Moving Towards Diversity and Inclusion: Mitigating Implicit Bias and Its Effects

1. Moving Towards Diversity and Inclusion: Mitigating Implicit Biasand Its Effects Alexandra Sims, MD, FAAP Pediatrician, Washington DC @DrAlexSims West Virginia Chapter of the American Academy of Pediatrics Annual Spring Meeting March 29,2019 Stonewall Resort, Roanoke, WV

2. Learning Objectives By the end of this session, I am hoping you will be able to: Define implicit bias Describe the relationship between bias and health disparities Discuss how implicit bias impacts diversity and inclusion efforts Begin to formulate a plan to mitigate the effects of implicit bias in your AAP Chapter

3. Ground Rules This is a respectful space Recognize the diversity of background and experiences in the room Bring humility and assume good intent Be open to recognizing your own biases (we all have them!) without self-judgment or defensiveness Be open to entering a process of decreasing bias in your personal life, practice, and institution

4. Warm-Up Cases

5. What is bias?

6. Types of Bias Explicit Bias: • Conscious preference in favor of, or against, one or many groups • Biases you think about and report Implicit Bias: • Unconscious attitudes and beliefs • Can influence behavior

7. Physician Implicit Bias On average, physicians are biased against certain populations at the same rates as the general public This is despite having explicitly stated altruistic or egalitarian values In a recent systematic review (Maina, et al) , 31/37 (84%) studies found pro-white/anti-black or anti-darker skinned bias among health care providers Maina IW, et al. A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Social Science & Medicine. 2018 Feb 1;199:219-29.

8. Implicit Bias Among Pediatric Residents Johnson, T.J., Winger, D.G., Hickey, R.W., Switzer, G.E., Miller, E., Nguyen, M.B., et al., 2016b. A comparison of physician implicit racial bias towards adults versus children. Acad. Pediatr. 17 (2), 120e126.

9. Implicit Bias in Medicine Bias has been demonstrated among: Medical students Residents Fellows Community physicians Academic physicians Physicians of all disciplines (surgeons, sub-specialists, primary care) Bias has been demonstrated against: Black patients Latino patients Native American patients LGBTQ patients Overweight patients Elderly patients

10. How to Measure Implicit Bias Implicit Association Test, developed in 1998 • Aims to capture unconscious internal connections between groups and assigned value • Measures the time for subjects to match social groupwith positive and negative attributes Gold standard Validated Not diagnostic! Other IATs: • Gender, sexuality, weight, disability implicit.harvard.edu

11. What is the relationship between health disparities, race, and bias?

12. Implicit Bias in the Spotlight

13. Health Disparities in Care: Groundbreaking Study 1993 publication in JAMA Compared patients who presented to the UCLA Emergency Medicine Center with long-bone fracture Hispanic patients were twice as likely as non-Hispanic patients to receive no pain medication, no confounding factors

14. Understanding Health Disparities: Unequal Treatment Congress commissioned 1999; final report in 2003 Significant variation in rates of medical procedures and health outcomes “The study committee was struck by the consistency of research findings: even among the better-controlled studies, the vast majority indicated that minorities are less likely than whites to receive needed services, including clinically necessary procedures”

15. Understanding Health Disparities: Unequal Treatment Racial differences in patients’ attitudes, such as their preferences for treatment, do not vary greatly and cannot fully explain racial and ethnic disparities in healthcare “(al)though myriad sources contribute to these disparities, some evidence suggests thatbias, prejudice, and stereotyping on the part of healthcare providers may contribute to differences in care”

16. The Role of Disparities: A Conceptual Model

17. An Updated Conceptual Model Kilbourne AM, et al. Advancing health disparities research within the health care system: a conceptual framework. Am J Public Health. 2006;96(12):2113–21

