Examining and addressing unconscious biases has become an important goal for many in the medical community. Everyone has it, and the consequences are significant. But addressing it is slow and difficult work.
In this episode, you’ll learn:
- people’s personal fears around unconscious bias
- people’s concerns about organizations & institutions when it come to discussing unconscious bias
- what you can do to support your own – and others’ – examination of unconscious bias.
Episode transcript with research links
Hi. This is 10 minutes to better patient communication. I’m Dr. Anne Marie Liebel.
In this series, I take one communication question or issue that doctors have raised, dig deeper into with some research, then give you a strategy that you can use in your practice today. And I do it all in about 10 minutes.
Today’s episode is about unconscious bias. Recently 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.
Just last week, a collaboration among NPR, RWJF, and Harvard’s School of Public health released a study on Discrimination in America.
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.
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.
Numerous studies have also indicated how this bias exists within health professions.
As a result, models, guidance, and theoretical orientations have been developed to address bias and stereotyping. Some specializations and programs have made a goal of diversity and equity in the workplace.
But getting down to the work of actually addressing unconscious bias can make people nervous. And some of that, I argue, is with good reason.
It’s important to acknowledge this so we can take appropriate steps – whether we’re talking about our own unconscious biases, or it’s our job to facilitate others in talking about theirs.
And that’s what this episode is about.
I started talking about unconscious bias more than a dozen years ago, starting with my own. 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 some starting steps.
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.
I’ll briefly describe these now.
In terms of Personal doubts and fears, there’s three.
I’m already thinking about this
When I first began the process of confronting my own biases, I had already been teaching for several years. I remember thinking—and sometimes saying—things like, “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.”
As thoughtful, well-educated people who take our professional commitments seriously, We likely have good reasons for thinking we’ve already done our best to understand the communities we work with, and how we do that work.
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. It can feel like a personal showdown, as if one party is wrong and the other right.
Similarly, most of us want to avoid feelings of awkwardness, or pain. What might come from looking hard at ourselves. Or at the communities we came from, and the histories of those communities. All of this is potentially involved with conversations about bias and stereotypes.
That’s just the way it is
The process of facing biases or stereotypes is risky business. So is any threat to the status quo.
Wherever we are as individuals in the social hierarchy, it can be threatening to acknowledge
- that we live and participate in various networks and systems geared to work better for some people 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 may show us things we’d rather not see. Or, make us aware there’s more responsibility on our shoulders.
Concerns about organizational commitments
A trust issue
When I began my doctoral program, there was an explicit agreement that part of this process involved my examination of my assumptions and beliefs, including 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 would reward my willingness to do this work. And for the most part, that was true. 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’re willing to place our trust.
Conflict will happen
Examining our biases and assumptions is intensely personal. It invites vulnerability. And it’s sometimes done alongside 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 when I started this process. But some of my classmates and I did argue. My students argued among themselves. Some argued with me.
those who lead groups in examining biases need to be able to facilitate and explore–and not shut down–such tense interactions. Because they will happen, if learners are committed to fronting their assumptions and examining them (and not just pretending to).
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 often recognized or rewarded for this in our organizations.
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.
Organizational commitment and support
It’s often unclear what shifts in ourselves have to do with shifts in organizational culture.
Beyond asking individuals to address their own biases, what is being done at an organizational level to address bias and stereotypes in existing systems and processes?
For instance, If a learner is asked to examine their unconscious bias and stereotypes as part of a class, or a quality initiative, it can’t just stop there. what parallel action is happening at an institutional level?
Additionally, 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. We cannot continue to expect the solutions to deep-seated, systemic problems to be provided by those least served by these same systems. The heavy lifting should not be done by those already carrying disproportionate burdens.
I’ve been talking about the challenges I have come to know as part of the work of addressing unconscious bias. But because it is difficult does not mean we turn away. So what can you do?
Be conscious of the difficulties inherent in this work. That means in part being patient with yourself and with others. If you’re in a group, I recommend collecting readings and videos as a way to anchor discussions and a provide a bit of emotional breathing room.
It also means marshalling real institutional support and systems-level thinking. Take a look at one structure or process in your organization that may be marginalizing certain groups, even unintentionally.
Please join in this conversation. If you’re listening on iTunes, go to rate and review. If you’re listening at health communication partners dot com, please let me know your thoughts in the comment box. I read these! I’m Dr. Anne Marie Liebel and this has been Ten Minutes to Better Patient Communication.