SCCM Resource Library-The Elephant in the Room: The Many Impacts of Bias

Video Transcription

Hello, everyone. Is it on? Hello? Can you guys hear me through the microphone? You might not even need the microphone.  Yeah, I think it's just my voice. I think it's on now. Well, hello, everyone. Thank you guys all for coming to our last talk, and I appreciate you guys being here.  My name is Tony Gerlach, and I'm a pharmacist from Ohio State, and I'm going to be the moderator today. Our first speaker is Bala Venkatesh, who's an intensivist from Australia,  and he's going to be talking on what is implicit bias and how does it manifest itself in our practice. Thank you, Bala.  Thank you, Tony. I'm just waiting for the slides to load. There you go. Excellent. So what I plan to do this morning is as part of this exercise of looking at implicit bias,  my main focus is how does it influence on workplace behaviors. And I was the president of the College of Intensive Care for Australia and New Zealand. And during my time, we had  a major issue with bullying and harassment and discrimination and so on. So I led the college task force, and I'm going to present some data from that. I'll also give you some  global data. And then because gender is a big issue in intensive care, we led a study on female representation in ICU and what the challenges are. And then I'll give you some  insights from a very recent. One of our trainees is doing a survey on what are the challenges  of being a woman and doing the ICU training program. So these are my competing interests. I serve on the board of the college, and this is very Australian data. And I was the past  president of the College of Intensive Care Medicine, and I have no conflicts of interest. So we know what is implicit bias. Essentially, it's when you have any outside or conscious  awareness that leads to misleading or often negative evaluations of a person or a patient  on the basis of many characteristics but commonly race, ethnicity, sexual orientation, or gender.  And so importantly, we're sort of typically unaware of such a bias within us. And in addition  to the ones I mentioned, the nationality sometimes kicks in, the sexual orientation. If you have  a foreign accent, then there's a bit of a bias. If you're overweight, then people have a bias against that. So these sorts of associations are there. Now, there's plenty of data to  show the impact on patient outcomes, and Dr. Green will speak on that. It impacts on success  in interviews and job selection, in examination assessments and outcomes. There are plenty of data. Job promotions, when you go for an interview, it seems to manifest itself. What  I'm going to focus on is about workplace behaviors. Now, this is a paper written in 1967 when  intensive care was just coming up as a specialty. This was written by a very leading intensivist,  Professor Matthew Spence, from New Zealand. And this was a review article, and this is the title of the article there, An Organization for Intensive Care. And it basically describes  what's required in an ICU. But I want you to go to the last paragraph, the concluding paragraph there. It says it cannot be emphasized too strongly. The success of the unit depends  on the skill, enthusiasm, and nurses, physios, yes, team of doctors, yes. They should be young men physically able to cope with emergencies at any time and for prolonged periods. So  you would not have any editorial license to write this these days, but this was prevalent at the time. And about four years ago, when I was finishing off my presidency, we had  a famous vascular surgeon from Sydney who basically, in a tongue-in-cheek statement,  she had written a book, but basically said, if you want to advance in your surgical career, this is to female trainees, you have to accept sexual advances from your colleagues. And  she was obviously making a very provocative statement to start the debate. And this caused uproar, as you would expect, but then it led to a lot of work. The College of Surgeons  did their own work. Essentially, there were many, many allegations of bullying and sexual harassment, and the president of the College of Surgeons had to issue a public apology  on national television. Now, following this, there was a parliamentary Senate inquiry into this, and we then, all the presidents of all the colleges were summoned  to Parliament, and we had to front up, and we had to go through this exercise of trying to work out what the problems are with each college. And so that's where our work started.  And so we have, the SICM stands for College of Intensive Care Medicine, and the HAC stands  for what's called the Hospital Accreditation Committee. So every training unit in the country  is visited by the college at regular intervals, and we get feedback from trainees. And when  they complain, and it's anonymous, and so when they reply to us about bullying and harassment  and so on, the college takes it very seriously. So when we start to look at the data, then we saw that there were reports originating from that, so the trainee feedback said the  same thing, and so we had to do our own work on this. So we did a survey of all our fellows  and trainees, which we reported in our college journal back in 2016. So the fellows, people  who've completed the full training in intensive care and are practicing as independent specialists  and trainees, someone who is training to be a specialist. And these were the definitions we used for bullying and sexual harassment and discrimination. These are sort of standard  definitions. And we surveyed about 1,000 fellows and 1,000 trainees. And just to give you the  sort of headline bits of information there, so 20% of our fellows are females, and about 30% of our trainees are females. And you can see the age distribution of these people.  Now, these were the important figures there, so a third of the people surveyed reported that they were bullied. About 12% said that they had been discriminated against, and 3%  felt that they'd experienced an episode of sexual harassment at some time during their training. And interestingly, the last row is the number of people who said who had witnessed  the episode of bullying or sexual harassment or discrimination, but only the number of people who actually reported it to the hospital director. So that's only 40% of the people  who observed bullying actually were able, took it on to go and report it, and 18% and 13% for the other two categories. So people are not prepared. Even when you see it, people  are not prepared to call it. And what you walk past is what you accept, and that's, I think, it's something we've got to keep in mind, that if you remain quiet about it,  then it will continue. And the biggest perpetrators of this exercise, of these, were the intensive care consultants. And the bullying was, the biggest perpetrators  was in fact three groups, were the ICU consultants, consultants from other units coming into the ICU, and some people also mentioned a large number of, a proportion of nurses  were also responsible for bullying the doctors. So when you did a logistic regression analysis on a number of things there, interestingly, those taking Australia as one,  the odds ratio for people coming from other parts of the world was in fact less. So Australian trainees, Australian graduates, felt more bullied as compared to people  from other parts of the world. Sexual harassment, the risk is very high if you're a female, and with discrimination, again, if you're a female, and if you came from other parts  of the world, you felt discriminated against. So the message is that there's a high proportion of bullying that we identified from our survey, and both amongst fellows  and trainees, and females had increased odds of being sexually harassed