Implicit Bias and Its Association with the Delivery of Quality Care

1. Implicit Bias and Its Association with the Delivery of Quality Care Oglebay Resort & Conference Center September 18, 2018 Presenter: Rev. John C. Welch, M.Div., PhD Vice President for Student Services & Community Engagement Dean of Students Pittsburgh Theological Seminary Pittsburgh, PA

2. Objectives • Define implicit bias and explicit bias and their relation to racism. • Discuss the correlation of implicit bias on healthcare disparities among racial ethnic minorities. • Discuss the effect of implicit bias on physician-patient communications and treatment recommendations. • Review resources to improve awareness of implicit bias. • Discuss ways to mitigate the effect of implicit bias on the delivery of quality care. Implicit Bias and Its Association with the Delivery of Quality Care

3. Implicit Bias and Its Association with the Delivery of Quality Care Exercise: “A father and son were involved in a car accident in which the father was killed and the son was seriously injured. The father was pronounced dead at the scene of the accident and his body was taken to a local morgue. The son was taken by ambulance to a nearby hospital and was immediately wheeled into an emergency operating room. A surgeon was called. Upon arrival and seeing the patient, the attending surgeon exclaimed “Oh my God, it’s my son!’ Can you explain this?” Implicit Bias and Its Association with the Delivery of Quality Care

4. Implicit Bias and Its Association with the Delivery of Quality Care • Around 40% of participants who are faced with this challenge do not think of the most plausible answer. • The surgeon is the boy’s mother • the surgeon was his natural father, or • the father in the car was a priest. Implicit Bias and Its Association with the Delivery of Quality Care

5. Implicit Bias and Its Association with the Delivery of Quality Care What are Implicit Biases? “Implicit biases are discriminatory biases based on implicit attitudes or implicit stereotypes.” - Greenwald and Krieger (2006) Implicit Bias and Its Association with the Delivery of Quality Care

6. Implicit Bias and Its Association with the Delivery of Quality Care What are social stereotypes? “mental associations between a social group or category and trait.” - Greenwald and Krieger (2006) Implicit Bias and Its Association with the Delivery of Quality Care

7. Implicit Bias and Its Association with the Delivery of Quality Care What is a Implicit Attitude? “Social psychologists define an attitude as an evaluative disposition - the tendency to like or dislike, or to act favorably or unfavorably toward, someone or something.” - Greenwald and Krieger (2006) Implicit Bias and Its Association with the Delivery of Quality Care

8. Implicit Bias and Its Association with the Delivery of Quality Care https://youtu.be/zdV8OpXhl2g 1Junkerman, et. al., Practical Ethics for Students, Interns and Residents, 3rd Edition Implicit Bias and Its Association with the Delivery of Quality Care

9. Implicit Bias and Its Association with the Delivery of Quality Care “The unchallenged brain is not worth trusting” - Helen Turnbull, CEO Human Facets Implicit Bias and Its Association with the Delivery of Quality Care

10. Policing in America Legal vs Appropriate Use of Force Implicit Bias and Its Association with the Delivery of Quality Care

11. Policing in America Officers killed in line of duty – 94% male 81% vs 12% Killed with a firearm – 91% Killed responding to a crime in progress – 57% Ambushed – 22% Traffic stop or pursuit – 20% Disturbance calls – 16%1 1National Violent Death Reporting System (2003-2013) Implicit Bias and Its Association with the Delivery of Quality Care

12. Policing in America Most suspects were male – 84% Average age 34 years White suspect – 39% Black suspect – 36%2 2National Violent Death Reporting System (2003-2013) Implicit Bias and Its Association with the Delivery of Quality Care

13. Policing in America • All 50 states and DC fail to comply with international law and standards on use of force and law enforcement officers. • Nine states and DC have no laws on use of lethal force. • Three states provide that officers should create no substantial risk to bystanders when using lethal force. • Two states provide by statute training on use of lethal force.3 3Amnesty International (2017) Implicit Bias and Its Association with the Delivery of Quality Care

