Mitigating Implicit Bias in Med Schools Boosts Diversity

Tara Haelle

February 22, 2019

Recent news spotlighted the explicit racism in some medical schools' history, but another damaging, if more subtle, bias affects medical school admissions today. Implicit, or unconscious, bias has received attention in corporate and law enforcement environments for more than a decade. Now medical schools are taking notice.

Implicit bias "refers to attitudes or stereotypes that are outside our awareness and affect our understanding, our interactions and our decisions," according to a 2017 report from the Association of American Medical Colleges (AAMC) that resulted from a forum on diversity and inclusion innovation organized by the AAMC and the Ohio State University's Kirwan Institute for the Study of Race. Everyone's brain has developed "unconscious associations — both positive and negative — about other people based on characteristics such as race, ethnicity, gender, age, social class and appearance," the report explains.

The "unconscious" aspect is key: individuals genuinely don't realize they're influenced. Having implicit biases does not mean a person is bigoted. It means they're human. In everyday interactions, it could be as simple as associating pale green clothing with an ex-partner and subsequently feeling uneasy around anyone wearing pale green clothing, even if one doesn't recognize why. "These associations may influence our feelings and attitudes and result in involuntary discriminatory practices, especially under demanding circumstances," according to the AAMC report.

Quinn Capers IV, MD, as an associate professor of cardiovascular medicine at the Ohio State University College of Medicine, Columbus, became aware of implicit bias through his research into healthcare disparities. He read a study showing that more than 70% of people who took an implicit bias test had an unconscious preference for white Americans over black Americans. When he became associate dean of admissions, he wondered whether his admissions committee had those same biases.

"That would be important to find out, because if they do, that could put certain minority candidates at a disadvantage," Capers told Medscape Medical News.

The admissions committee members took some implicit bias tests in 2012. They discovered that many of them "exhibited implicit white race preference, implicit bias against homosexuals, and unconscious association of men with 'career' and women with 'homemaker,' " Capers writes in a recent article in AAMCNews that created a buzz on Twitter.

The admissions committee members started annual training to mitigate the effects of that bias. The proportion of underrepresented minorities entering Ohio State's medical school increased from 17% to the current 25%, and women have outnumbered men in each new class for the past 5 years.

In giving talks across the country, Capers pointedly emphasizes that "there's no reason to feel ashamed or upset about what you get on the implicit bias test." An unconscious bias against women does not make someone sexist, he said, and an unconscious bias against black people does not make someone racist.

"It's possible to be a good, fair, egalitarian person consciously but have these unconscious biases," Capers told Medscape Medical News. "It's pattern recognition." Becoming aware of it and taking steps to mitigate it make someone a more objective decision maker.

Among those particularly taken with Capers' article was Ajay J. Kirtane, MD, a cardiologist and associate professor of medicine at Columbia University Medical Center, New York City, who found the studies on implicit bias "quite eye-opening." He had heard the term before — from his daughter, who in high school is heavily involved in issues regarding social justice.

"It's pretty clear in my field that there are disparities that exist," Kirtane told Medscape Medical News. "I think it's important to understand why those disparities exist across a number of levels, and if there's some way I'm perpetuating those disparities, I'd like to be able to understand that more and have the power to rectify it."

Training in how to care for people's medical conditions does not include human resources training on interviewing applicants for jobs, fellowships, and similar responsibilities of physicians, Kirtane said. Although not involved in admissions selection, he sees how implicit bias could affect fellowship selection and patient interactions.

"Well-meaning people will pass judgments not because of any nefarious reasons but just because that's how humans process things," he said. "We process fast, and that may be to the detriment of someone you're interviewing and to the detriment of your organization. I'm a strong believer that you want to embrace various people's viewpoints, to accumulate the best of all worlds."

Kirtane repeatedly credited his daughter with familiarizing him with concepts such as implicit bias, and her optimism inspires him, too: "A lot of these issues related to diversity and underrepresentation evoke strong emotions, and if you bring these things forward, there will be challenges," he said. "But I view education as the way to overcome these challenges."

Training Resources on Implicit Bias Available

The AAMC has made it a priority to help with such education for clinicians.

"Once the AAMC began to track and recognize studies as [to how implicit bias] pertains to delivery of care, we became really interested in doing something about it," Laura Castillo-Page, PhD, the AAMC's senior director of diversity policy and programs and organizational capacity building, told Medscape Medical News.

Implicit bias affects more than admissions. If also affects areas such as how physicians assess patients and how institutions make hiring decisions. The AAMC's early training focused on faculty search processes, Castillo-Page said. Today, the organization offers multiple workshops, train-the-trainer opportunities, customized training, and webinars on implicit bias.

"We know from research it affects all of our decisions, day in and day out, and is something we have to constantly work on," she said. But it's harder to mitigate it — and to avoid denying opportunities to worthy people or overlooking talent — if people aren't cognizant of it.

Castillo-Page emphasized that implicit bias can apply to any number of characteristics — names, height, even rural vs urban, a bias she recognized in herself when she realized she felt less comfortable in rural areas and began examining that bias.

"It's not one particular group against another group," she said. "We all have biases based on our past experiences or our understandings of things."

The AAMC has a free introductory webinar on unconscious bias aimed at helping search committees alleviate the impact of implicit bias in decision making. They have also employed the consulting firm Cook Ross to develop training materials on implicit bias. Their video interview with the firm's founder, Howard Ross, introduces viewers to the concept of implicit bias, why it exists, and how to mitigate it.