and being discriminated against,  and respondents who obtained their degree in primary medical qualification in Asia or Africa  appear to have been at increased odds of discrimination. So we had to draft a national response  to this, which we, the college board, which we did, and then we had to put in policies in place, so we had to have minimum standards for each intensive care unit, which incorporated  appropriate cultural awareness and professional standards of behavior, and we had to have a special  policy on, it seems so obvious that you can't bully people, but then we had to have a policy for people to read and be aware of this. And we, since then, since these  findings, we've actually deaccredited tertiary intensive care units because of ongoing  bullying. So when we deaccredit a hospital, what it means is that they obviously can continue to function  as a hospital, but trainees cannot go there anymore. If trainees go there, their term is not  counted for training. So which means if an ICU is not accredited, then people, trainees don't go there,  they can't get junior staff, and the ICs almost have to stop functioning. So the college has been  very, very effective from that perspective. We are now doing a six-monthly survey, and there's, the Australian  Medical Council also does an independent trainee survey, and we've had some educational modules. Now, this is  just to show you the, you know, the prevalence of these behaviors globally, and, you know, it varies anywhere from  30% to 70%, depending on which part of the world you come from, and depending on the specific study, and again, this is the same slide there, and we, and it's  common in other colleges in Australia. It's common in other parts of the world. There's gender bias in U.S., amongst U.S. physicians, and  if you look at the gender discrimination and racial discrimination, it is reported in the literature. So the, what's the impact of these? So, apart from the ones I mentioned  before, it obviously leads to job stress. We've had trainees who have discontinued their, not in  intensive care, but in surgery, we've had a difficult consultant surgeon, and people have withdrawn from the training program.  There are, you know, anxiety, suicide, suicidal thoughts, depression, burnout, staff turnover, staff won't stay in the ICU, and obviously it impacts on patient care  and healthcare costs. Now, why does it happen? What drives this behavior? Obviously, bias is recognized as one of the risk factors there, but also our method, if we have a  hierarchical system, well, we have to, we have no other choice, because a buck stops at someone. Somebody has got to take  responsibility. So there is a hierarchy, but when you have a hierarchy, then these behaviors tend to creep in.  The teaching methods, the personality traits, it's also, ICU is a male-dominated specialty, and so, and particularly intensive care, it's a stressful environment.  We are sort of running around, making decisions at, within short time frames, and also, because we sort of get into a mindset, we are the ones who fix everything finally.  If anything goes wrong in the hospital, the ICU fixes it, and so that sort of mindset engenders a behavior of superiority and aggression sometimes,  and we certainly have a closed ICU model, which where I think it's very good for patient care consistency and so on, but then you, again, you sort of  protect your boundaries and territories, and there's a potential problem with that.  So that's just to give you that, and then in the last couple of minutes, I just want to tell you, so I then led a study called the  WIN study, Women in Intensive Care, following on from this work, to see what actually, how many women,  I don't have any idea, how many women do ICU in different parts of the world? So this was an international study  where we had more women than men in the authors list, as you can see,  and I conceived the study, and I asked them, should this be led by a woman, and they said, no, no, no, we want this to be led by a man,  because we just, we don't want other people to think women are driving the same thing over and over again.  We want this to be led by a male investigator, so I led the study, and as you can see, it's an international one, and we surveyed 84  intensive care organizations across the world. So that's the reach of the survey. So you've got different colored dots there, but essentially there are two orange dots  in Australia, so green is one where, so blue is one where the survey was sent to all those parts of the world. Green is one where they had partial data.  Red is they had no data, no response, and orange is where we had a full set of data. So from ANZ, we have a detailed database of what happens over years for women with training,  the outcomes, and so on. The other societies did not seem to have. Interestingly, if you look at the presidency of various societies and bodies, again, you can see there  the proportion of female representation at the top level has been very small. If you look at the  academic representation and various scientific, the major scientific meetings, again, it's a very small number.  This is an interesting paper in JAMA, which is they looked at the, if there are joint first authors on a paper, then if it's a male and a female,  who goes first? And so they looked at it and they said, so what they found was essentially if it's a clinical study, the male names came first. If it's a basic science study,  the female names came first. And if the senior author was a female, then it's more likely to have a female  first author. If the senior author was a male, it's more likely to have a male first author. So it's a very brief report, interesting report. And finally,  this is one of our trainees who is doing the work, and it's a long survey, but this is the questions.  I just put down the main questions there. So one of the questions, have you felt negatively judged  by a colleague? Because she did part-time work. She had taken some maternity leave and coming back to work part-time.  And so this was the question, and the answer is yes, nearly a large proportion, two-thirds said yes, they have been judged  negatively for being part, working part-time. Have you been discriminated against because of your gender? Yes.  Have you witnessed a fellow ICU trainee who is female being discriminated against because of their gender? It's about 50%. If it's a male, it's about 10%.  And have you been questioned at job interviews about plans for family and children? And it still happens 25% of the time. And do you have an adequate role model? And interestingly,  two-thirds said yes, and interestingly, two-thirds of those role models are also male. So it's a fascinating combination. So there are challenges in trying to get rid of  these behaviors. It's not easy. It requires time. It requires a shift in thinking.  It requires behavioral adaptation, cultural change, but also teaching these causes a lot of anxiety  and disengagement. They have the implicit association tests and so on, but there are some question marks with the validity  of that. But nevertheless, I think looking ahead, to conclude, Mr. Chairman, I think we have to provide  training in appropriate behavior. And that's about implicit bias, about resilience.  It needs to happen on both sides, performance under pressure and speaking up, speaking up when you see these  behaviors. That's very important. And people need to understand what constitutes inappropriate behavior,  take responsibility for that, and recognize the rights of victims to be able to report, and  providing appropriate response and confidential counseling and support for those who have been affected. Thank you.  First of all, thank you, Bala. Second of all, we'll do a question, a panel discussion at the end.  