UNCONSCIOUS BIAS - InDemand · PDF fileNew Study Finds Unconscious Bias in MD Decision-making...

1 THE NEW SCIENCE OF UNCONSCIOUS BIAS

UNCONSCIOUS BIAS – Implications for Healthcare

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UnconsciousBias:

Implications for Healthcare

By:DavidB.Hunt,J.D.PresidentandCEO,Cri8calMeasuresSponsoredbyInDemandInterpre1ng


Does MD Bias Impact Patient Care?



MDs and Implicit Bias/Implicity-Association Test (IAT)

2,535ProjectImplicitwebsitepar1cipantsreportedhavinganMDdegree.MDswhotooktheIATracialbiastestshowedsignificantpro-Whitebias.Thedegreeofimplicitracebiasvariedbyphysicianraceandgender.InSabin’sdata,thepresenceofpro-WhitebiaswassignificantamongphysiciansofallracialgroupsexceptAfricanAmericans,whowereneutral,whilewomenshowedsomewhatlessimplicitracebiasthanmen.

J. Health Care Poor Underserved. 2009:20(3):896-913.


https://implicit.harvard.edu/implicit/


TwostudiesfoundthatBlackpa1entsseeninemergencydepartmentsreceivedmuchlessanalgesiathanWhitepa1ents.

Studies Show MD Bias Impacts Patient Care

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.


TheEffectofRaceandSexonPhysicians'Recommenda1onsforCardiacCatheteriza1on•  720physiciansviewedrecordedinterviews

•  Revieweddataaboutahypothe1calpa1ent

•  Thephysiciansthenmaderecommenda1onsaboutthatpa1ent'scare

Source:Schulman,NewEnglandJournalofMedicine

Source: Schulman et.al. NEJM 1999;340:618. SponsoredbyInDemandInterpre1ng


New Study Finds Unconscious Bias in MD Decision-making

•  Emergencyroomdoctorsinthestudyweretoldtwomen,onewhiteandoneAfrican-American,wereeach50yearsoldandcomplainedofchestpain.

•  AWerthedoctorsinthestudyevaluatedthetwosimulatedpa@ents,

theywerethengivenanimplicitassocia1ontestexaminingunconsciousracialbiases.

•  Thestudy,byAlexanderGreenoftheDispari1esSolu1onsCenter,affiliatedwithHarvard

UniversityandMassachuse\sGeneralHospital,isthefirsttodealwithunconsciousracialbiasandhowitcanleadtoinferiorcareforAfrican-Americanpa1ents.Itwaspublishedintheonlineedi1onoftheJournalofGeneralInternalMedicineinJune,2007.



THERESULT:Mostdoctorsweremorelikelytoprescribeapoten1allylife-saving,clot-bus1ngtreatmentforthewhitepa1entthanfortheAfrican-Americanpa1ent.

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ResearchhasfoundthatHispanic,Asian,andAfricanAmericans,comparedtowhites,reportlowerqualityintheiroverallinterac@onwiththeirphysicians,less1mespentwiththeirphysicians,poorerpa1ent-physiciancommunica1on,diminishedtrustintheirphysicians,andlessrespectfromtheirphysicians.



Battling Bias– What Works?



Battling Bias–As Individuals

①  Usetoolstoexploreyourownunconsciousbiases(IAT,ICS)

②  Slowdown,shiWfrom“thinkfast”brainsystems(amygdala)to“thinkslow”brainsystems(pre-frontalcortex).(DanielKahneman)

③  Inpar1cular,thereareseveralstrategiesthatappeartomakeadifference:Informa@on–re:thepsychologicalbasisofbiasMo@va@on–internal(vs.external)mo1va1ontochangeIndividua@on–learningtoseediverseothersasindividualsratherthanasmembersofgroupsDirectcontactwithmembersofothergroupsWorkingtogetheronteams,asequals,inpursuitofcommongoalsContext/environment–displayposi1veimagesofleadersfromdiversegroups

④  Obtain360-degreefeedbackfromdiverseemployees/colleagues.Reverse-mentoringprocessescanalsohelp



First year medical students, nursing students, pharmacy and dental students at the University of California San Francisco are learning about unconscious or implicit bias as part of their medical school curriculum.

Medical Students Confront Their Own Unconscious Biases THE NEW SCIENCE OF UNCONSCIOUS BIAS



Confronting Unconscious Biases

OnlyaboutadozenmedicalschoolsintheU.S.are

currentlyteachingstudentsaboutunconsciousbias.



