Unconscious Bias

Hi everyone, this is Alex Cassar, one of Dr. Todd Ponsky's pediatric surgery research fellows at Cincinnati Children's Hospital. Today I'm here to introduce a podcast that's very different from what we've done before, coming right after Black and Women's History Month. It's meant to serve as a reminder that diversity and inclusion are fundamental in healthcare and deserve recognition year-round. The topic is unconscious bias, something we all have and should work towards addressing in our workplace, as it impacts both patient care and physician well-being. Last fall, my co-fellows Alex Gibbons and Ray Hankey and I had the opportunity to interview 3 seasoned experts in the field. This is how it went. Stay Current is a multimedia publication designed to keep healthcare professionals up to date on standards of care and new emerging ideas. This chapter is created and edited by Todd Ponsky, Alex Cassar, Alex Gibbons, and Ray Hankin and is recorded and produced at Cincinnati Children's Hospital in Cincinnati, Ohio. Welcome to State Current and Pediatric Surgery. This is Todd Ponsky recording from Cincinnati Children's Hospital. And today we're gonna be talking about a very uh different topic than we've talked about in the past. Uh, the, all the other topics have been clinical based and this one's not. What happened was we did the annual update course uh back in August and a lot of people noticed, Danielle Walsh, Celeste Hollins, and my uh new research fellows, Alex Cassar uh and Ray Hankey noticed that I had all white men in my panel. And if you look back, even though there have been different genders, different races, ethnicities, it definitely has been a majority of white men. I never noticed this, never paid attention to it, and they told me about this thing called unconscious bias or implicit bias that a lot of the panels and medical meetings are what are called manmals, that they're mostly made up of men. A lot of the people that arrange these meetings have an unconscious bias towards white men, and I told them there's no way that I would have a bias. I have 3 girls. My wife is a better doctor than I am. There's just no way. Well, I took the, the unconscious bias or the implicit bias test. Lo and behold, not only was I biased, I was strongly biased, right, Alex? Yeah, so strongly biased. This is a big problem. If I am biased, I can imagine that so are probably a lot of other people, and this is something we need to address, and we felt it was important enough to do a podcast about it. As I mentioned, we have the 3 new fellows. Uh, we have Doctor Alex Cassar, Doctor Ray Henke, and Doctor Alex Gibbons. So we decided to invite the real experts on implicit bias, people that, uh, not just have an opinion but really have, have been working in this area and can teach us about what this thing is about implicit bias. So, Alex, Ray, and Alex, who do we have with us today? Today we have Doctor Julie Freischleg, Chief Executive Officer of Wake Forest Baptist Medical Center and Dean of Wake Forest School of Medicine. Alex, who else do we have? Uh, we also have with us Doctor Mary Brandt, who's professor of Surgery, pediatrics, and medical ethics at Baylor College of Medicine, and a pediatric surgeon and director of the adolescent bariatric Surgery Program at Texas Children's Hospital. Great. And Alex. And also with us today, we have Doctor Quinn Capers the 4th. He's the associate dean for admissions, as well as an associate professor of medicine in cardiovascular medicine, as well as the program director of the Interventional Cardiology Fellowship at Ohio State University College of Medicine. Great. Well, thank you all for joining us today. So, Doctor Brandt, could you give us a brief description or explanation of what unconscious bias is to you and maybe an example of how you've experienced it in your career? Yeah, so, you know, there is a lot of work on implicit bias. It's also called unconscious bias. Um, and that's different from explicit or conscious, which is sheer racism or sexism or one of the other isms. The best definition I've heard from this is from the Kerwin Institute, um, at Ohio State, and it's this, and it's an important definition that implicit bias is the attitudes or stereotypes that affect our understanding, actions and decisions in an unconscious manner. So to go back to Todd's introduction, there's absolutely no one who recognizes they have implicit bias. No one. And the flip side of that is that everyone has it. And so this is something, it's different degrees and it's may be about different things. So your implicit bias might be about various kinds of groups or religions or gender or sexual preference, but you have implicit biases about all those things. So that's, that's the most important thing. As for example, you know, the, the mantle is a great example. I think for pediatric surgery, one of the studies that came out recently was actually about um pain medicines in children and in a diverse group of, of doctors, minority children were consistently given less pain medicine than white children. And there's like no reason to explain that except for um some kind of implicit bias and stereotypes again, so attitudes and stereotypes that affect our understanding and actions and decisions. So that's why that definition is so important, I think. Um, have you yourself experienced it, Mary? Oh, absolutely. And I, there's no woman in surgery or in medicine that has not. Um, and, and even more profoundly if we look at our colleagues who are from underrepresented minorities who have gender differences, whatever their differences away from what our society defines as the dominant group, which is white male Protestants, anyone that's not in that group is going to have experienced this. It's amazing. So, when I had, again, what sparked all this was my last update course, Mary, and when Danielle Walsh pointed out the, the mantle, uh, that was one issue. Then Celeste Hollins noted something. She noticed that. Of my three research fellows, Alex Cassar, who's a female, Alex Gibbons, who's a male, and Ray Hankey, who's a female, Alex Gibbons' name said Alex Gibbons MD, uh, or it said Doctor Alex Gibbons, whereas the two female residents, Alex and Ray, didn't include MD with their name. Right, or they, you didn't say doctor. So in the actual text, Gibbons referred to himself as Doctor Gibbons, whereas we referred to like to ourselves as Alex and Ray within the text. Where Alex, the male resident wrote, can referred to himself as a physician in his description. Alex and Ray, the female residents did not, and I said to Celeste, well, they wrote that description themselves, and she said, exactly, there's even implicit bias amongst themselves that they even left out doctor in their description. That was another criticism that we had about the course. So what you're talking about there is another extremely important concept that we all need to be very aware of, which is microaggressions, micro insult, um, and then there's micro assault which we don't wanna necessarily get into, but these very tiny paper cuts. We're not stabbing someone, not being, you know, blatantly prejudiced