Category Archives: Diversity

Caring for patients from different backgrounds, includes cultural awareness, responsiveness and engagement with communities; diversity within the healthcare workforce.

Interrupting and Responding to Bias

Goals:

  • Introducing concepts of ingroup, outgroup, and creating opportunities for positive exposure to individuals different from oneself.
  • Introduce (de)individuation and empathy as key factors in quality of care.

(1) WATCH: Verna Myers TEDTalk at “How to overcome our biases?  Walk boldly toward them.”

  • Verna Myers urges viewers to move beyond denying or suppressing bias, to employing strategies to alter perceptions of certain groups over time.

(2) LISTEN to the short podcast and read the accompanying article. “A Patient, Not a Person“: Medicine’s bad habit of dehumanizing patients.

  • Discussion with Adam Waytz about how physicians tend to dehumanize their patients over time and the consequences this can have on the care provided.

(3) READ the op-ed piece by Dr. Okwerekwu. “The patient called me ‘colored girl.’ The senior doctor training me said nothing.”

  • Read this post from STAT Newsthat describes a medical student’s experience with racist comments during her clinical training and how it felt when no one spoke out against it.

(4) READ the JAMA op-ed piece “Speak Up” by Dr. Merrill. 

  • Read this JAMA Piece of My Mind“Speak Up” which describes one physician’s experience with speaking up when witnessing micro-aggressions or biased comments or behavior in the clinical workplace.

(5) REVIEW “Tools for Responding to Bias” on the EHM WordPress site.

  • Read over methods for responding to witnessed bias. Consider how you might respond as a bystander or the person receiving the bias.

Socialization and Implicit Bias

Review the following terms from the EHM WordPress Lexicon. Identity, Implicit Bias, Cultural Competency and Narrative Humility.

Discover the basic tenets of socialization. Watch the following video to develop a basic understanding of socialization.

Socialization: Crash Course Sociology #14

 

Understand how bias is ubiquitous. Watch the following video to understand how bias is an everyday part of our lives.

“Are you biased? I am.” | Kristen Pressner | TEDxBasel

 

Read the systematic review and focus on the sections of “Background” (2-3) and “Existence of Implicit biases/stereotypes…” (13-14).   Gain an appreciation of how implicit bias can lead to direct and indirect consequences in patient care.

FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Medical Ethics. 2017;18:19. doi:10.1186/s12910-017-0179-8. 

 

Supplemental.

  1. Refresh your memory on how narrative humility can improve our experience with patients.  Reread the article from Immersion – The art of medicine – Narrative Humility.
  2. Learn basic first steps for recognizing bias in your communication and interaction with others. Read the last sections on “Checking Perception” and “Getting Competent – Communication in the Real World: An Introduction to Communication Studies. 2.4 Improving Perception: http://open.lib.umn.edu/communication/chapter/2-4-improving-perception/   

Confronting institutionalized inequity in medicine

Activities

  1. Read: Taylor, A. (2004). Combination of Isosorbide Dinitrate and Hydralazine in Blacks with Heart Failure. NEJM, 351(20), 2049-2057.
    • Do not worry about details of biological mechanism, focus on big picture: what was studied, in whom, what were results and what’s the clinical application?
  2. Read: “The art of medicine. The short life of a race drug” by Sheldon Krimsky
    • Understand how and why BIDIL was able to be marketed as a race-specific treatment.
  3. Optional – Watch: Dorothy Roberts, The problem with race-based medicine (TEDMED 2015)

 

Social Determinants of Health in US Populations

Required:

  • Link and Phelan. 1995. “Social Conditions as Fundamental Causes of Disease” Journal of Health and Social Behavior pp.80-94
    • In this foundational article, social epidemiologists Bruce Link and Jo Phelan argue three main points:
      1.  social conditions (e.g., SES, inequality, racism, segregation) have a causal effect on health and well-being,
      2. to understand patterns of disease prevalence and incidence, we need to contextualize risk factors and understand what conditions put people “at risks of risks” (i.e., people in poor neighborhoods have an elevated risk of exposure to crime which increases the risk of stress accumulation), and
      3. researchers need to acknowledge that social conditions are not just distal causes of disease, they are FUNDAMENTAL causes, meaning that the relationship between the social conditions (e.g., SES) and health is robust and will remain present even as the risk factors for disease and the leading causes of disease/death change.
    • This is because high SES individuals are afforded flexible resources that they can use to avoid risks and minimize the consequences of disease.
  • Frieda, Misha. 2016. “For Native Americans, Health Care Is a Long, Hard Road Away”.
    • NPR : https://www.npr.org/2016/04/13/473264076/for-native-americans-health-care-is-a-long-hard-road-away
  • Social Determinants of Health PPT