Another strategy to mitigate the impact of implicit bias is perspective-taking. Perspective-taking is a conscious attempt to envision another person’s viewpoint.

Perspective-Taking THE NEW SCIENCE OF UNCONSCIOUS BIAS



Perspec@ve-takingisaconsciousa\empttoenvisionanotherperson’sviewpoint.Drweckiet.al.appliedperspec1ve-takinginaclinicalse;ng:NurseswereshownpicturesofeitherBlackorWhitepa1entswithgenuineexpressionsofpainandaskedhowmuchpainmedica1ontheyrecommendedforthepa1ent.•  Nursestoldtousetheirbestjudgmentrecommendedsignificantlymorepain

medica1onforWhitethanBlackpa1ents

•  Nursesinstructedtoimaginehowthepa1entfeltrecommendedequalanalgesictreatmentregardlessofrace.

DrweckiBB,Moore,CFWardSE,PrkachinKM.Reducingracialdispari1esinpaintreatment:theroleofempathyandperspec1vetaking.Pain.2011:152(5):10001-6.

Perspective-Taking



Battling Bias–Within Hospitals

①  Collectpa1entrace,ethnicityandlanguage(REL)data.

②  Tiepa1entRELdatatopa1entoutcomes.(<22%currentlydo…)

③  Stra1fypa1entcomplaintsbypa1entdemographics.

④  Stra1fypa1entsa1sfac1ondatabypa1entdemographicdata.

⑤  Createpa1entsa1sfac1onreportcardsforprovidersbasedondifferentpa1entdemographics.(KaiserPermanente)

⑥  ConductDiversityWorkforceAssessmentsorClimateAuditstoassessemployeesa1sfac1on/engagementbydiversegroups.

⑦  ConductProviderCulturalandLinguis1cCompetenceAssessmentstoexamineself-assessedpreparednessandclinicalprac1cebehaviorswithregardtodiversegroupsofpa1ents.

⑧  Create“dispari1es”dashboardsforkeymetricsonbothsidesofthehealthcare“house”(workforceandpa1entexperience).



Non-English-SpeakingPa1entsLessSa1sfiedWithTheirCareatHospitalA

•  Cri1calMeasuresexaminedHospitalA’spa1entsa1sfac1ondatastra1fiedbylanguagefromJanuary2011toDecember2013.

•  Wecomparedposi1veresponsesbyEnglish-speakingpa1entstoposi1veresponsesbynon-English-speakingpa1entsfor68HCAHPSques1ons.

•  English-speakingpa1ents’scoreswereconsistentlyhigherthannon-English-speakingpa1ents’scores.

•  Non-English-speakingpa1entsscoreswerelowerthanEnglish-speakingpa1entsscoreson59of68ques1ons(87%)indica1ngthattheywerelesssa1sfiedthanEnglish-speakingpa1entswiththeircareandtreatmentatHospitalA.




•  Sta1s1callysignificantdifferenceswerefoundon27ofthe68ques1ons(40%).Fortheseques1ons,non-English-speakingpa1entswerelesssa1sfiedthanEnglish-speakingpa1entswithrespecttotheircareandtreatmentatHospitalA.

•  Sta1s1callysignificantresponseswerethosewherethep-valuewaslessthan0.05.

•  Clinicallysignificantdifferencesinresponsesoccurwherethedifferencesbetweenthecomparedgroupsare10%to15%ormore.

•  Clinicallysignificantdifferenceswerefoundon28ofthe68ques1onsthatweexamined(41%).Ineachcase,non-English-speakingpa1entswerelesssa1sfiedwiththeircarethanEnglish-speakingpa1ents.




•  Majorareasofdissa1sfac1onbynon-English-speakingpa1entsincluded:

-paincontrol-communica1onwithproviders-treatedwithcourtesy/respect-confidence/trustinproviders-familyissues(allowedtobew/pa1ent,familyhadtobesurepa1ent’sneedsweremet)-qualityissues(confirmediden1tybefore

meds/procedure)-wouldrecommendhospitaltofamily



Non-English-SpeakingPa1entsLessSa1sfiedWithPainControlatHospitalA

Patient Satisfaction Question English + Response

Other Lang. + Response P-Value

Did everything to help control your pain. 75.9% 67.2% 0.007

Pain well controlled during stay. 58.8% 45.6% <0.001

Pain effectively managed during delivery 60.4% 43.6% 0.011



Non-English-SpeakingPa1entsLessSa1sfiedWithCommunica@onatHospitalA



Dr’stalkedinfrontofyou 88.9% 77.2% 0.006

Dr. / Nurse explained things differently. 79.0% 62.5% 0.003

Dr. discussed pain control options 71.0% 56.4% 0.020

Got enough info. about delivery before delivery 71.7% 54.8% 0.007

Patient information about procedure 73.6% 58.7% 0.008

Surgeon explained things 77.4% 64.5% 0.008

Nurse discussed worries 64.0% 48.5% <0.001



Non-English-SpeakingPa1entsLessSa1sfiedWithCourtesy/RespectatHospitalA



Treatedwithcourtesyandrespectby:

