Just Read: #WhatADoctorLooksLike – Implicit Bias in Academic Medicine – via JAMA

Where I went to medical school (University of Arizona College of Medicine), we had the typical “wall of fame” of all the previous graduating classes prominently mounted, covering the history of the school’s first class from 1967 to the present.

It was amusing to note that as you walked along the wall that the number of women in each class steadily increased, to the year after mine, when for the first time there were more women than men in incoming class.

Except that in retrospect, it wasn’t really funny.

The other thing I noticed was that the Nursing School building, erected a few years after the medical school building next to it, didn’t seem to have very many men’s rooms…

The wall showed another thing, that there were no LGBTQ human beings enrolled in this school. Except that there were. However, all the signs and signals in our curriculum and the behavior of our faculty conspired to keep this just an “allegation.”

And so…we can now measure the impact.

This issue of JAMA Internal Medicine includes three studies looking at sex and racial bias in academic medicine, and as it has been shown in many (many) other studies, the profession tends to mirror the society around it. No more, no less. This is a link to the editorial accompanying the studies, written by Molly Cooke, MD (@mollymcooke) at the University of California, San Francisco.

Cooke M, AJM A, RA G, E M, M N-S. Implicit Bias in Academic Medicine. JAMA Intern Med [Internet]. 2017 Mar 6 [cited 2017 Mar 15]; Available from: http://archinte.jamanetwork.com/article.aspx?doi=10.1001/jamainternmed.2016.9643

This wouldn’t be a problem (actually, it would always be a problem, but maybe not as high-stakes) if our society’s health didn’t depend on physicians who understand the life experience of the communities they serve (It does).

Another bank of studies show clearly that people learn better from people who resemble their life experience more closely. It’s just science, not an opinion. And so, when people are selected to present at grand rounds:

To the extent that those role models do not mirror the sex and racial composition of the trainee pool, we are delivering the implicit but powerful message that these leadership roles and examples of excellence are for someone else. Women, blacks, Asians, and Latinos need not apply.

I have previously posted on the environment around LGBTQ trainees, also studied, and also with outcomes that parallel these.

Just Read: Sexual and Gender Minority Identity Disclosure: “In the Closet” in Medical School

This gendered quote from a general practitioner in 1966 (the ancestors of my medical specialty, family medicine) is relevant here:

S/He does more than treat them when they are ill; he is the objective witness of their lives. They seldom refer to him as a witness…that is why I chose the rather humble word clerk: the clerk of their records.

If this is what doctors do (it is), then we have an interest in examining our biases and modulating them. And there’s science to show that can be done, too. Isn’t this century grand 🙂 .

One more from Shania Twain, because it’s my RSS feed.

She’s a geologist, a romance novelist
She is a mother of three
She is a soldier, she is a wife
She is a surgeon, she’ll save your life
She’s, not, just a pretty face
She’s, got, everything it takes

I’ll post again on the actual studies referenced.

A few thoughts about gender equality and respect in the 21st Century

2016.03.30 Human Rights Campaign Corporate Equality Index Best Places to Work Reception 03870
2016.03.30 Human Rights Campaign Corporate Equality Index Best Places to Work Reception 03870 (View on Flickr.com)

I recently finished Sheryl Sandberg’s book Lean In: Women, Work, and the Will to Lead (I know, 3 years behind the rest of society, posting on that later), at the same time I participated in a historic (in my opinion) creation of Workplace Guidelines Pertaining to Transgender and Gender Non-conforming Employees.

I had these thoughts as I was given an opportunity to co-lead (with an excellent leader who happens to be a woman) an introduction to this topic:

  1. Everyone here was made in the 20th Century
    • By definition, today’s health care workforce was born in the 20th Century. The overwhelming majority of us were educated in the 20th Century, which is where much of gender expression was imposed on society:
    • When Did Girls Start Wearing Pink? | Arts & Culture | Smithsonian@SmithsonianMag

      For example, a June 1918 article from the trade publication Earnshaw’s Infants’ Department said, “The generally accepted rule is pink for the boys, and blue for the girls. The reason is that pink, being a more decided and stronger color, is more suitable for the boy, while blue, which is more delicate and dainty, is prettier for the girl.”

    • Fashions: Baby’s Clothes – TIME | Where to buy pink clothes for boys, 1927 – Gender MystiquePink is for boys
    • BBC – Future – The ‘pink vs blue’ gender myth

      Various studies have looked at colour preferences in different age groups. In the US most have found that babies and toddlers, whether male or female, are attracted to primary colours such as red and blue.

    • Medical science is also a conspirator here. With the advent of amniocentesis in the 1980s, and with it, the ability to know a child’s sex at birth, the marketing of imposed gender expression became even more aggressive.
    • The majority of the workforce being “made” in the 20th Century of course is changing rapidly, which is going to contribute to all of the above being an even more distant memory. Since it’s not based on science, it won’t be missed by this physician.
  2. Now that we know that much of what we were taught was arbitrary and not based on science, it’s up to us to unlearn and relearn.
    • This quote really helps with that.

