3/2/2018 Implicit Bias, Race and Medical Care We have nothing to disclose Kate Lupton, MD Sarah Schaeffer, MD, MPH University of California, San Francisco Bias and Equity Implicit Bias & Health Care Disparities Two sides of the same coin Clinical Appropriateness & Need Patient Preferences Quality of Health Care The Operation of Health Care Systems Difference Discrimination: Non Minority Disparity Biases, Stereotyping, and Uncertainty Minority Populations with Equal Access to Health Care Gomes and McGuire, 2001. 1
3/2/2018 Medicine is talking about it How Implicit Bias Impacts Healthcare Healthcare Medical Worker’s School Trust in Trust in Admission Attitudes & physician physician Beliefs Graduate Perceptions Perceptions School Admission & Experience & Experience Treatment Communication Faculty of Care of Care Hiring and Practices Promotion Provider-Patient Patients’ Perception of Healthcare Workforce Encounter Care Objectives How Implicit Bias Impacts Healthcare • Describe implicit racial bias and how it develops Healthcare Medical Worker’s School Trust in Trust in Admission Attitudes & • Recognize how implicit bias about race can physician physician Beliefs Graduate School Perceptions Perceptions Admission impact health care providers and patients & Experience & Experience Faculty Communication Treatment of Care of Care Hiring and Practices Promotio • Identify strategies to reduce the impact of n Provider-Patient Patients’ Perception of implicit biases Healthcare Workforce Encounter Care 2
3/2/2018 Overview Overview • Development of Implicit Bias • Development of Implicit Bias – Evolutionary, Historical, and Structural Basis – Evolutionary, Historical, and Structural Basis – Messaging that contributes to implicit bias – Messaging that contributes to implicit bias • Examples of Implicit Bias and Patient Care • Examples of Implicit Bias and Patient Care – Treatment decisions – Treatment decisions – Prevalence of bias among healthcare providers – Prevalence of bias among healthcare providers – Communication & experience of care – Communication & experience of care • Tools to Counter Implicit Bias • Tools to Counter Implicit Bias – Reducing biased behavior – Reducing biased behavior – Reducing personal bias – Reducing personal bias Implicit Bias Defined How Implicit Bias Develops • Bias - Prejudice in favor of or against one thing, 1) Evolutionary Basis person, or group compared with another, usually in a • Humans process huge amounts of way that is unfair. (Oxford Dictionary) environmental stimuli organize into – Explicit (conscious) categories with similar characteristics – Implicit (unconscious) • Evolutionarily helpful to quickly categorize • Implicit Bias - Social stereotypes about certain groups • Categorization is hard wired, even as of people that individuals form outside their own categories themselves evolve conscious awareness (Fiske & Taylor, 1991; Valian, 1998) 3
3/2/2018 How Implicit Bias Develops How Implicit Bias Develops 2) Historical Basis • Specific to each environment: our country, state, city, community • Long history of marginalization and injustice 3) Structural Basis • Systemic discrimination and oppression Frank, R. Trolley—New Orleans , 1955 We All Have Implicit Bias Origins of Implicit Bias - Race • Usually incompatible with our conscious values and beliefs • “The result of mental associations that have formed by direct and indirect messages we receive about different groups of people” (Staats 2016) 4
3/2/2018 Origins of Implicit Bias Origins of Implicit Bias - Gender Gender and Race "There's the guy responsible for turning Katinka Hosszu, his wife, into a whole different swimmer” – NBC commentator on Olympic Gold medal swimmer’s coach “Oh, say can you see … the Olympic gold medalist "No apologies from [Lochte] or other athletes slouching during the playing of the U.S. national are needed…We have to understand that these anthem? kids were trying to have fun. Let's give these Her expression was blank and distant. kids a break. Sometimes you make decisions that you later regret. They had fun, they made By all means, do not use the podium to pout, and a mistake, life goes on." it seemed like Gabby Douglas was simply pouting.” Origins of Implicit Bias Measuring Implicit Bias Gender and Race Implicit Association Test (IAT) • Introduced in 1998: >15 million participants • Used widely to measure implicit bias • Measures time to match representatives of social groups (age, gender, race, others) to particular attributes (good, bad) • Quicker matching = strong unconscious linkage • Relatively resistant to social desirability concerns 5
3/2/2018 Measuring Implicit Bias Overview • Development of Implicit Bias – Evolutionary, Historical, and Structural Basis – Messaging that contributes to implicit bias • Examples of Implicit Bias and Patient Care – Treatment decisions – Prevalence of bias among healthcare providers – Communication & experience of care • Tools to Counter Implicit Bias – Reducing biased behavior – Reducing personal bias implicit.harvard.edu Race and Pediatric Pain Management Goyal et al, JAMA Pediatrics. 2015 6
3/2/2018 Race and Pediatric Pain Management Race and Pediatric Pain Management Goyal et al, JAMA Pediatrics. 2015 Goyal et al, JAMA Pediatrics. 2015 Race and Pediatric Pain Management Race and Thrombolysis As pediatricians implicit pro-white bias Black Patients White Patients increased Patient likely to have CAD 40.1% 29.8% • Less likely to recommend opioid treatment for African American Very likely children 42.7% 58.2% to offer thrombolysis • Recommendations for white children did not change Green et al., JGIM. 2007 Sabin & Greenwald, AJPH. 2012 7
3/2/2018 Race and Thrombolysis Implicit Bias in Healthcare Providers • Healthcare providers across disciplines and training levels have implicit racial biases • Variable association between provider implicit bias and patient treatment recommendations and outcomes • Consistent association between implicit bias and poorer provider-patient communication Maina et al., Soc Sci & Med. 2017 Green et al., JGIM. 2007 Race, Bias and Communication Implicit Bias and Communication • Explicit attitudes → objec�ve ra�ngs of verbal friendliness • Explicit attitudes → self-perceived friendliness • Implicit attitudes → objec�ve ra�ng of non- verbal friendliness • Implicit attitudes → partner’s perception of friendliness Dovidio et al., J Personality and Social Psychology. 2002 Blair et al., Ann Fam Med. 2013 8
3/2/2018 Implicit Bias and Communication Implicit Bias and Communication PCPs with high levels of pro-white implicit bias PCPs with high levels of stereotypes of Blacks as non-adherent Black Patients White Patients Black Patients White Patients • • • longer visits shorter visits Objective • ↑ verbal dominance ↑ verbal dominance Objective • • slower speech faster dialogue observations • ↓ pt positive affect observation • • ↓ pt-centered ↓ clinician verbal dialogue dominance • ↑ clinician posi�ve Patient • ↓ respect for pa�ent • ↑ respect for pa�ent affect perceptions • ↓ like clinician • ↑ clinician likes • ↑ pt-centered dialogue • ↓ confidence in patient Patient • • ↓ trust ↓ involvement in • ↓ clinician is clinician perception • ↓ confidence in decisions • ↓ recommend to participatory • provider ↓ likelihood of others • ↓ involvement in recommending decisions Cooper et al., AJPH, 2012 Cooper et al., AJPH, 2012 Overview When Implicit Bias is Triggered • Development of Implicit Bias Environments where we are… – Evolutionary, Historical, and Structural Basis • Busy – Messaging that contributes to implicit bias • Have competing responsibilities • Examples of Implicit Bias and Patient Care • Multi-tasking CLINICAL MEDICINE!! – Treatment decisions • Under high pressure – Prevalence of bias among healthcare providers – Communication & experience of care • Have less personal experience with other • Tools to Counter Implicit Bias group members – Reducing biased behavior • Need to fill in information gaps – Reducing personal bias • Asked to use pattern recognition 36 9
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