 On behalf of the McLean Center and the University of Chicago Trauma Center, it's a pleasure to welcome you to our 20th lecture in the lecture series on ethical issues in violence, trauma, and trauma surgery. It's my pleasure also to introduce to you today's speaker, Dr. Diel Heider. Dr. Heider is a trauma and acute care surgeon and also an expert in public health and health services research. Currently, he's the Kessler Director of the Center for Surgery and Public Health, which is a joint initiative of the Brigham and Women's Hospital, the Harvard Medical School, and the Harvard School of Public Health. Before joining the faculty at the Brigham, Dr. Heider was the Director of the Center for Surgery Trials and Outcomes Research at Johns Hopkins University. Dr. Heider has published more than 250 peer-reviewed papers. His work has greatly advanced the study of inequities in health outcomes, and he has been credited with creating the field of trauma disparities research. He's focused on understanding mechanisms that lead to disparities in outcomes after surgery and trauma, as well as on developing clinical and educational solutions to reduce disparities and improve outcomes. A recent paper of Dr. Heider's In the Annals of Surgery reported on disparities and rates of surgical intervention among racial and ethnic minorities in Medicare-accountable care organizations, that is, these ACOs. Dr. Heider serves as the Deputy Editor of JAMA Surgery and is the President of the Association for Academic Surgery. This past year, he was awarded the Ellis Island Medal of Honor for his service and work toward eliminating health care inequality. Dr. Heider's talk today is entitled, as you see behind me, Impact of Physician Unconscious Biases on Patient Care. Please join me in giving Dr. Heider a warm welcome. Thank you so much for that very kind introduction. Can everybody hear me okay? So I do have some financial disclosures and some of these organizations have funded parts of the research that you'll see, but they never have controlled what we've studied or what we're going to present to you. It truly is a privilege to be here today. This is a picture from your website and today I got to be in your beautiful library, but more important than the nice wood paneling and everything that's up there was the discussion that we had. I mean, many of the fellows were there and I really learned a lot and even got a signed book from you, so thank you so much for that. I really learned a lot today. I'd also like to, before I begin, acknowledge, you mentioned that I am the Kessler director of the CSPH. Well, the founding director of the CSPH is sitting right there, that's Selvon Rogers, who started the CSPH by Mark Zinner and stuff at the Brigham, so I have big shoes to fill figuratively and in reality as well, because you're much more taller than me. So what I'm hoping to do today is to talk about unconscious bias and its impact on clinician care and then not just talk about biases, but some of the work that we're doing to move forward and actually do something about the potential impact of unconscious biases. Now, somebody mentioned that they have a Twitter account here, right, and so I always love to start my talks with this thing, equality is the cornerstone of medicine. I'm sure many people here would agree with that. So if any of you do a tweet, this is one that you might consider tweeting. I wanted to start with this first paper, really. This is from the New England Journal of Medicine, 1977, and this paper shows that if you happen to be a minority at Johns Hopkins Hospital, this is an institution I used to work at, and you need to get a hernia fixed or if you're getting an open gallbladder, of course back then in the 50s and 60s, which is the 20-year time span from where this data is, in the 50s and 60s, you could only get an open gallbladder, right? And if you happen to be black, you would get operated on by one of the residents. And if you happen to be white, you'd get operated on by a fully qualified surgeon, right? Even if you had insurance, and it turns out that back in the day, the only kind of insurance you could have had in Maryland is Blue Cross Blue Shield, you still were more likely to be operated on by a surgical resident if you happen to be black, right? Now those disparities continue in 2018, here just a small example of healthcare disparities in surgery, which we all have heard about, right? But trauma we thought would be immune, right? You're about to open a new trauma center here at the University of Chicago. You're not going to look at, right, you're not going to look at who's coming in, you're not going to be checking insurance at the door. Trauma is supposed to be, or emergency care is supposed to be, color-blind. So why would there ever be disparities in trauma care? Now nearly 10 years ago, we did begin to find some data on this. We saw one study where they looked at young children and found that kids in the inner city who happened to be black got less of a workup and observation period after a head injury, right, compared to kids in the suburbs who most were white. So if you were a little kid, a nine-year-old, you fell off something on a playground. You seemed to be oozy after you get up. You go to the hospital, you get a CAT scan, you get a workup. If you're a black kid in the inner city, you get a pat on your back and you're sent home, right? So that's kind of what this data was suggesting. So for our first study on racial differences in outcomes, we actually looked at traumatic brain injury amongst kids, and we wanted to identify if there were functional and outcome differences amongst little kids who had severe traumatic brain injury. And in this study, we looked at the National Pediatric Trauma Registry and we analyzed about 7,000 very severely injured kids, 4,000 white, 1,200 black, and about 1,000 white, right? And what we found was is that black children didn't have a difference in mortality, but they had a difference in functional outcomes. So the red line is the reference group. These are white children. These are black children. And they had an increased odds in their disabilities at discharge, in their ability to eat on their own, in their ability to walk on their own, and their ability to talk, right? Now, when you have this kind of data, as a clinician, you immediately think about patients that you may have taken care of, right? And this young lady came to the hospital where I used to work. Now more than 10 years ago, I actually remember the date very well. It was August 11, 2006. And the reason why I remember the date is because it was the first time I was on call as a trauma attending the very first time. Dr. Wilson, you remember the very first time you were on call, right? Yeah, you do. A little longer than that, right? So anyway, she comes in, and she's tachycardic, and her blood pressure is low. We take her right up to the OR. She becomes briefly pulseless, aorta cross-clamped, had a bad IVC injury fixed at, had multiple bowel injuries, left her in discontinuity, three take-backs to the OR, back and forth, back and forth, finally got closed out of the ICU on post-op day number 12, and now on the floor, two weeks later, refusing all care. So Dr. Siegler, this is my first case as a trauma