White Fragility

Activities 1-3

  1. Read pages 54-58 (stop before the section Factors that Inculcate White Fragility) in the article White Fragility, by Robin DiAngelo
    • Discussions about race and racism can be inherently uncomfortable. Acts of racism can take all forms and it is important to consider intent versus impact when racist behavior is exhibited. Much of this is driven by societal norms and socialization.
  2. Review In-class handout: The Art of Mindful Inquiry and Health Ways to Communicate
    • In order to have a deeper discussion please review recommendations for inquiring about difficult topics and look over the discussion points that will be discussed.
  3. Watch the video clip Just Be American from the film Color of Fear.
    • This video in an excerpt from the 1994 film The Color of Fear. Eight men of different backgrounds, races and ethnicities were gathered by director Lee Mun Wah, for a dialog about the state of race relations in America as seen through their eyes. This is a response by David C. after hearing about experienced racism from other members of the group.

Your goal for each activity

  1. Create a personal definition of white fragility.
  2. Understand how societal norms can lead to power differentials that exist between racial groups.
  3. Create a framework for discussions that may be difficult or challenging.
  4. Create a framework for understanding why talking about racism may be more difficult for some than others.

 

Race and Racism in Medicine

Watch “The Biology of Race in the absence of Biological Races” by Dr. Rick Kittles

Watch video or read transcript:

Race: The Power of an Illusion – Episode 2

Read:

Goal for these activities:

  1. Recognize why using race in biomedical studies can be problematic.
  2. Recognize how and why race is a social and political construct and its current function in society.
  3. Recognize how race is still used in medicine, and “pros” and “cons” to using race as a social identifier.

Interrupting Bias

Required:

Cultural Context of Pain

Objectives

  1. Recognize and discuss factors leading to pain treatment challenges, variability, and access due to race, gender, ethnic, social and economic disparity
  2. Describe unique pain assessment and management needs of special populations
  3. Describe the role of the clinician as an advocate in assisting patients to meet treatment goals
  4. Explain how health promotion and self-management strategies are important to the management of pain
  5. Describe patient, provider, and system factors that can facilitate or interfere with effective pain assessment and management
  6. Design an individualized pain management plan that integrates the perspectives of patients, their social support systems, and health care providers in the context of available resources
  7. Reflect on the wider role of the clinician, within and beyond the healthcare system, as an advocate for patients suffering from chronic pain
  8. Describe the impact of pain on society

Before Class

1. Required reading

After reading the articles, write a short reflection that includes the following, and upload it to the pre-class quiz on Canvas.
For each article:

What is one finding in each article which surprised you? Why?
What is one thing you have a question about?
How and where will you seek answers to your questions?
One of the studies noted in the first article mentioned that some Native patients have an ‘expectation of empathy.’ The Native patients “expressed the conviction that it was the provider’s role to perceive and experience the patient’s pain in order to treat it” without the patient having to describe their pain in detail. What do you think about this? Do you believe this is possible across cultural beliefs and practices? Why or why not?

2. Required videos

Some questions to ponder as you watch:

In the field of medicine you are particularly interested in, how might historical trauma express itself in a patient’s life? What would be some possible physical, psychological or emotional manifestations?
Do you think historical trauma is different or the same as social determinants of health?

  • Interview with Chaplain Joisky Caudill: An Indigenous Perspective on Health and Wellness (12 min) 

    Some questions to ponder as you watch:
    How did Chaplain Joisky negotiate her care with her physicians? As a provider, how might you offer opportunities for your patients to negotiate their treatment with you? What would you do, say or ask?

Some questions to ponder as you watch:
What are ‘positive’ stereotypes about Native Americans/Alaska Natives? Why are they harmful?
What is your reaction when you hear Chaplain JoiSky’s definitions of medicine and health?  How would you know if your patients defined these concepts differently than you do? Why might that be important to be aware of?

