a equity in an era of innovation and system transformation

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The Eighth National Conference on Quality Health Care for Culturally Diverse Populations

Oakland, California Oakland Marriott City Center

March 12, 2013

Achieving Equity in an Era of Innovation and Health System Transformation

National Center for Cultural Competence

CONSCIOUS AND UNCONSCIOUS BIASES IN HEALTH CARE:AN INNOVATIVE CME AND DISTANCE LEARNING RESOURCE

CREATED BY THE NATIONAL CENTER FOR CULTURAL COMPETENCE

IN PARTNERSHIP THE

AMERICAN COLLEGE OF RHEUMATOLOGY

LUPUS INITIATIVE

March 12, 2013

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Slide Source:© 2013 ‐ National Center for Cultural Competence

PRESENTERS

National Center for Cultural Competence Tawara D. Goode, MA

Suzanne Bronheim, Ph.D.Vivian H. Jackson, Ph.D.

American College of RheumatologySheryl McCalla, Esq.

ConsultantsKimberly Papillon, Esq.

David Newhouse, MD MPH

Disclosure

None of the aforementioned presenters have conflict of interest. The presenters have only a shared interest to improve health by reducing health care inequities,

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This CME is designed to:

bring awareness to members of the health care community about the impact of conscious and unconscious biases on health care, and how bias contributes to health care disparities; and

increase knowledge of how to recognize and mitigate biases in the diagnosis, treatment, and management of lupus for diverse patient populations.

PURPOSE OF THE CME


The CME offers an array of innovative activities, based on current evidence and best practices, that are intended to diminish the negative impact of biases.

Salient findings from a literature reviewQuick Check QuizzesVideo narratives from patients, health care providers, and researchers Self‐test of implicit biasAn in‐depth exploration of the neuroscience of unconscious bias using video lecturettes and brief narratives Five case studiesEssential tools and strategies to combat conscious and unconscious biasesResource listing

FORMAT & STRUCTURE OF THE CME

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Upon completing this CME, participants will be able to:

1. Describe five key epidemiological facts about systemic lupus erythematosus (SLE), or lupus;

2. Cite the primary demographic groups disproportionately impacted by lupus‐related health disparities;

3. Define conscious (explicit) bias and unconscious (implicit) bias;4. Define health disparities;5. List four areas in which unconscious bias can adversely impact the health care

provided to racially, ethnically, and linguistically diverse patient populations;6. Cite and describe four seminal studies from the literature on bias that affects

health care;7. Describe three strategies, which draw on neuroscience of unconscious bias, that

can be used in everyday practice to mitigate the negative effects of bias; and8. List two strategies that apply cultural competence to address conscious or

unconscious bias in patient care.

LEARNING OBJECTIVES


Defining Bias and its Manifestations

This CME module is designed to foster a shared understanding of terms commonly found in the literature that are used to delineate differential or disparate treatment between and among racial, ethnic, social, or other cultural groups. While there are many definitions of such terms, these were selected because they underpin the constructs and best represent the progressive thinking in those who study the intersection of health and health care disparities and bias.

Establishing Common Ground: Definitions related to Disparate Treatment, Health status, and Health Care

Pathways of Unconscious Bias

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Key Terms

Disparity

Health disparity

Disparities in health care

Group categorization

Stereotype

Discrimination

Prejudice

Bias

Unconscious or Implicit Bias



Cognitive

categorizationstereotype

conscious bias

unconscious bias

overt behavior

inadvertent behavior

Pathway of Unconscious Bias


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1. Smedley BD, Stith AY, Nelson, AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Board on Health Sciences Policy, Institute of Medicine. Washington, DC: National Academies Press; 2003:19.

2. Burgess DJ, Fu SS, van Ryn M. Why do providers contribute to disparities and what can be done about it? J Gen Intern Med. November 2004;19:1154‐1159.