      Notice your defensiveness and accept the discomfort of unlearning and relearning. To be competent in this arena is the same as learning to be competent in anything else. It requires a desire to know, motivation to become informed, opportunities to practice and the willingness to correct your mistakes.

      To say we don’t have biases is to deny our humanity. We all have to practice the desire to learn, with humility. In experience this can be very difficult for people (I’ll be writing more on this, known as the “illusion of objectivity”). Sheryl Sandberg, in her book, has had similar experiences to mine:

      My own attempts to point out gender bias have generated more than my fair share of eye rolling from others. At best, people are open to scrutinizing themselves and considering their blind spots; at worst, they become defensive and angry.

      Sandberg, Sheryl (2013-03-11). Lean In: Women, Work, and the Will to Lead (Kindle Locations 2287-2289). Knopf Doubleday Publishing Group. Kindle Edition.

  3. As we implement the future, we should be aware of its impact.
    • Creating an environment that’s open to everyone versus one where people are helped to “fit in” places an employer squarely in the group of the most elite employers to work for, internationally. I am proud to be a part of one of the 407 best places to work in the United States, with a 100% rating on the Human Rights Campaign Corporate Equality Index.
    • I can’t even count the number of times our work in this space has created more opportunity for thought partnership and mindshare around health in general. Not LGBTQ health, all health, total health. I personally know people who have joined our health system because of the knowledge that we respect this population, whether or not they are a member of it. The same goes for other nationally important stakeholders I have worked with – they are drawn to people and organizations that respect every human, in all work related to health.

      Photo Friday: It’s important for a health system to score 100% on the HRC Corporate Equality Index, too

    • Changing our world to help it learn to love better is the continuation of what a nurse or doctor hopes to become when they begin their training. It’s an incredible leadership opportunity to be part of these professions when we become who we are.

Speaking of leadership opportunities. I encounter them every day, sometimes unexpectedly, and they are awesome.

Can Health Care Be Cured Of (Unconscious) Racial Bias? : NPR

A growing body of research suggests that doctors’ racial biases and other prejudices continue to affect the care patients received. Medical educators say self-awareness is an important first step.

Source: Can Health Care Be Cured Of Racial Bias? : Shots – Health News : NPR

The opening story in this NPR piece is worth listening to.

As I’ve noted on this blog before, for LGBT and especially T individuals, there isn’t just unconscious bias in health care, there is frank, open, explicit bias (see: Just Read: Eliminating physician biases against gay and lesbian people, don’t forget the “T”).

I am glad this subject is getting covered in today’s health professions schools. In the end, health systems and academia need to design bias-free and de-biasing environments for learners and faculty.

Just Watched: “Managing Unconscious Bias” , for Facebook employees

Via the magic of Twitter, I was treated to access to Facebook’s publication of their own Managing Bias training for their employees. It’s an approximately one hour video of an actual training, also broken up into modules, plus slides and references, which you can view/download on demand.

Interestingly (and authentically) the notice didn’t come from Facebook’s Learning & Development organization:

I watched the one hour training and reviewed the materials as someone who’s been studying unconscious bias for a little over a year now, with the support of Kaiser Permanente’s own National Diversity and Inclusion Organization (thank you!).

Impressed by

  • The sharing of the video of the training by Facebook. It’s hard to find companies that are this open about a sensitive topic within any organization. The video shows employees working through (and maybe exhibiting) biased behavior. This is good. It’s human.
  • The teaching approach – with a video of several employees who are different introducing themselves to an invisible viewer. I honestly thought after watching that part, “I don’t have a preference for any of the individuals.” Some of the employees in the training did, which starts a good dialogue.
  • Use of validated tools – employees were asked to take the Implicit Association Test in advance. And they were asked, not ordered to, which is the correct way to introduce the test.
  • Counteracting behaviors like having structured decision making and clear criteria are great and important, really good discussion.
  • Connection to impact, and business impact. A good job was done, in my opinion, of making a case for eliminating bias for a better company.

Things worth further exploration

How I would add to/amend (as suggested at the bottom of the web site):

  • Explain the “unconscious” nature of unconscious bias. This bias is not something you can recognize and tell yourself not to have. If it was, it would be “conscious” (or “explicit” as they say in the literature). In an audience that’s more likely to have a preponderance of scientists/engineers (doctors/nurses), it’s helpful to explain how our brain wiring results in these associations that happen so fast, you can’t ask yourself if you have them, and often you can’t notice the behavior that comes from them. (A good paper that I wrote about helps: Just Read: Unconscious bias is like an iPhone version 20 inside your brain, and walking helps manage it (?) | Ted Eytan, MD).
  • Modulate suggestions like “don’t make assumptions.” These don’t really get at the unconscious nature of bias or de-bias a workplace. Again, this bias is not conscious, you can’t talk your way out of it.
  • Add a discussion about how to de-bias a workplace
  • Lori Goler (Facebook’s VP of People), Maxine Williams (Facebook’s Global Diversity Officer) and Mike Rognlien (Facebook Learning and Development) do a great job of introducing all the topics, including the importance of giving fair credit. However, the website in which their work is housed doesn’t list their names anywhere – you have to dive into the video to get them. Model giving fair credit – these trainings are not easy to create or perform.
  • I and others had the good fortune of a session with Professor Mahzarin Banaji (@banaji), one of the developers of the Implicit Association Test, earlier this year. One thing she did that was useful, was a live version of the Implicit Association Test, using hand claps. It’s very illustrative, but takes some setting up.