against them, but these little tiny paper cuts. The classic in meetings is men that are talking over women or over minorities. Um, women joke about it all the time, the mansplaining and what we call the he heat, so the woman in the committee has a great idea and it's ignored, uh, until 3 rounds of conversation later, a guy has the idea and suddenly it's really good. That's called a he peek, and it is a form of micro insults that goes totally unnoticed. Except to the people that are experiencing it, where again, it's so tiny that if you bring it up, people say, well, you're just overreacting. Of course, no one meant that, but over and over and over again, it starts to take a toll. And so that's another extremely important thing for us to be aware of. The other thing I would say is that it's actually not your two female residents' responsibility how they did that. It was your responsibility to point out that they did it and they shouldn't. If I noticed, yeah, if you notice it, and that's not, that's not to point a finger of judgment at you, but the people who are in the dominant positions are the ones that have to be responsible for calling this out. Yeah, I totally agree. And can I tell you why this podcast is important? So since Alex and Danielle, uh, Walsh and Celeste pointed this out to me. Um, since then, I don't know what was that, 23 months ago, I notice it all the time now. Once it's pointed out to you, uh, we even had a meeting in the hospital today and I was noticing that the female in the room was definitely getting talked over by the men in the room. Um, so since it's been pointed out to me, and I'm hoping the same thing happens with our listeners is that since it's pointed out, uh, you'll recognize it way more than you did before. Hey Julie, how would you answer that question if you have anything to add about what is implicit bias or unconscious bias and what examples can you give of it? Sure, I, like you, didn't really know a whole lot about it till probably 2005 and 2006 when I had implicit bias testing at Hopkins because it came to our attention that we actually were having a diversity problem. Inclusion problem and I did the testing and, and actually the way they proved to us that it actually works when you do it is they showed us first a series of pictures of people and associated them either with Harvard or Hopkins and so we were all from Hopkins, so of course we liked everyone from Hopkins we didn't like anybody from Harvard and so it showed to us that you can have bias just by where you sit and who you are. And so as probably Mary explained too, there's usually a white preference because it's thought and probably true that white individuals get more recognition and also get more opportunities than those that are not. And so people tend to have white bias because of that. For me, I think the implicit bias that I've seen is probably things that I didn't recognize initially, but I found out 20 years after I went through the match that at San Francisco, the chair of surgery there, the three women that were supposed to be ranked, he decided he didn't want any women in that program. So for 20 years I thought I wasn't good enough to train at UCSF, but I actually wasn't given a chance. So I think a lot of the implicit bias that I've seen has actually been things that have happened that I didn't win or I didn't get what. Wanted and I didn't know. So I actually think there are many people that think women can't lead, that perhaps women can't be parts of executive teams. I think that's getting better, but as we know, the percentages are so low that there's obviously people that look at leaders and make those decisions without knowing that. That being said, all my search committees now have to go through implicit implicit bias testing and examination so that we know what foot we're on. And I do think it is a struggle. However, even if you know you have that bias of choosing someone that looks like you, that happens frequently, and I think people almost have to call it out in the room saying, Are you sure that you're not choosing this person because they remind you of yourself. I would actually argue what Julie experienced was not implicit. It was explicit. The guy that was in the room, Mary, actually waited till that chair died, and then he took me out to lunch and told me. Mary, I'm glad, I'm glad you pointed that out. That definitely highlights the difference between implicit and explicit. So that's a great thing to point out there. It's always good to start with the definition of unconscious bias and, and, and it's essentially, uh, associations or likes or dislikes that are occurring kind of outside of our awareness, uh, and, uh, and control. Uh, and that's always important to start out with that because when people hear the word bias, there's, there's always an initial recoil because they think you're saying that they're a bad person. So initially they'll say, oh well I'm you know I'm not biased, so this is not pertaining to me, but we all have these unconscious associations or preferences or biases and it's so important to know about these in healthcare because there there is data that that these unconscious biases, although they occur outside of our awareness, they can influence our decision making so that you can be somebody who really, uh, uh, you know, you're pure hearted, you're egalitarian. And you go out and you want to do the right thing, but because of these unconscious preferences or associations or biases, you actually may treat people differently based on things that you see like gender, race, age, height, weight, um, um, and things like that. So that's always something that that we I think we're best served and our patients are best served if we explore our own unconscious biases, and that's something that I really recommend all clinicians do. Um, and, um, and, and, and, and what we do, there is, uh, there are many, there are many opportunities. I'll, I'll tell you about some some uh opportunities for unconscious bias to impact patient care, uh, that I have encountered, not necessarily in cardiology, but it's happened in cardiology as well, uh, but, uh, I was recently, uh, made aware of a case. In which a patient was being treated for cancer by an outside hematologist oncologist that was coordinating with our physicians here at our cancer center, and this was a patient that, as far as our doctors at our cancer center know, was very compliant with medication, really, although he wasn't medical, had a very good understanding of a very complex medical situation. And was always, you know, showing up on time to appointments, uh, but this person's cancer, uh, although initially responding, uh, suddenly, uh, this person had a relapse. And the outside physician's notations noted that the likelihood for the relapse was probably that this patient was noncompliant with the chemotherapy, was not taking the outpatient chemotherapy properly, or wasn't taking it at all, and several months went by with continuing the same chemotherapy because this doctor felt that most likely the relapse is because of a lack of compliance. At a certain point, the patient unfortunately