Addressing Implicit Bias in Health Care Delivery For

Addressing Implicit Bias in Health Care Delivery For more information, contact the Center for Diversity and Health Equity at healthequity @aafp. org

Learning Objectives • Define Implicit Bias and describe how it operates in the health care setting • Use online tools to self assess individual biases • Describe and demonstrate debiasing techniques 2

Exercise • • Think of a number between 1 -10 Add 2 Double it Subtract your original number Add 8 Subtract your original number Divide by 3 Find the corresponding letter of the alphabet (i. e. , 1=A, 2=B, 3=C, etc. ) • Think of a country that starts with that letter • Think of an animal that starts with last letter of the country • Think of a fruit that starts with the last letter of the animal 3

Denmark Kangaroo Orange Countries that start with D • Denmark • Djibouti • Dominican Republic 4 Animals that start with K • Kangaroo • Kelpie • Kid • Kitten • Koala • Koi Fruits that start with O • Orange • Olive • Okra

Defining Implicit Bias • Also known as: – Unconscious bias – Implicit social cognition • Definition: – Attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. 5

Implicit Bias IS IS NOT • Pervasive • Predictive of behavior in the real world • Distinct from conscious stereotyping or prejudice • Expressed indirectly • Related but distinct from each other (some reinforce each other) • Malleable – can be unlearned • Hard to teach • Always negative • Activated voluntarily or intentionally • Accessible through introspection • Always consistent or aligned with our declared beliefs • Always consistent with our own ingroups • Mutually exclusive • Something you should feel guilty about 6

The Doll Test (1940 s) • A study of the psychological effects of segregation on African American children (3 -7 yrs) • Measure of racial perceptions where children were asked to identify which color doll they preferred • White dolls = positive characteristics • CNN recreated a pilot study (2010) which showed a bias towards whiteness o Smart vs dumb o Nice vs mean o Good vs bad o Cute vs ugly Gordon Parks, photographer. Dr. Kenneth Clark conducting the “Doll Test” with a young male child, 1947. Gelatin silver print. Prints and Photographs Division, Library of Congress (62) http: //www. loc. gov/pictures/item/95505330/ 7

Positive Stereotypes Are Still Biases § Black ≠ athletic § Asian ≠ smart § Gay ≠ fashionable § White ≠ good credit § Jewish ≠ businessman 8

Bias Against People of Color In Health Care • Fewer prescriptions for pain medication • Fewer bypass surgeries • Less likely to receive kidney dialysis or transplants • More likely to undergo lower limb amputations for diabetes Number and percentage of quality measures for which members of selected groups experienced better, same, or worse quality of care compared with reference group (White) in 2014 -2015 Quality and Disparities in Quality of Health Care. Content last reviewed July 2017. Agency for Healthcare Research and Quality, Rockville, MD. http: //www. ahrq. gov/research/findings/nhqrdr/nhqdr 16/quality. html - AI/AN = American Indian/Alaska Native - NHOPI = Native Hawaiians and Other Pacific Islanders 9

How Does Implicit Bias Operate in Health Care Clinician Prior Experiences and Implicit Bias Attitudes and Behaviors Brought into the Clinical Encounter Differential Treatment and Adherence Differential Outcomes Patient Prior Experiences and Implicit Bias Source: Blair IV, Steiner JF, Havranek EP. Unconscious (Implicit) Bias and Health Disparities: Where Do We Go from Here? The Permanente Journal. 2011; 15(2): 71 -78. 10

Source: Harvard Implicit Bias Test https: //implicit. harvard. edu/implicit/index. jsp 11

Debiasing Techniques • Training • Intergroup contact • Taking the perspective of others • Emotional expression • Counter stereotypical exemplars and debiasing agents Source: State of the Science: Implicit Bias Review 2015, The Kirwan Institute, The Ohio State University

Debiasing is a Conscious Ongoing Process Awareness Minimization Self check-in

Suggested Actions for Clinicians to Understand Address Implicit Bias In Health Care • Consciously affirm egalitarian goals and consider specific ways to implement them. • Consider “gut” reactions to specific individuals or groups as potential indicators of implicit bias and consider how these reactions might affect your work. • Acknowledge and reappraise rather than suppress uncomfortable feelings and thoughts. • Consider the situation from the patient’s perspective. • Consider changing situations that increase negative or stereotypical responses. • Partner with researchers and participate in research to advance understanding of implicit bias and to develop evidence based interventions. 14