attending, right? I've spent all my life training to be able to take care of this young woman. And she doesn't want anything to do with us. You go talk to her, she's like, get out of here, right? So who are some surgical residents in the room? How would that make you feel? Be honest, you're sad, disappointed, frustrated, right? How about you, sir? You feel it, right? And remember, this woman got like 40 units of blood, and it was my first-ever case ever, right? And she doesn't want anything to do with us. It turns out that there was a lot more to this story, right? This young woman was actually in a hostage situation, where there was a, you know, she was taken into a convenience store, shots fired from the police and the, I guess, person who was taking her into the convenience store. And she got hit, and he got hit too. He was brought into the emergency department at the same time, like a minute later. It was my first day on call, and it was like a scene out of the movies, Dr. Siegel, right? She comes in, tachycardic, hypotensive. Let's go to the OR. The surgical chief resident goes to the OR with her. I stay with the other guy. He needs to go to the OR as well, rush upstairs with him. He codes on the table, open up his chest, cross-clamp his aorta. The chief resident from the other room comes running that she's crashing as well. At that moment in time, my partner, Elliot Houtt, shows up. He's like, what are you doing? I'm like, what do you think I'm doing? Anyway, Elliot takes over that case. I go over to this young lady. Turns out that that person survives as well. He has very severe injuries. He's in ICU at the same time she is. I mean, we knew all that had happened, right? But I didn't give her the benefit of the doubt, right? As her doctor, I failed her. You know, what was happening to her, I guess I'm missing a slide, what was happening to her is that she was having an early form of PTSD, right? That whenever somebody would talk to her, she felt like this whole thing was happening all over again. All she remembered was getting shot and the pain that she had. And so she just didn't want to deal with it. And only after spending time with her did we figure this out. We tried to get a psychiatric consult at one point. The psych fellows started asking questions that had nothing to do with her injury or her. So she got upset at that, right? And we basically failed her because we thought, we didn't realize where she was coming from. She was a little kid who got shot, right? But because she came from a community where violence is endemic, nobody was willing to think of that for her. By the way, this newspaper headline that you see here, I just generated this on Google because like here in Chicago, a young girl getting shot is not gonna make the news, right? Now, when we published that work that I started off with, you know, some people liked it. I got some awards and so on. That's me, 10, 12 years ago. I used to look much younger and much more smiley, as you can see in that picture. But some people were very unhappy and wrote letters to the editor like this. That just studying the idea of racial disparities, especially in trauma care, is not fair and counterproductive, right? And see what they say. And insult to those who take care of injured children, right? Now, of course, in response, that's Eddie Cornwell who was my mentor and remains my mentor, in response, we wrote back saying that, listen, before we impugn anybody else, we're looking at ourselves. We all take care of minority patients at trauma centers. And so if we're saying this about anybody that maybe the care is different, we're saying that about ourselves first. And that's how we need to start this discussion. But what happened after all this hubula of starting talking about racial disparity and so on, is that we said that we'd really need to bring the best possible science. And so we were like, is this all about race or is there more about socioeconomic status? And so for our next paper, we looked at the impact of insurance status as a poor predictor of socioeconomic status. Now remember, this is 10 years ago, this is before Obamacare and so on. And we used the National Trauma Databank which had even at that point 1.5 million patients in it and more than 700 trauma centers at that point were contributing to the National Trauma Databank. Nowadays to be a trauma center, you must contribute to the National Trauma Databank and you will of course hear, you're already working on that. And this is what we found. This is the reference group, this group here. These are white patients who have insurance, okay? So compare these white patients who have insurance to black patients who also have insurance and they just happen to be black. They're similarly injured. 20% more likely to die. Just because you happen to be black. 50% more likely if you happen to be Hispanic. And then if you are not insured, white insured versus white not insured about 50% increase odds, at least that's the association we found. And then if you're a minority and not insured, you see it goes even higher, right? Now this data got a lot of press, right? And so when you talked about the, you know, building the field of trauma disparities, that's where this all really started, right? And after this, we created the National Disparities Working Group and of course Dr. Rogers was quite heavily involved, you know, when he was at Brigham back at the time. And one of the things we did with that group was to do a meta-analysis and to push the field forward. Worked with lots of folks who were doing these kinds of studies and analyses. And you'll see that multiple authors published and looked at similar data looking at disparities in trauma outcomes and you'll note that, again, even on the meta-analysis, it's about a 20, 19%, 20% increase odds of death if you happen to be black after traumatic injury. Now when we were presented with this data, we said, well, what are we gonna do about this? Right? And so what we did is we tried to plot all the possible mechanisms that lead to disparities in trauma outcomes and then tried to sequentially study each and every one of them. And so when I talk, I'm gonna talk about unconscious bias, that's where this comes from. It's just one thing that we're talking about and amongst a whole suite of things that we've tried to study. And I wanna give credit just like we saw some brilliant ethics fellows today. There are a myriad number of fellows who were just fantastic and really tackled the methodologic questions that needed to be answered in order to do this kind of work. So the one thing I wanna talk about, specifically, mechanism-wise, is this thing about unconscious bias. I mean, do we treat people differently because of the way they look or do we just care about that x-ray? And you can see that x-ray, can people see it a big open book pelvis fracture, right? Does it make a difference if the person is white or black? Now, I'm sure many of you have heard of this concept of unconscious preference, right? That maybe we don't know that we're treating people differently, right? This whole issue of implicit bias. And there's been a lot of work on unconscious bias because of this thing called the Implicit Association Test or the IAT. How many people have heard of