started to do very poorly clinically, came to our academic medical center and had genetic testing which showed that the initial cancer that was being targeted by therapy had actually mutated, and that was the reason for the lack of response to therapy, not noncompliance. So at that point then with the genetic testing, the therapeutic agent was switched. Unfortunately it was too little too late, um, but, but this person was, had an identity as an underrepresented minority, and there is data that physicians when they see an underrepresented minority make an unconscious association with noncompliance with medical noncompliance, and so what we can never be sure, but this is a case where it's possible that the physician saw an underrepresented minority. And unconsciously made the association of underrepresented minority equals noncompliance and and then made therapeutic decisions based on assumed noncompliance when noncompliance really was not the reason that the patients started to deteriorate so that's that's maybe a very graphic example. I have a lot of my own questions, but I'm gonna go with the next question that we have because I want to hear, uh, Mary, first your answer and then we'll go to Julie. How does unconscious bias relate to social identity? This is an interesting concept that I've just recently learned that I think helps us understand a lot. Social identity, and again, I'm gonna give you a quote. I think this one's from Wikipedia. Is the portion of an individual self-concept derived from perceived membership in a relevant social group. So, for instance, Todd, white male, I'm white female, Harvard versus Johns Hopkins. This could be your gender, your um sexual orientation, it could be all kinds of things. So how you define your identity in a relevant social group. But the twist here is that if you are in one of the dominant groups in our society, and again we've stated earlier that that's white male Protestants, uh, cisgendered, by the way, so white male Protestants, cisgendered, if you're in those groups, when you are interacting with other people. Because you're in the dominant portion of the social identity, it never crosses your mind. And this goes back to what you, I mean, so wonderfully said about just simply not being aware. And my favorite story about this is a story about two fish that are swimming along, these young fish, and this old fish comes by him and says, Hey boys, how's the water? And he swims off and one of the young fish looks at the other and says, What's water? So I, if, if you're white, male, Protestant, cisgendered, you've never had to think about what's water because you've had all the privilege associated with that and all of the social power associated with that, and that puts your social identity in a place where you don't have to think about who's around you, what's going on, and what the interaction is. So, I think it is related to implicit bias. I think, um. I in a way, so just maybe of being aware that that exists, uh, but as Julie pointed out, we all have implicit biases. I mean, I've taken the Harvard test and it, and again, this is a real take home message here. There's not a single person listening to this that doesn't have implicit bias. It's all a matter of recognizing that you do and then deciding what to do about it. That I love the fish story and that that really puts it into perspective. Julie, do you have a comment about the social identity issue? I agree with Mary and with that, you know, you don't really have a definition, so you sort of go along. Where the groups are, you know, as, as I've trained and seen things, I think one that is outside gender is sort of the doctor nurse relationship, you know, where you see people choosing physicians to do things rather than nurses or calling nurses by first names and not physicians. We sort of changed that up in the operating room where all of a sudden in order to be a good team, you need to not refer to someone as doctor, but they're, they're part of the team to make that happen. That being said, To that actually made this huge assumption that the women you see in a hospital are the nurses and not the doctors and the men you see are the doctors and not the nurses. When I was working in Sacramento, about 10% of our nurse population was male, and I heard a lot from them about how they were mistaken in their identity just because they were male and the assumption was made. Sometimes I think there is, you know, privilege to what they assume you do, similar to what Mary said. And sometimes there's actually bad feelings and things happen because they assume you're this kind of person. When I was looking at dean's jobs and CEO jobs, I had the executive search firm tell me that many people think surgeons can't lead organizations because they're so narcissistic and self-centered that they can't see beyond the operating room and what surgeons do. So one of the biggest things I had to overcome as I looked at these jobs, not only was being female because there aren't many women either, but many people would turn you off just because you said you were a surgeon because you were in that social identity group. Obviously you're that, and I've had many people tell me, I know Mary has to, you're too nice to be a surgeon, you know I'm not, what does that mean? But that's been our whole career. So I think it can be the way you look. It also can be the way you are, and, and sometimes you can actually feel it because some of the things that you are, you have to state out loud, such as your gender preference and, and what kind of activities, your hobbies, things you like to do, because you can't see that right to make it happen. It would be nice if everyone had multiple groups or many people could belong to them, but again, it's sort of choosing those that look, feel, and do what you do. So, so you noticed, you, you, you noticed that one of your colleagues has a mantle and you say, well, why didn't you have uh women on your panel? And they said, well, I didn't know any that were notable about this topic, or the ones I chose were the best. I didn't pay attention to gender. These were the best ones. How, how would you answer that? Well, um, Mainly I would sort of say, you know, I can help you with that, you know, when you're looking, when you're looking to put a panel or a team together, the way I look is you choose the mosaic and it's been proven in business that if you have a diverse inclusive team. Doing anything, doing something innovation, trying to do anything, you make more money, you make more progress, and you actually attract more to your, your panel. So if you have a panel that's purely white males, not many people are going to listen to you nor believe you. So that you really need that mosaic. And not only men and women, I think also ethnic background, age. I think that's the one I've been pushing a lot. When you look at many of our societies and who we elect to. Lead them or be on teams, we tend to go very senior and, and, and that also, I think is a mistake that you need to make sure you include the next generations coming. So I would say I can help you. I can make this happen. There's many