Last week I was in Baltimore, at the International Conference on Communication in Healthcare/Health Literacy Annual Research Conference.
Every one of the keynote addresses discussed biases and stereotypes. Every one. (Biases and stereotypes was not the conference theme.) The importance of examining and addressing unconscious biases seems to be well understood in the research community.
Unconscious bias is something everyone has. An author from the Royal College of Surgeons recently described in BMJ that unconscious bias involves placing people in a ‘category’ when we first meet them. It is something we do “by mistake, without thinking, unconsciously—and that’s fine, that’s human nature. But the question is what we do with that.”
Similarly, a recent editorial in the Journal of Gerontological Nursing indicates that unconscious bias is “a universal trait and important for survival,” and that “even educated individuals with the best intentions can display” it. But biases also “can reflect a negative perspective that reveals one’s knowledge, beliefs and expectations about a particular group, such as older adults.”
As much as bias may be “human nature” or “a universal trait,” it is an obstacle, a blind spot –with some serious consequences.
Unconscious bias on the part of health care providers has been linked to errors in clinical decision making, as described in this recent BMJ paper. Disparities in care along racial and/or ethnic lines have been documented–even when the patient is a newborn, as described in this paper.
Numerous studies have also indicated how this bias exists within health professions. Foreign-trained doctors are treated unfairly in examinations. Gender inequality persists in specialist medical colleges.
As a result, some specializations and programs have made a goal of diversity and equity in the workplace. Models, guidance, and theoretical orientations have been developed to address bias and stereotyping.
But talking about unconscious bias can make people nervous. And some of that, I argue, is with good reason.
I say this, in part, because I started talking about unconscious bias more than a dozen years ago (starting w/my own biases). For a decade now, I’ve also been leading conversations with others about examining our biases and assumptions as practitioners. It is a long, difficult, entirely worthwhile journey.
Here is some of what I have learned about why this process can make us uncomfortable, and where we can go from there.
From the learners I have worked with directly, or in research from those undertaking similar work, I have found people’s fears or doubts around addressing bias and stereotypes can cluster into two groups:
- People’s personal doubts and fears, and
- People’s fears pertaining to organizations, institutions, or systems.
Personal doubts and fears
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I’m already thinking about this
I first began the process of confronting my own biases, stereotypes and assumptions more than a dozen years ago in my doctoral program. At that point, I had already been teaching for several years. I remember thinking—and sometimes saying—things along the lines of, “I haven’t not been thinking about biases and prejudices all this time. I work hard. I care about all my students.”
A 2011 JAMA editorial opens with a similar sentiment: “The evidence that physician behavior and decision making may contribute to racial inequalities in health care is difficult to reconcile with the fact that most physicians are genuinely motivated to provide good care to all their patients.”
Conversations about unconscious bias can put us in a defensive position. As thoughtful, well-educated people who take our professional commitments seriously, we can resist reconsidering our assumptions. We likely have good reasons for thinking we’ve already done our best to understand the communities we work with, and how.
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Don’t tell me I’ve been doing it wrong
No, we don’t like the idea of others criticizing us. Conversations about unconscious bias can conjure fears of being attacked. They certainly did for me. When we’re feeling attacked, we tend to focus on our defenses. Concerns over what we’ll say next can take our attention away from the issues being raised.
Similarly, most of us want to avoid feelings of awkwardness, or discomfort, or pain. We might dislike looking hard at ourselves. Or at the communities we came from, and the history of those communities. All of this is potentially involved with conversations about bias and stereotypes.
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That’s just the way it is
The process of facing biases or stereotypes is risky business. For instance, it can be threatening to acknowledge
- that we live and participate in networks and systems geared to work better for some than for others;
- we have a place in maintaining these.
These networks and systems can be large-scale, like schools, health systems, carceral systems, the ‘open market.’ They may be smaller-scale or local, like neighborhoods, online communities, or voting precincts.
Acknowledging these contextual realities, and related systemic injustices, may show us things we’d rather not see. Or, potentially put more responsibility on our shoulders.
Concerns about organizational commitments
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A trust issue
When I began my doctoral program, there was an explicit agreement that part of this process involved my intentional and systematic examination of my assumptions and beliefs. These included assumptions I held about the communities I was serving.
I didn’t fully understand what that meant at the time. But I believed in the program and the people in it. I trusted that these experiences were designed for my benefit, and would reward my willingness to change. And for the most part, that was true for me in my experience. I know this is not always the case.
This kind of work can mean our taking a close look at the relationships we have to the various organizations and institutions of which we’re a part. And deciding in whom, or what, we’ll place our trust.
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Conflict will happen
In general, people don’t like conflict. To make things more complicated, examining our biases and assumptions is intensely personal and invites vulnerability—and it’s sometimes (often?) done in front of colleagues. Or in front of someone in a supervisory position.
I had some very patient and skillful instructors and classmates, who had been facing their own assumptions for years before I did. They certainly helped in the volatile time I had when I started this process. But some of my classmates and I did argue. Years later, some of my students argued among themselves. Some argued with me.
Educators do seem to need another level of skill here in facilitating and exploring–and not shutting down–such tense interactions. Because conflict will happen, if learners are committed to fronting their assumptions and examining their biases (and not just pretending to).
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Being able to check the box
Addressing our own biases and stereotypes is not something we can ever get right. We don’t land, or arrive, or get the good grade.
We are not necessarily recognized or rewarded for this.
On the contrary: we may be asked to come to some sort of conclusion about ourselves. To fill out the survey. To pronounce ourselves ‘this kind of person,’ rather than being able to be tentative and in process.
4. Organizational commitment and support
It’s often unclear what shifts in ourselves have to do with shifts in organizational culture.
When organizations declare change, how much skin do they have in the game?
Who is inviting us to do this work? Why, and under what conditions?
When people choose to share their stories—ultimately, to be vulnerable—how are organizations responding? If a learner is asked to examine their unconscious bias and stereotypes as part of a class, or a quality initiative, how is that learner protected, supported, and not left feeling exposed? If these concerns are not taken seriously, we may run the risk of doing more harm.
It is possible that in confronting our assumptions, we learn something about ourselves we don’t like. Something we are not proud of. In these times, we need—and deserve–organizational support.
We cannot continue to expect the solutions to deep-seated, systemic problems to be provided by those least served by those same systems. The heavy lifting should not be done by those already carrying disproportionate burdens.
Examining our own assumptions is a starting point. But it is only that: a starting point.
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