And next, our next presenter is going to be Dr. Wendy Green, who received her M.D. from Howard University in Washington.  Her postgraduate medical training included a residency in general surgery at Howard University Hospital, a surgical critical care fellowship at Washington Hospital, and trauma  critical care at Envona Fairfax Hospital. Prior to Emory, where Wendy works, she's led hospital quality, safety, IT committees, as well provided leadership to the medical staff.  She's also been involved in program development, leadership, board chairman roles on many national surgical and critical care societies.  I just worked with her, and she just is coming off her work on council, so I can attest for her great work.  Her research interest includes disparities in the surgical and critically ill patients. And at Emory, she serves as director of the acute care and critical care service as attending  in the surgical ICU at Emory University Hospital, as well as a quality and safety representative for surgical patients that are critically ill. Wendy's our next speaker. Thank you.  Thank you so much for the opportunity for the program committee to allow me to speak today. I have no financial disclosures, but I must disclose my full disclosure is that I'm a  woman of God. I am a product of a surgeon and a pharmacist. I'm a daughter, a sister, a wife, a mother.  I'm a fellow of the American College of Surgeons, as well as a fellow of the Academy of Acute and Critical Care Surgery. We talked about implicit bias.  The bias that results from the tendency to process information in a way that is based on an unconscious level. You aren't even thinking about it.  And those associations and feelings, when these are contrary to what you might normally do, it just comes up underneath the surface. It just permeates our every being.  Today I'm going to be talking about the intersection of bias and patient outcomes, whether it's  socioeconomic, ethnicity, gender, sexual orientation, and how this affects patient outcomes, whether  it's patient-centered communication concerns, clinical decision-making, what is it that ultimately affects the healthcare outcomes of our patients?  We know that the effects of bias on patient care can influence the treatment decisions, the compliance and health outcomes.  There's a lack of trust of the healthcare system, poor patient experience, pain medication  administration, impaired communication, low adherence to healthcare utilization, morbidity, and mortality.  So some of my earlier work in the disparities realm was looking at an injury profile that should not be affected by your insurance status.  Who knows what your insurance status is when you come through the door? You're a trauma victim. So why would that be affected by your insurance status? So let's take a look.  Some of our early work looked at the outcomes of insurance status, and we looked at the insured and the uninsured.  And we found that the insured patients, based upon their ethnicity, had different outcomes.  So the white being the baseline, and then looking at the African American and the Hispanic population, we found that there were worse outcomes for the uninsured versus the insured  based upon ethnicity. This then led us to ask additional questions. What is going on? Why are we having these disparities based upon, could it be the injury type?  Maybe it was a penetrating, there was more penetrating injury in those groups. Maybe there was something to do with their socioeconomic status. So we wanted to dig deeper.  So we looked at the penetrating injuries, whether they were blunt or penetrating trauma, and we hypothesized that with each injury type, there should be no outcome difference  between the insured and the uninsured. We used our National Trauma Data Bank. We had certain exclusion criteria.  We looked at the insured as those that have private, government, military, Medicaid versus those that were uninsured. And we had four comparison groups.  The blunt insured, the blunt uninsured, the penetrating insured, and the penetrating uninsured. The outcome was mortality, and we did some multivariate analysis on these.  And as you can see here, the white was the blunt insured, the blunt uninsured was the green, the yellow was the penetrating insured, and then the penetrating uninsured had the  highest odds of death. So when we look at this, and we did all of our analysis, the penetrating insured trauma  patients still have the greatest risk of death than the blunt uninsured trauma patients. And the impact of insurance status persisted even when we were analyzing young patients  through the 18- to 30-year group who we presumed had fewer comorbidities. Now of course there were some limitations to our data because it's a voluntary sample  and there's some missing data, but it was very interesting to look at this in this group. And so this evidence continues to mount in support of the proposition that a productive  first step in eliminating health outcomes disparities would be to address health coverage disparities, insurance status.  My mentor, Dr. Cornwell, has assisted with additional work where we started to look at the actuarial survival algorithms.  And we usually look at this in the cancer population, and it may take years or months for you to see a poor outcome of death. But we used it in the trauma population.  So we looked at survival versus time and days, because you got about 14 days in the hospital as a trauma patient to kind of see what's going on. You don't have years.  So we looked at a 14-day period of time, and we compared females and males. And as expected, women had some slight survival advantage within a 14-day period as opposed to males.  Then we looked at Caucasian versus minorities, and we identified that there was also still some differences in the outcomes in these patients who had experienced trauma.  Now you see the big difference. The insured versus the uninsured were more likely to die as compared to any of the other gender or ethnicity outcomes that we were looking at.  So you can imagine this raises the question, there are a number of factors that may be playing into our biases as to leading to the different outcomes in these patients.  So we concluded that the risk of death on the first hospital day after injury differs by insurance status, and the disparity becomes more pronounced during the patient's hospital  stay. Further study is necessary to determine whether this is a result of additional unmeasured  patient covariance with insurance status or a difference in provider behavior in response to the patient insurance status, which is our big talk today.  How does someone's socioeconomic bias affect patient outcomes? And the answer is yes. Now we know there's been a history of unequal treatment.  If we look at the landmark study of unequal treatment, we know that racial and ethnic minority patients are more likely than white patients to refuse treatment, but differences  in refusal rates are generally small. The minority patient refusal does not fully explain healthcare disparities.  In addition, racial and ethnic minorities among the U.S. health professions are underrepresented and need to be increased.  These recommendations are put in there, were put in there because the thought was that if you had an underrepresented, you had more underrepresented minorities taking care of  these patients, the biases may be limited and therefore the outcomes, the healthcare outcomes may be improved.  Additionally, they recommended that the consistency and equity of care should be promoted through the use of evidence-based guidelines.  Payment systems should be structured to ensure an adequate supply of services to minority patients and limit provider incentives that may compromise their care.  