it, right? So maybe 30, 40% of the people in this room have heard of it, right? And it's a computerized test of cognition and it helps you figure out if you have a preference towards one thing versus the other at an unconscious level, right? And you can do it for black versus white. You can do it for fat versus non-fat. And if you really wanna have a lot of fun, you can go to implicit.edu and try doing one of the political one, Democrat versus Republican. You might find some interesting things about yourself, right? Now it works basically on word pairing, right? And so if you have these faces here on the computer and you're very fast at pairing these faces with these bad words and then taking these white faces and pairing them with good words, you have an unconscious preference towards whites. That's how this test works, right? And similarly, if you had all these European American faces and you hooked them up with these bad words, much faster than you did with these good words, you would have an unconscious bias against whites. Does that make sense to everybody? That's how it works. Now, as most surgeons, I was very skeptical when I first heard of the IAT. I was like, ah, this is not real. You could probably trick it or whatever. But turns out that there are many meta-analyses that show that this actually works, right? And they have collected data on about one million Americans. Okay, this is all self-reported. People go to www.implicit.edu and they wanna do this test to find out about themselves. Similarly, those Facebook personality tests that millions of people have taken, right? And this is what they found, okay? Can somebody actually help me here? You help me come down here. Can you help me? Can you add that up? 27 plus 27, how much is that? 54. And then 16? 60%. 70%. 70%, right, 70%. Good round of applause for you and your math skills. So 70%, and I want you to remember that number, right? 70% of Americans have an unconscious bias against blacks. And about 17% have no preference. Now if you show this to a social psychologist, they would say, why is that surprising? People have a preference towards people who look like them. The country is about to do third white, if not more. So this should not be surprising if you ask a social psychologist that's what they'd say. But the question is, do these unconscious preferences impact how we take care of patients? And it turns out that there are multiple medical studies that suggest that it does. Specifically studies done by, for example, Lisa Cooper. And what she did, what Lisa Cooper did, is that she gave the IAT to multiple dozens of family practice doctors. And then she recorded the conversations that she had, that those doctors had with patients. And turns out that when she analyzed the transcripts, her team found that doctors who had unconscious biases against black patients, when they talk with patients, they talk down at the black patients. They did not give them opportunity to speak much. They didn't elicit their opinions. Essentially they didn't provide patient centered care compared to the white patients. That's what Dr. Cooper really found in her work. And so we were concerned that this idea of unconscious bias and how it might impact in the trauma world maybe even more important. Because you know, when does trauma happen? Typically trauma happens at night. What happens to the providers when it's nighttime? They're tired. You have less cognitive luxury, right? You have less time to give people the benefit of doubt. You're more likely to stereotype. In fact, we teach people stereotyping, right? Remember that case I showed you, heart rate high, blood pressure low, go to the OR, right? We teach stereotyping more or less. And so we were worried that in the trauma world, because of these factors, it's more likely that unconscious bias may play a difference. And so for our first study, we looked at unconscious preferences amongst medical students, right? So we went all the way back to medical students. And this is what we found, right? This is about 200 medical students from Johns Hopkins. And this is their unconscious preference, explicit here in green, compared to their implicit preference. And if you add these up, these three bars, they're unconscious preferences. This, you know, I'm sorry, I misspoke there. The explicit is what they're explicitly saying. So 50% of them say that they don't prefer anybody. They prefer everybody the same. And the blue here is their unconscious preference, or their implicit preference. If you add these bars up about 20%, about 30%, and about another 20% or so, you'll notice that those medical students, 70% of them had an unconscious preference towards whites, just like the general population, right? So these superstar medical students are just like everybody else, as far as their preferences go. Even though explicitly, and there's specific ways in which we ask about explicit preferences, even though explicitly, they say that they treat everybody the same. Does that make sense to everybody? This is one of the key slides. That's why I wanted to, and I'm sorry, I messed it up a tiny bit, so I just want to make sure I've made it. You're good with it? As long as you're good with it, then I'm fine. All right, good, all right. Now, did this impact how they would assess patients? So then we took those IIT scores of people, but before we took their IIT, we actually gave them clinical scenarios, right? And then we went back to see if they treated, in the clinical scenarios, either would have a white patient or a black patient, and we randomly gave them a black patient or a white patient. And these clinical scenarios turns out that they treated black and white patients nearly the same on almost every assessment that they did. So unlike the medical doctors, in this work we found that medical students had unconscious preferences, but that did not impact how they would make clinical assessments. So then we said, okay, well maybe it's something happens after they get trained. So let's go ahead and look at surgical residents, right? So we did this amongst residents, and if those graphs look similar, it's because they are very similar. Look at the unconscious preferences for unconscious race preferences for surgical residents. If you add that up, again, nearly 70% of surgical residents had an unconscious preference towards whites. In this work, we actually went a step further, and we actually built an implicit association test for social class. And we did that for social class over here, and you'll see that many residents actively said that they prefer the higher social class, right? And that's probably not surprising, right? You went to medical school, now you're becoming a surgeon, you think you're gonna drive a real fancy car like Dr. Wilson there, and that's what you want to be able to do, right? And so now the question was, does this impact unconscious, or does this impact clinical decision making? And we did multiple clinical vignettes, and we found that like the medical students, these unconscious preferences for both social class and race, none of them impacted how they would treat the patients. So then we said, okay, maybe it's our nursing colleagues. I mean, that's where this comes from. Maybe the difference is in maybe the way