We all know what explicit bias is and some even have firsthand knowledge or experience. When we think about health care, we all would like to think that boas do not exist in the professions of healthcare. But nothing can be further from the truth. As a nation, we started to question systemic biases and here I want to explore implicit biases in Healthcare.
Why implicit biases? Because it is very rare to encounter explicit or all-out biases in healthcare. Most of the time we face implicit or unconscious biases and most of the time we do not know what not do about them.
*The majority of the material for this presentation came from a Pri-Med presentation.
Implicit vs. Unconscious Bias
Implicit
• “implied though not plainly expressed”
• “inherent”
• “inbuilt”
• “understood”
Unconscious
• “inaccessible to the conscious mind”
• “done without realizing”
• “instinctive”
• “unthinking”
Implicit/Unconscious Bias: We all have them. It is like a blind spot that most of the time we don’t see.
- Hidden Biases of Good People − Mahzarin Banaji and Anthony Greenwald
- Implicit Association Tests (Project Implicit®)
Often a result of our cultural conditioning or a byproduct of our societal norms. Often biases are contrary to our personal values and implicit bias:
- Can be Personal: internalized, interpersonal
- or systemic: institutionalized or structured
Assumptions: We have been socialized into a society in which there exists individual, institutional and societal biases associated with race, gender, and sexual orientation. None of us are immune from inheriting the biases of our ancestors, institutions, and society. It is not “old-fashioned” racism, sexism, and heterosexism that is most harmful to people of color, women, and LGBT persons but the contemporary forms known as microaggressions.
“Old Fashion Racism” or Microassaults: it is uncommon, it is usually deliberate, conscious, and explicit. It often has the intention to hurt, oppress, or discriminate. Examples: −Refusing service to minorities −Displaying the hood of the Ku Klux Klan
Microaggressions
Microaggressions are constant and continual without an end date (an everyday hassle may be time-limited). Microaggressions are cumulative and anyone may represent the feather that breaks the camel’s back. Microaggressions must be deciphered because they contain double messages (especially micro invalidations). Microaggressions are constant reminders of a person’s second-class status in society. Microaggressions symbolize past historic injustices.
Micro insults and Microinvalidations
•Not Intentional−Typically occur due to underlying biases and prejudices outside of awareness
• Microinsults −Convey insensitivity, are rude, or demean an individual’s identity or heritage
• Microinvalidations−Exclude, negate or nullify an individual’s thoughts or feelings
Definition of Microaggressions
“Microaggressions are brief and commonplace verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative slights and insults that potentially have harmful or unpleasant psychological impact on the target person or group.”
Could be based on race, income, social capital, religion, ableness, gender, immigration status, sexual orientation, and/or other characteristics
Sue DW, et al. Racial Microaggressions in Everyday Life. Implications for Clinical Practice. Am Pschol. 2007;62(4):271-276.
Examples of Microaggressions
“Are you a nurse?” to a female physician examining a patient?
“Are you the sitter?” to a black physician walking into a patient room?
“You look too masculine,” to a self-identified lesbian physician.
“Minorities are still hung up on race” to a fellow physician.
“Your people must be so proud of you” to a physician with an accent.
“You speak English really well,” to someone born and raised in the United States.
Montenegro RE. My Name Is Not “Interpreter”. JAMA. 2016.
Psychological Consequences of Microaggressions
Many times, the person at the receiving end is not aware in the moment of the consequences of the microaggression but as time pass they may feel anxious or depressed. Many times we internalize these feelings to be our own thoughts and feelings without realizing where they came from.
•Anxiety
•Depression
•Sleep difficulties
•Diminished confidence
•Helplessness
•Loss of Drive
Cumulative Consequences
- Assail the mental health of recipients (Sue, Capodilupo, & Holder, 2008),
- Create a hostile and invalidating campus climate (Solórzano, Ceja, & Yosso, 2000),
- Perpetuate stereotype threat (Steele, Spencer, & Aronson, 2002),
- Create physical health problems (Clark, Anderson, Clark, & Williams, 1999),
- Saturate the broader society with cues that signal devaluation of social group identities (Purdie-Vaughns, Steele, Davies, & Ditlmann, 2008),
- Lower work productivity and problem-solving abilities (Dovidio, 2001; Salvatore & Shelton, 2007).