Doctors 82.9% 73.2% <0.001

Nurses 80.3% 68.4% <0.001

Surgeon 88.7% 76.6% 0.001

Staff 83.5% 67.6% <0.001

Housekeeping 79.0% 62.7% <0.001



Non-English-SpeakingPa1entsLessConfidentandTrus@ngofHospitalAProviders



Confidence/trustin:

Doctors 70.9% 56.6% 0.001

Nurses 67.7% 54.8% <0.001

Surgeon 85.9% 67.5% <0.001



MDCulturalCompetenceAssessment

Cri@calMeasures’assessmentaddressesthefollowingtopics:

①  Extentofformaltrainingincross-culturalhealth.②  Opinionsregardinghealthdispari1es.③  Self-assessedpreparednesstotreatimmigrants,LEPandpa1entswhose

healthbeliefsmaybeatoddswithWesternmedicine.④  Knowledgeofandadherencetolanguageaccesslawsandself-discloseduseof

languageaccessresources.⑤  Knowledgeofandactualprac1cebehavioraladherencetona1onalbest

prac1cesincross-culturalmedicine,immigrantandrefugeehealth&travelmedicine.

⑥  Interestinreceivingaddi1onaltrainingincross-culturalmedicine.



MDCulturalCompetenceResults

97%ofMDshadLEPpa1ents.Nearlyhalffelt“lessthanwell-prepared”tocareforthesepa1ents.



MD Cultural Competence Results

①  PrimarycareMDsoWenfeltleastpreparedtoprovidecaretoLEPpa1ents.

②  30%didnotusequalifiedinterpreterstoobtaininformedconsent.50%didnotrecorduseofinterpreterinpa1ent’smedicalrecord.

③  92%treatimmigrantsandrefugees.

+60%werelessthanwell-prepared

④  56%-70%ofMDsdidnotrou1nelyaskaboutcountryoforiginorrecenttravelhistory.

⑤  52%ofMDsunfamiliarwithSchistosomaisis;65%unfamiliarwithStrongyloides–twoofthefivemostcommondiseasesfoundinimmigrantsandrefugeestotheUnitedStates.



MPSScoressegmentedwith3yearsoftrending,3yearaverage&colorcoding

Segment Items Score

Difference Score Your Overall Fac/Dept 2007YE 2008YE 2009YE 3-Yr Avg 3-Yr Avg (Your - Fac/Dept)

Familiar Visit 75.1 89.1 89.9 85.5 85.1 0.4 Stranger Visit 69.0 65.0 75.0 69.1 64.4 4.7 Under 18 75.0 18 - 34 46.4 62.5 68.2 58.9 65.0 -6.1 ( - ) 35 - 44 74.1 76.8 92.6 80.5 73.1 7.4 ( + ) 45 - 64 79.7 77.7 86.9 81.5 80.4 1.1 65+ 75.0 73.9 84.3 78.9 82.2 -3.3 African Amer. 66.7 80.0 77.5 Chinese 81.1 70.0 85.1 79.8 75.6 4.2 Filipino 78.9 90.0 72.2 83.9 78.3 5.6 ( + ) Hispanic/Latino 77.3 66.7 78.9 73.5 77.1 -3.6 Japanese 84.2 76.7 Other 11.5 75.0 82.8 56.0 75.8 -19.8 ( - - ) Other Asian 73.5 90.4 82.2 83.2 72.3 10.9 ( + + ) White 70.3 69.4 90.3 77.8 82.0 -4.2 Female 73.0 70.1 90.5 78.5 76.9 1.6 Male 70.5 82.4 70.1 74.7 81.0 -6.3 ( - )


New Kaiser MPS Format


CAUTION: Talking About Bias May

Backfire!

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Caution: Talking About Bias May Backfire!

①  Growingnumbersofpeopleareworkingtoraiseawarenessaboutbias.

②  Theassump1onisthatwhenpeoplerealizethatbiasesarewidespreadtheywillbemorelikelytoovercomethem.