nurses treat patients. And if you're looking at the slides and saying, hey, didn't you just show me a similar slide? Yeah, it's because the nurses unconscious preferences for both race and social class were nearly the same, right? So then we said, okay, well maybe it's coming from the top. Maybe it's not the medical students, residents, nurses, maybe it's the surgical attendings, right? And so for our next study, we looked at surgical attendings. Now, everybody in this study is a double board certified surgeon, member of the Eastern Association for Surgery of Trauma. There are 240 surgeons or so who responded to this computer-based survey. And just to let you know, it's like a half an hour survey, almost maybe 20 minutes, I'm sorry. And you log in, you first have to do the clinical scenarios and then you get the IAT, right? And by the way, like I'm nowhere mentioned or anybody who does healthcare disparities is nowhere mentioned so that we don't give away what this is for, right? In fact, the email comes from Peter Pronovost and Elliot Hout who are healthcare safety experts and because we built the whole thing behind safety, that's what we were trying to do. And if you're wondering how did we get surgeons to do a 20 minute survey? It was an Amazon.com gift card of $200. And it was oversubscribed, yeah, it was oversubscribed within like a week, right? Immediately, the Amazon.com gift cards work. But if you're looking at those slides and saying, hey, didn't you just show me those slides? Yeah, it was nearly identical again that unconscious preferences were there, but it didn't impact how we treated patients. And so now after we did this work, the chair of medicine at Hopkins where I worked called me and said, I'd love for you to give a grand rounds in which you explain why the surgeons are different than the medical doctors. Like what is it? Why do you think surgeons are different than medical doctors? And if you think about it, and of course I talked a lot about this with Lisa Cooper whose medical work showed that there was an impact. I think what happens is that when you have more protocolized care, when the decisions are fairly straightforward, right? It's easy to just follow those decisions. And maybe that's why at least on clinical vignettes, we did not pick up the impact of unconscious bias on how people would assess patients, right? Or just make decisions for patients. But maybe when you really need to develop a close relationship with your patient, when you need to consent them about a complex surgical operation, when you need to manage their pain, when you need to really understand why they were having PTSD, when you need to do what I should have been able to do with that young girl, that's probably where unconscious biases come in, right? And make a difference in how we care for patients. Now, another way to look at it is maybe it's not unconscious bias at all. And maybe it's a different thing. Maybe it's this thing called in-group favoritism. Where if somebody looks like you, you can relate to them better, you might do more for them. And because you did more for them, it makes a difference. You remember that first X-ray I showed you up on the front with the open book public fracture? That happened to be a white kid, right? And he was a kid, that's why I'm calling him a kid, right? And turns out that I noticed on rounds I would always go to his room last. And the reason why I'd go to his room last is because I'd always spend more time in his room. Now, why did I spend more time in his room? Is because he's white? Or it's because his parents always had very interesting things to talk about, right? His dad was an architect and he built this, like when he went home with that public fracture, he built this whole thing for him to go there. He also had the coolest video games. And I'd go there and play with them sometimes, right? And so was that me being biased or was that me just enjoying the company of this patient's family? And just kind of not even thinking about the fact that I always would end up going there. It's also, they were a little bit farther away because they were in a special wing. But that's another thing that might be operationalizing here. Now, I've talked a lot about how clinician unconscious biases and so on may impact how we take care of patients. But I wanna switch gears a minute here so that I can give you some good and more uplifting news, okay? Now, since we've been working with several colleagues from around the country on impacting surgical disparities, a group from the American College of Surgeons was formed called the American College Surgeons Committee on Optal Access and that became the American College of Surgeons Committee on Healthcare Disparities. And that committee has worked with the NIH to come up with a national research action plan for healthcare disparities. And the main thing that that group did was about three years ago, they held this summit on the science and the symposium on surgical disparities research. And that summit brought together folks from around the country and it came up with a research agenda for surgical disparities research. And one of the top things on that research agenda, in fact, the number one thing on that research agenda was improving patient provider communication through culturally dexterous care, right? Now, what is this concept of cultural dexterity, right? Now, many of you have heard, who's heard of cultural competency, right? Everybody's heard of cultural competency, right? And that's a very nice definition of cultural competency by Bettengourt at all, right? But my issue with cultural competency and it's with the issue of competency, not Dr. Bettengourt, and that is that this implies that you should be able to be tested for competence in some field, right? So how are you gonna be competent in 60 different cultures, right? You're taking care of so many different diverse patients, right? And how can you be competent without really living in another person's culture? And that's why we think of this idea of cultural dexterity, where we're saying that instead of trying for you to be knowledgeable about everybody else's culture, which in fact may lead to stereotyping, saying that everybody who looks a certain way is gonna act a certain way, how about we give you tools so that you can really provide patient-centered care no matter what that person's culture is and wherever they're coming from. And for this, we've created this thing called the PACS work, the Provider Awareness and Cultural Dexterity Toolkit for Surgeons. So we're actually trying to build a toolkit that surgeons can use to be more culturally dexterous. We've done some work doing this. We started actually with doing qualitative research where we asked both patients and surgeons about what they thought they needed to learn to have in that kind of a toolkit to be more culturally dexterous. We brought all that qualitative research to a big workshop and then came up with what we are calling the PACS curriculum. And just to give you an idea of what those qualitative themes look like, what I have here is some comments that the residents made and then I show how that leads to the curriculum learning goals of the PACS program. So this is the first one. I'll give you the next one