Get Empowered: Understanding Bias [Podcast]
Published April 2022
As female physicians, Khalilah Gates, MD, Michelle Prickett, MD, and Susan Russell, MD, face implicit bias every day. In this inspiring conversation, your podcast hosts discuss their experiences and how to recognize implicit bias.
As assistant dean of medical education at Northwestern University Feinberg School of Medicine, Dr. Gates leads the faculty and student council on racism, justice and equity for the Augusta Webster, MD, Office of Medical Education (AWOME), reviews curriculum for bias, educates faculty members on best practices for discussing bias in education, and serves as a mentor for students from underrepresented groups.
Disclaimer: This podcast does not substitute for medical advice from a clinician.
Russell [00:00:02] Let's get stronger.
Gates [00:00:04] Healthier.
Prickett [00:00:05] Calmer.
Russell [00:00:05] Smarter.
Gates [00:00:06] Better.
Russell [00:00:06] Living a healthier life is a journey, not a destination.
Gates [00:00:10] You can always get better.
Prickett [00:00:12] Let's get better together.
Gates [00:00:20] Hi, I'm Dr. Khalilah Gates.
Prickett [00:00:21] I'm Dr. Michelle Prickett.
Russell [00:00:22] And I'm Dr. Susan Russell.
Gates [00:00:24] Today, we're going to talk about bias. But before we do, I want to designate this podcast as a brave space in the words of Mickey Scott Bay Jones: "There is no such thing as a safe space. We exist in the real world. We all carry scars and we all have caused wounds. We will not be perfect. This space will not be perfect. It will not always be what we wish it to be, but it will be our brave space together, and we will work on it. Side-by-side."
Russell [00:00:54] I would like to start this by saying that Dr. Gates is a true expert and has a lot of background knowledge about implicit bias in her work at Northwestern.
Prickett [00:01:03] Seeing that we do have an expert in the house, I'm not. I'll start with the opening question. So, what is implicit bias? Who would like to enter some thoughts on this?
Gates [00:01:13] I want to first start off by saying what implicit bias isn't. Implicit bias isn't a right or wrong thing. Implicit bias is not equal to racism, sexism, ableism. Those are the things that it is not. The fact that we all have biases, it's just a reality of being human beings, and being human beings in a society and in a world in which we are influenced. What exactly is implicit bias? It is the beliefs about something, or a group of somethings or someones, that may be positive, may be negative. But we are often unaware of those biases. Those biases are often impacted by the images in which we see from society, the experiences that we have in life, or the lack of experiences of differences that we also have in life. It is one of those things in which, based on the things that we experience, the people in our lives, that we experience that are different from us to give us that understanding of different natural processes that make connections and associations. And that's what we're really dealing with when we're talking about implicit bias. And it is implicit because often we're not aware of it. And it can be quite shocking, and it could be very counter to what we would believe or otherwise state to be true.
Russell [00:02:35] I think about it as a way that your brain is trying to process information. You get so much data coming at you all the time, from social media, from things you're seeing on the street, from people in new situations that you're in. And your brain is trying to help you organize all that information and help you understand it all. And, so it draws on all your previous experience, right or wrong, to try to put things into boxes. And I think it's just you as a human being who has higher level brain functioning. It's your job to take that information and then say, OK, was that right? That instinct I had, was that correct in helping me understand all this information?
Gates [00:03:21] Definitely the brain's way of very quickly dealing with and processing information. And one of the examples that I like to use is a simple example, but it is: We don't have to think about a chair being a chair. Because we have had enough experience with a chair that our brain automatically says, that's a chair. We should sit in it and our brain does that with many other things as well, including people.
Prickett [00:03:46] We have to categorize things, we have to do it quickly, and it's not something we're thinking about. The example I have is growing up in the city, and it's a lot of sounds. So, like, I'm so used to the sounds of the city that's just like the background of my existence in my experience. And then when people that come in from rural areas where they're not used to that they're like, "How do you deal with this?" And it's, like, it's just the sounds of my life. It's something that's so innate to me. It doesn't get me nervous because it's part of what I feel is normal. But you put me out into a rural area in the country where it's quiet, it sets me off. It's something within me that it's like, "OK, this is different". And I have to be conscious of it, because it's this unconscious thing that happens. So again, I think there's many ways that we can kind of understand this. I hope we can talk about how it affects our day-to-day lives as people within a universe and how it affects us socially, professionally and within the medical community. So, I think, again, this is not a judgment, it's just how we process an understanding that it's that process of difference, and we might need to slow down to say, "Hey, is that not something wrong, it's just something different." And we need to give it that space to understand how we process this effectively to do the right thing.
Russell [00:04:56] But I think implicit bias gets a lot of attention based on the negative connotations of it. That's the thing that people talk a lot about. Taking that and flipping it to the perspective of somebody who's on the opposite side of you categorizing somebody, what are microaggressions and how does this relate to the concept of implicit bias?