Of course, I have assessed my own biases. It’s a good thing to do because we all have them, which means we are human.

It’s nice to know, even at Facebook, that to train people on something, you still need to bring them into a room and teach them. Not everything can be learned virtually. Thanks to Facebook for sharing it with the world.

If the diversity team was available on any social network to continue the conversation as part of a community committed to eliminating bias that would be great. Regardless, the commitment is visible and it’s appreciated, we’re all here to make sure everyone has the opportunity to achieve their life goals.

Just Read: Eliminating physician biases against gay and lesbian people, don’t forget the “T”

This is a study from Yale University about medical students’ explicit and implicit attitudes toward people who are gay and lesbian. Not surprisingly, medical students reflect the biases of the society around them:

Explicit and implicit attitudes among medical students 54443
A lot of bias: Explicit and Implicit attitudes among medical students against gay and lesbian individuals (Where’s the “T”?) (View on Flickr)

I created the chart above from the study data which shows that a little less than half of medical students today harbor openly negative attitudes toward gay and lesbian people. When looking at their unconscious attitudes, that jumps to 82 %.

This is about the same percentage as adult physicians’ negative implicit attitudes toward latino individuals, but more negative than adult physicians’ attitudes toward african american people. (see: Blair I V, Havranek EP, Price DW, et al. Assessment of biases against Latinos and African Americans among primary care providers and community members. Am. J. Public Health. 2013;103(1):92–8.)

What you do with it that matters

This data obviously doesn’t make people feel good about their potential treatment in health care, which can be hostile bordering on brutal (I’ll post on that in the near future).

What’s more important is that physicians and the profession in general should desire to know their biases, and do something about them. The researchers in the first paper correlated attitudes to prior contact with gay or lesbian individuals, and found that, indeed, having had positive contact was protective, as has been shown in the literature for many years.

In other words, there are things that can be done, we should not be disappointed that bias exists, we should be disappointed if it is allowed to continue unmodulated.

Enter the “hidden curriculum”

The commentary piece attached to this one brings up, again (for the nth time this month alone – must be newly popular?), the concept of the “hidden curriculum,” which has been foreign to me as a non-academic, so I appreciate it being defined here:

The compilation of implicit biases, explicit biases, institutional climate, and ingrained behaviors at an academic health center also form the foundation of the institution’s hidden curriculum, or what health professions trainees learn from what they observe and experience rather than what they are overtly taught.

This doesn’t strike me as good news, since recent research shows that the hidden curriculum seems to be promoting rather than eliminating bias (see: Just Read: Sexual and Gender Minority Identity Disclosure: “In the Closet” in Medical School | Ted Eytan, MD). For example this quote:

On my surgery rotation, we saw a male- to-female transgender patient who had “do-it-yourself ” silicone breast implants which had become infected. He [sic] was treated like a freak by the residents and attendings behind closed doors, joking at his [sic] expense. (25-year-old, third-year, lesbian, white, female, U.S. MD student)

I’d like to point out that the researchers in the study above didn’t get the pronouns right themselves when they transcribed the quote, so bias is quite pervasive.

There’s no “T” in this discussion of “LGBT”

I used the quote above to point out that while the topic of the commentary piece is “anti-LGBT” bias, bias against people who are transgender or non-conforming is not mentioned once.

The study of medical student bias did not address this bias (against transgender or gender non-conforming individuals) at all. There is currently no implicit attitudes test for people who are trans or gender non-conforming, but I understand one is being developed. It would have been useful to at least ask about explicit bias for this group, because if we think about the harm to gay and lesbian people in health care, imagine the special harm that people who are transgender face. I diagrammed it out here to assist:

Impact of implicit and explicit bias in the health of transgender persons 54442
Impact of implicit and explicit bias in the health of transgender persons (View on Flickr)

I’m wondering if academic medicine is going to follow, rather than lead, in changing the profession.

In my glass 3/4 fullness, that’s okay, the rest of us are here and we have accountability too. We have to change the health care industry’s position on providing medically necessary care, so that care is provided routinely in the first place.

In addition we need to bring a human understanding to the lives of the people we are serving, which seems quite lacking. That’s what #KPLantern is working to accomplish. Watch this space for updates 🙂 .

Papers cited:

Burke SE, Dovidio JF, Przedworski JM, et al. Do Contact and Empathy Mitigate Bias Against Gay and Lesbian People Among Heterosexual First-Year Medical Students? A Report From the Medical Student CHANGE Study. Acad. Med. 2015.

Fallin-Bennett K. Implicit Bias Against Sexual Minorities in Medicine: Cycles of Professional Influence and the Role of the Hidden Curriculum. Acad. Med. 2015.