- Responsible for creating inequities in education, employment and health care (Purdie- Vaughns, et al, 2008; Sue, 2010).
Managing Microaggressions in the Moment Use of the Interrupt Framework
The following is a framework on how to handle microaggressions without attacking the person but rather guide them to understand that their words are hurtful:
- The “Interrupt” framework can help observers to respectfully address microaggressions in the moment:
− Inquire
− Nonthreatening
− Take responsibility
− Empower
− Reframe
− Redirect
− Use impact questions
− Paraphrase
− Teach using “I” phrases
Inquire
Ask the speaker to elaborate on what they meant −Helps us understand their perspective
Examples:
− “I’m curious. What makes you ask that?”
− “What makes you believe that?”
Avoid “Why?” questions as can increase defensiveness
Paraphrase/reflect
Same skills we use in motivational interviewing
•Demonstrates understanding
Reduces defensiveness in rest of conversation
Examples:
− “You’re saying…”
− “So it sounds like you think…”
Re-direct
Shift the focus to a different person
−Particularly helpful when someone is asked to speak for his/her entire race, cultural group, etc.
Examples:
− “Let’s shift the conversation…”
− “Let’s open up this question to others and see what they think.”
Use Impact and “I” Statements
A clear, nonthreatening way to directly address these issues on behalf of oneself
- It communicates the impact of the situation while avoiding blaming
- Examples:
- “I felt … when you said … and it ….(describe impact on you)”
Use Preference Statements
Clearly communicate one’s preferences rather than stating them as demands or having another guess what is needed
- Examples:
−In response to racist, sexist, homophobic, etc. jokes- “I don’t think this is funny. I would like you to stop.” −“It would be helpful to me…”
Use strategic questions
The skill of asking questions that will make a difference
- A question that creates motion and options can lead to transformation
- Examples:
− “How might we examine our implicit bias to ensure that gender plays no part in this and we have a fair process.
- What do we need to be aware of?”
− “What would you need to approach this situation differently next time?”
- Examples:
Revisit
Even if the moment of the microaggression has passed, go back and address it. Research indicates that an unaddressed microaggression can leave just as much of a negative impact as the microaggression itself.
- Examples:
− “I want to go back to something that was brought up in our meeting…”
Individual Response
•Assume offense was not the intent.
•Explain how the slight was interpreted.
•Ask a follow up question.
•Identify and talk to individuals with whom you feel comfortable
When You Meet Resistance
•Will further conversation be beneficial and productive?
•What is my current level of stress?
•Am I able to respond non-emotionally?
• Reiterate that you are not blaming the person, only expressing the way the comment/action made you feel.
•Explain the cumulative effect of these occurrences.
Final Thoughts
Microaggressions are unfortunately present in our health and health education systems. As healthcare professionals and educators, we can employ tools to address implicit bias and microaggressions when encountered. As healthcare leaders, we can work to reduce the occurrence of microaggressions with a systems-based approach.
References
- Microaggressions: Understanding What They Are, Why They Are Harmful and How to Manage Them Aarati Didwania, MD, MSCI, FACP Primary Care NOW July 2020
- Banks, B. M. (2015). Microaggressions directed at Black college women: The moderating role of racial identity on self-control depletion.
- Murphy, M. C., Richeson, J. A., Shelton, J. N., Rheinschmidt, M. L., & Bergsieker, H. B. (2012). Cognitive costs of contemporary prejudice. Group Processes & Intergroup Relations, 1-12.
- Sue, D. W. (2010). Microaggressions in everyday life: Race, gender, and sexual orientation. John Wiley & Sons.
- Sue, D. W., Capodilupo, C. M., & Holder, A. (2008). Racial microaggressions in the life experience of Black Americans. Professional Psychology: Research and Practice, 39, 329-336.
- Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M., Nadal, K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life. American Psychologist, 62, 271-286.
- White AA, Logghe HJ, Goodenough DA, et al. Self-Awareness and Cultural Identity as an Effort to Reduce Bias in Medicine. J Racial and Ethnic Health Disparities. 5 (1):34-49, Feb 2018.
- Wong-Padoongpatt G, Zane N, Okazaki S, et al. Decreases in implicit self-esteem explain the racial impact of microaggressions among Asian Americans. J of Counseling Psychology, 64(5), 574-583.