18. How does implicit bias affect child health?

19. Racial Disparities in Pain Control 2015 cross-sectional study sampled nearly 1 million children diagnosed with appendicitis from 2003-2010 • Reviewed how often patients were treated “any analgesia” compared to “opioid analgesia” after being diagnosed with appendicitis • Appendicitis is the most common surgical cause of abdominal pain in the ED and the provision of analgesia to patients with appendicitis is now accepted and encouraged • Hypothesized that black patients would be less likely to receive opioid analgesia than white patients Goyal MK et al, Racial Disparities in Pain Management of Children With Appendicitis in Emergency Departments. JAMA Pediatr. 2015 Nov; 169(11): 996-1002

20. Racial Disparities in Pain Control Goyal MK et al, Racial Disparities in Pain Management of Children With Appendicitis in Emergency Departments. JAMA Pediatr. 2015 Nov; 169(11): 996-1002

21. How does implicit bias affect diversity and inclusion efforts?

22. Implicit Bias in Diversity and Inclusion Efforts: Gender Key Findings: Overall Evaluators were significantly more likely to hire “Brian” Male job applicant rated as having done adequate teaching, research, and service compared to female with same record At the Tenure Level Equally likely to recommend tenure for male and females 4x more likely to include cautionary comments on CVs with female name

23. Implicit Bias in Diversity and Inclusion Efforts: Gender Key Findings: 1=excellent, superb, outstanding, etc 2= negative language, hedges, etc

24. Implicit Bias in Diversity and Inclusion Efforts: Race Key Findings: Overall Callback rate higher for “white-sounding” names (10.0% vs 6.6%) No improvement for employers with EOE status

25. Implicit Bias in Diversity and Inclusion Efforts: Race Key Findings: Difference in performance expectations related to race/ethnicity Devaluing of research on community health care and health disparities Assumption that achievements were attributable to special favors instead of merits

26. What can we do about it?

27. The World of Symphony Orchestras

28. What will be our screens?

29. What can we do from here? Implicit bias is a reality – cannot shame people for having it, can probably not entirely eliminate it, must work to mitigate the effects • Individual Strategies • Group Strategies • Systemic Strategies

30. Individual Strategies: Self-Reflection Do I consider myself to be part of any group that is historically marginalized and/or likely to be biased against? Do I personally think about my own race as a factor that impacts how I am perceived/how it impacts my interactions? Have I taken an Implicit Association Test (IAT)? Do I read books, consume media (television, movies, podcasts) with creators and stars who come from a different racial background than I do? Do I spend time in neighborhoods and have meaningful interactions with friends/neighbors/colleagues with a variety of racial/ethnic makeups?

31. Individual Strategies: Reflection in Clinical Practice Reflection on the role of race in the patient interaction Perspective taking Visualize positive images Invest time Naming bias

32. Group Strategies: Small Group Interventions “Journal Club” using an article that addresses implicit bias in the clinical setting such as • Brooks KC. A Silent Curriculum. JAMA. 2015; 313 (19):1909-1910 Implicit Bias Workshop (“Best Intentions”) Small group session on addressing bias on inpatient teams

33. Group Strategies: Large Group Interventions Grand Rounds on Implicit Bias Health Equity Rounds

34. Systemic Strategies: Clinical and Educational Settings Incorporating implicit bias curriculum into the curriculum longitudinally Visiting Professorship Diversity and Inclusion Officer Protocols and pathways

35. Systemic Strategies: Diversity and Inclusion Efforts Investment in pipeline program: Minority Senior Scholarship Program for 4th year medical students help recruit and promote residency candidates from background URM Implicit bias training for all residency selection committee members Investment in retention: URM residency group and minority faculty development group provide informal network, formal mentorship for trainees and faculty

36. Bringing it Together Through Longitudinal Programming Individual: • Take an IAT • Perspective taking, self-reflection in group programming Group: • “Best Intentions” Workshop: early intern year at the beginning of training • “Addressing Bias on Inpatient Teams” Workshop: senior resident year in supervisory role • Grand Rounds • Health Equity Rounds Systemic: • Supporting pipeline programming • Residency recruitment training • Implicit bias curriculum • Support for URM professional development

