Just over two weeks ago, I was giving a talk at Columbia University’s Mailman School of Public Health about addressing unconscious bias in our language. At the end, one of the questions I received from a participant was:
“It sometimes takes a lifetime to create those biases, that sometimes become innate. How do [we] unlearn those biases?”
Ten days later, national attention was drawn to a deeply disturbing and problematic set of events at a Starbucks in my hometown of Philadelphia. Starbucks’ CEO’s response eventually included a decision to close 8000 stores, for one half day, to train on unconscious bias.
Yesterday, the New York Times asked: “Can training undo bias? Researchers are divided on the effectiveness of the anti-bias training that Starbucks will give its employees.” The focus of the NYT article was on ‘training,’ and a few examples of anti-bias training were given (though details on the ‘training’ in those examples were few).
I am continually inspired by the work of health providers and public health professionals in helping shape public discourse around some of the most pernicious and difficult issues facing society.
Starbucks’ high profile gives us a chance to locate current conversations of the role of unconscious bias in health disparities within the context of public debates–about unconscious bias, and about the ways organizations seek to address unconscious bias.
In the spirit of continuing a cross-sector dialogue, and sharing in the goal of creating the conditions where everyone has the opportunity to reach their full health potential, I offer here some of what I’ve learned as an educator.
I’m not trying to provide a fixed or proper way to address unconscious bias. Rather, I’m sharing some topics you might want to think about, if your organization is considering the issue of unconscious bias. I ground this essay with references to a highly influential article from education leader Marilyn Cochran-Smith.
Unconscious bias and health disparities
As you know, historically, Americans have experienced variable access to care based on race, ethnicity, socioeconomic status, age, sex, disability status, sexual orientation, gender identity, and residential location (AHRQ 2016 National Healthcare Quality and Disparities Report).
Health disparities are due to many factors that are man-made. One of them is unconscious bias.
Recent research on unconscious bias has shown how medical care, public health, and human service providers can unintentionally contribute to racial/ethnic health disparities. There are documented links between health care professionals’ unconscious bias, and disparities in receipt of health care and in multiple clinical outcomes. These links extend to differences in health services offered and provided to minority populations.
In terms of health research, unconscious bias has been identified as a cause for underrepresentation of particular groups in public health and epidemiological studies, as well as clinical trials.
As I’ve written before, some specializations and medical schools have made a goal of diversity and equity. Models, guidance, and theoretical orientations have been developed to address bias and stereotyping.
“Risky business”
Yet reaching these goals, or actually following these various models, can be distressing and uncomfortable for everyone involved. On an organizational level, part of what makes this difficult is that people are all over the map in terms of their willingness to engage with the complex topic of unconscious bias.
The process of facing biases or stereotypes is, as Marilyn Cochran-Smith pointed out years ago, “risky business.” It can be threatening to acknowledge that we live and participate in networks and systems geared to work better for some than for others, and that we have a place in maintaining these.
Seeing blind spots
Yet some educators have been addressing racism and discrimination on individual and systemic levels for multiple decades.
This work itself is built on years of sustained efforts of marginalized people from different race and class groups, who have focused national and international attention on issues of discrimination.
I turn again to Cochran-Smith:
“How we are positioned in terms of race and power vis-à-vis others has a great deal to do with how we see, what we see or want to see, and what we are able not to see.” (emphasis mine)
I join with many who undertake examining issues of racism and discrimination by considering our blind spots.
What might this mean in your organization?
Three considerations
I don’t think there’s a researcher out there who would say, “Yes! a one-shot workshop would undo bias.”
It’s probably safer to say there are researchers who would agree that ‘training’ can be helpful as part of larger efforts. If you find yourself in an organization which is or may be addressing unconscious bias, I offer these considerations.
Small changes can be the enemy of large changes
We have all be involved in events or initiatives that have given more the illusion of progress than have made substantive progress.
The problem: doing little things can push ‘larger things’ further from view, and ultimately make more meaningful change difficult to engage with.
Take food banks, for example.