14. Policing in America Implicit Association Tests (IAT) Measures respondents reactions to correlations between subjects and value laden labels. Harvard University IAT www.implicit.Harvard.edu Implicit Bias and Its Association with the Delivery of Quality Care

15. Policing in America • Most officers are White (17,000-18,000) • Most deaths due to legal interventions are African-Americans • African-Americans are more likely to be violent (formally/informally) • African-Americans are more likely to be involved in criminal activity (formally/informally) • Disproportionate share of assailants that kill officers are African-American. Implicit Bias and Its Association with the Delivery of Quality Care

16. Policing in America Perceptions: Race relations are bad 61% vs 34% Police deal less fairly with African Americans 84% vs 50% Courts deal less fairly with African Americans 75% vs 43%4 4Pew Research Center (2016) Implicit Bias and Its Association with the Delivery of Quality Care

17. Bias in Healthcare African-American Mistrust • High morbidity rates • High mortality rates • Less likely to be properly prescribed pain medication • 900,000 lives could have been saved between 1990-20005 5Steven H. Woolf, et al, "The Health Impact of Resolving Racial Disparities: An Analysis of US Mortality Data," American Journal of Public Health 98.Supplement_1 (2008): S26-28 Implicit Bias and Its Association with the Delivery of Quality Care

18. Bias in Healthcare Mortality rates6 6Williams, David R. "Race, socioeconomic status, and health the added effects of racism and discrimination." Annals of the New York Academy of Sciences 896.1 (1999): 173-188. Implicit Bias and Its Association with the Delivery of Quality Care

19. Bias in Healthcare IOM Report – Unequal Treatment Confronting Racial and Ethnic Disparities in Healthcare (2003) • Identified healthcare provider bias, stereotyping as contributors to healthcare disparities Implicit Bias and Its Association with the Delivery of Quality Care

20. Bias in Healthcare Implicit Bias by Medical Professionals related significantly to: • Patient provider interactions • Treatment decisions • Treatment adherence • Patient health outcomes Implicit Bias and Its Association with the Delivery of Quality Care

21. Bias in Healthcare Patient - Provider Interactions: • White patients receive better quality of care6 • Dominant communications styles • Fewer demonstrated positive emotions • Infrequent requests for input on treatment decisions • Less patient-centered care 6National Healthcare Disparities Report Implicit Bias and Its Association with the Delivery of Quality Care

22. Bias in Healthcare IAT Study among MDs:7 • Males more biased than females toward White Americans • Higher participation rate of patients for female physicians • Patient satisfaction is higher for female physicians • Female physicians have more collaborative relationships • Spend more time • More likely to discuss social and emotional issues 7Sabin, Nosek, Greenwald, Rivara (2009) Implicit Bias and Its Association with the Delivery of Quality Care

23. Bias in Healthcare IAT Study among MDs:7 • Difference in clinical styles between male and female physicians due to difference in implicit attitudes 7Sabin, Nosek, Greenwald, Rivara (2009) Implicit Bias and Its Association with the Delivery of Quality Care

24. Bias in Healthcare Cognitive Stressors8 • Cognitive stressors can increase implicit bias • ED overcrowding and caring for more patients during an ED shift. • Moderators of bias such as patient volume should be taken into consideration in future studies that seek to understand how bias impacts patient care in the ED. 8Johnson et al. (2016) Implicit Bias and Its Association with the Delivery of Quality Care

25. Bias in Healthcare Reducing Implicit Bias • Awareness of habitual engagement • Individuation – conscious effort to focus on specific information about a person • Time pressured circumstances and incomplete information is normal (rely on stereotyped assumptions) • Perspective-taking – envision the viewpoint of the other. Implicit Bias and Its Association with the Delivery of Quality Care

26. Bias in Healthcare Reducing Implicit Bias Questions? Implicit Bias and Its Association with the Delivery of Quality Care