By: James H. Lee
On November 30, a crowd of Mayo employees and students gathered in Phillips Hall to unpack unconscious bias. We were presented with a narrative of four individuals with absurd names – Nin, Goo, Zug, Yak – and then asked to rank these characters from least to most moral. Through a simple single-page story, we began to assign these silly three-letter names with rich character traits and attitudes.
However, as we progressed to morally rank these individuals, we unconsciously (can you see where this is going?) began to assign them other characteristics outside the scope of the story. These personal and moral traits were almost immediately accompanied with preconceptions of gender and age. Nin was easily manipulated and emotionally vulnerable – so we concluded she was a young, helpless woman in distress. Zug was Nin’s ex-lover, clearly a romantically petty and emotionally distant man. Goo, as the name implied, was slimy, sneaky, and underhanded – charmingly slick male con artist. Yak nailed Zug in the schnoz – a classic “dumb jock”.
At the end of the activity, these characters were no longer confined by the words on the page, and our generalizations extended even further than gender. The majority of us matter-of-factly pictured them as young, white, straight, and thin. Why? Because systems larger than ourselves like family, friends, and personal experiences dictated what we think about individuals. Probably the largest influence on our unconscious bias is the media that flits around us daily. Many of us, even people of color, tend to immediately jump to heterosexual white people when placing faces onto characters. The “classics” in our media like Friends, How I Met Your Mother, Titanic, and Casablanca press onto us the narrative that attractive white people make up the majority of the world. The movies and TV that play on screens dictate the appearances of how stories play in our heads.
This activity showed us what our “defaults” look like. If given a characteristic, which gender, race, or sexual orientation comes to mind? We create links between a population’s stereotypes and their external qualities, and this linkage allows us to immediately conjure images of women when we hear the word “emotional” or men when we think “violent.” We consciously know that emotional men and violent women exist, but our minds love taking mental shortcuts to make life simpler.
This activity facilitated an important realization with the audience: we have “defaults.” However, it did not even begin to delve into the uglier and far more pervasive side of unconscious bias. Rarely do we hear about a person without any identifiers and then proceed to make judgments about their external appearance. Rather, the far larger issue with unconscious bias is when we flip this scenario on its head. Far more frequently are we presented with a living person in front of us. From their visible identifiers (e.g. age, race, gender), we make snap judgments and construct their story before the person has opened their mouth. From the color of their skin, we gauge their work ethic. From the clothes they wear, we judge their ability to perform in high-pressure situations. Completely irrelevant aspects of appearance begin to palpably affect an individual’s perceived morality and personality, and we are jarred when our stereotypes of certain populations are disproved.
Unconscious bias is something that we should be actively wrestling with, especially as representatives of healthcare. Personally, I am terrified of my own unconscious biases. As someone who works hard and tries to let my story speak for itself, I realize that the stereotypes I use for others based on their appearance inherently dismiss their unique stories and hard work. As a result, I have been criticizing my own implicit biases and trying to slap them out of me, even though I know they are an inevitable part of being a human. However, through critical thought, we can minimize their effects on how we treat others.
Someone at the event remarked how stereotyping could be a good thing. After all, the world is so chock full of information, and our brain has to come up with immediate associations to prevent mental overload. This is true – animal brains have created incredibly nifty reflexes for it to keep up with all of the thoughts that pass through it in a day. However, surpassing the basic fight-or-flight mentality that we are biologically given is essential to becoming a more compassionate human. We understand that every person comes from a different background and requires unique consideration. Yes, this is mentally exhausting. Yes, we will make mistakes. Yes, this will not be an easy battle to win.
But as healthcare professionals, as people interacting with other people, as human beings, we owe it to each other to work past the basic impulses that our unconscious biases give us. That is the basis of understanding unconscious bias, ensuring that we give the best care to every patient regardless of their walk in life. Understand it, fight it, overcome it.
Repacking Unconscious Bias
By: Domenic F. Fraboni
Well, that’s great! Thanks to the astute observation and reasoning above of my blog managing compadre, James H. Lee (JHL), we all perfectly understand this unconscious bias thing. Right? Now we can repack this bag of oblivious preconceptions and notions and trudge on. Now that we know these biases indeed exist, we’re set. Right?
Wrong! Understanding the complex role that unconscious bias plays in our daily patient-clinician and inter-professional interactions is complicated, maybe only fully understood by PhD’s in neurology and social psychology. The brain circuitry involved in the subconscious development of these processes is definitely beyond my level of educational prowess. So, what are we to do? How can we repack this suitcase in a thoughtful enough way that we may move forward in our daily interaction without the underlying terror that we may insult someone due to our inert biases?
As an aspiring Physical Therapist, and current PT student, I (DFF) tend to revert back to my musculoskeletal and neuromuscularly directed thought process. Because of this, I am going to try hard to convince you all that helping reprogram these unconscious pathways can be accomplished with a similar approach to fixing poor posture. Say I am working with a middle-aged woman (48 years old) who is presenting with severe kyphosis (rounded, “hunched” shoulders) that results in bilateral, radicular pain in both upper extremities. Clearly, the suboptimal nature of this individual’s posture did not appear overnight. It likely developed over the course of 20-30 years of holding her back and neck in an incorrect manner. This disorder needs to be treated in the same way it developed: with years and years of postural and activity change that ultimately results in complete behavioral overhaul of how this patient holds their posture. In my mind, unconscious bias can be handled similarly.
We potentially begin developing these biases as soon as our infantile form begins to walk, talk, and lay down memories. These biases continually ebb and flow as we are exposed to culture, family, media, and the opinions of those closest to us as we (and our brains) grow and develop. This complex web of intertwined experiences and intrinsic thoughts are not unraveled so easily. We must approach this topic in a similar manner to the postural example above. The biases we have developed over our first 20, 30, 40…. 70 years of life may take long, laborious, and conscious efforts during our interactions and thought processes to undo.
Here’s the issue. During patient interviews and examinations, we may only have 5 minutes or so (combined with pre-appointment chart review, if available) to try to get an accurate depiction of the patient scenario. How in the actual heck are we supposed to do this without applying some sort of bias based on our previous experience? My solution: ask. Ask those questions that will help you understand your patient. Their social status. Their sexual orientation. How they are emotionally and mentally dealing with their health situation. Their preferred name or pronoun. Learning styles that may be more optimal for said patient. Don’t assume. Ask. Once you feel you have an accurate depiction of the human being sitting in front of you, only then should we dive into their symptoms, diagnosis, or medical complication. From here on out, the two of us (JHL and DFF) challenge you all. Let’s make the unconscious conscious and repack our bags.
Acknowledgements: A huge thank you goes out to Leslie Wallenfeldt for presenting the “Two Islands” story and beginning a dialogue surrounding unconscious biases. Another shout-out to the Office for Diversity and Inclusion for hosting the event.
JHL is a first year student in the Mayo Clinic School of Medicine pursuing Pediatrics or Child and Adolescent Psychiatry. He loves eating all kinds of food, jogging when it is not icy outside, and rock climbing with his friends. He can be reached at firstname.lastname@example.org.
DFF is a second year DPT student in the Mayo Clinic School of Health Sciences. He has been a student blog manager for just as long and is looking forward to having some snow on the ground for fat tire biking, snow shoeing, and cross country/downhill skiing.