here. Even with a good interpreter, there's something lost. We found that many residents didn't really know how to work with an interpreter. Look at this statement about pain. Certain patients handle pain a certain way. It's a short but heavily loaded statement, right? And that's why we thought managing pain is something we really need to get a better handle on. And then about informed consent. And I want you to read this one. Look at that. If you don't get them involved in the management, they will just agree with what you're offering. Essentially, if you trick the patient and not tell them what they're gonna get, they'll agree to what surgery you want to perform, right? And so that's why informed consent we felt was very, very important. And so we have those four learning modules and we teach them with the concept of the major themes of cross-culture care, which are curiosity, respect, and empathy. The reason why we think it's important for surgeons to be curious is that, if a patient makes a decision about some treatment that you're offering and you don't think it's the right decision or you don't understand it, unless we're truly curious about why they're making that decision, we can't help them get to the place they need to be. Unless we truly respect their point of view, right? And we've had some sessions with our surgical residents in pilot testing this. For example, our patients who are Jehovah's Witness, unless you truly believe that your attitude towards blood donation is not superior to their attitude towards blood donation, unless you truly respect where they're coming from, you can't be able to move forward with the patient. And then third, empathy, right? And so we think that if we teach those four concepts through the lens of these three items, we'd be able to improve the cultural dexterity of our surgical residents. And so this is kind of the module that we have. We're designed a new curriculum and now we hope to test them by a randomized trial and then eventually expand them to the American College of Surgeons. I'll give you a very quick, just brief overview of how they work. We have four modules, then they go into a skills assessment and then they do a teaching osky. That's kind of how the way we've set this up. And I'll just give you an idea of how the curriculum works. So first, for example, if this was about limited English proficiency, we would give them some facts about limited English proficiency. We talk about the kind of model through which limited English proficiency may lead to problems, right? And then we present a scenario in case and then we have questions for discussion about that case. And by the way, this was all designed not by just surgeons and not just by curriculum experts, but actually we had lots of patients in the room when we designed it. And for the assessment, the patients recommended that instead of us just assessing them on a test or something, we should have an expert patient see them interact with another patient and then determine if they are able to follow the tenets of culturally at extra care. That great idea came from a patient, didn't come from one of us. That's why it's necessary to have patients in the room when we're developing it. So this is where we are for the evaluation piece. We've submitted a grant and we have two groups, an intervention group that's gonna get a pre-test and you can see how it is. But that's kind of where we are. We've gotten a good score on the grant. We hopefully will hear about it very soon. And if it moves forward, we'll be doing it at eight large academic medical centers. So just in closing, I can't take you enough for allowing me to be here and I wanted to share this very nice checklist from Augustus White, who's one of the most amazing people that I've ever met. He's an orthopedic surgeon and he wrote a beautiful book about called Seeing Patients, one of the first people to really introduce the concept of unconscious bias. And this is a checklist he did with some of his colleagues about how to improve cross-cultural communication and I just wanna leave you with that and leave that up there as I close. So thank you very much. The writers talk, it's looking for questions and comments. Way up in the back. Bios in the society. We're all bias in a different ways than most of the problem of the world. I'm sure you agree from bias of this group against that group. Yeah, the best major part with the people who are bias as you said of are unconscious. They do not know it. And the most important way is how do you treat this social illness? Because how do you approach it like I was several decades ago in Oak Ridge, Tennessee to learn about ice and dope and I worked with a couple of doctors and we were very friendly. But during the coffee time, and it just was only an anonymous standing over there so once I asked one of my friend how many times did I come here and we are all separate. He said because you were an order. I'm over an interest. But I saw, I felt that he is ill rather than I am. We worked together for about a month on ice and dope at the end of the afternoon and he said you really are a good man. You're a nice person, so believe in me. I was. What I am saying is that you need to find to reach and bring attention to the way you bring the interaction with the patient and relation to all others. 50 years ago there was a holdout for women here in medical school. Many places only accept that kind of stuff. Men were not vicious, they were just prejudice. Now today, even through their own dignity and integrity, through, that they are equal. And now we have more than 50% men. So the treatment I think is not too necessary. It's like pneumonia. If you're trying to kill people and insult them, you got pneumonia, you're not a man. But you have to find ways to prove that the person is not correct, that you, this is unfair, and let the person learn that it is prejudice, that you sit unconscious, just like the sabbatist would aim to our attention, that he really has to work hard and treated that way. What do you think of this method? I think you've got the mic. You want to start? I think that your method has very interesting ideas about it. But I was quite moved by the kind of data that Dr. Heider presented us on implicit bias, the range of implicit bias, the impact and effects of implicit bias. And presumably the study that is currently being reviewed and has gotten high marks may be a way to generate data, which I think we need to move further in this area. I think that's going to be extremely important. The other comment I wanted to make, and I'm sorry that Dr. Peek is not in town, but she's written a series of wonderful papers on the difficulties of shared decision-making in African American patients. And you've pointed to some of them in your studies. And I'm concerned that it's not going to be the easiest thing to overcome some of the implicit problems that you've identified and those that Monica Peek has also in regard to shared decision-making. Yes, please wait for the mic. So thank you for the talk. It was great and I really like the cultural dexterity because I've always chafed about cultural competence. Even when I ran a course at county about cultural competence, I hated the name of it for pediatric residents. When you talked