3. Carter‐Pokras O, Baquet C. What is a "health disparity"? Public Health Rep. September‐October 2002;117(5):426‐434.4. Braveman P. Health disparities and health equity: concepts and measurement. Annu Rev Public Health. 2006;27:167‐194.5. Balsa A, Mcguire TG. Prejudice, clinical uncertainty and stereotyping as sources of health disparities. J Health Econ. 2003;22:89‐116.6. US Department of Health and Human Services. The Secretary’s Advisory Committee on National Health Promotion and Disease

Prevention. Objectives for 2020. phase I report: recommendations for the framework and format of Healthy People 2020. section IV. Advisory Committee findings and recommendations. Available at: http://www.healthypeople.gov/hp2020/advisory/PhaseI/sec4.htm#_Toc211942917. Accessed October 9, 2012.

7. Blank RM, Dabady M, Citro CF, eds.Measuring Racial Discrimination.Washington, DC: National Academies Press; 2004.8. Oxford Dictionaries. Definition of discrimination. Available at:http://oxforddictionaries.com/definition/english/discrimination. Accessed

October 9, 2012.9. Braverman J, Blumenthal‐Barby JS. Assessment of the sunk‐cost effect in clinical decision‐making. Soc Sci Med. July 2012;75(1):186‐192.10. Stone J, Moskowitz G. Non‐conscious bias in medical decision making: what can be done to reduce it?Med Educ. 2011;45:768‐777.11. van Ryn M, Burke J. The effect of patient race and socio‐economic status on physicians’ perceptions of patients. Soc Sci

Med. 2000;50(6):813‐828.12. Dovidio JF, Fiske ST. Under the radar: How unexamined biases in decision‐making processes in clinical interactions can contribute to

health care disparities. Am J Public Health.May 2012;102 (5):945‐952.13. Santry H, Wren S. The role of unconscious bias in surgical safety and outcomes. Surg Clin North Am. February 2012;92:137‐151.14. Burgess D, van Ryn M, Dovidio J, Saha S. Reducing racial bias among health care providers: lessons from social‐cognitive psychology. J Gen

Intern Med. June 2007;22(6):882‐887.

References: Defining Bias and its Manifestations


Impact of Biases on Health & Health CareThere is clear and compelling evidence that biases, both conscious and unconscious, have a deleterious effect on health and health care‐for both patients and practitioners. This CME module examines the findings from studies that document patients’ perspective of biases and the experience of care, and the impact of biases on beliefs, clinical decision‐making, and communication on the part of health care practitioners.

Quick Check Quiz Environmental Scan of the Literature on Conscious and Unconscious BiasesWhat the Literature is Telling UsKey ThemesBias Among Practitioners Case Studies

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ENVIRONMENTAL SCAN OF THE LITERATURE

Literature Reviewed: Primarily 75 items published between 1990 and 2011 (except for one dated 1987) on unconscious or implicit bias and conscious or explicit bias in health care from both the provider and patient perspectives. Additional items published in 2012 were reviewed. Studies con

Search Methods: PubMed search of articles published between 1990 and 2011 in English, published in the United States. Search terms and number of articles resulting were as follows:

implicit bias and provider (1) implicit bias and patient (120) explicit bias and provider (2) and explicit bias and patient (180)

Additional PubMed searches were conducted to locate any articles on bias and religion. None were found.

Impact of Biases on Health & Health Care


ENVIRONMENTAL SCAN OF THE LITERATUREBiases and Health Care Contexts

Implicit and explicit biases take place:‐ in diverse health and behavioral health care contexts and settings ‐among multiple medical specialties, types of professionals, and students

Health professionals identified in this literature were non‐Hispanic White, Asian, African American, and Hispanic/Latino. There were no American Indian/Native Americans or Alaska Native health care practitioners or professionals noted in this literature.

Research was conducted in all regions of the United States. The sample sizes varied; however, studies were primarily conducted in urban settings with little mention of rural settings, tribal communities, or U.S. territories.


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Majority of the studies focused on African American patients, followed by Hispanic/Latinos with White patients as a comparison group. Little mention of Asians and barely any reference to American Indians/Native Americans. Within‐group diversity was rarely considered beyond the socioeconomic status of patients.Studies included non‐ethnic cultural groups (i.e., patient populations who are elderly, obese, and those with disabilities without specifying race or ethnicity).Several studies identified women without reference to any other demographic characteristics (i.e., race, ethnicity, age). Several studies combined racial minority identity status and sexual orientation and gender identity.


