Objectives Review the impact of bias on clinical care Caring for - PowerPoint PPT Presentation

Objectives  Review the impact of bias on clinical care Caring for Patients with Diverse Backgrounds  Describe the current understanding of the neuroanatomy of implicit bias  Discuss strategies to combat bias in clinical care through Nicole Rosendale, MD cultural humility and relationship centered communication Assistant Professor of Neurology UCSF/ZSFG Recent Advances in Neurology 2020 No relevant financial disclosures 1 2 Why is it important to be discussing this today?  Research has consistently shown disparities in access to and outcomes in healthcare based on sociodemographic factors In a study of the 2006-2013 Medical Expenditure Panel Survey, - black patients were 30% less likely than white patients to see an outpatient neurologist; Hispanic patients were 40% less likely The neuroanatomy of implicit bias Example can be found across neurologic specialties, including - stroke, headache, epilepsy, and neuroimmunology  Research has also suggested that clinician behavior can contribute to these disparities White AA, et al. J Racial Ethn Health Disparities 2017 Hall WJ, et al. Am J Public Health 2015 Saadi A, et al. Neurology 2017 Li CC, et al. LGBT Health 2015 Marulanda-Londoño ET, et al. Neurology 2019 Van Ryn M, et al. Am J Public Health 2003 3 4 3 4 1

There are two types of bias: explicit and implicit Neuroanatomy of bias involves a complex circuit  Explicit bias = consciously held beliefs  The formation and regulation of implicit bias involves a complex circuitry of neural networks  Implicit bias = unconscious beliefs Social stereotypes about certain groups of people that individuals - form outside their own conscious awareness  The exact neural networks activated may be influenced by the type of information input into the network Perception-based input (i.e. face, attire, etc.) - Knowledge-based input (i.e. prior knowledge of social category -  Bias is prejudice in favor of or against one thing, person, or such as occupation) group compared to another, usually in a way that is unfair Perceiver characteristics (i.e. importance of appearing non- (Oxford Dictionary) - biased, own social category, etc.) Fiske & Taylor, 1991 Mattan BD, et al. Curr Opin Psych 2018 Valian 1998 5 5 6 Network activated by knowledge-based input Network activated by perception-based input Mattan BD, et al. Curr Opin Psych 2018 Mattan BD, et al. Curr Opin Psych 2018 Zink CF, et al. Neuron. 2008 7 8 2

Neural networks are influenced by perceiver The environments in which implicit bias is characteristics triggered are…  Prior experiences can attenuate amygdala activation  Busy  Have competing responsibilities  Neural networks are differentially activated based on internal  Multi-tasking motivation to not appear biased  Under high pressure  Have less personal experience with other group members  Power increases racial implicit bias and racial stereotyping  Need to fill in information gaps  Asked to use pattern recognition Schmid PC, Amodio DM. Soc Neurosci. 2017. 10 9 10 • Less access to high-volume stroke centers & IV thrombolysis for Black, Hispanic & Native American Stroke individuals 1 • African American race independently predicted a lower likelihood of anterior temporal lobectomy for Epilepsy temporal lobe epilepsy 2 Neuro-disparities • Lower rates of rehabilitation referrals for Hispanic, Asian and uninsured patients 3 TBI • African Americans are less likely to receive migraine diagnosis and appropriate acute treatments for Migraine migraine 4 12 1. Kimball MM, et al. J Stroke Cerebrovasc Dis 2014 3. McQuistion K, et al. J Surg Res 2016 11 2. McClelland S III, et al. Arch Neurol 20101 4. Befus DR, et al. Curr Pain & Headache Reports 2018 11 12 3

Language also plays role in health disparities  Limited English proficiency has consistently been associated with poor outcomes Increased risk of 30-day ED presentation / 30-day readmission for - COPD and HF, but not pneumonia or hip fracture 1 COPD and HF are chronic conditions requiring complex - management – similar to many neurologic conditions  Race/ethnicity and language have a complex role in contributing to disparities 2013 study showed that both race and limited English proficiency - contributed to disparities in surgical treatment for medically refractory epilepsy 2 Attention to English proficiency may highlight important, and - previously hidden, disparities 3-4 Center for Immigration Studies 2018 / US Census Data 2017 1. Rawal S, et al. JAMA 2019 3. Sentell T, et al. JGIM 2007 13 14 2. Betjemann JP, et al. Epilepsy Behav 2013 4. Saha S, et al. JGIM 2007 13 14 LGBTQ+ individuals also experience unequal care LGBTQ+ identity is relevant to neurology  2015 U.S. Trans Survey 1 found:  Transwomen taking gender- 33% of respondents reported at least 1 negative experience in affirming hormones may - accessing healthcare have a higher risk of stroke 1 31% of respondents reported that none of their health care and higher risk of developing - providers knew they were transgender MS 2 23% of respondents delayed or avoided accessing care out of - fear of discrimination or mistreatment  Gender affirming hormones may also  2017 nationally representative survey 2 showed interact with AEDs 3 - 8% of ~900 LGB respondents were refused care because of their - influence prevalence, - sexual orientation severity, and treatment of 9% who did see a clinician reported use of harsh or abusive - other hormone-sensitive language during that encounter conditions like migraine 4 1. National Center for Transgender Equality, 2016 2. Mirza SA & Rooney C, Center for American Progress 2018 1. Getahun D, et al. Ann Intern Med 2018 3. Johnson EL, Kaplan PW. Epilepsia 2017 15 16 2. Pakpoor J, et al. Mult Scler J 2016 4. Pringsheim T. Neurology 2004 15 16 4

Interventions for implicit bias  Make the unconscious conscious Implicit Association Test - Providing patient-centered care  Challenge automaticity Slow down decision making, use data, monitor outcomes/decisions -  Challenge stereotypes Individuation, increased intergroup experiences, etc. - 17 18 17 18 Practical tips for an inclusive practice Practical tips for an inclusive practice  Start with inclusive language  Explore the individual’s perceptions and fears In the first meeting, avoid assumptions about someone’s name - and relationships of others in the room  FIFE Use gender-neutral terminology until the patient provides the - FEARS - correct term (i.e. parents, spouse, significant other, siblings)  What worries do you have about the symptoms? Check in about need for interpreter - IDEAS - Write this information down, so you don’t need to ask again and -  What do you think might be causing this? consistently use chosen name in future interactions FUNCTION -  How has it affected your daily functioning?  When using an interpreter EXPECTATIONS - Speak slowly and clearly, allow time for translation -  What are you expectations for your hospitalization (or clinic appt)? Avoid non-translated side conversations (or at least explain what - you are talking about if those happen) American Academy on Communication in Healthcare 19 20 19 20 5

Practical tips for an inclusive practice  Be aware of non-verbal communication Clinic posters / flyers - TV in the waiting room - Intake forms - Positioning of you and the patient in the clinical space - Clothing -  Ask – Teach – Ask when counseling about diagnosis or treatment plan  Written communication in the form of notes matters as well Swayden KJ, et al. Patient Educ Couns 2012 Petrilli CM, et al. BMJ Open 2018 Goddu AP, et al. JGIM 2019 21 22 21 22 The complexity of patient-centered The effect of stigmatizing language communication in the clinical setting  Comfort in dosing pain medications correlated with more aggressive pain management for the neutral language scenario but not for stigmatizing language scenario  There was an inverse relationship between year of training and PASS score Goddu AP, et al. JGIM 2019 Epstein RM, et al. Soc Science & Med 2005 23 24 23 24 6

Thank you for your attention! 25 25 7