The AAMC's training involves a six-step model that starts with recognizing that everyone has unconscious biases. "Some are quick to acknowledge that. Other people may be less willing to accept that it applies to them," Castillo-Page said. The subsequent five steps involve taking ownership of that reality:

  • Begin learning about and recognizing your biases.

  • Practice "constructive uncertainty" by questioning yourself and your preconceptions and assumptions.

  • Explore awkwardness and discomfort, "putting yourself in those circumstances or interacting with people you may perceive as different from you," Castillo-Page said.

  • Actively engage with people you might consider "others," those whose backgrounds or experiences are different from your own.

  • Get feedback, whether from colleagues, family members, or friends, or even take implicit bias tests.

And the payoff? "When you have people from all [walks] of life working on a problem, you're more likely to get a better solution to a problem," Castillo-Page said. It's akin to using a team of diverse medical specialists to care for someone with complex health problems. And inclusion is just as important as diversity, she added. It doesn't do any good to have a specialist on a care team if he or she isn't actively helping make medical decisions. The same goes for boosting diversity.

"You could have a really diverse organization, but if you don't have diversity at the table in making decisions, you're not going to get the benefits of having that diversity," Castillo-Page said. "You need both. You have to make people feel comfortable."

Removing Obstacles to Diversity Attracts High-Quality Applicants

It was being invited to the table and feeling comfortable that made his years at Ohio State's medical school so enriching, said Jason L. Campbell, MD, who graduated in 2018 and is now a resident physician in the Department of Anesthesiology at Oregon Health and Science University (OHSU) in Portland.

"Being at Ohio State as a black man, I felt I belonged there and had purpose," Campbell told Medscape Medical News. He credited Capers for much of that, but diversity among residents and attending physicians played a role too. "Everywhere I walked through the hospital, I saw somebody who looks like me," he said. Campbell graduated with about 10 other black men in his class of 200, a proportion very close to that of black men in the US population. "That was all because Ohio State made us feel comfortable to excel there," he said.

Prioritizing diversity and inclusion also drew Campbell to OHSU, which has begun implementing institution-wide unconscious bias training. Campbell, who is from Washington, DC, originally, was deciding between Georgetown and OHSU. "A program that would pull me that far from home had to be special," Campbell said, especially in such a nondiverse state as Oregon. "You really need to make minority providers feel comfortable so there is a reason to come here."

It was that combination — OHSU's focus on diversity and its unconscious bias program in a state with low overall diversity — that clinched it, because Campbell wants to engage in outreach and to mentor others. "I knew that by being one of few, it was a chance to take that path that was less taken and leave a better road for others to pursue," he said.

OHSU's program officially launched its first phase a year ago. It aims to "help all of OHSU's workforce identify and remove barriers to individual and group recruitment, hiring, promotion and growth opportunity, compensation, and the like," said Brian Gibbs, PhD, vice president of equity and inclusion and an associate professor at OHSU's School of Public Health. So far, more than 40% of OHSU's workforce has undergone training, and a student training pilot program will begin this spring.

"We believe that encouraging people to become aware of their own biases and educating them about the ways to mitigate them will help OHSU's entire workforce achieve that vision," Gibbs told Medscape Medical News. "Thus far, OHSU faculty, staff, students, and trainees have embraced this initiative as a part the institution's culture."

Many other medical schools have or are implementing similar programs, Castillo-Page said. Others in medicine at large are thinking about implicit bias too. Reid Waldman, MD, a dermatology resident physician at the University of Connecticut Health Center in Farmington, and colleagues recently pointed out the pitfalls of including photos with residency applications.

As he previously told Medscape Medical News, a "photograph does not provide useful information that is necessary for selecting qualified candidates." Requesting a photo after inviting someone for an interview makes sense to help with identification and as a visual memory cue for later discussion of the interviews, but requesting one before then can strengthen the negative impact of implicit bias.

"You form this idea of who it is you're going to be interviewing based on this photo," Waldman told Medscape Medical News in a recent follow-up interview. "I don't think people are bad or being intentionally hurtful," he said, but people naturally make judgments when a photo is the first thing they see. "It's a lot easier for people to make judgments about someone they haven't met in person and haven't humanized," he said.

Even without institutional training, individuals can take steps to offset their brain's unconscious machinations. One such technique is "considering the opposite," Capers said.

"Whenever you have evidence to make a decision, before you make a decision, call a time-out and force yourself to go back through that evidence one more time, looking for evidence for the opposite conclusion," Capers told Medscape Medical News. "That's been shown to blunt the impact of your implicit bias." If someone's application leads Capers to question the applicant's academic qualifications, he then looks for evidence of the opposite, re-reading recommendation letters and considering whether the applicant has shown exceptional critical thinking or persistence and resilience.

Ultimately, Capers wants to see all institutions prioritizing unconscious bias mitigation.

"What I hope will happen is that training on implicit bias and implicit bias reduction techniques will become part of medical school curricula across the nation," Capers said. He wants to see it become a prerequisite for committees that review applications for residency, admissions, faculty searches, and the like. "That's what I'm working for," he said, "and I'd be real pleased if that was the outcome."

Kirtane reports institutional funding to Columbia University and/or the Cardiovascular Research Foundation from Medtronic, Boston Scientific, Abbott Vascular, Abiomed, CSI, CathWorks, Siemens, Philips, and ReCor Medical. The other interviewees have disclosed no relevant financial relationships.

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