people that have a qualification and are great to be on your panel. And also it's a different point of view which could make it much more interesting and make you a much more popular panel for people to come listen to you. Right now we're planning our next year's course. I need to come up with faculty and you know what? I always keep ending up with men because I know more men. I've said to my fellows here, we need to design this agenda. How do I find out who I don't know? How do I find out the talent out there when we all surround ourselves with our little clique? How should I be doing it the right way? Hey, I can help with that. OK, I'm a pediatric surgeon. I'm a senior female pediatric surgeon who understands implicit bias. You tell me what you need. I'll help you find it. That's kind of what we were thinking is it would be great if there were people to call to say, hey, help us reach outside of our same old circle that we use every single time. I think that's a great answer, um, and I think what you can do too, Todd, is you don't even have to call. Now it's so easy to connect, you know. You can send an email, you can send a text. You can start off with someone that knows someone that knows someone. And even if you didn't know Mary well, you know, there are people that know Mary. And so that's also the other way to do it. Or you could ask some of your trainees who perhaps are female or underrepresented in medicine and ask them who do they admire in the field, and they will know them. They will know, I knew where I knew the first woman chair of surgery, Olga Jonas. Where she was, I knew every single division chief that went into Vaskar. They will know too, so they can point you to that direction and frankly we would answer, you know, that's the other thing, because those of us that want to have better representation, we'll answer your email, your text, or your, your Facebook requests because we want to be involved to help make your mantle become a panel. If we're, if we're ever going to kind of turn the tide. Uh, we've got to be intentional, uh, about what we do. I think when you're starting with a panel just like every other time you start with a panel, you start out thinking, uh, excellent. So, uh, the panel is going to be on topic X. I want the very best, uh, speakers, uh, on topic X for my panel. I'm gonna have 4 people on this panel discussion. Well, like you, like you have already said, typically what we have done typically is not necessarily say. Who are the most, most, uh, uh, published, the most, uh, uh, wide spoken, the most recognized for people in this area? What what we typically do is we say who do I know? Who do I know, uh, in this area, you know, who, who, who are my pals who are my buddies, or who are or or let me call, let me call Joe at Harvard and see what recommendations he has and so we tend to we tend to go with really people that are in our, uh, social network so I think. Have to be intentional about it and just about every field, unless it's a really obscure field, you're going to have at the very least gender balance in terms of expertise in that field. And since we've got to be intentional about it, you will often find racial diversity on expertise in that field. But you've got to, it has to be intentional though. If you just, if we just keep doing it the way we've done it, like, hey, I know some, I know some good folks in this field, then it's going to be my buddies. I wish there was a better way to explore who we don't, who I don't know, you know, I know who I know, but who do I not know? Um, and so I wish there was a better way for me to find a group of people that are equally as good but more diverse, and I still, even with intention, I still think it's hard. One thing that you can do is, um, uh, let's say, let's start with gender balance first. So let's say I'm gonna have 4 panelists, uh, and gee, it would be nice if I had 2 men and 2 women. Um, and, and, and I'm just not familiar, uh, with women who might be an expert in this area, but I know a woman dean at so and so at the University of Connecticut or whatever. I just threw out University of Connecticut, um, and she's in a field that's related. Let me call her up and ask her for some recommendations. Um, and so you ask her, you say, listen, can you tell me who are some women that are that are really heavy hitters in this area? If you don't know people, then call, call people that you know will know people, and that's a way to diversify the panel. I also want to make one other point that you said something that struck me, Dr. Capers, is that When I think of who to put on my panel, I think of who I've seen on other panels, so I'm perpetuating the bias. I've been guilty of the same thing myself. As we've said a couple of times so far, everyone has some kind of unconscious bias. Um, I took several of the IATs myself and I was ashamed with some of my results. Didn't think that I had any kind of preference, but for the sexuality IAT told me that I had a moderate preference for straight over gay people. Um, and like I said, I, I just found that pretty shameful. Like anybody who takes these tests and doesn't want to allow that implicit bias to become explicit or to kind of manifest itself as a prejudice in any way, um, what would you recommend that people do? What I would tell you is that one, you should take shame out of your vocabulary. I'm sure Mary was going to say the same thing because this is the way you were raised. It's the people around you, you know, you can't pick your parents and you can't pick your hometown and frequently you can't pick your high school, but that's where you were raised and the people around you. So I wouldn't call it shame. What I would call it is surprise and the fact that you felt bad about it means that you're going to go take some action about it and And I think pointing that out and figuring out where does that come from, you know, is that comments you heard when you were a child? Was it things that was in your nature of your community? And in my place, you know, where I grew up, there were no non-white people in my high school except for three black people who actually were deaf, and that's why they came to our school. So not only did we think black people were not involved in the school, the only 3 we knew were deaf. Actually put them in a category of being impaired in a in a way. So therefore you associated that. It was first when I went to college where I started seeing and listening to what was going on with other people. I think the way to get beyond your implicit bias is to adopt appreciative inquiry, and I think I've learned to do that over the last years instead of assuming you know the answer and you know how to fix it, to look at those areas and say, why? Tell me more. About you, tell me where your preferences are and what happened. I know I've, I've had people, if you take sexual preference, I've had people I've worked with that are, have sexual preference different than mine, and I actually would sit down and talk to them about them, you know, when, when, when did you figure out that's who you were and how do you explain that to people? And I had someone