about the implicit bias in the nurses and the residents and the attendings, but not finding it in the clinical vignettes, I think that's because it was clinical vignettes. And so that's explicit. You're describing the amount of pain and it's easy to ignore black or white or Hispanic. You've told us how much pain they're in because it's a clinical vignette and we believe you. We may or not believe the patient in front of us, but we believe you and so we're gonna treat that patient for pain. And I would bet with no data that if you'd reviewed transcripts like the family practice study, you would have found just as much bias in each of those groups as the family practice study had. I think it's an explicit test. So the explicit bias takes over and in a relationship, the implicit bias takes over. So I agree with what you're suggesting and I don't think that we can use these data to say that there's no association being unconscious bias and how clinicians will take care of patients. I do think my hunch is that it works more in a situation where there's just like what you said, where there's room for a physician to have to make a decision where there's some clinical ambiguity. There's probably more room there for it to operationalize and that effect how we're gonna do something. We did have a study that we proposed where we would videotape trauma resuscitations and look at pain management and thought of that as a kind of model to study this. And I'll tell you something very interesting happened when I moved from one institution to another. In one institution where I worked, the stereotypical young black patient was somebody who was shot in an area that was endemic with violence. Anyway, it went to another place where there was much less penetrating trauma. The last few young African-American patients that I took care of all happened to be kids who were on their bicycle going home from college or something like that. And so the way they were perceived in the emergency department seemed to be very different to me compared to how we were perceiving other patients. And it all had to do with the local culture and local context of what was going on. And so you're right, we do need to study this in much more detail. The reason why I have this thing still up there is because no matter what way this is working, if we can come up with ways to mitigate the impact, true or not of unconscious preferences or even explicit preferences, we'll be providing better care. And that's why I've been working towards moving towards solutions now. Thank you. Me? Yeah. Yes. Thank you for being here. Your talk was wonderful. Being in the library earlier was great. And I really appreciate the work that you're doing, mainly because of the questions that you're asking. You had mentioned the simulation that you're going to start doing with residents, is that correct? Is that falling under the pretense of a score curriculum also? Or is that independent of the score curriculum, the surgical council, yeah? Sure. So the question really relates to, if this training is successful, will we be able to disseminate it through the American Board of Surgery? Right. And the answer is yes, we're very fortunate that on the expert advisory panel for this trial that I have just mentioned, the American Board of Surgery Executive Director is one of the experts on it. And so the idea is that if this trial shows that it works at date-large medical centers in a rigorous way, and by the way, the outcome measures that we're looking at is not just surgical resident skills on an OSCE, but actually the outcome measures we're hoping to look at is real patient-centered outcomes. So what we're planning to do is that we will take photographs of the patients, I'm sorry, of the surgical residents to patients, and we'll ask them, is this your doctor? Is this resident taking care of you? And if they are able to identify, yes, this is the person I've interacted with a lot, she comes on rounds every morning, he has been here to take out my drains, then we'll ask them about how their interactions were with that patient. And that's the outcome measure we're looking for. Let me tell you about a study that Dr. Vinnie O'Rourke did here, goes back about six or eight years, there was a recognition with regard to inpatient services that patients just couldn't tell the difference among medical students, residents, attendings. Many of them wore similar outfits and long white coats. And so Dr. O'Rourke set up in each patient's room a picture frame that held pictures of the attending, the resident, residents, and the one or two students with names and identified their position. She then went back to see if patients could better identify who the different people were. And the answer was no, there was no difference. So watch out for that study and look up her work, O'Rourke. Thank you. In the, I guess, if I followed you there, you could demonstrate bias in, let's say, in house staff, in based on decisions that were made and then I guess various training programs are being thought about or being instituted to try and change some of that. Was there any discussion with individual people, house staff, to see if they were aware themselves of a bias? Were they aware of the thinking? I mean, your title was that this is unconscious. I don't know if you mean that in the strictest sense of unconscious. But was there any effort to find out if these people were aware of the thinking that was actually very important in the way they were conducting themselves professionally in their decision making? And if that was done, at least with some, was there any attempt to see if that changed by bringing attention to this by whatever training programs or so forth that they were exposed to? So thank you for asking that question. I did show about four slides with the qualitative research questions that we asked surgical residents in building the PACS curriculum. And so we ask folks what they thought they needed to learn before we developed a curriculum. And then last year, we pilot tested it at three academic medical centers to generate data for this large study that we're doing. And we then didn't do any large assessments because they're small sample size, but we did focus groups discussions on this. And it was very amazing to see what the focus group discussions brought up when we tried to assess it. The work has been published in the Journal of Surgical Education and Riya Udaver is the first author on that work. And what Riya's focus groups show is that the residents really were surprised at the candidness in which they were able to discuss this and about their own feelings and felt like this was a kind of new thing that they got to talk about in a kind of structured way because they could talk about things where, well, I need to make sure I have a interpreter when I'm taking care of a patient who has limited English proficiency. But how do I do that? And they all know that they're cutting corners, but when they start and talk about it, they're like, okay, well, we're all cutting corners. Maybe we should do something about it. So then they together came up with the plan of how they're gonna fix this issue and fix this problem. And so just that empowerment of the residents to bring them together through just discussion