ENVIRONMENTAL SCAN OF THE LITERATUREDemographic Make‐Up of the Research Subjects: Patients


The population of health care practitioners and other health professionals identified in this literature was non‐Hispanic White, Asian, African American, and Hispanic/Latino.

There were no American Indian/Native Americans or Alaska Native health care practitioners or professionals noted in this literature.


ENVIRONMENTAL SCAN OF THE LITERATUREDemographic Make‐Up of the Research Subjects:

Practitioners & Other Health Professionals

Most of the literature focuses on patients’ reported experiences of bias based on their race, ethnicity, English language proficiency and fluency, SES, and gender.1‐4

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ENVIRONMENTAL SCAN OF THE LITERATURECategorical Groupings of the Studies

Directly measure unconscious bias and its impact on care Directly measure unconscious bias and its relationship to

conscious bias Suggest differences in treatment that are related to bias,

but do not actually measure that construct Describe approaches to address bias among health care

practitioners Delineate whether and how bias impacts communication

in health care settings as an underlying cause to disparities in health care

Critique the concept of practitioner bias as a cause or contributing factor to health disparities

Age Disability Education English language

proficiency and fluency (including the capacity to speak Standard English for native‐born English speakers)

Ethnicity Health status Disease/diagnosis

(HIV/AIDS)

Insurance Obesity Race Socioeconomic status (SES) Sexual orientation, gender

identity, or expression Skin tone Substance use (injection

drug user) Social contact (amount of

contact that practitioners have with patient populations


ENVIRONMENTAL SCAN OF THE LITERATUREIdentified Areas of Bias

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ENVIRONMENTAL SCAN OF THE LITERATUREKey Themes

Most of the literature focuses on patients’ reported experiences of bias based on their race, ethnicity, English language proficiency and fluency, SES, and gender.1‐4

Although the phenomenon clearly exists, little in the literature documents implicit or explicit bias on the part of patients.7

Studies tend to describe patients who:1. perceived or experienced discrimination, prejudice, and disrespectful

treatment in health care settings from non‐race or non‐ethnic concordant practitioners and as a consequence express a preference/bias for practitioners of their own race or ethnicity; or

2. received care from health care professionals whom they perceived as culturally sensitive or culturally competent practitioners and thus express a clear preference/bias based on these experiences with racial or ethnic concordant practitioners.2,5



“African Americans, Hispanics, and Asians were more likely than whites to agree that:1) they would receive better medical care if they belonged to a different race/ethnicity; 2) medical staff judged them unfairly or treated them with disrespect based on their race/ethnicity; and 3) medical staff judged them on how well they speak English.”2(p106)

These researchers also found that African Americans believe they are treated with disrespect and in an unfair manner because of how they speak English.

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“Individuals who:

perceive more provider discrimination have higher unmet needs for health care utilization.

have negative experiences within the health care setting will be less likely to continue to seek health care services, even when they report a recognized need for care.

perceive more provider discrimination are more likely to have poor health.”

“Negative experiences within the health care setting will create additional vulnerabilities in an already vulnerable population, and acts as one mechanism for creating and sustaining health disparities in African Americans, Hispanics, and Asians.”12(p8)



Most practitioner bias is at an unconscious level and is influenced by multiple factors, including exposure over time to negative images and messages about certain groups of people.9‐11

“Physicians rated African Americans as less likely to be the kind of person they could be friends with, as being less likely to be free of substance abuse problems, and less likely than non‐Hispanic whites to be interested in an active lifestyle and cardiac rehabilitation. Moreover, physicians rated African Americans as less intelligent and less educated than non‐Hispanic whites. All of these relationships were stronger if the patient was from a lower socioeconomic class.”3(p357)

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Perceived discrimination and bias have an adverse effect on patient health and are closely linked to health and health care disparities.13‐15

Perceived discrimination may be related to both mental and physical health outcomes. This relationship may occur through the mechanisms of patient stress responses and health behaviors.16

Implicit bias can be conveyed through interpersonal communication (body language and posture, facial expressions, distance) and can have a negative effect on patient‐practitioner interactions.

