medical schools are black. Black faculty members are less likely
than their white counterparts to be promoted, to hold senior
faculty or administrative positions and to receive research awards
from the National Institutes of Health. 31% of the 84,195 white
faculty members at U.S. medical schools were full professors in
2011, compared with just 11% of the 3,952 black faculty members.
Source: Bias, Black Lives, And Academic Medicine, New England
Journal of Medicine, March 19, 2015 Diversity and
Productivity
Effective diversity programs are associated with higher
productivity (+18%). (National Urban League, 2004) Gallup found
that 27.7 million U.S. workers, or 18%, are actively disengaged.
Another 52% of workers were not engaged, while only 30% of workers
were actively engaged. Result: 70% of workers are not fully
engaged. Actively disengaged" employees -- those fundamentally
disconnected from their jobs -- cost the U.S. economy between $450
billion and $550 billion a year. (Gallup 2012) What causes workers
to disengage at work? One notable cause is DRIs Diversity Related
Incidents of Disrespect. Workplace Incivility DRIs
Studies have found that over 71 percent of the workforce has
experienced some form of workplace incivility in the last five
years. Incivility is evidenced by disrespectful behavior. Source:
Don Zander, Brookings Institution, 2002 Of the reported incidents
of workplace-related DRIs: 32% were related to gender; 28% were
related to race; 20% were related to age; 14% were related to
sexual orientation and 6% were related to religion. Workplace
Incivility DRIs
Fiscal Impact of Workplace Incivility: Of those who experienced
work-place related DRIs: 28% lost work time avoiding the instigator
of the incivility; 53% lost time worrying about the incident/future
interactions; 37% believe their commitment at work declined; 22%
have decreased their effort at work; 10% decreased the amount of
time that they spent at work; 12% actually changed jobs to avoid
the instigator. Source: The Sparticus Group: 2003. Race, Ethnicity
and Perceptions of Workplace Relationships in Healthcare
Management
White Asian Black Hispanic Race relations within my company Women
79% 60% 41% 55% are good. Men 90% 70% 53% 73% Managers of Color
usually have to Women 6% 29% 75% 47% be more qualified to get ahead
here. Men 3% 33% 66% 35% White managers share vital growth Women
57% 29% 10% 18% and career-related information with Men 55% 37% 12%
30% managers of color. The evaluation of both whites and Women 69%
51% 18% 33% employees of color are equally Men 75% 50% 22% 43%
thorough and carefully evaluated . Has a strong feeling of
belonging Women 82% 70% 58% 71% to the organization. Men 85% 72%
72% 79% Source: A Race/Ethnic Comparison of Career Attainment in
Healthcare Management: American College of Healthcare Executives;
Institute for Diversity in Healthcare Management, 2002 Its Not Just
Physicians -- Racial Discrimination Among NBA Referees
Price, Joseph and Wolfers, Justin, "Racial Discrimination Among NBA
Referees," NBER Working Paper Series, Vol. w13206 (2007). Available
at Does Unconscious Racial Bias Affect Trial Judges?
This article reports the results of the first study of implicit
racial bias among judges Jeffrey J. Rachlinski, Sheri Lynn Johnson,
Andrew J. Wistrich & Chris Guthrie, Does Unconscious Racial
Bias Affect Trial Judges?, 84 Notre Dame L. Rev (2009) Patient Care
Considerations
* 07/16/96 Patient Care Considerations * ## The Effect of Race and
Sex on Physicians' Recommendations for Cardiac
Catheterization
720 physicians viewed recorded interviews Reviewed data about
ahypothetical patient The physicians then made recommendations
about thatpatient's care Source:Schulman et.al. NEJM 1999;340:618.
New Study Finds Unconscious Bias In M.D. Decision-Making
Emergency room doctors in the study were told two men, one white
and one African-American, were each 50 years old and complained of
chest pain. The patients were not actually real people, but rather
computer-generated images seen by the doctors only on a monitor.
After the doctors in the study evaluated the two simulated
patients, they were then given an implicit association test
examining unconscious racial biases. The result was most of the
doctors were more likely to prescribe a potentially life-saving,
clot-busting treatment for the white patients than for the
African-American patient. The study, by the Disparities Solutions
Center, affiliated with Harvard University and Massachusetts
General Hospital, is the first to deal with unconscious racial bias
and how it can lead to inferior care for African-American patients.
It was published in the online edition of the Journal of General
Internal Medicine in June, 2007. M.D.s and Implicit Bias/IAT
Sabin examined implicit race bias in physicians as a whole using
data from Harvards Project Implicit website. Overall, the 2,535
website participants who reported having an MD degree showed
significant pro-White bias. J. Health Care Poor Underserved.
2009:20(3): The degree of implicit race bias varies by physician
race and gender. In Sabins data, the presence of pro-White bias was
significant among physicians of all racial groups except African
Americans, who were neutral, while women showed less implicit race
bias than men. Lessbut not zeropro-White bias has also been found
among non-White vs. White resident physicians and medical students.
But Does MD Bias Impact Patient Care?