ask me just the other day, do you think gay individuals can actually apply for surgery programs and let people know they're gay? Without being discriminated against, it was a very, I'm at the American College of Surgeons as Mary is, and, and in my mind, the answer was yes, if it was my program, but I don't think it's every program because not everyone has appreciation that that could make a great mosaic in your program. So I think appreciative inquiry, listening and helping understand where you came from, getting yourself educated. I know I went and spent time with my LGBTQI committee. At Davis to learn about needs and thoughts they had similar when I talked to those underrepresented in medicine because I don't know the answer about how you can better treat them just like a patient. You need to ask them what they want to do and then adopt some of that in your conversations and inclusion so that you find yourself understanding and feeling that that's part of the team that needs to be around you as well. Mary, yeah, I would totally echo everything. I do, you know, I agree totally with the same thing, but I, we have to all recognize this is 100% of us and so taking the test and learning you have it. Is the first step, right? So it exists. I have it. It's not my fault. I mean, we have, uh, in our media, if you, if you are a young queer black person, there's nobody like you on TV. There's nobody like you on, on any advertisement. We grew up in a society that's not just where we were raised, it's all the messages that are around us all the time. So, recognizing that it's there and it's in you, OK? And it's just part of being a human being, and then, how are you gonna behave differently? How are you gonna do it? And I echo completely, you have to learn more about it. Um, you also have to be prepared that this is hard work. This is really a journey that's gonna make you extremely uncomfortable, and when you get uncomfortable, that means you're making progress. And a book that I'm recommending widely right now is by uh Robin D'Angelo called White Fragility, and it has to do with exactly the kind of things you were saying earlier, Todd. Well, I, you know, I don't have any bias. I just pick the best person, and, and then when people confront someone, in particularly in areas of race, which is what this book is about, they, they are fragile about it. It may, it hurts them or they get angry or they are not rational in their response oftentimes, and this book really helps people understand how pervasive the issue of race is in our society and how, as people who are white, we have a responsibility to respond to that and, and behave appropriately. So, I would know it's a journey, it's going to be hard, read a lot about. Valid and realize it's everyone around you, not just you, but you have a responsibility for what you do. The one thing I want to stress, and I guess I'll keep using myself as a straw man here, but when I was first confronted, I was defensive. I was saying, what are you talking about? I am not biased. And once you get over that, which is probably the hardest part, because I imagine 90% of people would have that response, that's when you start realizing that it's absolutely true. I mean, how could I deny that I have a bias when it's all white men? I did have that reaction and that, and it's just to say it again, white fragility. Yeah, it's an outstanding book. I think it'll help you and help anybody listening to this understand kind of our normal reactions to someone essentially implying that we're biased. When we don't feel that way at all, because until you understand implicit bias, this unconscious bias, you don't see yourself as biased, so it's kind of understandable, but you need to understand that mechanism to be able to get beyond it. Yeah, and uh. I imagine if someone had a white panel and someone said you didn't have anyone who's underrepresented minority, basically you're saying, wait, you're saying I'm a racist, you know, it can be perceived as an attack and it's a very delicate way of how to approach it. This is what Danielle Walsh and I talked about. Um, because it can be a very sensitive topic. I really believe, I may be naive, but I really believe that physicians want to do the right thing. Physicians are good-hearted people that want to do the right thing, but what is so insidious about these unconscious biases is that they can, as I'd like to say, they can hijack our good intentions so we can have well-meaning, well-intentioned doctors who, because of these unconscious associations or preferences, can make decisions that That leads to inequitable care. There are actually several research proven strategies to reduce our unconscious bias or at the very, excuse me, at the very least reduce the impact of our of our unconscious biases and. Uh, one of them is, uh, uh, well, all of them are actually the, the, the beauty is in their simplicity. One of them is to, uh, simply find out as much as you can, uh, about the patient with whom you're interacting because it turns out we all belong to certain groups, and when I say groups I don't mean race or ethnicity or gender. I mean, uh, groups like, um, you know, a first born child, uh, grew up on a farm, etc. and if you're in that group, you have an automatic bond with others who are in that group. And uh once you find out that you have that group in common, that common group identity, that actually reduces any unconscious bias that you may not even know you have against that person. So, so how might that work when you are interacting with somebody, whether it's an interview, you're interviewing somebody for medical school or for residency or for a job or for a grant or you're interviewing a patient. Um, uh, keep probing until you find, uh, where your, uh, common group identities, uh, uh, interact with their common group identities. In other words, what common group identity do you share? Um, and at that moment, you know, the, the moment you find out that you grew up on a farm and this person grew up on a farm or that you're a big, uh, fan of the Cleveland Cavaliers and this person is a fan of the Cleveland Cavaliers, the moment you find out that you have a common group identity. Uh, uh, that actually, uh, uh, inhibits the unconscious bias, uh, that you would have against them. Uh, so that is one proven strategy keep probing until you find where your common groups, uh, intersect, so to speak. Uh, another is, uh, is simply, uh, perspective taking and find out as much as you can about that person and really try to develop empathy for them. Now how do I develop empathy for you? So if you're a patient I'm seeing, I think about, uh, what is, uh, what have you gone through today to get to me? I'm at a big academic medical center, so parking was probably a headache, uh, and then you had to, you know, even, even paying to park at our academic medical center is confusing, you know, you park one place, you get a ticket, then before you go back to your car, you gotta take that ticket to a certain desk, uh, and pay. So you've had to go through that, that's stressful. Uh, what did you have to go through in the prior week? You had to