There is mention that some Native people may understand illness and pain as manifestations of sickness of soul or as something which happens as a result of something a person was meant to do but hasn’t done. How would you work with patients who hold beliefs such as these? Would their beliefs change how you would provide care for them?

‘Racial Disparities in Pain Medication Use’ (10 min)

Review from EHM Cultural Humility Film (first 12 of 15 min) 

Historical Trauma: Hozhonahaslíí: Stories of Healing the Soul Wound Part III (11 min)

In Class

Students will work in small groups to discuss the case story with a community consultant.
Small groups should designate a member to write up a brief summary of their discussion with guest consultant (please include in your summary who your guest was, and the names of the people in your group).

The summary should include
1. One thing which was surprising to hear or was a new perspective
2. Two points of information you will carry forward as a future physician

We will reconvene as a large group for report out.

Please sign in for attendance of small group.

After Class

Healing the Warrior’s Heart 

 

Responding to Bias: Strategies and Skills

Start by reading this JAMA Piece of My Mind “Speak Up” which describes one physician’s experience with speaking up when witnessing micro-aggressions or biased comments or behavior in the clinical workplace.

Then read this post from STAT News that describes a medical student’s experience with racist comments during her clinical training and how it felt when no one spoke out against it.

Tools for Responding to Bias

Goal: Communicate a message of disapproval without damaging interpersonal relations

Be ready 

  • Rehearse what you would do or say in situations before they occur
  • You know what feels most natural for you
  • Remember the Bystander effect
  • No one else will probably say anything
  • Consider saying something, even if it is a small effort

Decide whether to say anything 

  • Silence is often interpreted as passive complicity
  • Consider saying something simple like “that’s not cool” or “I don’t appreciate that”
  • You don’t have to take a dramatic stand if you’re not comfortable or not able

Consider taking more time if:

  • You know you respond badly in the heat of the moment
  • You fear retaliation or mistreatment and need more support
  • The situation is not appropriate (ie during a patient care emergency)

Stay calm 

  • Try to speak calmly, or consider waiting until another time
  • Try to avoid inducing defensiveness

Clarify or Restate what was said  

  • Make sure you are understanding what was said
  • Make the speaker think about what they said
  • “So I am hearing you say….” Or even “excuse me, what was that you just said?”
  • If a joke was made, ask the speaker to explain it to you
  • When identifying the behavior, avoid labeling, name-calling or the use of loaded terms.
  • Describe the behavior; don’t label the person.

Appeal to principles 

  • “I’m surprised to hear you say that.  I think of you as more… (egalitarian, open-minded, etc).”

Change the subject (more effective than it sounds) 

  • You may not change beliefs but you may change behavior

Reflect on what happened 

  • Journaling or meditation
  • Debriefing with a peer or college mentor

It’s never too late to bring it up 

  • Defer until later: “let’s talk about this when we have more time”
  • Bring it up later: “I’ve been thinking about what you said last week…”

Don’t get discouraged 

  • You won’t know the lasting impact you’ll have later on, both for the speaker and those who were present

Know your resources 

  • College mentors and college heads
  • Other trusted faculty
  • Student Affairs office

Traps to Avoid

Avoid making light of any comments, making jokes (which often backfire!), or getting defensive

Honoring the Individual: Narrative and Cultural Humility

This New York Times article, written by Harvard Professor of Economics Sendhil Mullainathan discusses how our identity shapes how we think about inequality and our advantages and disadvantages.

To Help Tackle Inequality, Remember the Advantages You’ve Had, by Sendhil Mullainathan

This PBS Newshour video and brief accompanying article by Kamaraia Roberts about young Black Republicans suggests that individual identities can be challenged by society and peers.

The stigma of being young, black and Republican, by Kamaria Roberts

Watch this compelling YouTube video by Director Vivian Chavez.  Melanie Tervalon, a physician and consultant, and Jann Murray-Garcia, a nursing professor at UC Davis, thoughtfully discuss the philosophy and function of cultural humility and the need for cultural humility to improve provider to patient interaction and care.

Cultural Humility, by Vivian Chavez