Demonstrating that physicians have measureable implicit bias does
not prove that this bias affects patient-doctor interactions or
alters the treatment patients receive. However, research supports a
link between disparate treatment decisions and implicit provider
bias. This research exists in two forms: studies comparing
treatment recommendations for patients who are identical except for
social category information and studies directly measuring implicit
bias and then determining the correlation between measured bias and
physicians treatment decisions. Studies Show MD Bias Impacts
Patient Care
Two studies found that Black patients seen in emergency departments
receive less analgesia than White patients. Hispanic patients in
one study were seven times less likely to receive opioids in the ED
than non-Hispanic patients, even after adjusting for other factors.
These findings were duplicated in Black patients. In a follow-up
study, researchers assessed physicians ability to quantify pain in
Hispanic patients compared to non-Hispanic patients. They found
that physicians could accurately judge patients pain severity
regardless of ethnicity yet still provided less analgesia to
Hispanic patients with severe injuries. Todd KH, Lee T, Hoffman JR.
The effect of ethnicity on physician estimates of pain severity in
patients with isolated extremity trauma. JAMA 1994:271(12)925-8.
When Health Care Isnt Caring
Lambda Legal surveyed 4,916 GLBT people and people living with HIV
nationwide in the spring of Results showed that these populations
were frequently: Denied care; Treated in a discriminatory manner
while obtaining care; Subjected to harsh or abusive language by
health professionals; Treated by health professionals who refused
to touch them or used excessive precautions when doing so; Blamed
for their conditions by health professionals When Health Care Isnt
Caring
Source: When Health Care Isnt Caring: Lambda Legals Survey on
Discrimination Against LGBT People and People Living With HIV, (New
York: Lambda Legal, 2010). Available at: When Health Care Isnt
Caring
Source: When Health Care Isnt Caring: Lambda Legals Survey on
Discrimination Against LGBT People and People Living With HIV, (New
York: Lambda Legal, 2010). Available at: How Might Implicit Biases
Impact Clinical Objectivity?
Taking a sexual history (presumptions of heterosexuality, monogamy)
Incidence of HIV Travel history Country of Origin Health literacy
use of the teachback method Making the unusual into the common and
vice versa Race Gender U.S. Patient Satisfaction Data Race
Research has found that Hispanic, Asian, and African Americans,
compared to whites, report lower quality in their overall
interaction with their physicians, less time spent with their
physicians, poorer patient-physician communication, diminished
trust in their physicians, and less respect from their physicians.
A Harvard School of Public Health/Robert Wood Johnson Foundation
survey of 4,334 randomly selected U.S. adults compared perceptions
of the quality of physician care among fourteen racial and ethnic
groups with those of whites. On each measure examined, at least
five and as many as eleven subgroups perceived their care to be
significantly worse than care for whites. In many instances,
subgroups were at least fifteen percentage points more negative
than whites. Many of the differences remained after socioeconomic
characteristics and language skills were controlled for. Health
Affairs, May 08. Picker Inpatient Satisfaction with Doctors By
Race, CLIENT A
Question/StatementWhiteOf Color Signif? Didnt always have
confidence/trust14.5%26.1% Yes in my doctors. Doctors talked as if
I wasnt there %23.2% Yes Courtesy of doctors fair or poor2.5%5.5%
Yes Doctors/nurses gave conflicting info.21.5%26.5% Yes *Scores
over 20% are considered problems by Picker. Picker Inpatient
Satisfaction with Nurses By Race, CLIENT A
Question/StatementWhiteOf Color Signif? Didnt always have
confidence/trust24.8%34.7% Yes in my nurses. Nurses talked as if I
wasnt there %22.9% Yes Courtesy of nurses fair or poor3.5%5.6% Yes
Nurses answers to questions %29.6% Yes werent always understood.
*Scores over 20% are considered problems by Picker. Picker Treated
with Courtesy, By Race, CLIENT A
Question/StatementWhiteOf Color Signif? Courtesy of admissions
staff rated2.0%5.9% Yes fair or poor. Courtesy of people who took
blood2.8%8.8% Yes samples rated fair or poor Courtesy of people who
brought food5.0%8.8% Yes rated fair or poor. Courtesy of people
bringing to and from1.2%6.2% Yes room rated fair or poor. Courtesy
of people taking x-rays rated1.4%7.6% Yes Courtesy of people who
cleaned room3.3%8.6% Yes rated fair or poor Picker Other Key
Indicators of Care By Race, CLIENT A
Question/StatementWhiteOf Color Signif? Not always treated with
respect and13.1%21.6% Yes dignity. Didnt always get help in time
going 20.4%30.8% Yes to the bathroom. After using call button, had
to wait > %4.3% Yes minutes for help. Staff definitely did not
do everything19.7% 26.3% Yes they could to control pain. Didnt have
enough say about pain26.1% 38.4% Yes control during delivery.
