1. 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

2. 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.

3. 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

4. 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

5. Examples of discrimination in health care and consequences

6. 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

7. 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

8. 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

9. Unknown Face

10. 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

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

12. 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

13. 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

14. Measuring Implicit Beliefs: The Implicit Association Test (IAT)
A widely used, indirect measure of implicit social cognition
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

20. Definition of Terms

21. Carla the Quilter

22. 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

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

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

25. 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”

26. 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

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

28. 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.

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. Learning Environment
Definition of Terms

37. 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

38. 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

39. Equitable Imagery

40. Medical School Faculty Letters: Women

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

42. 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

43. 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,

44. Objective 3

45. 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

46. 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

47. 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

49. 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

53. 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.

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

55. 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