37. Summary Health disparities continue to persist Implicit bias contributes to disparities in patient care Implicit bias can affect recruitment, selection, and retention in organizations and leadership It is crucial to acknowledge implicit biases in order to change them Ongoing efforts are needed to teach physicians and the public about the impacts of bias

38. Additional Resources Books: Tweedy, Damon. Black Man in a White Coat: A Doctor's Reflections On Race and Medicine. First edition. Picador, 2015 Banaji, Mahzarin R, Greenwald, Anthony G. Blindspot : Hidden Biases of Good People. New York :Delacorte Press, 2013. Print. Media (Audio/Video): Hannah-Jones, Nikole. The Problem We All Live With. This American Life Podcast, 2015. Vedantam, Shankar. An American Secret. The Hidden Brain Podcast, 2017. Adelman, L., Smith, L., Herbes-Sommers, C., Strain, T. H., MacLowry, R., Stange, E., Garcia, R. P. Unnatural causes: Is inequality making us sick? Public Broadcasting Service (U.S.). 2008.

39. Additional Resources Academic Articles: Johnson, T.J., Winger, D.G., Hickey, R.W., Switzer, G.E., Miller, E., Nguyen, M.B., et al., 2016b. A comparison of physician implicit racial bias towards adults versus children. Acad. Pediatr. 17 (2), 120e126. Brooks KC. A Silent Curriculum. JAMA. 2015; 313 (19):1909-1910 Hall WJ, Chapman MV, Lee KM, et al. Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. American Journal of Public Health. Oct 15 2015:e1-e17 Workshops: Gill A, Thompson B, Teal C, et al. Best intentions: using the implicit associations test to promote reflection about personal bias. MedEdPORTAL. 2010;6:7792. Brooks KC, Rougas S, George P. When race matters on the wards: talking about racial health disparities and racism in the clinical setting. MedEdPORTAL. 2016;12:10523.

40. Collaborative Discussion

41. Group Discussion Questions: Personal Reflections on IAT What was it like to take the IAT? If you feel comfortable, please share your experience with us. Were your results what you expected? Why or why not? Regardless of whether you expected them or not, how do you feel about your results? What was useful/provocative/interesting about taking the IAT? How do you think taking the IAT relates to any past experiences you have had? Did taking the IAT trigger you to reflect on (or remind you of) past experiences with bias?

42. Group Discussion Questions: General Questions Did anything from this presentation surprise or challenge you? Does the research about bias match your experiences in clinical practice or organized medicine? Have you ever witnessed physician bias? • Explain the circumstance. • Was the bias acknowledged or addressed? If so, by whom and how? • Do you think the bias was explicit (the person was aware of it) or was it implicit (they were unaware they held a bias)? How might health care providers be particularly at risk for, or resilient towards, having implicit biases?

43. Group Discussion Questions: Personal Experience w/ Bias Other than taking the IAT, have you previously experienced insights about your assumptions or beliefs about patients? • How did you recognize a bias in yourself? • If you have previously identified biases in yourself, how have you managed those? What strategies did you learn about today that you are excited to incorporate? What strategies that we learned about today seem challenging?

44. Group Discussion Questions: Chapter & District Involvement Are there efforts currently underway in your chapter or region to address bias? Has your chapter or region done anything to specifically address the career development needs of women or ethnic minorities? • If so, please describe what that was. • If not, can you think of any efforts you can implement in the future? What barriers may you face at your home chapter or region? How can you develop a plan to use individual, group, and systemic strategies to address bias in your chapter or region?

45. Thank you!Alexandra Sims, MD, FAAP General Academic Pediatrics Fellow, Children’s National Research Instructor, George Washington University Co-Director, Minority Senior Scholarship Programamsims@childrensnational.org @DrAlexSims