Just Read: Moral Self-Licensing Part 2 – Challenge to Eliminating Bias in Health Care

It gets better.

This is a 2015 update from Author Daniel Effron at London Business School (@lbs) – and yet another reminder that the business profession has done as much if not more work in the area of behavioral health as the medical profession.

Continuing from the previous post on this topic (Just Read: Moral Self-Licensing – a continual challenge to eliminating bias in health care), this update adds more information about human motivation.

I’m framing this post through the perspective of bias, but the principles apply to health behavior, consumer behavior, etc….

Specifically

  • Counterfactual transgressions – humans will license biased behavior even if they didn’t do something bad in the past (as opposed to doing something good)
  • Prefactual virtues – when a human plans to do something good in the future, they may act biased today
  • Counterfactual virtues – when a human would have planned to do something in the future, they may act biased today
  • Vicarious virtues – the one that concerns me most in health care – when humans reflect on good deeds that the group they are in performed. Why the concern? The general posture of health care as a healing profession and the way organizations inhabit this space provides a tremendous amount of license. It explains, in my mind, why I have seen very UN-virtuous behavior in my career, almost implausibly so, in the profession and in the organizations in this space (well described in this TEDx talk I did with @ReginaHolliday).

This paper adds a scientific lens and the validation that these are human behaviors, with an effect size of 0.31 to be exact, which is

modest in size but robust … (As benchmarks, the average effect sizes in the fields of motivation, social influence, and attribution have been estimated as, respectively, d = .30, .28, and .26; Richard, Bond, & Stokes-Zoota, 2003).

The overall picture, then, is of multiple avenues, real and imagined, that humans use to support biased behavior while engaging in impression management – the view of others and their view of themselves that they are virtuous. It turns out the view of ones’ self is more important than the view of others, which is an asset to leveraged, see below.

And as I wrote about in the last piece, the managed impression tends to be seen as more virtuous by people in the ingroup, and less so by the people in the outgroup, which are often the most vulnerable populations in health care. This would be something along the lines of the scantily clad emperor ….

Impression Management – Leveraging bad for good

Science is great because it can be used to support good as well as not-so-good.

As I have seen in clinical medicine, even the most intractable, frustrating conditions that physicians treat can become less so when they understand the science. Actually, especially those because they are the ones that many practitioners don’t investigate as much, which only increases frustration (I am thinking about things like pain syndromes, musculoskeletal issues, nutrition, etc…).

Here, the fact that human beings are driven by impression management is an asset as much as a liability. Allowing employees opportunities to license themselves (which they will seek anyway) may increase their honest engagement in topics around bias, or to identify compliance issues more readily.

Who you are vs What you do

The other finding in the research is that

For example, framing a past virtue as demonstrating commitment to a virtuous goal (“who I am and what I believe”) compels people to act more virtuously, whereas framing it as progress towards that goal (“what I’ve done”) leads to licensing (Fishbach & Dhar, 2005; Susewind & Hoelzl, 2014).

My interpretation of this data is that linking a person to who they are may limit their tendency to search for evidence that they are “good” and center the impression of their deeds on who they are as a person, which the research points out is a most powerful motivator (vs. if other people think they are virtuous).

These are the pieces of good news – that these mechanisms exist because people want to be virtuous – they are not looking for excuses not to be virtuous.

It is this motive to protect a moral self-image that inhibits people from acting in ethically questionable ways without a license – and that drives them to execute a variety of mental gymnastics when they anticipate that they will need a license.

As usual, many implications for me, for clinical medicine, for health and society

As I mentioned in the last piece, there are well documented, significant biases in health care directed toward groups of patients by their doctors and doctors in training, and the research also shows that physicians have the same level of bias as those in the communities they inhabit. Not more, not less, the same amount. They/we are human.

The way I operationalize this research in my life (and I am human too, so I license) is to

  • Check my licensing with others not in my ingroup
  • Help others check their license, especially those not in my ingroup. An example of this is the conflation of free speech with moral virtue.
  • Avoid licensing opportunities like clicktivism or monetary donation to causes – I tend to give of my mind rather than my money

2017 will be my 5th Capital TransPride (@TransPrideDC), where I serve on the production team, working to be an ally, acutely aware of all the things I have access to because of my place in society, and at the same time as a member of another vulnerable population (LGBTQ) in need of allies. I also look for opportunities to bring leadership from the outgroup into the ingroup, and then leave the ingroup (“the physician role is to bring the patient story into every conversation, then to get out of the way and let the patient tell their own story”)

Always a work in progress. It’s not what you do, it’s what you tolerate.