Food banks are a front-line, short term resource. They are glad when people donate food.
But they also know they are not a solution to food insecurity.
As people feel they are doing their part by donating to food banks, they can lose sight of the root causes of food insecurity. One organization points out “In fact, food banks are counterproductive because their existence creates the illusion that food insecurity is being taken care of in the community.”
No one is going to tell you not to donate to a food bank. But donating to food banks, and giving attention to expanding their reach, can distract needed attention from why they are there in the first place. Large issues like poverty and income inequality.
So be cautious when small changes in addressing unconscious bias in your organization may unwittingly become the enemy of larger changes.
If you are interested in taking your language use seriously, why not start with your metaphors? This workshop shows you how to break down the metaphors you use, understand their cognitive and affective aspects, and evaluate them in use. On demand, right on this site.
Limitations of individual-level thinking
Yes, unconscious bias is enacted by individuals. And it is hard work delving into how care providers understand and construct issues of bias, and how they link these to their roles as providers.
But as I’ve written before, individual level efforts must be matched and supported by systems-level thinking.
Sure, Starbucks is closing 8000 stores for half a day. This seems to indicate it’s the front line people, the employees at each site, who will be ‘trained.’ But what are they doing systemically?
Bias can hide in plain sight– in normal routines.
I was talking about this with a medical educator, who laughed and, citing Atul Gawande, said, “If you want to move away from the cowboy culture [in medicine], look at our structures!”
Take a look at some of the structures and processes at your organization. These can hold sedimented biases, often invisible through years of use. Are your structures working against your goals?
For example, in a medical school, one potent structure is the curriculum.
The assumptions you make about teaching, learning and your audience of learners in your educational programs, endeavors, and materials may challenge biases—or (unwittingly) normalize them.
I have heard multiple providers in academic medicine talk about the ‘hidden curriculum’ in medical education. I certainly have first-hand experience with unearthing hidden aspects of curriculum in education.
Turning to Cochran-Smith again: because materials and ways of structuring programs are drivers of students’ professional learning experiences, it is especially important that educators
“interrogate the racist assumptions that may be deeply embedded in our own courses and curricula, [and] own our own complicity in maintaining existing systems of privilege and oppression”
How is your organization handling conversations about who and what is represented in curricula, and who is left out? What is being done, if anything, to examine program structures to identify the assumptions about the ‘kind of student’ who is privileged in these structures?
Unconscious Bias training as separate from work
Part of what makes for less-than-effective professional development sessions is when they are separated from work.
Sure, there is often the need to get people together at the same time, maybe in the same space. And that does mean stepping away from the normal tasks and routines of one’s job.
This makes a complicated situation worse in multiple ways. The connection between what is done and said in the ‘training’ and what is done and said in ‘real work’ is left for facilitators and participants to make for themselves. It is to hope for some kind of transfer of these ‘add on’ actions to everyday work.
Or the responsibility is placed on participants to find a way to make it work. The subtext is – if they don’t, well that’s on them. Again turning to Cochran-Smith, I join my voice with those who suggest
“Making issues of diversity (particularly of race and racism) central and integral, rather than marginal and piecemeal” to the work of health care.
That is, recognizing that addressing unconscious bias is not something we do once (or once a year), but as an ongoing project of our professional lives. As central to and inseparable from the work we do each day.
The implications are many.
This can involve dramatic changes in syllabi, materials, evaluation methods, faculty recruitment, and opportunities for collective learning and action on behalf of students, faculty, and community members.
Communities of practice
In this short space, I hope to draw your attention to things you might not have noticed. In leaning on Cochran-Smith and the metaphor of blind spots, I hope to offer you a way to think about some of what is involved in addressing unconscious bias.
It is challenging to look for absences, lacks, automatic manners, or fixed positions. That is why communities of practice are essential. We are socialized into language, and into ways of thinking.
Therefore, communities of practice – of those who are committed to equity and justice – can, over time, be powerful forces for socializing us into ways of thinking, talking and acting. And out of others.
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