Overcoming Implicit Bias to Deliver Better Care

Saturday, December 1, my husband lost his very best friend. His name was Rob K. Berry. He was his best friend for literally 52 years. They met each other in the fifth grade.

They talked almost every single day. They texted, and in modern times, I swear, every time I turned around, they were communicating in some kind of way. If they were Black women, they would be Oprah and Gayle. They covered everything.

They’re from Detroit, so they talked about the Red Wings. They talked about the Tigers. They talked about Aretha. They talked about work and politics, children, marriage, divorce, marriage, divorce and marriage again.

There’s so much that I could say about my Rob and his best friend, Rob K. Berry. But what I really want you to know is that when we lost our dear family friend, we knew that he left this world feeling fully accepted, feeling fully appreciated and with a strong sense of belonging.

Everybody, all of us, as we just heard, should have somebody who is so irrationally crazy about us. Someone who knows every single thing about us. They understand our hopes, our dreams, our failures, our missed opportunities, our crash landings and what made all of that make sense for us.

The fact is, the more we see, the more we understand and the more information we have, the harder it is to judge.

So this idea of belonging becomes really important. I just want to shout out john a. powell, who has really helped us center this conversation around belonging. This idea of acceptance, of being a natural member of a group, this fundamental emotional need that we have to be in relationship with each other.

What I want to add to that is what it really means to be seen, to be understood and not be judged. That is also critical with respect to belonging.

Imagine someone steals a loaf of bread. We can quickly make a rash judgment and say, “Oh, well, she’s just a thief.” When we find out that maybe she’s trying to feed her family, that quick judgment may turn into empathy, maybe even compassion.

So imagine the two Robs knowing each other for 52 years and the kind of information they had about each other. It was really hard to pass judgment. Their brains were filled with so much information, knowing all of those histories, hopes and dreams. It made it much more difficult not to root for each other and not to love each other unconditionally.

How do our brains make meaning?

When we talk about belonging, we’re talking about this idea that human beings are trying to use each other and groups to make sense of the world. We know that at the end of life, that’s what we want. We don’t want to be seen only for all of our accomplishments and failures. We want to be understood in this way.

What also makes us human is not just the fact that we will all die, even though our ends of life will be different, but the fact that our brains are also hardwired in some very interesting ways.

Some of us have learned not to see each other and to judge each other very quickly because of how our brains are wired, particularly with respect to race, which is what I want to center today.

Some of us will have an end of life that is far different from many others. That means some of us will have an end of life that will be less human.

Before I go into some of the key studies I want to explore, I thought I would create an experience for all of us in the room so that we understand how our unconscious brains operate.

Can you all see the slide up here? I want you to state the color of the text together. It’s a group exercise, okay?

We can do better. Good morning.

Okay, great. We’re going to start again. Ready? Go.

Oh my gosh, what happened?

We have a lot of work to do before we get to our ends of life. We just said, “State the color of the text.” What happened? Anyone want to tell me what happened? When did it get messed up?

When the word “red” was in the color black, it got harder, right? Because your brain was completely primed.

When I asked you to state the color of the text, and the colors were aligned with the words, every time you read them, they were consistent, what we call schema-consistent. You were able to stay on beat.

The minute it flipped, the minute some bit of information was inconsistent with how your brain wanted to see it, it became harder to do.

Why is that?

Our brains process 11 million bits of information unconsciously in the same amount of time that we process about 40 bits of information consciously.

In order for us to move very quickly and navigate through the day, we have to create what are called schemas, these mental structures that help us process information efficiently and consistently.

Part of what we’re trying to do is create these quick categories so that we can move through the world.

Think about the schemas that we create about people. Those are called stereotypes. Stereotypes embedded in our brains, particularly negative stereotypes, are what we call implicit bias. They are automatic, instant associations, oftentimes without our conscious awareness.

But I would say that we can actually be conscious of what our implicit biases are and still have a hard time overriding them. You still had a hard time overriding them.

How did your brain feel once you realized what was going on? It felt a little off, right? A little confused.

Most of us believe in fairness. We believe that we are treating each other as equals. Upwards of 90 percent of Americans believe in the equality of race and gender, and yet we see the outcomes. We see disparities in outcomes, particularly in healthcare, but also in education, criminal justice, politics and so many other realms.

We also believe in this idea of the fairness paradox, the idea that we can believe ourselves to be fair and yet not see outcomes that align with our values.

We raise this question: Perhaps the way we’ve been taught to practice fairness is flawed. It isn’t that we aren’t fair, but perhaps we’ve been taught to consider fairness in an incorrect way.

Many of us in the post-Civil Rights generation have been taught that we’re supposed to be colorblind. We’re not supposed to notice race at all. When we do, our brains get a little bit nervous.

We’ve been taught that we can be fully objective in how we evaluate and see people, and yet sometimes we make mistakes in that evaluation.

So what does that mean for end-of-life care and medicine more broadly?

There has been so much work around understanding how biases affect patient care. It seems that doctors do fairly well in terms of diagnosing a patient. Yet when they prescribe the treatment that may be best for that patient, biases can come into play.

Perceptions of a person of color, whom they may think will be less compliant or may not follow a pill regimen, can affect their decisions. They may recommend more invasive surgeries at the end of life.

In fact, Black patients tend to receive more intensive treatments during the last six months of their lives than white patients. They’re more likely to die in the ICU than white patients.