Implicit bias has been demonstrated to impact clinical decision‐making. Findings have reflected differences in care or proposed care based on race and ethnicity for cardiac conditions, HIV/AIDS, end‐stage renal disease, psychiatric treatment, surgical safety and outcomes, and treatment of pain, among others.9,17‐20


References: Impact of Biases on Health & Health Care

1. Henry J. Kaiser Family Foundation. Race, ethnicity, and medical care: a survey of public perceptions and experiences. 2009. Available at:http://www.kff.org/minorityhealth/loader.cfm?url=/commonspot/security/getfile.cfm&Page(D=13294. September 19, 2012.

2. Johnson RL, Somnath S, Arbelaez J, Beach MC, Cooper LA. Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med. February 2004;19:101‐110.

3. Ferguson WJ, Candib LM. Culture, language, and the doctor‐patient relationship. Fam Med.2002;34(5):353‐361.4. Blanchard J, Lurie, N. R‐E‐S‐P‐E‐C‐T: patient reports of disrespect in the health care setting and its impact on care [online]. J Fam

Pract. September 2004;53(9).5. Tucker CM, Herman KC, Pedersen TR, et al. Cultural sensitivity in physician‐patient relationships: perspectives of an ethnically diverse sample of

low‐income primary care patients.Med Care. 2003;41(7):859‐870.6. John D. Piettea,*,Bibbins‐Domingob K, Schillingerb D. Health care discrimination, processes of care, and diabetes patients’ health status . Patient

Educ Couns. 2006;60(1):41‐48.7. Newhouse D. Service score segmentation of diverse populations to improve patient and physician satisfaction‐a multicase quality improvement

study. Perm J. Fall 2009;13(4):34‐40.8. Good MJ, James C, Good BJ, Becker AE. The culture of medicine and racial, ethnic, and class disparities in healthcare. In: Smedley B, Stith A,

Nelson R, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press; 2003.9. Santry HP, Wren SM. The role of unconscious bias in surgical safety and outcomes. Surg Clin North Am. February 2012;92(1): 137‐151.10. Sabin JA, Rivara FP, Greenwald AG. Physician implicit attitudes and stereotypes about race and quality of medical care.Med Care. July

2008;46(7):678‐685.11. Sabin J, Nosek B, Greenwald A, Rivara F. Physicians’ implicit and explicit attitudes about race by MD race, ethnicity, and gender. J Health Care

Poor Underserved. August 2009;20(3):896‐913.12. Lee C, Ayers S, Kronenfeld J. The association between perceived provider discrimination, healthcare utilization and health status in racial and

ethnic minorities. Summer 2009. Ethnic Dis. 2009;19(3):330‐337.13. Balsa A, McGuire T. Prejudice, clinical uncertainty and stereotyping as sources of health disparities. J Health Econ. January 2003;22(1):89‐116.14. Blair IV, Steiner JF, Havranek EP. Unconscious (implicit) bias and health disparities: where do we go from here? Permanente J. Spring

2011;15(2):71‐78.15. Smedley B, Stith A, Nelson R, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National

Academies Press; 2003.16. Pascoe EA, Richman LS. Perceived discrimination and health: a meta‐analytic review. Psychol Bull. 2009. July 2009;135(4):531‐554.17. van Ryn M. Research on the provider contribution to race/ethnicity disparities in medical care.Med Care. 2002;40(suppl 1):I‐140‐I‐151.18. Bogart LM, Catz SL, Kelly JA, Benotsch EG. Factors influencing physicians’ judgments of adherence and treatment decisions for patients with HIV

disease.Med Decis Making. 2001; 21(1):28‐36.

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19. Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for Black and White patients. J Gen Intern Med. 2007;22(9):1231‐1238.

20. Schulman K, Berlin J, Harless W, et al. The effect of race and sex on physicians’ recommendations for cardiac catheterization. N Engl J Med. 1999;340(8):618‐626.

21. Dovidio JF, Fiske ST. Under the radar: how unexamined biases in decision‐making processes in clinical interactions can contribute to health care disparities. Am J Public Health.May 2012;102(5):945‐952.

22. Penner LA, Dovidio JF, West TV, et al. Aversive racism and medical interactions with Black patients: a field study. J Exp Soc Psychol.March 1, 2010;46(2):436‐440.