Reference: Effron, Daniel A., Beyond ‘Being Good Frees Us to Be Bad:’ Moral Self-Licensing and the Fabrication of Moral Credentials (April 14, 2015). P. A. M. Van Lange & J. W. Van Prooijen Van Prooijen, (Eds.), Cheating, corruption, and concealment: Roots of unethical behavior. Cambridge, UK: Cambridge University Press, Forthcoming. Available at SSRN: https://ssrn.com/abstract=2594403

Just Read: Moral Self-Licensing – a continual challenge to eliminating bias in health care

Earlier in my career, I remember a colleague saying to me, in a challenge to observed, biased behavior, “this is organization x, those things don’t happen here.” He said it with a dismissive chuckle. And yet, it did happen…

I have been intensely interested in the concept of “Illusion of Objectivity” especially in health care, and so have done a deep literature review. It brought me to several helpful papers and the concept of moral self-license (Merritt AC, Effron DA, Monin B. Moral Self-Licensing: When Being Good Frees Us to Be Bad. Soc Personal Psychol Compass [Internet]. Blackwell Publishing Ltd; 2010 May [cited 2016 Aug 13];4(5):344–57).

One of the authors, Daniel Effron now at London Business School (@lbs), has written another piece more recently which I’ll post on next.

It’s yet-another-place where the professions outside of medicine can teach us a lot, and why shouldn’t they, we need each other, and our patients need us to perform our best for them.

Moral Self-License, a fascinating concept that shapes our actions

When under the threat that their next action might be (or appear to be) morally dubious, individuals can derive confidence from their past moral behavior, such that an impeccable track record increases their propensity to engage in otherwise suspect actions. Such moral self-licensing (Monin & Miller, 2001) occurs when past moral behavior makes people more likely to do poten- tially immoral things without worrying about feeling or appearing immoral.

Several study situations of note (summarized here, you can review for control situations, etc):

  • When people expressed support for a Black presidential candidate (Barack Obama), they were more likely to subsequently express bias toward less-qualified White candidates for a police job.
  • People asked to describe a time in their past when they acted immorally were more likely to endorse prosocial activities such as giving to charities.
  • The converse situation, people describing a moral act in the past were more likely to cheat on a math task

So there is something about doing (or even thinking) about past behavior that causes people to engage in less-than-virtuous behavior or to minimize the less-than-virtuousness of the behavior.

What does this mean for health care?

A lot.

There is much public controversy presently around institutions and people who express commitment to an unbiased environment, and yet biased environments persist.

Interestingly, further research shows that there is greater sensitivity to what is seen as hypocrisy by people in the affected, targeted groups, which makes sense. The converse, however, is that people who are not in the targeted groups are less likely to see hypocrisy and license biased behavior, which allows it to persist. This is a difficult problem if the actors and the licensors are all part of the same ingroup – there will be less introspection.

Here’s a reason why this is important

Explicit attitudes among medical students 54441
Explicit attitudes among medical students 54441 (View on Flickr.com)

Explicit and implicit attitudes among medical students 54443
Explicit and implicit attitudes among medical students 54443 (View on Flickr.com)

Because, today, medical students feel comfortable explicitly stating bias against lesbian and gay individuals (and even more bias against obese individuals), an atmosphere of moral license (“we don’t do that here, our policies say so”) can allow this to continue.

Note that because of the concept of impression management, students (and physicians, other research) are much less likely to openly state bias toward African American individuals, even though their behavior may reflect it (see: Just Read: Eliminating physician biases against gay and lesbian people, don’t forget the “T” ) .

Who I am vs What I do

There appears to be a protective effect in the understanding of a person’s commitment (who they are and what they stand for) versus what they do (progress toward a goal). Labeling is tied into this:

several studies have found that labeling people as ‘‘helpful’’ after they agree to a small request increases their likelihood of acting consistently by agreeing to a subsequent, large request

Value of Listening, Introspection

There are a few more papers that I’m going to summarize here, because this is such a fascinating topic, and frankly, a head scratcher for people in vulnerable groups who observe repeated, biased behavior in people who otherwise are committed to being bias free.

The reconciliation of all of this is that we are all human, and the “this doesn’t happen here” turns out to be one of the most dangerous statements that can ever be made.

As I reflect on some of the most impressive leaders and concepts I have seen/heard, they involve listening better (“Just Read: Just 6 more seconds of listening needed to elicit the patient’s agenda“) and understanding that improvement is always possible (“There’s Always Something to Do Better” – Medical College of Georgia, home of patient and family centered care). In the latter concept, just think about the statements from people who say they always want to get better and how compelling they (and the people behind them) are.

Working to be an Ally

Right now, I think one of the most topic areas for this exploration is the work of being an ally, to a group of people that is not your own. This is a space where the research points to a great risk of moral license (because the actor and the target are not in the same ingroup), and where, consistency is needed the most for the persons an ally is working to support.

Maybe good advice here is to be introspective about actions, query those who you are working to be an ally for about actions, and listen to their answer. Otherwise, a person may be inadvertently licensing themselves to do things they will not notice are unhelpful, and later regret. It’s what all humans do, therefore, work with other humans to mitigate this risk :).

This is still one of my favorite quotes (from: Not using the term “Transgendered” and respecting people) :

**Don’t get defensive**

If you get defensive, notice it and accept the discomfort of unlearning and relearning

This requires a desire to know, motivation to become informed, willingness to correct mistakes

Just Read: How to Bias and Debias your readers around LGBTQ patients at the same time

Great and novel study in Jama Dermatology (@JamaDerm) on the association of skin cancer and indoor tanning in sexual minority women and men.

