Can Bias Be Reversed?

Starbucks has been in the headlines more than usual lately – and not because of record-setting earnings or because of its latest limited-edition frappe. In April, Starbucks came under fire when two black men were wrongfully arrested at a Philadelphia store. The story went viral and within hours the hashtag #BoycottStarbucks was trending.

In addition to a swift apology, Starbucks CEO Kevin Johnson said he will personally address the issues that led to the situation. The first step in that process came last week when the company closed 8,000 of its stores to host a four-hour anti-bias training session for employees. Some 175,000 employees attended the training which, reports said, was intended to make people more aware of unconscious discrimination.

According to Howard Schultz, Starbucks Chairman until announcing that he will step down just earlier this week, a four-hour training session on racial bias is not the final answer, but it’s a start. “We realize that four hours of training is not going to solve racial inequity … but we have to start the conversation,” he said.

The conversation Starbucks is now leading – whether by choice or not – is one that is not, and should not, be limited to your friendly neighborhood coffee juggernaut. It’s a conversation that’s been happening quietly for decades, and in recent years has begun to echo in every corner and industry across the country, and medicine is no exception.

In 2003, the Institute of Medicine released a report detailing significantly lower quality of health care services received by racial and ethnic minorities and recommended increasing awareness about these disparities among health care providers to help reduce unnecessary variations in care. Together with the Association of American Medical Colleges, the group also recommended that medical schools train students in skills related to community engagement, including the “cultural humility” needed to deal non-judgmentally with patients from very different walks of life.

Though skeptics are questioning whether training is enough to move the needle on implicit bias – defined as “the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner” – new data presented at the 2018 Society for Academic Emergency Medicine conference suggests educational programs can improve awareness of implicit biases and how it may affect patient care.

In the study, participants – who were all Emergency Medicine residents, 47 percent female, and 84 percent white – completed an online Implicit Association Test (IAT) on race and then participated in a 45-minute discussion on implicit bias, led by a trained facilitator. The goal was to determine whether a formalized implicit bias curriculum would improve self-awareness of implicit biases on race among the group.

“We all want to be part of an inclusive and safe environment for patients, regardless of their race, religion, gender, etc., but it’s important to be aware that we all have room for improvement when it comes to our own biases,” said study lead author Amy Zeidan, MD, a resident in Emergency Medicine at Penn. “As health care providers, we are a critical part of our patients’ lives, and it’s imperative that we’re aware of how they’re being treated and how they’re feeling. Health care doesn’t work if patients don’t feel comfortable and safe.”

Results showed that after the intervention, participants’ awareness of their individual implicit biases increased by 33.3 percent, and their awareness of how their IAT results influences how they deliver care to patients increased by 9.1 percent.

The results were just the first part of a larger research effort stemming from Penn’s House Staff & Advanced Practice Provider Quality Council. The team is currently analyzing the program’s success among other groups including residents in General Internal Medicine and Radiation Oncology, as well as Advanced Practice Providers.

“The question for us was ‘what can we at the resident level do to address the disparities that exist in health care?’ The first step is to encourage people to say ‘yes, this is a problem, and let’s talk about it,” said project co-leader and Emergency Medicine Resident Utsha Khatri, MD. “By focusing solely on raising awareness of the issues, we’re taking a very small step in starting the conversation.”

Just like at Starbucks, increasing awareness of underlying bias is just the start. Among Penn Medicine’s Emergency Medicine residents, one next step beyond that involves gaining a deeper understanding of the patients they’ll be seeing and treating. The goal, Khatri says, it to challenge the assumptions medical providers might make about patients whose background is different than their own, whether that is racial or socioeconomic.

“Coming into residency, it’s hard to have any idea how difficult it is for patients to access health care,” Khatri said. “Exposure to our community’s resources and understanding the background of our patients is an important part of continuing the broader conversation about how implicit bias could affect health care.”

As part of the experience, new residents spend a day visiting community sites, including a health clinic, a senior citizen day program, and a homeless shelter where they will gain appreciation for the resources available to the patients they will soon serve. The new residents will also meet with a community health worker to talk about the psycho-socioeconomic issues that affect the health of patients outside of the hospital. CHWs are trusted laypeople who come from the local community, and are hired and trained by health care organizations to support high-risk patients. In addition the playing a vital role in our patients’ daily lives, CHWs are taking more of an active role in preparing young healthcare trainees for what to expect from the patient populations they’ll serve.

In addition to their work with residents through Khatri’s program, CHWs are also taking medical students under their wing, in a new kind of “medical” rotation that gives students the opportunity to understand life from a different perspective.

In 2013, the Perelman School of Medicine launched the IMPaCT Training Service, a new elective rotation for third and fourth year medical students specifically aimed at eliminating bias. On the IMPaCT Teaching Service, students serve as apprentices to trained community health workers. Students and CHWs help hospitalized patients with any health-related need, from accompanying them to post-discharge appointments, to applying for affordable housing, to reconnecting with estranged family members.

“Thirty-year-old, uninsured, and taking street Xanax. You automatically think . . . difficult patient,” one student recalled. “She had little dreads and they were dyed red. And the community health worker loved it. She was like ‘oh my god, your hair is so cute!’ Then the patient got this big smile on her face and was so willing to talk to us. My whole impression of her changed from this really difficult patient to just a sweetheart.”

Mara Gordon, MD, now a resident in Family Medicine & Community Health, took the program during med school and recalls that it helped her to better relate to her patients, asking open-ended questions and developing patient-centered goals.

Instead of practicing IV insertion or listening for heart murmurs, Gordon says the class taught her another side of health care.

“It taught me how to take a stepwise approach to care, which helps patients reach their long-term aspirations and stick to them,” she said. “We’re teaching them how to do those baby steps. Maybe holding a patient’s hand as they go to the social security office and helping her apply for a new social security card won’t solve all of her problems. But having reliable identification makes it easier for her to get tapped in to government resources for vulnerable patients like her. That kind of support can start a chain reaction of positive change. We’re showing these patients what they can do, and assisting them in that process.”

Penn’s early experience with this teaching experiment has been so promising that the course is now a permanent part of the curriculum, and is being expanded for nursing and social work students.

Like Schultz, Khatri acknowledges that on their own, none of these efforts will tackle the larger issues of racial disparities or implicit bias. “But,” she says, “our hope is that our department and others will use our study as a stepping stone in developing other programs that can affect change.”

SEE ORIGINAL STUDY