maybe, uh, take off work and get somebody to come with you. Um, so, so, uh, really trying to put myself in that person's shoes. What happens when I'm doing that perspective taking it's called, is I develop empathy for them, and empathy actively opposes unconscious bias. So, um, the more empathy you develop, the less room there is for unconscious bias. So these are, these are a couple of, uh, things that have research behind them that can reduce the impact of our unconscious biases that really anybody can do, uh, at any time. Uh, in any time you're interacting with someone, so we actually published our work in uh in 2017 in the Journal Academic Medicine where we actually had our admissions committee. We've got a large admissions committee, 140 people, uh, we actually had them take, yes, the, the Harvard IATs, the implicit association tests. They took 3. They took one for sexuality. There was a, there's an interesting one called the male career stereotype. Uh, IAT, which actually looks to see if unconsciously you prefer the image of a man at work and, uh, and the woman at home in a domestic setting, uh, and then the third we had them take is the black white race IAT. So we had them take those, uh, we gave them some prep, letting them know that listen, everybody has unconscious biases, doesn't mean you're a bad person, uh, so please know that before you take the test. Uh, after the test we showed the aggregate results to the committee at our annual admissions committee, uh orientation. As you might imagine, there was some shock, um, and, uh, uh, but then we talked about uh some of the some of the things that you and I just discussed what are some ways that we can reduce our unconscious bias or if we can't reduce them. And I'll tell you there are some psychologists that think you can't, you can't get rid of them, you can't reduce them. They're, they're baked in there over decades, and there are others who say no, you can actually reduce them if you put in the work. But whether or not you can reduce them, you can reduce the impact of your unconscious bias, and that's what some of those strategies are. So we talked about those strategies. The good news is the way that paper turns out is the very next cycle we admitted the most diverse class in the history of the College of Medicine. Um, uh, so that was, that was very gratifying. So, so now every year we have an annual admissions committee, uh, retreat or orientation if you will. It is mandatory for all members of the admissions committee. And every year we recommend that they take several of these IATs, and we work hard to and we have kind of a miniature workshop on implicit bias reduction strategies, and it's kind of a vignette vignette based workshop. So, so this is the medical student that's coming in. These are their qualifications. This is what the letter of recommendation says. So let's break out into little groups and talk about all of the ways that implicit bias could come in. And then let's talk about what strategy you would use to reduce that implicit bias that you might not even know is there. So as we start wrapping up, uh, the next question is, what are the three most important points you'd like people to take home about discrimination in medicine? So I would say first of all, um, you have implicit biases and assuming you're a fair and kind person, which I'm gonna, we have to assume they are getting in your way and you probably don't recognize it because you haven't thought about this or learned about this, but you have them and they're getting in your way they're also getting in our way in a community in being able to support, hire and retain. Really good people and to have that mosaic that Julie talked about, um, of diversity and voice that makes us stronger, it hurts us as individuals, it hurts us as a, as, as a profession. And then I think my final take home message is this takes courage and you've got to have courage. As I said earlier to Todd, the people that need to stand up and call this out when it happens are the people that are in power. Whatever the dynamic is of wherever you are, you're responsible if you're in that position of power to say, you know what, this just isn't right. That's a microaggression, call it for what it is. That was a racist comment, call it for what it was. And actually say those things and let us start moving beyond this um in a really powerful way. And I, I totally agree with Mary. I think big pieces this exists you own some of this and everyone that's working with you does too, so that this is it could be a team sport that you all can have those comments and make sure you have people on your teams that can call it out. In medicine it's such a hierarchy that the people that are younger that tend to be our more diverse individuals coming into our specialty are not the ones that feel comfortable to call it out. So those of us that are leaders and have been in the profession for long periods of time have to be very public about what happens. I will say if I hear something, saying I'm sure you didn't mean to offend someone. With a smile on my face and say, but this sounded, this is what we heard and this is what it sounded like, and I know you didn't mean to offend us, but it did. And therefore we wanted to bring it to your attention so that you would be able to understand how that could offend somebody. And I think those of us in charge can take a really good opportunity to make that happen because it really makes a huge difference. to the person standing there who may be much lower in the hierarchy to see that you defend them, and with that you actually, they'll come to you when they have issues and problems because they know for a fact you listen and you'll take care of them in that arena. The other thing is that whenever you are presented with a situation when someone comes to tell you about it, you need to listen. You need to be open minded and hear it from their way, because even if you were standing there and you did not take it that way because of your implicit bias, you may not have heard it the way. That happened to me yesterday. There was a lecture given here at the college that some young women told me was offensive, and when I talked to an older white male, he thought it was a great lecture. It was the same lecture, I think. People will hear different things, and you have to appreciate that. And then the more you can have different people around you, the easier the work will be. You do need to have courage, like Mary said, you need to do it. But if you have people around you that are from different places as far as their gender and sexual orientation, where they were raised, their skin color, their ethnicity, they will help you if they see that you're open minded and let you know how it appears to be and what you said and what you did, because you will make mistakes that leaders, you do your best to represent and say the right things, but you will make mistakes. and then having a public apology saying, you know what, I didn't mean to say it sound that way. That's not really how I feel, but I'm so glad you brought it to my attention. I think that's what we need to do. It needs to be