The editorial published along side it is even more important.

I’m bummed out by the image that the journal chose to adorn the web site and email message to advertise it. I was actually taken aback when I saw it in my email box.

Why? I’ve been studying unconscious bias for a little while now and what the data shows is that the way to combat it is to show counter-stereotypic images and positive exemplars when teaching about the issues of people who are minorities.

The editorial attached to the study goes beyond the “what” of the tanning bed/skin cancer association for sexual minorities (there is one, and it has implications for health) and into the “why” – the determinants that might cause this association to exist. And guess what, body image, societal pressure, explicit and implicit bias may play a role. If you don’t address those, the effectiveness of informing people about the dangers is going to be limited.

To double check my concerns about the image, I consulted with a researcher who I know is also doing work in this area. They said:

Not only is the image playing into gender role stereotypes of sexual minority men, but it’s also doing so with the actor displaying pleasant affect, while engaging in the behavior that the authors just spent so much time talking about being so very dangerous!

I agree. I think this choice, probably not intentional (the nature of unconscious bias) is unfortunate if the intent is to reduce bias toward sexual minority men among dermatologists and other readers of the journal.

Recent studies have shown that there’s still measurable explicit bias on the part of medical students with regard to sexual minorities, who, when surveyed feel “less warm” toward humans in this population. It’s just the tip of the effect, though, there’s significant implicit bias as well, measured in our future physicians.

Many physicians do not assess patient sexual orientation as part of routine care; however, when sexual minority patients are informed why this information is important to their care and that it will be kept confidential, many are open to sharing it with their healthcare professionals. Recent data have highlighted significant explicit and implicit negative attitudes toward sexual minorities by physicians and other health care professionals, sug- gesting that additional training in sexual minority issues is needed in medical school curricula. The expression of explicit or implicit bias toward sexual minorities is destructive to a physician-patient relationship and likely a liability to care. (Blashill, et. al)

see: Just Read: Eliminating physician biases against gay and lesbian people, don’t forget the “T” and Health Care Providers’ Implicit and Explicit Attitudes Toward Lesbian Women and Gay Men. – PubMed – NCBI

The nature of unconscious bias is that it’s unconscious. At the same time the impact of these choices are important across disciplines – enough for corporations like Facebook to train their employees in it (see: Just Watched: “Managing Unconscious Bias” , for Facebook employees).

I’m posting this because it’s a good example, in 2015, of how far we’ve come, and also of how challenging the issue of bias is and will continue to be for the medical profession.

I suggest the image used be replaced, and more thought put into future advertising of studies that look at health disparities – I’m confident that we all share the same goal, which is to eliminate them altogether – and we can 🙂 .

Walking and talking about transgender women’s health: HLTH471 University of Maryland Shady Grove

HLTH 471 University of Maryland Shady Grove 1243
HLTH 471 University of Maryland Shady Grove 1243 (View on Flickr.com)

Of course she let me do a learning walking meeting 🙂 .

Yesterday I had the most awesome opportunity to teach one class in HLTH 471 at the University of Maryland School of Public Health, on the University of Maryland Shady Grove campus, with instructor Sabrina Matoff-Stepp, Ph.D (@SabrinaMatoffSt).

She’s teaching about women’s health from a social determinants perspective, as has included a transgender woman persona in a group of types of women for students to learn about.

I thought the discussion was great, I was super impressed with the students’ life experience – I remarked that I have seen much less knowledgeable physician audiences than this. One of the many reasons I love the 21st Century.

Where the teaching magic happens w SabrinaMatoffSt UatShadyGrove women's health!
Where the teaching magic happens w @SabrinaMatoffSt @UatShadyGrove women’s health! (View on Flickr.com)
Another thing I love is knowing and collaborating with people whose answer to just about anything is “yes.” These are the people, who, when they haven’t done something before, they become curious rather than anxious. That’s Sabrina, from the walk and talk, to a short demonstration of in-class calisthenics that students can do to keep their minds sharp and their bodies tuned to the future. And why shouldn’t they, they (the students and their curiosity-embracing teachers) are the future.

My slides are below, with 1 big, huge, thank you to JaeLee Waldschmidt, who allowed me to use her image on the cover slide. She co-led this year’s Capital TransPride, and she’s also a submarine engineer. This is an example of why diversity (a) allows the human race to survive and (b) supports a world that’s learning to love better.

And one more big thank you to Brynn Tannehill (@BrynnTannehill) who’s story is also embedded within, from the wonderful New York Times Transgender today series. She so authentically relates the importance of achieving life goals, and being who you are, which really stimulated our thinking.

I want to recommend ONE more resource that’s current and super helpful, from the American Academy of Pediatrics: Section on
Lesbian, Gay, Bisexual and Transgender Health and Wellness
is hosting a series of fantastic webinars on the basics of transgender person care.

Finally, I want to acknowledge that it is somewhat of a conundrum for me that a cisgender man (me) is teaching about transgender women’s health issues. We had a discussion about what being an ally means, and for me that means having a person from the community doing the teaching. I promise I am remedying that at an upcoming CME – more details soon.

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.