There should be communication and trust between patients and providers should be enhanced  through financial incentives for practices that reduce barriers and encourage evidence-based decision making.  And if there is a need to have the use of language interpretation in your community, that should be included also.  You want to include community healthcare workers to help patients navigate the system. We use it in the oncology world. We should be using it throughout our systems.  And a multidisciplinary treatment and preventative care teams should be supported. One of the other important things, you can't make changes without having data.  So it's very important to collect and report data. Let me repeat that. It is very important to collect and report data on healthcare access and utilization  by patients, race and ethnicity, socioeconomic status, and language. And I'll just, I will use race and ethnicity here only because a lot of the studies use  that with the understanding that after the genomic studies that were done showed that we have one human race, but we have multiple ethnicities.  It was also important to include the measures of racial and ethnic disparities in assessing  provider performance and monitor progress toward the elimination of healthcare disparities. So why do we need to be intentional, intentional about addressing bias?  What do the studies demonstrate? Well we know that blacks, Hispanics, American Indians, Alaskan Natives have continued to  receive worse care for 40% of the quality measures that are measured by the AHRQ. And for those that were, and for Asians, they receive 20% of the measures of worse care.  Minorities also have higher incidence of mortality and advanced staging at diagnosis for several  cancer types including cervical, kidney, breast, prostate, colorectal, lung, and prostate. For children, there's disparities in infant mortality rates, chronic disease, quality  of care, organ transplantation, and leukemia related deaths have also been noted. So we need to find a better way to address these issues.  It's come up in the literature where you see the patients who have an acute coronary syndrome  or the cardiologists have not been, have studied these patients and found that black patients are less intelligent from their perception, likable, friendly, and more prone to risky  behavior as compared to their white counterparts. There's also concerns regarding patients' perceptions of discrimination in medical interactions.  When compared to white patients, minorities are more likely to believe they would receive  inferior care as respect to the medical staff or have better care if they belong to a different racial group.  Studies that examine more subjective and less quantifiable symptoms such as pain also is a concern.  And so there has to be more often in clinical ambiguous situations where you're looking  at pain that there has to be more of an algorithm to address those concerns to try to help mitigate the differences in care.  There have also been associations that there is a decreased patient confidence in treatment and recommendations from the oncologist in certain, because of implicit bias.  And that they have difficulty completing their regimens of care as a result of it. So research investigating the role of implicit provider bias based on healthcare has had  mixed results, mostly because there have been studies where they look at the vignette, the  implicit associated test where they're giving you kind of a controlled environment and scenarios  and people have to make assessments on their biases based upon these clinical vignettes versus when you look at it in the clinical scenario that people are more likely to show  their biases under a more clinical situation than a clinical vignette. So we have to think about when we're constructing our research studies that we need to include those cognitive stressors or try to find ways  to reduce those cognitive stressors so that people may be more inclined to not have their biases rise to the surface.  Some things that you can do is if you have clinic time or patient time, you limit the number of patients so that you can spend more time with that person  and not feel so rushed to move them along.  So we know that through implicit racial ethnic bias, there is implicit and racial ethnic bias among healthcare professionals, and this can influence the outcomes.  Most healthcare providers appear to have implicit bias in terms of positive attitudes towards whites and negative attitudes towards people of color.  There needs to be additional studies to look at these relationships and then target the disparities that occurs, especially with people of color.  We know that there's concerns, there are biases that have been reported in African-American patients when white physicians  who implicitly associated black patients with being less cooperative and that they were less likely to refer black patients with acute coronary symptoms or thrombolysis.  Other additional evidence found that women were more likely to receive less intensive treatment for a heart attack and less likely  to receive DVT treat prophylaxis as witnessed by one of our sheroes, Serena Williams.  Physicians were also less likely to discuss contraception, sexually transmitted diseases, and emotional health with lesbian, gay, bisexual, and transgender patients.  So the current literature reveals implicit bias is present in healthcare,  and students as early as the first year of training are affected by this.  So interventions aimed at reducing the effect of implicit bias on outcomes must begin as early as possible. Thank you very much.  Now for our final speaker of the day who's going to talk about overcoming bias is Dr. Roshni Sriharan, who's an anesthesiologist and intensivist at the Cleveland Clinic Foundation.  After her residency in anesthesia and a fellowship in critical care medicine, Roshni went on to do a fellowship in medical education.  She directs anesthesiology critical care medicine fellowship and is a faculty for the excellence in healthcare communication at the Cleveland Clinic Foundation.  She's a part of a core team that develop and conducts communication course for anesthesia members to enhance patient interactions and team communication.  Good morning, everyone. I'd like to thank the program committee for giving me this opportunity to speak on this topic that I'm very passionate about.  I put this slide up here to highlight that a lot of our communities, workplaces, and a lot of our families look like this, with people who look different,  who think differently, who believe in different things,  and who have different core identities from each other.  We want each and every person to be able to function to their best of their abilities and reach their highest potential.  Unconscious or implicit bias stands in the way of them achieving this potential, and it behooves each and every one of us to be able to recognize unconscious bias  and overcome it so we can help our co-workers, our colleagues, and our family members grow  and reach their complete true potential. The objectives of today's talk is to define unconscious bias. There's a little bit of overlap between the talks that we had before and mine,  but I think it is worth mentioning again about defining unconscious bias and listing the different types of implicit bias.  And we'll talk about tools which would help us reduce implicit bias with peers and personal interactions, with patient communication, and with team communication.  We'll start off with this picture.  It's kind of talking about what are the phrases that come to your mind when you see the picture to your right.  