out there publicly. We need to make sure people get trained in these areas. And then forgiveness, I guess that's the last one that I'd say is when people are on this journey, you know, you need to forgive people when they say and do things that are. appropriate. You know, some people are hopeless. I think that is a small percentage that they'll never get it, but most people want to get it. So having some forgiveness and kindness along the way so that people stay encouraged that they can change, because otherwise you will feel bad and you will not talk to different individuals because you worry so much you may make a mistake. I've heard that from people now with the Me Too movement, you know, do I talk to women? Do I go out to a drink with a woman? Do I, can I be in my office alone with a woman? I mean, people are getting way worried about just doing normal daily activities, and the answer is you really need to be forgiving and kind to take everybody on this journey because we all can get a little better. I think we need to do more of these types of podcasts. I know that people come on here looking for how to do a And anastomosis, but the truth is this is more, more relevant right now and uh more of a need. I just want to point out again how someone, and I, this is a plea to people like me, you know, 6 months ago, not only did I not know about this, but even when confronted, I just didn't get it. I couldn't believe it. I didn't know how to deal with it. I knew nothing about it. I just want to again mention Danielle Walsh who approached me in such a great way. That she taught me and, and made me realize, she just started explaining to me about how women are all having, you know, general lower salaries and why that is and she wasn't being confrontational at all and it was so eye-opening to me and we have to get more people to start realizing it and I applaud all of you, uh, especially my fellows here who really pointed it out to me, uh, Mary and Julie, the fact that you're leaders in the world and you're taking. a stand on this is going to help change things because I do agree that it's harder for the younger people to open up their voice. So one of my favorite points to make is that in, as I like to say, a wrestling match between your conscious mind and your unconscious mind, your conscious mind will win every time. That's not, it's not even a fair fight. So if we know what our unconscious biases are. They they're easily overcome. We have to know not only what they are, but also know when are the times when we're at highest risk for our unconscious bias kind of driving the bus, and we talk about when you're at the highest risk, there are going to be times that are very familiar with all physicians, that is times of high cognitive load. I.e. when you're thinking about 3 or 4 things at the same time, times when you're in a time crunch, you know, when you're, you're, when you're, when you're maybe in the emergency room and, and you gotta make decisions quickly, um, uh, when you are, uh, sleep deprived, uh, these are times when you're post call, uh, if that sounds familiar to anybody on the phone. So these are times when you're at most risk, at highest risk for your unconscious mind to kind of take over and start making the decisions for you. So being intentional, being present in the moment, and then some of these research proven strategies of using unconscious bias. They're things that you have to practice and work at again and again, but These implicit biases can be dangerous. They can cause us to make life or death decisions in a way that is biased against people. However, what I want to leave your listeners with is that we can overcome these biases. Um, it, it, it takes work, but it's uh it's well worth it. I think that's a great, uh, that's a great point that we. You know, I do believe at least in my world, the biggest problem that I'm seeing is recognition, which is why we're doing this. Once it's recognized, I can tell you for me, once I recognized it, it's ever present when I'm deciding what to do. But whether the bias is age or weight or if people have physical limitations or disabilities or race or ethnicity or religion or sexuality, these same things apply. Get to know the person, try to develop empathy for that person. Uh, another strategy I didn't mention, but it's one of my favorites is called consider the opposite. So when you have data pointing to one conclusion before you drop the hammer and make a decision, go through this exercise, go through an intellectual exercise where you force yourself to go back to the data one more time looking for evidence to support the opposite conclusion. And, and, uh, uh, and then make a decision. My, my favorite example to use with that, uh, when I give my implicit bias workshops is let's say I'm looking at a medical school application and I think the data shows that this student is not gonna be able to cut it academically in medical school. The reason I think that is because let's say they got a D in chemistry in their freshman year before I make a decision. Let me now I've got the file right in my hands. Let me go back to that file page by page looking for evidence for the opposite conclusion that they will be able to succeed academically in medical school. Maybe that evidence will be uh a very good critical thinking on a research project. Or uh uh uncommon persistence and resilience after a setback, but things that will say, you know, I think maybe this student will be able to cut it and now I make a decision. Going through that exercise blunts or softens the impact of any unconscious bias that's there and you can think of how you might do the same thing in, uh, let's say if you were on a panel deciding if somebody is a candidate for an organ transplant. You know, if at first you go through and say, well, no, we've got a history of noncompliance, we've got a history, even though they've recovered of substance abuse, before you make a decision, now let me go back to that file and look for evidence that that this person will be compliant and will be a good citizen with their transplanted organ. What are your thoughts about Using this test, the implicit bias test, uh, when someone's applying for a job, should we be, should we be able to choose or not choose someone based on how they score on this test and how do we interpret the results? Uh, so good question. So, so, so the answer in my opinion is no, we shouldn't be using it to screen for jobs, to screen for positions on the admissions committee, etc. because I think to do that then that, uh, uh, sounds as if we're, um. almost assigning conscious intent to this, and remember these are unconscious associations which are really just a reflection. Of interactions and stimuli we've seen and our unconscious brain has kind of taken notes that over the years have become these unconscious associations. So it really wouldn't be fair and just to say, well, you've got an unconscious bias against women, so no, you can't be on the admissions committee, or you've got an unconscious bias against this race, so no, you can't be on the police force. It will be better to use it so not as a screening tool