Implicit Bias: What is it? How is it Manifest? Prepared by Janice A. Sabin, PhD, MSW Research Associate Professor, University of Washington Department of Biomedical Informatics and Medical Education Affiliated Faculty: Center For Health Equity, Diversity, and Inclusion © 2016, University of Washington, Developed by Sabin, J.A., & Morales, L.S., Center for Health Equity, Diversity and Inclusion, all rights reserved

Definition of Terms QUIZ 1 We plan to evaluate this course and may present/publish this evaluation. Anonymous information gained from your quiz will be included in the evaluation.  (University of Washington IRB Exempt, 2016). If you do not want your information included in the evaluation, please do not respond to quiz.

Definition of Terms Terms Bias: an attitude that projects favorable or unfavorable dispositions toward people Stereotype: shared set of beliefs, fixed impression of a group Prejudice: negative attitudes and beliefs about out-group vs. in-group Discrimination: behavioral manifestation of bias, stereotyping, and prejudice, they way others are treated Definition of Terms

Definition of Terms Terms In-group favoritism: advantaging “people who are like me” Aversive racism: people who explicitly support egalitarian principles and believe themselves to be non-prejudiced but also unconsciously harbor negative feelings and beliefs, Stigma: the process by which certain human characteristics are labeled as socially undesirable and linked with negative stereotypes about a class of individuals, resulting in social distance from or discrimination towards labeled individuals (NIH) Definition of Terms

Examples of discrimination in health care and consequences

Definition of Terms Patient Reports of Discrimination American Indian vs. White parents worry doctors not trustworthy (24% vs. 13%), report low trust (19% vs. 5%), report discrimination (24% vs. 2%) 53% of overweight/obese women report inappropriate comments from their doctor 25% of sexual minority patients in Veterans Health Care Administration avoid seeking care due to concern about stigma Thiede-Call,et al., 2006, Puhl & Brownell, 2006, Simpson et al., 2013 Definition of Terms

Definition of Terms Perceptions of Discrimination Delay in seeking care Mistrust in provider/system Patient stress level Adherence to treatment Continuity of care Definition of Terms

Definition of Terms Implicit Bias Definition “attitudes or stereotypes that affect our understanding, decision making, and behavior, without our even realizing it” “Implicit bias in the courtroom”, UCLA Law Review(2012) by Jerry Kang, et al. Definition of Terms

Unknown Face

Definition of Terms First Impressions First impressions of a person as attractive, likeable, competent, trustworthy, and aggressive are made quickly Exposure to an unknown face for one-tenth of a second was enough to judge these traits (implicitly) Judgment did not change with increased of one second, but confidence in the judgment increased Definition of Terms Willis & Todorov, 2006

Implicit and Explicit Beliefs Explicit Attitudes and Beliefs Can report Rational Higher level thinking Implicit Attitudes and Beliefs Automatic Hidden Unaware Lower level thinking

Definition of Terms Explicit and Implicit Beliefs Can Disagree Even those holding egalitarian values may hold negative implicit attitudes and beliefs Implicit and self-reported attitudes and beliefs may differ, a person may be unaware that they hold contradictory beliefs Nosek, et al., 2007, Burgess et al., 2007, Banaji & Greenwald, Dovidio & Gaerner 2000 Definition of Terms

Say the color of the ink for each of the items below as fast as you can GREEN BLUE RED YELLOW YELLOW GREEN RED BLUE Stroop, 1935, Journal of Experimental Psychology

Measuring Implicit Beliefs: The Implicit Association Test (IAT) A widely used, indirect measure of implicit social cognition http://implicit.harvard.edu Greenwald, et al., 1998 The University of Washington is a leader in the field of implicit social cognition. Dr. Anthony Greenwald, Department of Psychology invented the Implicit Association Test. (IAT) We can measure implicit attitudes and beliefs Sort and pair images and words as they flash on a computer screen Based on the assumption that response to images that are more easily associated will be faster than response to images that are less easily associated University of Washington, Harvard University, University of Virginia (IAT) Greenwald, et al., 1998

Definition of Terms

Carla the Quilter

Carla, a woman in her late 20s, was rushed to the emergency room by her boyfriend She had cut her hand on glass bowl as it slipped to the ground and shattered Definition of Terms

Her hand was cut from mid-palm to wrist and bleeding

BF told the ED resident that quilting was very important to Carla and worried about damage to her fine motor control

Photo ok, too old? VanSchaik, Howe, Sabin, 2014 The resident stated that he was confident the hand would heal well if he could “just stitch it up quickly”

Buy photo or create one As the doctor prepared Carla’s hand, a student volunteer walked by and recognized Carla, who in addition to being a quilter, was also an assistant professor at Yale

The ED doctor stopped in his tracks and said, “You are a professor at Yale?” Istock must buy

What happened here? What if Carla was Carl? Within seconds Carla was headed for the surgery department and the best hand surgeon in Connecticut was called in. After hours of surgery Carla’s hand was restored to pre-injury function.