seemed to be one of the most important things that was happening through this curriculum. More than anything, that description was the most important thing. You're giving them an opportunity in a setting in which to realize something about their own thinking. I really liked your talk and I love the idea of doing standardized patients for this and giving people the time to talk about it. But I'm looking at your last point, just hold your institutionals accountable. And I'm thinking to do this at an institutional level versus just the surgical residents becomes time and money prohibitive, at least the way we do standardized patients and what we pay standardized patients. And I think it becomes an issue. I mean, pain management at this institution has reached an all time craziness because we've got national shortages and it has impacted us of all opioids. And so I have to have a nurse tell me that the patient's in pain. So if they have a bias, I have to then call a pharmacist or an anesthesiologist or somebody else to even get approval to give it. So there's potential bias there. And I worry that there's bias because there's some institutions in the city that aren't having this problem and there's other institutions that are. And is it because of how we've decided to buy medical supplies? And is that yet another bias because of who our population is versus other populations in the city? I don't know. So I love your idea, but we need to something to make it an institutional. So Tracy, you're gonna be very happy to hear this. So we'll zoom out from this individual doctor patient to now a macro level and go right to the American College of Surgeons which has been working with the National Quality Forum on building what are called disparity sensitive metrics for surgical care. This is a R01 grant that was funded through that same mechanism that I talked about that came from the NIH ACS conference. And the PI on this grant is LD Britt who's one of the joint commissioners. And the idea here is that we are developing metrics. It's a three-step process. We have done a literature review of all potential quality metrics that are out there like pain management and hundreds of others across all surgical specialties. We're then testing them for what are called disparity sensitivity. And the National Quality Forum has this great formula by which they've come up with. We've actually modified that formula for surgery. And then the next step will be testing them using surgical outcome metrics that we have from NISCWIP and other areas, Medicare data, et cetera. And that way we'll come up with a suite of metrics we hope that institutions can, that can be used to hold institutions accountable and then have the force with folks like LD Britt and David Hoyt and others from Chicago to then hopefully make that into an enforcement mechanism that you need to publish these results on your disparity sensitivity, your metrics. And then if you're doing poorly for one group of people, you'll have the opportunity to improve it. So that's where we're going with that. Hannah and then you. I have a microphone. Hi, I'm Hannah. I'm one of the medicine residents. You brought up this, I learned some new terms today too. The cultural dexterity one I really like. You brought up the cognitive luxury term. And I was curious if you could define that further. And then I'm wondering like from your perspective, how would one as a provider optimize your time in cognitive luxury to minimize your implicit biases or your unconscious biases? That seems to be the ideal, my sense of that term is that you want to live in a cognitively luxurious place, but on a daily basis in my care of patients, I don't think I do that. So the idea here is where do you find cognitive overload, right? So for example, when you're post-call and tired, do you ever feel like you're a little bit less tolerant of something? Yes. All right, I think we all feel that way, right? And so now you are post-call and tired and you have a thousand things coming at you, right? You're gonna have less time to process all of those things and less processing power to process all those things. And so that's where our automatic stereotyping starts happening, more and more, right? Now if you have more time, then you're able to really think through why is this person acting this way? You can look through the lens of curiosity, you can look through the lens of respect and empathy, right? And that's where we need to go. Now you might say, well, how are we gonna do this? I have 50 patients in my clinic that I have to take care of, right? But there must be a way and there will be a way and I'll give you a very brief example. 20 years ago, if you needed to get, if you're a woman who had a lump in your breast and you needed to get an assessment for potential breast cancer and treatment, what would happen? You'd go, you'd get a two-minute consult for a likely male, from a likely male surgeon who didn't think you had much of a problem because it's a very simple operation, right? And that was that. Not lots of choices, not much of anything. Now, I'm sure the University of Chicago Breast Center must be a beautiful place where people get at minimum the first consult of 50 to 60 minutes, right? And so time has changed because we demanded that this is how care for breast cancer needs to be delivered to women, right? And I think that's where we need to move forward. If we can identify these problems, then we can create mechanisms to actually solve them. But the first step is, of course, identifying. With relationship to that one-on-one with patients but we also know nationally there's concerns with physician burnout and much of that is that depersonalization, work overload, these kinds of issues that are rampant that start in medical school and progress all the way through practice. I'm concerned that those issues will only accentuate these concerns, the time constraints, fatigue, depersonalization. And I don't know if you've given any thought to that but I do think that that's an important part of this because it speaks to that luxury, the luxury of time and being able to frame and be able to put it into perspective. I don't know if you've given that any thought or if you have any observations with regard to that. When we look at it institutionally and as a society, how we care for patients. So I'll give some anecdotal response to that. I read a very nice article in the New York Times just a couple of days ago where there are lots of physicians leaving large academic medical centers because of the burnout issue and moving towards concierge medicine. That's what this story was about because in concierge medicine, they're able to provide a lot more luxurious time, lots more care, a lot more satisfaction. That old country doctor knowing their patient, the patient having their cell phone, kind of a very nice story is what they're moving towards. And whereas that may be difficult to see how we're gonna get there, I really do believe that there are definitely mechanisms to ensure that we're able to do that. And that might require rearrangement of the physician workforce, the way we actually provide care. That might require going to different alternate payment models to achieve this. But if we keep true North patient-centered