Just shout it out. What are some of the things that come to your mind? Let's say this person is approaching you, it's going to come and sit next to you  in the airplane, in your bus, in the train. Okay, so that is, that is, yes, so, so that, and it's important to highlight that, too,  because that is a learned, you have the knowledge, you know who the person is.  The person on, yes, the person who's in the suit.  Yes, smart.  What about the person, what's that, scary, yeah, mad, angry, yeah, jail, okay, yeah.  And what makes you say jail?  The number, the tattoo, yeah.  What about the person with the suit on this side, on the other side?  I'm just going to say my, my left.  What's that, Colton, yeah, all right.  He's graduating, yes, he's an old, it's an old photo, yeah.  What's that?  Yes, so it's kind of, and I want to say that when we, when we see people, and this is all based on not having a knowledge, right, this is assumptions that we make.  Based on what we have experienced before, what has been told to us in the past,  and repeatedly, and you see it on TVs, movie shows, and TV shows. They depict certain people in a particular fashion that makes us think  about people that we see in a particular way. So to kind of to say, the person with the tattoo is Mr. John Fetterman. He is the Lieutenant Governor of Pennsylvania.  He was the Mayor of Braddock, Pennsylvania from 2005 to 2016, re-elected three times,  highlighted for revitalizing his community, and he was noted to be the coolest mayor of America.  And the tattoo on his arm is a zip code of the place, Braddock, Pennsylvania, and he has a number of tattoos on his other arm, too, with different numbers.  And each of those numbers were the dates when deaths due to violent attacks happened  since he took over as mayor in Braddock. Every single date has been tattooed on his arm.  So it's different. It's different from our perceptions based on what has been ingrained in our minds.  And I think a lot of you probably would recognize the person on my left, the person in the suit.  Ted Bundy, yes, serial killer.  After several years of trials back and forth, confessed to kidnapping and murdering over 30 women.  So our assumptions, especially when it's not based on facts, can be completely wrong.  So the...  Yes. It's not a scary person. You say, but it's not a scary person. Absolutely, yes.  And their perceptions and how you perceive a person and you assume a person is going to be like just because of how they look and how you associate with it.  So the bottom line is, are you conscious of your unconscious bias? And this is the one thing we probably have to take away from this.  And I just wanted to highlight these books, and I think they are fantastic, some of them for effective communication and having difficult conversations.  If there's one book that I would highly recommend, it's the one in the middle, we can't talk about that at work, it was eye-opening, fantastic book about having difficult conversations, and it gives you the tools to have those conversations.  And I would be referencing a couple of things from all of these books as we go through this talk today.  So we talked about unconscious bias, right? And both of our fantastic speakers before were talking about this. These are natural people preferences that we have.  And this is from, you know, years, years ago from our ancestors. This was a protective mechanism that we had. We were living in groups.  We wanted to be with people who looked like us, talked like us, thought like us, and anybody who did not do it was perceived as a threat because this was an outsider who's coming in to take over whatever you had.  So we don't live in those circumstances anymore, but those instincts are still within us.  And this results in us stereotyping people. Most of the time, it's a product of threat.  Now, just because you recognize that you have an unconscious bias, an implicit bias, that doesn't make it bad. That doesn't make you a bad person.  What is bad is not recognizing the impact that the bias that you have has on the interactions that you have with people and the decisions that you make every day in life, and not trying to overcome it.  Now, that is what is not acceptable.  So the cycle of events that leads to this is most of the time it is a situation or some sensory cues that you're getting, and you associate it with your background, you know, the previous experiences that you've had, stereotype exposures that you have had through your life.  And then you start making assumptions from it, and then you draw conclusions and you start acting upon them.  And I have to say that in the last decade or so, this has become more so prevalent because of Facebook.  It is an open book into the choices and preferences of people, what they like, what they don't like, whom they friend, whom they unfriend.  All those things leads us, based on our previous experiences, to judge people, whether you may not have even ever seen this person in real life or talked to them, or know truly why they're choosing what they're choosing.  But then we stereotype them, and then we act upon it. And it's just important to keep this in mind when we interact and associate with people.  There are several different types of unconscious bias, and it's important to know because they affect us in different walks of our life.  Affinity bias, when you think that, oh, this person is like me, so they have to be good. And this often happens while hiring people, while looking at trainees.  A person who's better looking in your mind functions better than the person who's not. That's beauty bias.  Contrast bias is also important because it is important in the workforce, in teams, when you're trying to compare a person to another person instead of comparing them to a standard.  And you'd see it very often when you're trying to do evaluations, assess people, when you are the person in that leadership role.  Gender bias, thinking that one gender works, functions better than the other gender.  The halo bias is when you're focusing on one great thing that you love about this person and overlooking everything else. And the horn bias is the opposite of that.  When you're focusing on this one thing that you really don't like about the person, and then you're overlooking all the other things that might be great.  So keep in mind that there are various different types of implicit biases that are there around, and we have to recognize it to be able to overcome it.  How does this manifest in our everyday interactions?  A lot of the times, we climb this ladder of inference, just like how we were talking about the image that we looked at of Mr. Fetterman, right?  That you observe, you select certain data that appears really strong to you, you make assumptions, draw conclusions, you believe those conclusions, and you act upon them.  It is really, really common that these things, and if you think about the everyday interactions and the assumptions that we draw, there are far too many.  Rather than climbing this ladder of inference, we might have to focus on climbing down that ladder with curiosity and an open mind before we assume things about what is going on.  A common example, and I have to say that I am guilty of this, before I became conscious of it and started acting on it.  Now, if there is a person who always shows up, a trainee, there was a trainee who was, you know, coming late to sign out every day.  And, you know, coming late, I'm like, thinking about it, previous associations, well, this person is unprofessional, not showing up on time, you know, is not dedicated to the work.  I mean, this is really not good. So this is an inference that I've drawn.  Climbing down that ladder with curiosity, just an open question that, hey, I noticed that you're coming late to sign out. Can you tell me what's going on?  Well, I recognized and I realized, and I was ashamed of myself for making those conclusions.  