Probably would or would not % 28.8% Yes recommend to
family/friends. Application Disparities Worlds Apart Video
Vignettes
* 07/16/96 Application Disparities Worlds Apart Video Vignettes *
## Worlds Apart: Video Vignettes
Mohammad Kochi, an Afghani man with stomach cancer, refuses
chemotherapy in part because of poor communication between his
doctors and his daughters, who act as his translators. Robert
Phillips, a 29-year-old black man, has been waiting three years for
a kidney transplant. He's frustrated with the medical bureaucracy
and feels that black patients may not be readily referred for a new
kidney because physicians think "they're just going to ruin it
anyway." Justine Chitsena, a 4-year-old girl from Laos, needs
surgery for a congenital heart defect. Her grandmother adheres to
traditional Laotian and Buddhist beliefs and worries that the scar
will affect Justine's spirit in her subsequent lives, while her
mother worries that her family will blame her if something goes
wrong. Video: Mr. Kochis Case Issues Presented: Family
decision-making and
* 07/16/96 Video: Mr. Kochis Case Issues Presented: Family
decision-making and withholding of information. Effects of
immigration and acculturation on family dynamics. Language barriers
and communication Religious beliefs, spirituality and negotiation.
The culture of American medicine. * ## Mr. Kochis Case Take-Away
Points
Assess how patients prefer to make medical decisions individually,
as a family, or through a specific authority figure and try to
accommodate. Even within the same culture, there can be very
different values and perspectives on health and illness. Language
barriers can lead to miscommunication and poor health outcomes. LEP
patients have a legal right to an interpreter. Use of family
members risks poor communication. A non-confrontational patient may
be agreeing with the physician just to show respect Beliefs in
fatalism can lead a patient to refuse treatment, but they are
rarely absolute. Probe for a deeper understanding of patients
beliefs and negotiate acceptable treatment options. Video: Robert
Phillips Case
* 07/16/96 Video: Robert Phillips Case Issues Presented: The
distinction between disease and illness Discrimination and
racial/ethnic disparities in health care. Stereotyping and clinical
decision-making Mistrust and communication style Conflict style
differences * ## Video: Justine Chitsenas Case
* 07/16/96 Video: Justine Chitsenas Case Issues Presented:
Understanding the familys health and illness beliefs. Family
decision-making and authority figures. Traditional/alternative
medical practices Cross-cultural medical ethics. Barriers to
effective communication. * ## Battling Bias What Works?
* 07/16/96 Battling Bias What Works? * ## Useful Metaphors for
Unconscious Bias
Unconscious bias is like a chronic illness it needs constant
monitoring and attention. We are all carriers Unconscious bias is
like a pilot flying above the clouds. With no reference point on
land, pilots must learn to fly using instrument panels Key is
Pattern Recognition Battling Bias As Individuals
* 07/16/96 Battling Bias As Individuals Use tools to explore your
own unconscious biases (IAT, ICS) Slow down, shift from think fast
brain systems (amygdala) to think slow brain systems (pre-frontal
cortex). (Daniel Kahneman) In particular, there are several
strategies that appear to make a difference: A.Information re: the
psychological basis of bias B.Motivation - internal (vs. external)
motivation to change C.Individuation learning to see diverse others
as individuals rather than as members of groups. D.Direct contact
with members of other groups. E.Working together on teams, as
equals, in pursuit of common goals. F.Context/environment display
positive images of leaders from diverse groups 4.Obtain 360 degree
feedback from diverse employees/colleagues. Reverse mentoring
processes can also help. * ## * 07/16/96 Perspective-Taking Another
strategy to mitigate the impact of implicit bias is
perspective-taking. Perspective taking is a conscious attempt to
envision another persons viewpoint. Drwecki et. al. applied
perspective-taking in a clinical setting. Nurses were shown
pictures of either Black or White patients with genuine expressions
of pain and asked how much pain medication they recommended. Nurses
told to use their best judgment recommended significantly more pain
medication for White than Black patients, whereas Nurses instructed
to imagine how the patient felt recommended equal analgesic
treatment regardless of race.Drwecki BB, Moore, CF Ward SE,
Prkachin KM. Reducing racial disparities in pain treatment: the
role of empathy and perspective taking. Pain. 2011:152(5): * ##
Reducing Bias In Physicians
* 07/16/96 Reducing Bias In Physicians Racial and ethnic
disparities in the quality of medical outcomes are widely
documented. A.Institute of Medicine report Unequal Treatment (2002)
B.Research indicates that little progress has been made since 2002.
Michelle van Ryn of the University of Minnesota and colleagues
recently published some evidence-based recommendations for
combating bias among health care providers. See: Burgess, D., van
Ryn, M., et. al. Reducing Racial Bias Among Health Care Providers:
Lessons from Social-Cognitive Psychology, 22 Journal of General
Internal Medicine (2007). Their conceptual model (depicted on the
next slide), recognizes the importance of motivation, information
and skills as key ingredients for successful interventions. The
next slide discusses the approach advocated by van Ryn. * ## Can
Implicit Bias Be Controlled?
* 07/16/96 Can Implicit Bias Be Controlled? * ## Battling Bias
Within Hospitals
* 07/16/96 Battling Bias Within Hospitals Collect patient race,
ethnicity and language (REL) data. Tie patient REL data to patient
outcomes. (