23. McKinlay J, Potter D, Feldman H. Non‐medical influences on medical decision‐making. Soc Sci Med. 1996;42(5):769‐776.24. Hall JA, Epstein AM, DeCiantis ML, McNeil BJ. Physicians’ liking for their patients: more evidence for the role of affect in medical care. Health

Psychol. March 1993;12(2):140‐146.25. Ferrante JM, Piasecki AK, Ohman‐Strickland PA, Crabtree BF. Family physicians’ practices and attitudes regarding care of extremely obese

patients. Obes. 2009;17(9):1710‐1716.26. Loomis G, Connolly K, Clinch C, Djuric D. Attitudes and practices of military family physicians regarding obesity.Milit Med. 2001;166(2):121‐125.27. Magliocca KR, Jabero MF, Alto DL, Magliocca JF. Knowledge, beliefs, and attitudes of dental and dental hygiene students toward obesity. J Dent

Educ. 2005;69(12):1332‐133928. Schwartz LM, Woloshin S, Welch HG. Misunderstandings about the effects of race and sex on physicians’ referrals for cardiac catheterization. N

Engl J Med. 1999;341(4):279‐283.29. Epstein R. Disparities and discrimination in health care coverage: a critique of the Institute of Medicine study. Perspect Biol Med. 2005;48(suppl

1):S26‐S41.30. Weisfeld A, Perlman RL. Disparities and discrimination in health care: an introduction. Perspect Biol Med. 2005;48(suppl 1):S1‐S9.31. Satel S, Klick J. The Institute of Medicine report: too quick to diagnose bias. Perspect Biol Med. 2005;48(1):S15‐S25.

References: Impact of Biases on Health & Health Care


Even Well‐Meaning People Have Bias People with egalitarian values and beliefs, including health care professionals, often have a difficult time accepting that they harbor prejudicial attitudes or would do anything that would be negative toward another person. Yet, as well documented in the literature it is the practitioner’s expression of bias that contributes to health care disparities. This CME module explores this apparent contradiction.

Quick Check Quiz Two Types of Bias How is it Possible that Well‐Meaning People Act in Ways that Contradict their Values and Belief Systems? It’s How We Are Wired Unconscious Bias and the Neuroscience

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Even Well‐Meaning People Have Bias 1. Smedley BD, Stith AY, Nelson, AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Committee on Understanding and

Eliminating Racial and Ethnic Disparities in Health Care, Board on Health Sciences Policy, Institute of Medicine. Washington, DC: National Academies Press; 2003:19.

2. Amodio D, Ratner K. A memory systems model of implicit social cognition. Curr Dir Psychol Sci. 2011;20(3):143‐148.3. Smith ER, DeCoster J. Dual‐process models in social and cognitive psychology: conceptual integration and links to underlying memory systems. Pers

Soc Psychol Rev. 2000;4(2):108‐131.4. Bobula KA. This is your brain on bias (. . . , or the neuroscience of bias). Faculty lecture series presented at: Clark College; May 3, 2011; Vancouver,

Wash. Developing brains: ideas for parenting and education from the new brain science. Available at:http://www.developingbrains.org. Accessed September 19, 2012

5. Blair IV, Ma JE, Lenton AP. Imagining stereotypes away: the moderation of implicit stereotypes through mental imagery. J Pers SocPsychol. 2001;81(5):828‐841.

6. Satpute AB, Lieberman MD. Integrating automatic and controlled processes into neurocognitive models of social cognition. Brain Research. 2006;1079:86‐97. Available at:http://ebookbrowse.com/gdoc.php?id=22760899&url=f4bcbdd6f9b495db5c688b2d3178349f. Accessed September 26, 2012.

7. Macrae CN, Milne AB, Bodenhausen GV. Stereotypes as energy‐saving devices: a peek inside the cognitive toolbox. J Pers Soc Psychol. 1994;66(1):37‐47.

