From
StayCurrentMD
Unconscious Bias
With Dr. Mary Brandt & Dr. Julie Freischlag & Dr. Quinn Capers · hosted by Dr. Alex Cassar & Dr. Todd Ponsky & Dr. Alex Gibbons
Chapter 6 of 9 · Evidence & Research
Test results
Responding to Test Results and the Journey of Change
Cued at 30:59 · press play
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What the experts said
No one recognizes they have implicit bias, and everyone has it to different degrees about different groups (religions, gender, sexual preference).
Anyone not in the dominant group (white male Protestants) will have experienced implicit bias; women in surgery and medicine universally have.
Microaggressions are 'very tiny paper cuts'—not blatant prejudice but repeated small insults (e.g., men talking over women, 'mansplaining,' 'he-peats') that take a toll over time.
People in dominant positions are responsible for calling out microaggressions and bias, not those experiencing them.
At Hopkins in 2005–2006, implicit bias testing showed that people have bias based on where they sit (Hopkins vs. Harvard) and that white preference exists because white individuals get more recognition and opportunities.
Julie Freischlag learned 20 years after the match that the UCSF surgery chair decided he didn't want any women in the program, so the three ranked women (including her) were excluded.
All of Julie Freischlag's search committees now must go through implicit bias testing and examination.
Unconscious biases are associations or preferences occurring outside awareness and control; they can influence decision-making so that even well-intentioned, egalitarian clinicians may treat people differently based on gender, race, age, height, weight.
In a case Quinn Capers was made aware of, an outside oncologist assumed an underrepresented minority patient's cancer relapse was due to noncompliance with chemotherapy; genetic testing later showed the cancer had mutated, but the delayed switch in therapy came too late and the patient died.
There is data that physicians unconsciously associate underrepresented minorities with medical noncompliance.
If you are in a dominant group (white, male, Protestant, cisgender), you never have to think about your social identity during interactions—'you've never had to think about what's water.'
Many people assume surgeons can't lead organizations because they're 'so narcissistic and self-centered that they can't see beyond the operating room'; Julie Freischlag had to overcome this stereotype when seeking dean/CEO positions.
A panel that is purely white males will not attract many listeners nor be believed.
To diversify panels, one can ask trainees (especially women or underrepresented minorities) who they admire in the field, or reach out via email/text to people outside one's immediate network.
When assembling panels, people typically ask 'who do I know?' or call a colleague for recommendations, which perpetuates homogeneity; intentionality is required to achieve diversity.
Todd Ponsky admits he thinks of who to put on panels by recalling who he's seen on other panels, thereby perpetuating bias.
Implicit bias arises from how you were raised, the people around you, your parents, hometown, and high school—not from personal moral failing; recognizing it should prompt action, not shame.
Appreciative inquiry—asking 'why? tell me more' instead of assuming you know the answer—helps overcome implicit bias.
Recognizing implicit bias is the first step; it exists in 100% of people, it's not your fault (media and society reinforce it), but you have a responsibility to behave differently.
Addressing implicit bias is hard work, a journey that will make you extremely uncomfortable; when you get uncomfortable, that means you're making progress.
Robin DiAngelo's book *White Fragility* explains how pervasive race issues are in society and how white people have a responsibility to respond appropriately; it addresses the defensive 'I'm not biased' reaction.
Physicians are good-hearted people who want to do the right thing, but unconscious biases can 'hijack our good intentions' and lead to inequitable care.
Research-proven strategy: find common group identities with patients (e.g., both grew up on a farm, both fans of the same sports team); discovering a shared group identity reduces unconscious bias.
Perspective-taking—imagining what a patient went through to get to the appointment (parking, stress, taking time off work)—builds empathy, and empathy actively opposes unconscious bias.
At Ohio State, after the 140-member admissions committee took three Harvard IATs (sexuality, male career stereotype, black-white race) and received bias training, the college admitted the most diverse class in its history the very next cycle.
Ohio State now mandates annual admissions committee orientation with IAT testing and a vignette-based workshop on implicit bias reduction strategies.
Mary Brandt's three key points: (1) you have implicit biases that are getting in your way; (2) they hurt individuals and the profession by preventing diverse hiring/retention; (3) addressing this takes courage, and those in power must call out bias when it happens.
In medicine's hierarchy, younger and more diverse individuals are not comfortable calling out bias, so leaders must be public about it and say 'I'm sure you didn't mean to offend, but this is what we heard.'
When someone reports an offensive incident, leaders must listen with an open mind, because implicit bias may cause the leader to have heard it differently than the person who was harmed.
Julie Freischlag recounts a lecture at her college that young women found offensive but an older white male thought was great—'people will hear different things' based on their identity.
Leaders will make mistakes and should publicly apologize: 'I didn't mean it to sound that way. That's not really how I feel, but I'm so glad you brought it to my attention.'
Forgiveness is important on this journey; most people want to improve, and a small percentage are 'hopeless,' but kindness keeps people encouraged to change.
In a wrestling match between your conscious mind and your unconscious mind, your conscious mind will win every time—if you know what your unconscious biases are.
You are at highest risk for unconscious bias driving decisions during times of high cognitive load (thinking about 3–4 things at once), time crunch (e.g., emergency room), and sleep deprivation (post-call).
'Consider the opposite' strategy: before making a decision, force yourself to go back to the data looking for evidence to support the opposite conclusion (e.g., if you think a student can't succeed academically, look for evidence they will).
The IAT should not be used to screen people out of jobs or committees (that would assign conscious intent to unconscious associations); it should be used to guide education and professional development.
Implicit bias is defined by the Kirwan Institute at Ohio State as 'the attitudes or stereotypes that affect our understanding, actions and decisions in an unconscious manner.'
In a study of diverse doctors, minority children were consistently given less pain medicine than white children, with no reason except implicit bias and stereotypes.
Social identity is 'the portion of an individual's self-concept derived from perceived membership in a relevant social group' (gender, sexual orientation, etc.).
It has been proven in business that diverse, inclusive teams make more money, make more progress, and attract more people.