Hidden Discrimination Carla the quilter vs. Carla the professor is a case of in-group favoritism Hidden discrimination- less an act of overt hostility - can be an “absence of helping” In-group favoritism can increase “the relative advantages of those who are already advantaged” Not an act of overt hostility Not intentional If this happens the same way over and over, measurable disparities “In-group favoritism may be the largest contributing factor to the relative disadvantages experience by Black Americans and other already disadvantaged groups.” Blindspot Greenwald, & Pettigrew, 2014, Banaji & Greenwald, Blindspot, 2013

Definition of Terms What Happened? Carla the quilter vs. Carla the professor is a case of in-group favoritism Hidden discrimination- less an act of overt hostility - can be an “absence of helping” In-group favoritism can increase “the relative advantages of those who are already advantaged Definition of Terms

Definition of Terms Evidence Some studies find implicit bias and others do not Some studies show that implicit bias is associated with quality of care and others do not Most studies focus on medicine but other types of providers are included too Few studies exist for clinical behavior and outcomes, few measure actual care Definition of Terms

Acute Coronary Symptoms Physicians hold strong implicit attitudes favoring white Americans vs. Black Americans (IAT) Stronger white preference- less likely to refer Black patients to treatment for acute coronary symptoms African American physicians no implicit bias 2007 Green, et al., Treatment Acute Coronary Symptoms

Blair, et al., Implicit Bias: Hypertension Implicit racial bias exists No differences in treatment intensification for White, Latino, and Black patients Increase of clinician bias from average to strong associated with change of less than 5% in all outcomes 2014 Blair, et al., Implicit Bias: Hypertension

2012 Lower patient positive affect Patient less liking of clinician Less confidence in clinician Lower perceived respect from clinician More clinician verbal dominance 2012 Cooper et al., 2012 Stronger clinician implicit bias favoring White Americans over Black Americans

2012 Pediatricians showed weak implicit race bias Implicit race bias not associated with 3 treatment scenarios Stronger clinician implicit bias favoring White Americans over Black Americans, less likely to prescribe pain medication for Black adolescent, not white adolescent 2012 Sabin et al., 2012

Learning Environment Definition of Terms

Definition of Terms Decrease likelihood of graduating Diminished performance on the MCAT, USMLE Contribute to apprehension during clinical clerkships, resulting in reduced evaluation of performance There are strategies to address stereotype threat Burgess et al., 2010 Can trigger negative emotions whether the person believes the stereotype or not Burgess 2010

Definition of Terms 2015 Racial Bias is Contagious Just observing subtle bias toward a Black person can shift an individual to be more biased Egalitarian individuals can shape social structure to be more equal Definition of Terms 2015 Willard, Isaac, Carney

Equitable Imagery

Medical School Faculty Letters: Women

Medical Student Experiences 49 US Medical Schools Took Race IAT first year and 4th year, overall small decrease in implicit race bias

Definition of Terms Student Perceived Mistreatment Perceived mistreatment is particularly harmful for minority students Students are faced with the possibility that mistreatment is due to their race or ethnicity Reinforces stereotype threat and can result in diminished performance Burgess et al., 2010 Definition of Terms

How Implicit Bias Creates Barriers Snap judgments In-group favoritism Presumptions of competence (or incompetence) More comfortable around those who are “similar” Subjective assessment of potential Adapted from Moody, 2010, http://www.engr.washington.edu/lead/biasfilm/

Objective 3

Definition of Terms What Not To Do DO NOT Try to change providers implicit racial/other attitudes This is not effective This may be counterproductive- can produce interracial anxiety Teaching cultural competence is not enough What Not To Do Definition of Terms Penner et al., 2014, Perry, Murphy, Dovidio, 2015, Zestcott, 2016

Definition of Terms Strategies to Interrupt Bias Collect data organizational, individual levels Monitor equity – find patterns Ongoing process If disparities/differences exist explore why Strategies to Interrupt Bias Definition of Terms

Definition of Terms Strategies to Interrupt Bias Objectivity Reduce discretion in decision making Develop standardized processes (decision tools) Clinical guidelines Strategies to Interrupt Bias Definition of Terms

Definition of Terms Strategies to Interrupt Bias Teaching Strategies Historical context of racism Psychological basis of implicit bias Would do vs. should do exercises Build confidence inter group interactions Demonstrate and promote patient-centeredness Strategies to Interrupt Bias Definition of Terms

Definition of Terms QUIZ 2 We plan to evaluate this course and may present/publish this evaluation. Anonymous information gained from your quiz will be included in the evaluation.  (University of Washington IRB Exempt, 2016). If you do not want your information included in the evaluation, please do not respond to quiz.

Thank You! The Team: Janice Sabin Leo Morales Frederica Overstreet Wendy Barrington Lynne Robins Marjorie Wenrich Michael Ryan Joe Benfield Michael Campion

Small Group Describe a time when you (or you observed) made assumptions about a situation or person that proved to be a mistaken snap judgment Think about a time that you observed “in-group favoritism” (eg. bias toward a student, in hiring, admissions) Identify a structured process in your organization/setting that might interrupt bias