8. Balsa AI, McGuire TG. Prejudice, clinical uncertainty and stereotyping as sources of health disparities. J Health Econ. 2003;22(1):89‐116.9. Burgess DJ. Are providers more likely to contribute to healthcare disparities under high levels of cognitive load? How features of the health care

setting may lead to biases in medical decision making. Med Decis Making. 2010;30(2):246‐257.10. Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for Black and White patients. J Gen

Intern Med. 2007;22(9):1231‐1238.11. Gaertner SL, Mann J, Murrell A, Dovidio JF. Reducing intergroup bias: the benefits of recategorization. J Pers Soc Psychol. 1989;57(2):239‐249.12. Burgess DJ, Fu SS, van Ryn M. Why do providers contribute to disparities and what can be done about it? J Gen Intern Med. November

2004;19(11):1154‐1159.13. Fiske ST, Taylor SE. Social cognition.McGraw‐Hill Series in Social Psychology. 2nd ed. New York, NY, England: McGraw‐Hill Book Co; 1991.14. Mitchell JP, Macrae CN, Banaji MR. Dissociable medial prefrontal contributions to judgments of similar and dissimilar others. Neuron. 2006;50:655‐

663.15. Amodio DM. The social neuroscience of intergroup relations. Eur Rev Soc Psychol. 2008;19:1‐54.16. Frith CD, Frith. Implicit and explicit processes in social cognition. Neuron. 2008;60(3):503‐510.17. Navarrete CD, Olsson A, Ho AK, Mendes WB, Thomsen L, Sidanius J. Fear extinction to an out‐group face: the role of target gender. Psychol

Sci. 2009;20(2):155‐158.18. Phelps EA, O’Connor KJ, Cunningham WA. Performance on indirect measures of race evaluation predicts amygdala activation. J Cogn

Neurosci. 2000;12(5):729‐738.


What’s a Well‐Meaning Health Professional to Do?

This literature also tells us that because conscious and unconscious biases follow different neurological pathways and affect different parts of the brain, efforts to address and mitigate these biases will require different types of interventions. This CME modules offers an array of interventions that health professionals committed to addressing their own biases can try out and hopefully adopt. The suggested approaches focus on both conscious and unconscious biases. However, a greater emphasis has been placed on those interventions that address implicit bias, because it is virtually impossible to act on feelings, attitudes, and behaviors that are outside of one’s conscious awareness until they are brought into awareness.

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Interventions to Address Conscious Bias

Six Interventions to Address Unconscious Bias Acknowledge and Accept Assume Individual Responsibility Engage in Self‐Reflection & and Self‐Assessment Take a Go at the IAT Make Good Use of the Neuroscience Collect and Use Data Effectively & Perform Self‐Monitoring Incorporate Cultural & Linguistic Competence in Your Practice

Unconscious Bias and the Use of Analytics

David Newhouse, MD,MPHAssistant Physician‐in‐Chief ,TPMG

March 12,2013

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The Beginning

MPS ( Member Patient Survey) Project began in 2003 with my own MPS scores

• Noted that I did not score highly with young women

• Recognized my bias toward younger patients

• Got past these bias to create a positive encounter

• Small Change, Big Impact

Patient Age

0

20

40

60

80

100

18-34 35-44 45-64 65+

Scores shown are % Very Good/Excellent (Top 2 Box) for MD/HCP Average = composite measure of five questions related to experience with MD/HCP (health care provider)

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Analytics

New Data FormatReleased once a year in April

Segment Items

Score

Difference ScoreYour Overall Fac/Dept

2009YE 2010YE 2011YE 3-Yr Avg 3-Yr Avg (Your - Fac/Dept)

Familiar Visit 74.8 84.3 88.6 83.4 85.6 -2.2

Unfamiliar Visit 69.2 69.4 61.0 65.7 69.3 -3.6

Under 18 83.6

18 - 34 78.9 72.0 40.0 64.1 70.1 -6.0 ( - )

35 - 44 65.5 87.0 79.3 76.5 76.2 0.3

45 - 64 72.7 83.3 85.6 80.3 80.4 -0.1

65+ 77.9 83.1 88.1 83.5 82.9 0.6

African Amer. 81.3 76.0 85.4 80.1 78.9 1.2

Chinese 62.5 100.0 64.7 76.0 74.0 2.0

Filipino 100.0 100.0 92.3 83.9 8.4 ( + )

Hispanic/Latino 78.3 85.1 81.5 82.2 78.8 3.4

Japanese 100.0 80.0 76.9 78.6 -1.7

Other 40.0 44.8 75.3

Other Asian 70.0 73.9

White 74.5 85.2 85.7 82.6 83.3 -0.7

Female 75.8 82.0 81.6 79.9 78.5 1.4

Male 73.4 85.6 92.8 84.9 82.5 2.4

<1 Yr Tenure 54.8 64.1 65.0 74.8 -9.8 ( - )