care and being able to do all these things that are up on that checklist, then we can get there. We just need to make a commitment that we wanna move in that direction. That's right. Whoa. I guess I'm sitting too close. Thank you for coming. One of the things that I actually enjoy about reading your articles and where you came from specifically in Baltimore, you're in an ivory tower, but you're not in an ivory tower. You're studying at the street level as you demonstrated with the 16-year-old female. I actually used to go to church on Wolf Street before Hopkins bought up the entire block. So I know exactly what you're surrounded by is very similar to this. But I also know being from Baltimore that when you read this story, the 16-year-old girl, I think of myself as being a 16-year-old in Baltimore. And at this point in time, being pinch-dragged by the police when my white Jewish friend is standing next to me and you don't even look his direction, being accused of slashing a tire on a town that's on a car that's all the way on the other side of the city, right? Because I fit a description. Freddie Gray, right? So this is now 40 years after I was at age. So now you're 16 years of age and you're strapped in a crucifix and the majority of the faces of the institutions are still white. So when you talk about biases, I'm wondering, a lot of us will come to these situations, not trusting, potentially angry. And a lot of things are happening around us that it feels a lot like the community outside. You're doing things that I'm sitting here. So when the 16-year-old girl wakes up, a lot of this may be attributed to post-traumatic stress disorder, but have you ever studied or maybe you consider studying it from an angle of the implicit bias of the patient who now interacts with the person from rural Indiana who's an NRA member? Because they may not be getting the best patient care because they're actually prohibitive of getting the best patient care because they're bringing their own bias from their life experience versus someone else's experience. Have you ever looked at that intersection for the trauma patient? So I mentioned Dr. Cornwell earlier who remains one of my closest friends and mentors. And we've had situations where, just like you described, the young African-American male patient is on the gurney and some poor interaction is happening between the patient and the non-black, let's put it this way, healthcare provider. And Dr. Cornwell always would explain that whenever this will happen, it is the worst day for that person on the stretcher and they would probably do anything to change places with you, right? So no matter what happens, and however they react, you cannot, may not, and will not respond inappropriately and that you must be a professional taking care of it. I know that doesn't answer your question, Dr. Wilson, because I don't know how to answer that question. I haven't done studies and have related with patients. I once did try to create a violence prevention program by doing a 12-step harm reduction kind of thing, just like you have for alcohol interventions. And I'll tell you what happened. We tried to build this program and we did interviews of patients who had been involved with violence circumstances and the patients said a very simple thing. The simple thing was that we would like, when we do these meetings, you know, we're gonna do this intervention thing, we should do it at the hospital because the hospital is a safe place and we'll feel respected that we're coming into this ivory tower, as you said, and we're gonna have this discussion about our healthcare and how we're gonna prevent future acts of violence. And that study, despite getting funded, never got off the ground because the IRB and then security was concerned about bringing patients with violent pasts inside the hospital and then said that we would have to do a, we would have to, people would have to go through a metal detector before, you know, we got them all together in a room. I said, okay, once you do that for everybody who goes into the cancer center, you could do it to our trauma patients too. But those are the, yeah, but those biases are there and it's a lot of work, yeah. And unfortunately, it never got off the ground but it would be very interesting to see. What I don't know is, and the reason why we're focusing on patient provider interactions here and metrics for disparities and so on is because as physicians, we feel like we can impact those. There's a lot to be fixed in society and we wanna contribute to that but these things are in front of us that we can make a difference to, I think, today and that's why at least we've been focusing on those. We'll take one last question up in the back though, please. This is slightly similar to the previous one. Since the issue here, the ultimate issue is successful care of patients. It's crucial, the work that you're doing on uncovering the bias. However, I'm reminded of recent reading where we found that, or people doing the studies have found that African-American men are dying way faster than white Americans, that African-American women are having much more problematic childbearing experiences. So my only question is, are you, how do you add that into this research so that, even for example, your case of the 16-year-old who you suddenly discover has all this other stuff, how does the, whatever it is that's happening in people's previous lives, how is it that that is going to be part of this research so that something is found about that as well as the implicit bias that medical providers have? Well, the first step towards doing that is incorporating the patient's needs, values, and ideas into the research process. And a lot of great work has been done by the Patient-Centered Outcomes Research Institute to promote that. And one reason why we're hopeful that this PACS curriculum would work is because it was partly designed and built by patients and that the folks who are gonna do the assessments are going to be patients. And so I'm not sure this fully addresses your question, but I think that's the first step that we can do, which is to really bring patients in as true partners, not just for lip service, having them on a board, and not really contributing, but actually having them as true partners in designing these studies and evaluating these studies with them in mind. And I must give props. I mean, I know I talked about my previous institution a lot, but both Hopkins and the place where I work right now, Brigham, they've done a lot to encourage patient-centered care. And more importantly, the fact that somebody asked me earlier today, and maybe I'll just finish up with this, Dr. Siegler, that, you know, why do you do this work? The reason why I do this work is because I remain very hopeful that in a country like ours, we've had a long history, but we've made progress. And we sometimes make a lot of progress and then take a couple of steps backwards, and it might feel like that right now. But we continue to make progress over the long arc of history. And that by doing stuff, each one of us, if we can contribute towards this work, we will make those incremental differences that eventually over time will hopefully mitigate disparities. So thank you very much. Thank you.