This person, his wife was living in a different state, had a little baby who was sick, so couldn't drop the daughter off to daycare on time for this week, and was waiting for the babysitter to come and couldn't find a babysitter.  So the neighbor had to come, and it was taking time for the neighbor to come every day. So this is literally a one-week thing that was going on.  But I was very, very quick to assume and draw those conclusions.  So just to put it in perspective, it happens way too often, and we have to climb down that ladder with curiosity and be open before we draw conclusions and have our biases about people.  And we see this way too often, racial microaggressions. And I have to say, people who are saying these statements mean well.  They're not intending to make you feel terrible or make you feel bad. These are unintentional, but these are the things that make people function lesser in their workplace.  And I've heard this. So where are you from? Where are you really, actually, really from? So what that is telling me is that I'm actually not from here.  So that's what you're telling me. I'm really not from here. I mean, oh, your English is so good. So you're assuming that I should not be speaking good English.  So these kinds of things, these are not meant to be inflammatory statements coming from the person who's saying it, but then it can really impact the person who's hearing it and the receiving end.  And this is something about bias that we have to keep in mind about how are your statements affecting the person who's hearing it and who's on the receiving end. So why?  Why should we uncover and overcome bias?  Dr. Green gave a fantastic talk on this, on how it affects patient outcomes and how it affects us and why we need to work on recognizing and overcoming this.  Diversity and inclusivity efforts, regardless of how much diversity and inclusivity efforts we might make and take, if unconscious bias is not addressed, it does not go anywhere.  Because there is no amount of these efforts which are going to be successful if unconscious bias is not addressed.  Recruitment and retention becomes difficult because people don't feel engaged. They don't feel as a part of the team because they feel like they're an outsider.  They're not in the in-group. Team building, productivity is affected. Treatment decisions are affected.  We saw a lot of data that is there to support that treatment decisions are affected when there is unconscious bias. Why?  Everyone talks, whether we like it or not, whether it is politics, social injustice. People talk about polarizing topics in the workplace.  We have our workplace which is made up of mixed ethnicity, nationality, sexual identity. Everybody needs to be engaged in the work that we're doing to be productive.  And people, when they feel that they're not included, they bring their fears and anxiety and their emotion to work.  Be it about their race, be it about their ethnicity, be it about whatever is going on in the world.  So we need to be inclusive and supportive of our coworkers and employees by addressing the concerns that they have. And when we do that, it reduces their anxiety.  It brings about an increased sense of well-being, inclusion, engagement, and therefore productivity gets better. So what can I do? So I'm looking at it, what can I do?  How do I overcome this? First step, reflect. Think about what your cultural identity is. Think about what perspectives, what experience has shaped your perspectives.  We have to recognize what our biases are in the first place. 100% of us have implicit biases. It is all about recognizing what those biases are.  There is an implicit association test. There are a couple of tests. But as Dr. Venkatesh was pointing out, there is some question about the validity.  But reflection is an important aspect about recognizing what your biases are. Like John Dewey said, we don't learn from experience. We learn from reflecting on our experiences.  And it's important to go beyond blindness, to recognize the differences that our team members bring and how different they are and not to minimize it.  For example, I think it's an important thing, and this is from the Winters book. There is a huge difference between equality and being treated the same.  Yes, I want equal opportunity as my male colleagues, as a woman and a minority. But I don't want to be treated the same as my male colleague.  What that means is I want you to see me as a woman and the experiences that I have had and the challenges that I had to overcome to get to where I am.  So the golden rule used to be that, oh, you know, I always treat people just like how I want to be treated.  But that's not what makes people feel included. What makes them feel included is treating them how they want to be treated, looking at them how they want to be looked at.  And once you've recognized what your biases are, explore them and work to undo them.  Like we said, these are things that are imprinted in our brains since we were young, certain cultural stereotypes that are repeated to you that almost makes it true for you.  Explore it and practicing the three E's. Exposure. So if you recognize that there is a certain bias towards a certain group, mingle more with the group.  And if you notice, a lot of us, I mean, I am also guilty of it. And I noticed that a lot of my friends are Indian. And that is just because they are the community.  And then I recognize with them. I resonate with them. They have the same experiences. But if there is a bias about a different group, make yourself exposed to that group.  Understand where they're coming from. Exposure and experience is different. Experiences is truly learning from them.  It's just not enough if you go out and have a beer or a coffee with them. But actually learning what their experiences are.  These are things that we can do to undo the biases that exist. And education, to learn truly about where the community of people are coming from. And to be empathic.  An important distinction between empathy and sympathy. Sympathy can be really patronizing.  Empathy is actually standing in the shoes and trying to understand the perspective of a different person.  So the four Es can bring about positive, reaffirming thoughts about whichever group that you might have a bias towards.  Always challenge your interpretation. Just like I said, climbing up that ladder of inference, it's important to challenge the interpretation that you're making.  The Winters book gives a great tool. It is called a DNA tool. It is about describing objectively an event before drawing conclusions. Objective, no judgments. Describe it.  Navigate it. And then adapt your responses to it.  If you look at it, so this is a description based, you know, the stuff that's written in it is based on the description of a scenario that Winters mentions in her book.  But if you look at it, thinking about the first picture of Mr. Perryman. A gentleman sitting who is larger and who has a tattoo on his forearm. That's pretty much the description.  You can interpret it in different ways. One person might interpret that, okay, I think that this person is probably from prison.  The other interpretation could be I have no idea who this person is. Maybe I have to explore this further. And your actions can be based on those interpretations.  You can choose your action based on those interpretations. So when we are faced with difficult situations, if we kind of take this route, it would be a more unbiased approach to it.  Listen and separate the person from the position. This is more towards social media.  Just because a person takes a position as far as politics goes one way or the other, that doesn't make the generalized group of people a certain way.  