1 - 2 Yrs Tenure 47.1 53.3 48.6 78.0 -29.4 ( - - )

3 - 5 Yrs Tenure 88.1 94.7 89.0 77.6 11.4 ( + + )

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Service Score BreakoutSecond Generation Indian Physician

MPS Scores ‐ Race / Ethnicity

50%

55%

60%

65%

70%

75%

80%

85%

90%

95%

Af Amer Chinese Filipino Oth Asian Latino Other White

%

Physician EvaluationImpact Of Demographic Ratios

Hypothetical Case –Two Medicine Department Physicians with identical regional scoresFamiliar Chinese 80%, Familiar White 85.6%, Stranger Chinese 55.7%, Stranger White 68.4%

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Performance Example‐ PartnershipFemale Chinese Physician

MPS Score & % Return visits

0

10

20

30

40

50

60

70

80

90

100

2003

2004

2005

2006

2007

2008

2009

2010

year

sco

res

Service Score

% Returns

Partnersh

ip

Bias, when present, is best identified in the first encounter between

physician and patient. Body language is read in 115 milliseconds.

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African‐American PhysicianIntervention 2006, Focus “Stranger” White

Women

60%

65%

70%

75%

80%

85%

90%

95%

100%

2006 2007 2008

FamWhite

StrWhite

Hayward/Fremont Physician Service Scores over

time by Race/EthnicityGap has closed between Chinese and White (13 points to 5.1 points)

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Q4 05 Q4 06 Q4 07 Q4 08 Q4 09 Q4 10 Q4 11

Af Amer

Chinese

Filipino

Latino

White

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Conclusions

• Data Collection is critical

• Analytic breakdowns of a service score is an effective approach for improvement

• No limit to the complexity of demographic groups added to the program

• Identification of potential unconscious bias by provider and/or patient is possible

• Program now reaches 6,000 physicians



A focus on Self‐Assessment and Self‐Reflection

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While the IAT was developed to research unconscious bias, it is now available to those interested in learning about themselves.

https://implicit.harvard.edu/implicit/demo/background/thescientists.html

TAKE A GO AT THE IAT


Tune into Your Internal Narratives

Practice self‐monitoring and mindfulness

The first component involves the self‐regulation of attention so that it is maintained on immediate experience, thereby allowing for increased recognition of mental events in the present moment.

The second component involves adopting a particular orientation toward one’s experiences in the present moment, an orientation that is characterized by curiosity, openness, and acceptance.



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Tuning into the Outside Narratives

Think about and write down the following for non‐Hispanic White people and one other race or ethnicity:

Name and label the negative and positive images presented in your history books in grades K‐12 (e.g., presidents, founding fathers, criminals, other historical figures);

Name and label the negative and positive images presented in your three favorite television shows when you were in middle or junior high school;



Tuning into the Outside Narratives

Think about and write down the following for non‐Hispanic White people and one other race or ethnicity:

Count the number of times you have seen individuals interviewed or pictured on local television news for stories not related to crimes this week; and

Count the number of times you have seen individuals interviewed or pictured on local television news for stories not related to crimes this week.



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1. Tucker C M, Herman KC, Pedersen TR, Higley B., Montrichard M, Ivery P. Cultural sensitivity in physician‐patient relationships: perspectives of an ethnically diverse sample of low‐income primary care patients.Med Care. July 2003;41(7):859‐870.

2. Cooper LA, Roter DL. Patient‐provider communication: the effect of race and ethnicity on process and outcomes of healthcare. In: Smedley, BD Stith AY, Nelson A.R. eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health CareWashington, DC: Institute of Medicine, National Academies Press; 2003:552‐593.

3. Johnson, RL, Somnath, S, Arbelaez, JJ, Beach, MC, Cooper, LA. Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J Gen Intern Med.February 2004;19(2):101‐110.

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This project was supported by Grant 7 MPCMP111064‐01‐00

from the U.S. Department of Health and Human Services Office of Minority Health (HHS, OMH).

Its contents are solely the responsibility of The Lupus Initiative and its collaborators and do not necessarily represent the

official views of the HHS, OMH.

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