Managing Our Implicit Bias Kimberly Curseen, MD Associate Professor of Internal Medicine Emory School of Medicine Director of Emory Outpatient Supportive Care Clinic kacurseen@emory.edu January, 17 2017
Join us for upcoming CAPC events Webinar: ➔ – How to Use CAPC Membership: Wednesday, January 25, 2017 | 12:00-1:00 pm ET – The Effective and Efficient ED-Palliative Care Consult: Tuesday, February 7, 2017 | 1:30 - 2:30 pm ET Virtual Office Hours: ➔ – Palliative Care models in the Community with John Morris, MD, FAAHPM: TODAY | 4:00 pm ET – Team Health and Wellness with Phil Higgins, PhD, LICSW: Thursday, January 19, 2017 12:00 pm ET – Palliative Care in Long Term Care Settings with Katy Lanz, DNP, ANP, GNP: Monday, January 23, 2017 | 12:00 pm ET – Ask Dr. Diane Meier: Open Topics: Monday, January 23, 2017 | 3:00 pm ET – Home Health Agencies Delivering Palliative Care in the Community with Bob Parker, DNP, RN, CENP, CHPN: Tuesday, January 24, 2017 | 2:00 pm ET – Ask a Program Leader: Open Topics with Andrew Esch, MD, MBA: Wednesday, January 25, 2017 | 2:00 pm ET (30 minute session) Visit www.capc.org/providers/webinars-and-virtual-office-hours / 2
Managing Our Implicit Bias Kimberly Curseen, MD Associate Professor of Internal Medicine Emory School of Medicine Director of Emory Outpatient Supportive Care Clinic kacurseen@emory.edu January, 17 2017
➔ I have no relevant disclosures 4
Objectives ➔ The learner will be able to define and identify implicit bias ➔ The learner will be able to evaluate how culture can affect interactions with patients ➔ The learner will be able to implement tools to overcome implicit bias to improve care given to patients 5
Common language 6
➔ Implicit bias is the bias in judgment and/or behavior that results from subtle cognitive processes (e.g., implicit attitudes and implicit stereotypes) that often operate at a level below conscious awareness and without intentional control ➔ Ethnocentrism is the belief that one’s own cultural view is the only correct view ➔ Prejudice is unreasonable feelings, opinions, or attitudes, especially of a hostile nature, regarding an ethnic, racial, social, or religious group ➔ Racism is prejudice or discrimination directed against someone of a different race based on such a belief 7
Implicit Bias: Kirwan Institute ➔ Implicit biases are pervasive . Everyone possesses them, even people with avowed commitments to impartiality such as doctors. ➔ Implicit and explicit biases are related but distinct mental constructs . They are not mutually exclusive and may even reinforce each other. ➔ The implicit associations we hold do not necessarily align with our declared beliefs or even reflect stances we would explicitly endorse. ➔ We generally tend to hold implicit biases that favor our own in-group , though research has shown that we can still hold implicit biases against our in-group. ➔ Implicit biases are malleable . Our brains are incredibly complex, and the implicit associations that we have formed can be gradually unlearned through a variety of de-biasing techniques. 8 http://kirwaninstitute.osu.edu/research/understanding-implicit-bias/
Implicit Bias ➔ Not recognizing the impact of implicit bias can prevent palliative care providers from providing the type of care that our patient’s need and deserve ➔ Implicit bias can rob the palliative care provider of the patient interactions along with the type of care that we find fulfilling, leading to frustration and contributing to burnout ➔ “I came here to help and I’m not helping, can’t they see I am looking out for them” Butler M et al. Improving Cultural Competence to Reduce Health Disparities; Agency for HealthCare Research and Quality; Mar 2016 9
Implicit Bias Impact ➔ A literature search performed by Partners in Equity & Inclusion/Michelle Van Ryn revealed > 1000 studies detailing the inequalities and disparities and healthcare ➔ In systematic review published in the American Journal of Public Health in 2015 it concluded that: “Although some associations between implicit bias and healthcare outcomes were nonsignificant, results showed that implicit bias was significantly related to patient – provider interactions, treatment decisions, treatment adherence, and patient outcomes” ➔ A study showed that racial bias reduces empathic sensorimotor responses to patients complaints of pain Avenanti et al. Racial bias reduces empathic sensorimotor resonance with other race pain. Current Biology 2010 Hall W. et al. Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. Amer J of Pub Health; 2015 http://www.p-e-i.org/