Gates [00:05:16] The first thing I want to say is, I don't think that there is a negative connotation with implicit bias. The fact is that we often don't understand it or are uncomfortable with the fact that we are biased. All of us are in our discomfort, we make it this negative thing.
Russell [00:05:33] Maybe I have implicit bias, the negative.
Gates [00:05:38] Then unfortunately, there are some negative consequences of our implicit biases. I'm excited that we're having this conversation so that we can really kind of dig deep through it. To answer your other question about what are microaggressions, I like to think of them as little outgrowths, daily presentations of our own implicit biases. The fact that they're called microaggressions, this term was coined in the 1990s, is the fact that the "micro" part of it means that it happens every day. And the "aggressor" part of it does not mean that the person saying the statement, typically it is a saying of a statement, is trying to be aggressive. It is that it is essentially offensive or has a unwarranted impact on the recipient that is often detrimental. And so that is what microaggressions are. Some of us experience microaggressions much more than others: underrepresented minorities, Black, white, LatinX, LGBTQ. Some people are definitely more susceptible to experience microaggressions on a regular basis. One of the videos that I like to show is making microaggressions are often similar to mosquito bites, where they're annoying, and that can be painful. And then, depending on what it is, they can actually be quite harmful. And so it is important for us to understand and arm ourselves with these definitions.
Prickett [00:07:05] Or just the sheer volume. So if you get one mosquito bite, no big deal. If you get a lot of mosquito bites, or you get them every day, it becomes unbearable. And so, I really like that example.
Gates [00:07:17] I think we have really well defined implicit bias. I think that we have explored this definition of microaggressions as well. And so let's jump into real life. Can you all think of, and are willing to share, some real-life experiences that we've had with microaggressions or implicit biases, or both?
Russell [00:07:37] I used to have a southern accent, one that was more prominent, and sometimes people would assume certain things about me that were not positive, or negative, just based on that. Like, they would assume that I knew a lot about college football or that I like to listen to country music, just because of my speech pattern that were not exactly true. Although, Roll Tide!
Prickett [00:08:01] You still haven't gone to a college football game (laughs). You know, I think when I was thinking about my experience with this, I come from tall stock, I'm like a six-foot-tall woman. I'm actually fairly short for parts of my family that go into almost seven feet. When you get that, it's always "Do you play basketball? Do you play basketball?" Yeah, I did play basketball. (Laughs) So, but it's that's probably when people see you, again, then there's this idea that they're kind of already lumped you into a group that you may or may not identify with, but you're going to be in there, and you're going to get reminded of it all the time. I remember a time, though, I was rounding in the ICU, the pre-COVID times where I used to wear a dress and heels and a white coat. And a pretty sick patient who had a surgical consult. And so one of the attending surgeons came over to this big group, and I'm there kind of with everyone, and the surgeon came over said to the group, "Do you guys have this patient?" And someone said, "Yeah, we have this patient." Male surgeon went and talked to the person right next to me, who is a six-foot-tall white man, but was about 15 years my junior, and gave him the whole story. "And this is what I want to do and blah blah blah. Are you OK with this?" And I'm standing right there and I'm, again, I'm about six-two at this point myself. Like, I got my heels. I look good. I don't look like that anymore. Scrubs now. But. And he kind of was like, "Well, you'd have to ask the attending." And the surgeon said, "Well, well, where is he?" And he had to be like, "Well, she's right here." And that was awkward for everyone. But it was just an example to me of, despite, like, that whole, the contextual, you know, signals were all there, but that implicit bias of, obviously the ICU attending is going to be a man, just kind of came through. And again, no fault of the surgeon. It was just, it was to me an example within a large group, and we were actually able to talk about it.
Russell [00:09:54] It's happened a few times to me, that same scenario where an attending from another service has come up to our, like, floating group and assumed somebody else is the attending. And it's happened a little more now that we've leveled the playing field in terms of how people look with all of us wearing scrubs and then all of us wearing masks. So, everybody's, nobody's hair looks good. Nobody's wearing anything different from anyone else. It's a great equalizer, but then assumptions come behind that.
Gates [00:10:22] So those moments are tough, but the tougher moments for me are the microaggressions and, my favorite, I'll share two. One, I was a fellow, and someone that I hold near and dear to my heart, I am born and raised on the west side of Chicago. This person knew that. And we were like applying for a grant, or something like that, and we're trying to figure out how I would write my statement and the person looks at me and says, "So did you have books at home?" And I paused very briefly. I said, "What do you mean did I have books at home?" I said, "Of course I have books at home. Now, do we have a designated library? No. But of course we have books." And it was this very weird moment of an assumption that, because I was from the west side of Chicago, I had limited means and limited experiences, which was actually quite frustrating, the inability to recognize that all groups are heterogeneous in the people that exist there. It was very frustrating. And then my absolute favorite, which I get on a regular, is how articulate I am. And I'm like, "What do you mean? I'm articulate? Why do you feel the need to point out the fact that I am quote-unquote articulate?" And that is a frustrating thing for me because, despite me having a higher degree, despite me attending very good universities and colleges, because the sheer fact that you looked at me and saw me as whatever, but probably the obvious being a Black woman, you assume that I could not quote-unquote speak? And that is the most frustrating but common microaggression that I experience. That's the painful part of it is when is this going to stop? When are we going to realize as a society that people are very diverse, very heterogeneous? And we have to stop labeling people and we have to broaden our own experiences and understandings of others so that we can move on. So, those are my two memorable microaggressions.