Butnewresearchsuggeststhatifwe’renotcareful,makingpeopleawareofbiascanbackfire,leadingthemtodiscriminatemorenotless.



How Can Talking About Bias Backfire?

Inastudy,managersweretoldthatstereotypeswereeithercommon,orrare.Then,theyaskedmanagerstoreadatranscriptfromajobinterviewofacandidatedescribedaseithermaleorfemale.Attheendoftheinterview,thecandidateaskedforhighercompensa1onandanonstandardbonus.Whenthemanagersreadthatmanypeopleheldstereotypes,theywere28%lessinterestedinhiringthefemalecandidate.Theyalsojudgedheras27%lesslikable.Thesameinforma@ondidnotaltertheirjudgmentsofmalecandidates.



Infurtherstudies,themanagersweretoldthateventhoughbiaseswerecommon,

“The vast majority of people try to

overcome their stereotypic preconceptions.”

Withthisadjustment,discrimina1onvanishedin

theirstudies.AWerreadingthismessage,managerswere28%moreinterestedinworking

withthefemalecandidatewhonego1atedasser1vely,andjudgedheras25%morelikable.

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32 THE NEW SCIENCE OF UNCONSCIOUS BIAS YourResponsibili1es

①  Whenwecommunicatethatavastmajorityofpeopleholdsomebiases,weneedtomakesurethatwe’renotlegi1ma1ngprejudice.

②  Reinforcetheideathatpeopleshouldwanttoconquertheirbiasesandthattherearebenefitstodoingso.

③  Mostpeopledon’twanttodiscriminateandyoushouldn’teither.

Conclusion THE NEW SCIENCE OF UNCONSCIOUS BIAS


VideoRemoteInterpre@ng(VRI)fromInDemandInterpre@ngInstantlyConnecttoExperiencedMedicalInterpreters24/7,365daysayear,inover200languages.InDemandprovidesinstantaccesstohigh-qualityVideoRemoteInterpre1ng(VRI)forlimitedEnglishproficient(LEP)andDeafpa1entsatthetouchofabu\on.Justselectthepa1ent’spreferredLanguage,andwithinsecondsamedicallytrainedinterpreterwillbeonlinetoassist.www.InDemandInterpre1ng.com


DavidHuntisthePresidentandChiefExecu1veOfficerofCri1calMeasures.Cri1calMeasuresisamanagementtrainingandconsul1ngfirmthatassistsemployerstoharnessthepowerofdiversitytocreatemoreproduc1ve,profitableandinclusiveworkforces.Over1me,Davidhasdevelopedsubstan1alexper1seondiversity-relatedma\ersinlaw,businessandmedicine:HealthCare:TwothirdsofCri1calMeasuresworkisintheareaofcross-culturalhealthcare.Davidisasought-aWerna1onalandinterna1onalspeakeronissuesofracialandethnicdispari1esinhealthcare,thelawoflanguageaccessandmedicaldispari1esthatresultfromgloballymobilepopula1ons.Hehasdeliveredkeynotepresenta1onsonsuchtopicsasTheNewScienceofUnconsciousBiasfortheAmericanHospitalAssocia1onandAmericanMedicalAssocia1onandTheLawofLanguageAccessfortheAmericanBarAssocia1on.TogetherwithphysicianpartnersfromHarvardandtheUniversityofMinnesotaMedicalSchool,Davidhascreatedsomeofthena1on'sfirste-learningprogramsoncross-culturalmedicine.Over175,000providershavenowbeentrainedontheseprograms.TheBlueCrossBlueShieldAssocia1onofAmericaselectedCri1calMeasuresasitsprimaryvendorforservicesrelatedtoculturalcompetenceinhealthcare.In2015,theAHA'sIns1tuteforDiversityManagementinHealthCareselectedMr.Huntasthena1onalconsultanttoits#123forEquitycampaigntoeliminateracialandethnicdispari1esinhealthcare.Priortoworkinginthediversityfield,Davidworkedasana\orney,specializinginemploymentandcivilrightslaw.Awriter,speakerandcurrenteventscommentator,DavidhasappearedontheMcNeill-LehrerNewsHourandpublishednumerousar1cles.HereceivedhisB.A.fromCarletonCollegeandhisJ.D.fromtheWilliamMitchellCollegeofLaw.

ABOUT THE AUTHOR

DavidB.Hunt,J.D. CRITICAL MEASURES PresidentandCEO


BeSerCommunica1ons,BeSerOutcomes

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UNCONSCIOUS BIAS - InDemand · PDF fileNew Study Finds Unconscious Bias in MD Decision-making...

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