Separate the person from the position that you're attaining and try to get common goals. We all can find common ground. We can all find common goals.  We want all our children to be safe. We want our communities to be safe. We want harmony. Those are all common grounds.  So conversations can be built up from the common ground that we're able to find with the people that we're interacting with.  Talking about implicit bias with patient encounters, and this is a fantastic paper as well. This was written by Christy Masters and colleagues.  It's about cultural humility and reflecting and using this five R principle when we are having interactions with patients.  The different R's, the first one, just a few questions that you can ask yourself to reduce implicit bias in our encounters with patients. The first R is reflect.  What can I learn from this situation beyond my current understanding? The second R is respect.  Asking yourself, did I treat every single person involved in this encounter with respect? Relevance. How is cultural humility relevant in this interaction?  I think this is the point where I have to say that cultural humility is an important term. It is different from cultural competence.  For cultural competence, you need to have deep knowledge about each of the individual cultures.  Cultural humility is just being open and respectful to all cultures and being curious. How is cultural humility relevant in this interaction? Regard.  Keeping everyone at the highest regard and thinking about did unconscious bias drive this interaction in any shape or form? And lastly, resilience.  This is to focus on self-care for the physician to give credit or the clinician to give credit to themselves to being the expert in the subject,  but also giving credit to the patient for being the expert in the life that they live. So the five R's, reflection, respect, relevance, regard, and resilience.  Using these questions can help think about our own implicit biases and to overcome it,  to make sure that implicit biases don't affect the encounters and the communication that we have with our patients.  It is shown to reduce implicit bias, increase empathy, and respect individuality of our patients. Going on to team communication. And we can all agree.  Team communication is essential for providing effective patient care.  And this is an interesting study that they did about interprofessional experiences of recent healthcare graduates.  So they took a bunch, a cohort of healthcare graduates from pharmacy, from nursing, and from medicine,  and they had given them like semi-structured group discussions, about 12 semi-structured group discussions,  and the plan was to discuss how interprofessional education will improve interprofessional performance, team communication, and teamwork.  They saw that consistently the themes of the goals were based on profession. It was not based on teams or patient-centered. It was profession-centered.  There was a lot of negative stereotyping. There was hierarchy in communication that came out.  And they came out with a couple of things that we need to address to improve effective teamwork and interprofessional collaboration. First of all was to find a common team goal.  A lot of us, it is providing safe, quality care to our patients. Finding common team goals and increasing the sense of value and worth for each and every member of the team.  And to recognize there's less need for competition when you have a common team goal.  These were the things that they recognized that we need to address to be able to effectively function as a team. And for all of this to happen, implicit bias has to be overcome.  And this is also a really important concept that I would like to introduce is we always talk about safe places.  You have to have a safe space to be able to communicate with honesty, curiosity, and respect. To kind of move that towards a brave space.  So safe spaces, and there are studies which have been done on this. And safe space, we commonly use it with learners and trainees to give them a safe space to be able to explore.  But it has been noticed that people equate safeness with comfort.  And any conversation that is around biases, be it gender, be it race, be it social injustice, it is not comfortable to have those conversations.  And people shy away from having those conversations because they don't feel safe anymore. They don't want to have those conversations.  So moving from a safe space to a brave space where you empower everybody in your team to be able to talk about things.  And to give them the tools to be able to have civil conversations which are productive about these difficult themes is important.  And team leaders and organizations should be able to work towards it. And team communication, it is important. And I want to say, I think Dr. Venkatesh mentioned the hierarchy.  And hierarchy is just there. Institutions, organizations, there is hierarchy. Now that doesn't mean there is no top-down decision-making.  That doesn't mean there is not a chief nursing officer or a CMO or a medical director. Yes, they are all there.  But it is everybody's responsibility to empower every single person on the team to be able to speak up and create that brave space for them.  If there is anything that is affecting, especially if it is involving patient care and safety, everybody should be able to speak up.  They did the study, Mills et al. did the study about teamwork and communication. They had a group of nurses, anesthesiologists, and surgeons whom they surveyed.  They did a medical team training questionnaire. They were talking about, you know, the culture of safety in the organization. It was completely skewed.  The surgeons had a very different perception of how hierarchy worked, what the organizational safety measures were, as opposed to what the anesthesiologists and the nurses perceived.  So it is important to level hierarchy. Leveling hierarchy is key to improving team communication and to overcoming biases in teams.  And it helps create, leveling hierarchy helps create that brave space where everybody can speak up when a question of concern comes up.  And it also helps us climb down that ladder of inference with curiosity if you open up and create a brave space for them.  Team communication and team training is another important aspect. We have to train our teams about effective communication and with implicit bias.  This is one of the models that we use. We have all of our trainees and physicians go through this course to improve communication skills and to overcome bias.  Several other organizations do. I'm just putting this up because this is what we do at the clinic. Inclusive habits to practice every day.  Acknowledge that you don't know everything. There's always things to be learned. Legitimize. Listen to understand. Reflect on what you've experienced.  Describe before you make assumptions. Pause before you respond to a difficult question. Accept people for what they are and for their identity. Respect everyone.  If you've made a mistake, truly apologize and empathize, not sympathize. In summary, to overcome bias, we have to reflect on how your experiences shape your perspective.  Stay curious with our judgments and assumptions and explore another's perspective.  Consider how their experiences have shaped their perspective and how your actions might impact them.  In closing, it takes courage to endure the sharp pains of self-discovery rather than choose to take the dull pain of unconsciousness that would last the rest of our lives.  Thank you. Thank you, everyone. Thank you, everyone, for staying. Unfortunately, we're out of time.  But I would invite if you want to talk to our panel down here to come up and speak if you have time. If not, have a safe flight home.