Implicit Bias Impact ➔ Beyond race: We should think about implicit bias in a broader sense, looking beyond race to factors such as: gender, generation/age, transgender, women, children, social economic status, language, disability, LGBQ, political affiliation, prisoner, religion, etc ➔ “Basically if you are looking at someone who is not you, you should consider if or how implicit bias maybe affecting your actions” 11
Strategies to managing implicit bias Deliberate Behavior Mindfulness Self awareness Perspective Taking Shared Decision Skills Making 12
Self awareness ➔ “In order to fix a problem it is necessary to be aware that there is a problem and be willing to work on it” 13
Self awareness ➔ Study by Michelle Van Ryn published in 2016 concluded that – “most physicians were unaware of their own biases” – “research shows that unintentional bias on the part of physicians can influence the way they treat patient’s from certain ethnic and racial groups” ➔ Study in Journal of General Internal Medicine in 2013 reviewed literature on implicit bias pertaining to physicians which concluded: – “The contribution of implicit bias to healthcare disparities could decrease if all physicians acknowledge their susceptibility to it, and deliberately practice perspective taking and individuation when providing patient care” Chapman EN et al. Physicians and implicit Bias; How Doctors May unwittingly perpetuate healthcare disparities. J Gen Intern Med. 2013 Van Ryn M. Minn med. 2016 Mar-Apr 14
How do you become self aware? ➔ First we need to understand us. Why do we struggle with this? 15 http://www.sensanalysis.com/news/implicit-vs-explicit-product-research-which-one-should-be-conducted /
Affective Flash ➔ We can develop cognitive beliefs that are consistent with our first emotional response ➔ This could influence our nonverbal behavior and set up essentially a negative feedback loop that reinforces our cognitive belief Example: I’m going out to do a home visit and when I drive up I see a very large Confederate flag hanging over-the-door. What do you suppose my Affective Flash could be? 16
Self awareness ➔ Implicit-Association Test ( IAT ) is designed to detect the strength of a person's automatic association between mental representations of objects/concepts in memory 17
Self Reflection I’m going out to do a home visit and when I drive up, I see a very large Confederate flag hanging over-the-door. There are couple of very large dogs barking at me while I am sitting in my car. The husband of my dying patient opens the door and waves me in. When I walk in the house none of the several family members acknowledge my presence. I see a Rebel Yell poster on the wall. The floor has parts that are rotted and I have to step over them to get to my patient’s bedside. There is a space heater in the corner. 18
Self Reflection My patient’s husband offered to take my bag and offer me a glass of water. I decline and said I’m okay. I ask to examine her and discuss my concerns with him and afterwards he expressed his fear that he thinks she is dying. I develop a plan to immediately take her to inpatient because a storm is coming and they frequently experience power outages. I return to my car with his son following at a distance behind me. 19
Self Reflection I get in my car and lock my door. I ask him through the window is there something I can do or answer for him. He says no but asks if the doctor is coming. I explain I am the doctor but Kelly her nurse is on her way. “She knows your mom really well.” I get a little nervous and call Kelly “Hey I think she needs to go to inpatient, but not sure they can handle it especially if they lose power. Her husbands says yes but I am worried that he may change his mind. Maybe if you tell them they will hear from you. They really trust you.” 20
Self Reflection ➔ What did you see in my reflection of events? ➔ What implicit bias could you identify? ➔ How did I express my bias? ➔ Did my bias affect the outcome? ➔ What do I do now? 21
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