Prickett [00:12:42] I think the fact that this is happening to us and, I will say that as, you know, women of privileged, privileged, academically privileged, professionally privileged, financially with our jobs, like, we, it makes me pause and makes me think of our patients. That is a very heterogeneous group, and how this happens and how these little biases that we have are kind of instinctual, like couplings or groupings, kind of transmits to other aspects of health care. So do you all have some thoughts on that?
Gates [00:13:14] We have to, as a healthcare community, understand that we all are walking into each patient encounter with some biases that can, if we don't recognize them, impact care. And it impacts care, as I talked about, as far as health care decisions and judgments and recommendations. But, I think more significantly, it impacts care in the sense of not being able to establish the trust and effective communication that's necessary for effective doctor-patient relationships, particularly long-term doctor-patient relationships, to actually help our patients deal with their various illnesses.
Russell [00:13:59] I think it's also been tougher in the COVID setting, where you're not seeing patients as much face-to-face, to really get a good sense of where they're coming from and what their values are. And it's been so much easier to, again, like, use that organization to try to, your brain, to try to put them in boxes in the hospital, too, because we haven't had families around as much as before. So we need to be even more vigilant than before to make sure that we're not making assumptions that are not true about patients. And it'll be interesting to see, you know, where this literature shakes out in a year or so. It is already starting to be that way because there are already some data about treatments in the COVID setting that show that this may be playing out as well.
Gates [00:14:46] There are persistent disparities in COVID across gender lines, ability lines and racial lines, and it's not all due to structures. I mean, it's very complex. But as you were suggesting, we're going to have a lot of reconciliation as we look back on this pandemic.
Prickett [00:15:08] Just as Susan said, like, how do we connect with patients is important in trying to find the similarities and understanding the differences and understanding that that's unique to patients and how we can better care for them and not just making assumptions off of what we see right on the immediate front.
Gates [00:15:23] And I think one of the more important things is to acknowledge that, and we're not saying get rid of your biases. We're saying more so recognize your biases, and then have the skills that are necessary to put some distance between your biases and the situation so that they don't impact it as much.
Russell [00:15:42] Switching gears a little bit, like, we've been talking about implicit biases, providers in the health care setting. But how does this affect, you know, everyone in general, like our patients and everybody out there listening? How does experiencing bias impact your mental and physical health?
Gates [00:15:58] There is a lot of data coming out that shows that bias impacts just about every aspect of our lives. What happens is that there is this level of mental health that is impacted by this. A lot of experience with bias and discrimination can lead to depression and anxiety. It can lead to additional stress. And in our podcast with Dr. Burnett-Zeigler, we talked about the links between increased stress and physical health. And so if you have populations of people and the data, the psychology data says, that those are underrepresented minorities. Those are women. Those are members of the LGBTQ community who report higher stress levels. If you could imagine that persistent ongoing stress from those experiences can definitely lead to then physical health issues. There was one study within the last couple of years that suggested that the racism that Black men experience in the U.S. is actually related to increased rates of cardiovascular disease. I think medicine is definitely moving to the understanding that mental health has direct relationships to physical health, and these things, like bias and discrimination, just add to increased stress for groups of people. And we have to be aware of that and concerned with that.
Prickett [00:17:34] The bigger fear to me is what happens when we do nothing, right? What is the, what is the end result of that? How does it impact people? What do you think?
Russell [00:17:42] We know that the cumulative effect of bias has caused groups of people to have adverse outcomes on their health. That connection seems pretty clear. It's well-trod ground, but I think as an individual, if you are leading with your bias, then you're going to have a progressively closed off life. I'll take the example from earlier, country music, like if I assume all country music is bad, I never want to listen to it. I'm never even get a turn on that station. Then I'm missing out on a whole genre of things that actually could help me quite a bit in understanding where certain people are coming from, where some of my patients are coming from. And then once you take that first step of doing that, then you'll be a person who's more open to experiences in general and have a more fulfilling life.
Gates [00:18:34] We end there with Russell, that we all want to live a fulfilled life. No half-lived lives. And that's what are our goals and, our hopefully our aim is for our lives. And so I like to leave you at the quote. It's my favorite quote so far. Anyone who gets an email from me sees it as a daily reminder, and it is by the author James Baldwin, and he says "Not everything that is faced can be changed, but nothing can be changed until it's faced."
Russell [00:19:11] Thanks for listening to Get Better.
Gates [00:19:13] We hope you leave this podcast better than when you started.
Prickett [00:19:16] For more information visit nm.org/healthbeat