Whether we are displaying it or experiencing it, implicit bias is an unavoidable part of life, according to Stephanie L. Graff, MD, FACP, director of breast oncology at the Lifespan Cancer Institute. Thoughts and feelings are considered “implicit” if we are unaware of them, or if we are mistaken about their true nature. This type of bias is rampant in the healthcare community, but when mitigated through diversifying staff and giving everyone a voice, patients receive better care, cancer centers become more successful and profitable, and members of the healthcare team challenge and confront their own implicit biases.
According to Dr Graff, who spoke at the AONN+ 13th Annual Navigation & Survivorship Conference held in November, we have a bias when, rather than being neutral, we have a preference for (or aversion to) a person or group of people. Thus, we use the term “implicit bias” to describe when we have attitudes toward people or associate stereotypes with them, without our conscious knowledge. A common example of implicit bias is evidenced in research: studies consistently show that White people associate criminality with Black people, without even realizing that they are doing it.
Science has found that most human actions occur without conscious thought. But while implicit bias may be inevitable, it can be mitigated when we are better able to identify it.
“Our implicit biases predict behavior more accurately than our conscious values,” said Dr Graff. “Most of what we do just happens; we don’t stop and think about it.”
Implicit Bias Is Fact
When it comes to implicit bias, the burden of proof has been met and, in fact, exceeded. “Implicit bias is undoubtedly prevalent in our interactions with our patients and with our colleagues,” said Dr Graff.
To illustrate, she provided several examples of implicit bias. The ways in which it harms patients might include:
- White women are more likely to be given breast biopsy results in the office, whereas Black women are more likely to be given those results over the phone
- White women are more likely to have a breast biopsy scheduled within 24 to 48 hours after being told their mammogram results are not normal, whereas Black women are more likely to be told some version of: “let’s just see what progresses”
- Black women have a 40% higher death rate from breast cancer (even after correcting for other factors), and Black women younger than 50 years are twice as likely as White women to die of breast cancer
Ways in which it harms other members of the care team are evidenced by:
- Lower-wage jobs in healthcare are disproportionately held by Black laborers, and approximately twice as many Black female healthcare workers earn less than $15/hour compared with White workers
- Black female healthcare workers are 9 times more likely to live in public housing, 3 times more likely to use food stamps, and twice as likely to be uninsured or use Medicaid
- Racial discrimination is an emerging risk factor for disease, decreasing the health of the entire care team
“Implicit bias harms,” said Dr Graff. “But the good news is, you can measure your own implicit bias, self-reflect, and learn how to be stronger and do better.”
While racial and gender biases might be the first to come to mind for many people, a multitude of unconscious stereotypes can also be measured, including biases related to disability, parenting, political leanings, vaccine status (especially prevalent in the past several years), religion, weight, and age.
The Implicit Association Test(s) are accessible online at https://implicit.harvard.edu/implicit/.
Mitigating Unconscious Bias
“But how do you change what you’re not aware you are doing?” Dr Graff asked. “Mitigating unconscious bias is hard, but science helps us learn how to do better.”
First, remember that practice makes perfect. A case study out of the University of Wisconsin–Madison divided departments into 2 groups: one group participated in a 2.5-hour gender-bias habit-changing workshop, and the other did not. The group that did the training increased female science, technology, engineering, mathematics, and medicine faculty hiring by 18%.
“This dramatic increase in the number of female faculty tells us that things as simple as education, learning, and engagement can help us learn to mitigate bias,” she said.
Cancer centers can address implicit bias in the workplace by bringing in consultants and invited lecturers, encouraging their staff to attend trainings on implicit bias, and promoting self-education (eg, books, podcasts, TED Talks).
Hiring smarter and stronger might look like enforcing term limits for leaders, she added.
“Rotational leadership gives everyone an opportunity to rise within the organization and creates opportunities for fresh ideas to come in,” she said. “When that’s the business plan, there are no hurt feelings.”
Find New Examples
Studies have shown that counterstereotypes can reduce prejudicial thinking while expanding flexible thinking.
“If I asked everyone to close their eyes and picture a president or CEO, chances are they’d picture a White man, because historically that’s what they look like,” she explained. “But the more we find and expose ourselves to counterstereotypes—people in those roles who don’t fit those descriptions—the more we expand our thinking.”
A male nurse, a female physician, or Barack Obama are all examples of counterstereotypes. These stereotypes can be challenged and considered in everything from hiring and promoting new faculty and staff (how can diversity be introduced to a pool of candidates?), inviting lecturers (consider someone metastatic vs cancer-free, or someone disabled vs young and healthy), what plays on a waiting room television (consider the Spanish news station instead of the local news station), and the art on your walls (does it reflect all of your patients or only some of them?).
Change the Picture
Pictures tell stories and evoke emotions. Consider whether you are portraying an image that does not represent the lived experience of many individuals.
“When I search for images of ‘breast cancer,’ I have to ask: Are all women with breast cancer supposed to be strong? Are all women with breast cancer supposed to have a built-in, happy support network? I don’t think that’s the universal experience of my patients with breast cancer,” she said. “Not all of our survivors rally around ‘Pink Ribbon’ culture.”
She noted that the images associated with cancer centers should be carefully and sensitively chosen, as they can introduce a form of bias. Some of the women in these photos might be smiling and happy, while others are serious; some are in groups, while others are alone; the majority are women, while very few (if any) are men.
“Who is chosen for which picture, and how does that change the tone of the image and the root of the message?” she asked. “It’s important that we’re thoughtful about how we represent what our patients see and how we think about the cancer experience when we’re selecting images for our cancer centers.”
Improve Collective Competency
A 2018 study on patient–physician gender concordance showed that women who presented to the emergency department with heart attacks and were cared for by male physicians had a higher mortality than men cared for by male physicians or women cared for by female physicians. However, male physicians with more exposure to female physician partners had more success treating their female patients.
“This tells us that collective competence can be improved by diversity,” she said. “Being surrounded by people who are not like us can help us learn to better take care of people who are not like us. That can apply to us as cancer specialists, as well.”
Research has also demonstrated that when diversity is improved within an organization, financial performance improves. “This is just fact,” she said. “Diversity is a competitive differentiator; it makes us better.”
According to Dr Graff, the “magic number” when it comes to diversity is about 30%. This number represents a critical mass, when minority group voices start being heard and having a representative voice. “It’s important that we try to hit that target, rather than just practicing tokenism,” she pointed out.
In their efforts toward workplace diversity, it is important that organizations consider alternative viewpoints, embrace heterogeneous thinking, and shift from complacency.
“This inspires us all to use clearer communications, and to work toward consensus building, which is a great way to build the best cancer programs,” said Dr Graff. “Ultimately, it broadens the perspective of our cancer center, which will result in the best care for all of our patients, as well as our colleagues.”
She concluded by offering her best “life hack” for use at the table: try “Brain Writing,” instead of Brainstorming. Have each person at the table write down 3 solutions to the problem at hand. This can elevate the quieter voices (that may be dampened by those of more confident extroverts), while diversifying the voices at the table and allowing every idea to be heard.
Thoughts on Compassionate Care from the AONN+ Blog
Compassion Starts with You
Mary Buffington, MSN, RN, OCN, ONN-CG, CLC