What does that mean? What does that mean for us and for how our biases operate? How does it interact with other social and psychological phenomena that could be incredibly important?

Racial anxiety is the idea that our automatic brains recognize the fact that they may be noticing race. But when our brains notice it, how do we actually engage across race and across racial interactions?

Racial anxiety is a physiological stress response that we often experience during cross-racial interactions. If you are a person of color, you may be concerned about discrimination, hostility or invalidation.

“You don’t really know what you’re talking about.”

“My pain feels like this.”

“I’m not really sure that’s what you mean,” says the doctor.

People who are white may fear that what they say to a patient, or vice versa, may be perceived as biased. So they may pull their punches in how they engage.

Racial anxiety can show up as shorter interactions. If I have a high degree of anxiety, I’m not going to want to spend a lot of time with you. I may even want to avoid the situation altogether.

It can lead to awkward connections. A patient comes in really wanting to have a conversation with their doctor about something critically important to them, and in an effort to make that patient feel better, something completely awkward comes out, like, “Hey, did you see Black Panther?”

“Well, actually, Doc, I wanted to talk about this really critical thing that was happening to me.”

I call it the brain on fire because our brains are literally going into fight-or-flight mode. We are so concerned about navigating the interaction that it turns into a cognitive shutdown, and it becomes really, really hard to override.

Whenever we experience anxiety, we’re more concerned with managing our own anxiety than with being able to see and acknowledge what is happening in front of us.

Black patients report worse communication with their physicians. That patient-doctor communication at the end of life explains a lot of the studies that I just discussed.

Doctors display fewer positive, rapport-building cues. They aren’t able to engage in the same ways. Bias is not just about how we articulate things verbally. It also shows up in our body language. When you see that body language, you also have a response to it.

That leads me to another phenomenon that we think is critical to connect to this work, which is called stereotype threat.

It seems that we all know the stereotypes about our social identity groups. I know the stereotypes about gender and women. I know what they are for being a Black woman. I know what they are for being a New Yorker. I get it all.

I understand that there are all these ways in which I have to show up and present myself that may challenge or reinforce the way someone sees me.

Patients can experience stereotype threat as well. When we’re in a situation where we’re worried about how we are being seen, it triggers our brain into a process of trying to compensate for it and fix it in the other person’s mind.

This is a direct quote from a patient who was at the end of his life and engaging with his doctor. He said, “You know, I just think there’s some kind of prejudice. There’s just a lack of respect, and they think they can get away with it because here’s just another dumb Mexican.”

Imagine that at the end of your life, you are not seen, and you are being judged in such a quick way that you feel it. You feel like you have to overcome it in someone else’s eyes.

You don’t have the luxury of spending your final moments, days or weeks focusing on what you need to feel as though you’ve lived your best life and that you can end well. Instead, you’re managing the anxieties, stereotypes and group identities that are coming through for other groups.

Imagine a doctor who has implicit bias and is making those quick judgments, who then has racial anxiety and engages in a shorter interaction. They aren’t eliciting the right information. The patient then responds by withholding or not wanting to adhere to the treatment plan before them.

That’s the risk we experience when we don’t address the kinds of bias, anxiety and stereotype threat that exist, not just in medicine, but across many sectors.

We do have the capacity to end well, but we have to start well.

When children are between two and five, they’re just learning how to navigate difference. They’re learning how to understand what makes us unique. What color skin does she have? What does her hair look like? How does she speak? Does she have an accent? Where does she live?

All those things are meaningful because they’re helping children differentiate and make meaning. But in many senses, they’re benign. They’re simply ways to describe.

Between five and eight, our children begin learning stereotypes, traits that are connected to social groups. They’re taking in the media.

As much as we think our wonderful children’s programming may offer a broadly diverse way of thinking about things, we’re actually seeing a lot of what I call colorblind diversity, where everybody is the same, but they just look different.

We aren’t creating the meaning that we need to navigate difference. We aren’t building that muscle to help us see each other and to help us be seen.

Between eight and 10, those stereotypes are hardening. They’re hardening in a way that teaches us hierarchy, a hierarchy of human value.

Then, from 10 to 100, we’re told to unlearn all of those stereotypes.

When you think about what it means to end well, for me, it means that we have to build a practice of learning how to live well.

I want to suggest that we actually can override these unconscious processes.

I want us to take the Stroop test again. This is the exact same test. Do you know what the secret is? There is no secret.

But I want you to really focus. I want you not to read the words.

Okay, go.

Give yourselves a round of applause.

What we just did was override our unconscious networks. We took our time. We were slow. We were focused. We were intentional. We did not make quick judgments. We allowed each color to be seen and recognized for the beautiful primary color that it was.

For us, this is the building block of belonging.

How do we create respect and individuation, that practice of recognizing someone’s social identity because it is meaningful, while also recognizing the unique individual they are?

How do we challenge ourselves to have conversations that may feel uncomfortable? How do we have those conversations in a way that allows us to focus on the experience the other person is having, as opposed to the anxiety it is causing us?

How do we do it with a bit of kindness, in a way that challenges us to resolve this paradox at the end of life so that we are all comfortable doing what I believe the Gospel according to Matthew asks us to do, which is, “Judge not, lest ye be judged”?

The more information we have about each other, the more focus we can build. The practice, starting from two to 100, of knowing what makes each individual tick will help us see one another as human and will help us end well.

Thank you.

Voice