Video Summary

The video transcript is a discussion about implicit bias and how it manifests in our everyday interactions, particularly in the workplace and in patient care. The speakers emphasize the importance of recognizing and reflecting on our unconscious biases and taking steps to overcome them. They discuss the various types of implicit bias, such as affinity bias, beauty bias, and gender bias, and how these biases can impact team communication, treatment decisions, and patient outcomes. The speakers provide strategies for reducing implicit bias, including self-reflection, exposure to different perspectives and experiences, and practicing empathy and respect in our interactions with others. They stress the need for creating safe and brave spaces to have open and honest conversations about bias and promote inclusivity and diversity in the workplace. Overall, the speakers emphasize the importance of acknowledging and addressing implicit bias in order to create a more equitable and inclusive society.

Asset Subtitle

Professional Development and Education, Ethics End of Life, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

Learning Objectives

Develop strategies that promote intra- and inter-team communication
Determine how to ensure that appropriate members are on the team
Identify constraints that lead to bias and develop strategies to mitigate bias

What Is Implicit Bias and How Does It Manifest Itself in Our Practice?

Balasubramanian Venkatesh

Effects of Bias on Patient Care and Outcomes

Wendy R. Greene

Overcoming Bias by Improved Communication Promoting Intra- and Inter-Team Communication

Roshni Sreedharan

Meta Tag

Content Type Presentation

Knowledge Area Professional Development and Education

Knowledge Area Ethics End of Life

Knowledge Level Foundational

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Communication

Tag Healthcare Delivery

Tag Administration

Year 2020

Keywords

implicit bias

everyday interactions

workplace

patient care

unconscious biases

types of implicit bias

team communication

treatment decisions

reducing implicit bias

promoting inclusivity

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