to exclude people, but more as a screening tool to say, OK, this is the way in which I need to educate and do the professional development with this group of people. Dr. Capers, thank you so much again for spending time with us today. This has been extremely helpful for us, and I'm sure it will be very important for the rest of the world to hear. If anyone has any other questions that um that we didn't address, I know we can't get to everything, but is there something that we didn't talk about? Doctor Freischlag and Doctor Brandt, as female general surgery residents, both Alex and I experienced this, on a regular basis in, in deciding to do this podcast and how to record this podcast, had to consider how we will appear as applicants. Do you have any advice for young female surgeons or professionals who are facing this and how to handle it in, in a way that's not going to have us labeled as the radical female? Well, I just stood up at the chair's meeting here. We had a whole afternoon on sexual harassment and, and I was just going to do cases, but I actually went through 20 years of. I would actually say I never was harassed, but I was, I wasn't assaulted. I wasn't raped, but I actually starting at age 17, I had people say and do things and not give me things, and, and, and it was 20 years before I raised my hand when I was an associate professor. And that's mainly because my, my husband to be said, Well, you can't take that, and I did. So it was 20 years of not saying anything because I guess I knew we did workarounds. I'm sure Mary did too. We tolerated people, we would say things, oh, you know, that's just so and so, and, and all those kind of things. I think the news now is that true leaders will listen to you and true leaders will help you. That's not to say everyone is going to be one, so you are going to need to choose those you speak to because there are some people that aren't good at this, that are in leadership positions, and that's just not going to change. But most leaders now want to hear, they want to understand, they want to help you. There's places you can go to talk, whether it's the. Faculty affairs office, the DIO, and ombudsman. I actually think it's great that you're out there as women surgeons now. There's 30% of us that are out there practicing as women surgeons. We have a pay differential. We have leadership differentials. There's only 22 women general surgery chairs. And then if you go into my position, you know, there's only about 20 women deans. There's, I think I'm the only woman CEO in Southeast United States. I think part of it is that you having these conversations really are helpful. I do see so much hope in the young people that are your age, men and women, because I think you have been brought up in a way that teams are men and women. I've know I've raised my children that way and that my son doesn't even blink if his immediate supervisor's a woman or someone. Represented in our country, he's been brought up that that's the team and that's what it is. I think your generation, I have tons of hope because you've trained and been with more women and more underrepresented in medicine that you get it and that you actually were raised better in areas. You still will have bias if you take the test. You have some bias because you see who wins and so you have bias against for those that win. Um, but I, I think it's, it's good. I, I think we are open and ready, but there will be people that won't listen. There will be people that don't want you on their team, and that's OK, you know, if those people can't figure it out and work with this, then you don't want to be on their team anyway. Actually, it will differentiate the place you want to be. I, I would second that and go back to the courage statement. And so certainly and for your direct question, which is doing this podcast, is that gonna help or hurt in PD surgery interviews? It's gonna help. I have no doubt about it. And if there's a small percentage of people that it doesn't, you really don't want to be there because it's a small percentage in our field right now. But the other part of this, and in the bigger picture and. Um, what we're talking about is how much of the position you want versus the integrity. And, and I, I, what I wanna challenge you to think about is, there is nothing radical about trying to do the right thing. And if anyone views you as radical, to be inclusive and to teach people about implicit bias. But, you know, be kind to them, try to instruct them, and if they're in that small percentage that Julie mentioned that, you know, can't hear you, then politely walk away and say thank you and don't look back. My theme this year is the inclusion at our university at Wake Forest Baptist, and it's been great. Last year it was health and wellness, and we're doing. A whole series of things for inclusion and there couldn't be more enthusiasm because everybody wants to be included and connected and respected, you know, everybody wants to be rewarded no matter what it is, whether it's how you look, how you feel, or your role in the hospital. So there's many people that will just be happy that you're talking about it because Many would be able to say some things that make them feel disconnected from their workplace and from their team. So make sure you put it on your CV so hopefully everybody that didn't hear the podcast will listen to it. Absolutely, I would, I would interview you just because you did a podcast. That's good news. Yeah, and I'm glad you, uh, I'm glad you both said that. That's great for them to hear. Anything else that we didn't touch on? Well, Todd, I just want to say thank you to you. We were talking about courage and bravery. I mean, your, your story is an important one, and the fact that you acted on it is a shining example. Thank you for the courage. Courage to confront your own implicit bias and do something about it and to make it a broadcast that's going to help a lot of other people too. Yeah, no, I and it's so powerful to have white males support these initiatives and to say we need to do this, uh, and, and it's wonderful to have you doing that. I totally agree with Mary. And, and I, I really appreciate you saying that, and that's another thing that that I've learned that we hopefully can get out through this podcast was what you just said. What was the hashtag he for she was that, and, um, we have to have, uh, more people recognizing this, and then that's gonna help move this forward. Thank you both so much. I, I know how busy you both are, so I really appreciate you taking the time to talk to us about this. I'm sure everyone else in the country in the world is very appreciative. And by the way, a lot of the comments we've had on this were not from the United States, as you can imagine. So this will be very well heard around the world. Thank you to my guest podcast participants here, Alex, Alex, and Ray, and thank you to everyone for taking the time, and we will talk to you next time. Thanks so much. Thank you. We hope you enjoyed this episode of Stay Current. You can listen, watch, or read our content at any time by downloading the Stay Current app. You next time.