Thank you. It really is such a pleasure to be here and to see these wonderful emerging leaders. Fantastic. It's good to be here. I think we're going to have some fun. Let's have some fun. All right? We're going to be here for a little over an hour. Let's have some fun together, but I think that you'll find some of this very useful to you. So, by way of introduction, I'm Quinn Capers. I am a professor and interventional cardiologist at University of Texas Southwestern. Okay. So, with that, we'll go ahead and get started. And I'll start with a question that you're probably, if I try to read your mind, a question that you probably have on your mind, and that is, you know, there's a lot of talk about implicit bias mitigation, a lot of talk about implicit bias mitigation workshops, but does it work? Is there a reason for it? Is it worth the investment? And there is some evidence that it does. So, starting from the top and going down, Molly Carnes and her group at University of Wisconsin did a randomized trial, if you will, a randomized trial of academic internal medicine departments, where they randomized those departments to either having a two-and-a-half-hour implicit bias mitigation workshop or not. And what they found was that several months after it, the departments that had the workshop on a survey had higher senses of inclusion and a climate where women and minorities were valued. Next is Gerard in academic medicine. They looked at the impact of a 20-minute intervention. Can you spare 20 minutes? A 20-minute intervention that was designed to break the bias that many of us have that leadership means men, not women. So this 20-minute intervention led to lasting feelings of inclusion and that they were valued amongst women in the departments that had the workshop. Next, we've got some data, and we can talk about this, where we trained an admissions committee, a medical school admissions committee, and bias mitigation strategies, and what we found was that the next class was the most diverse class ever at the Ohio State University College of Medicine. And then finally, Devine and Associates, again, back at University of Wisconsin, they've done a lot of work in this area, another randomized evaluation of academic STEM departments, so science, technology, engineering, medicine, and math, and this was designed to have strategies to help us overcome gender biases. What were the results six and 12 months after the departments that had the workshop had hired more women? So I know as you listen to those outcomes, some of them might sound a little soft, soft outcomes, but some of them are pretty good. Admitting more minorities to medical school, hiring more women engineers, I'll take that. So if your question is, does bias mitigation, quote, unquote, work, just wanted to start off by saying there is some evidence that, yes, it can. So I'm going to show you some photographs now, and I ask the question, which makes you feel comfortable? I'm going to show you some of these photos, and it is likely, it's likely that you're going to look at some of them, and there will be an automatic, unconscious, comfortable feeling that you have deep down in your psyche. And there may be others, there may be, that make you feel uncomfortable. It has everything to do, though, with exposure. How have you been exposed? If I show you a picture of someone who looks like someone that you've always had good opportunities with, warm interactions, then just like a deep tendon reflex, when you see someone who looks like that, there's a feeling of safety and comfort. On the other hand, if I show you a picture that looks like someone that you've had bad experiences with, or you might not have even had to have personally bad experiences with this person, if this person is always the bad guy in the movie, or always on the 6 o'clock news being shown in a negative way, then your unconscious mind might have a negative association with that. So which of these makes you feel comfortable? Which makes you feel uncomfortable? And exposure is everything. So we're going to come back to those pictures at the end. But first a word about implicit bias. As you likely know, we all have them. It really is just how the brain works. So as I say in a lot of the workshops we give, you're not allowed to feel guilty about any unconscious bias that you have, or if you've taken a test that shows you have a bias against this group or that group, guilt is not allowed. It's just how the brain works. So we all have them. It turns out you can find out what yours are. You can find out what your unconscious associations are. Many of you have likely taken the implicit association test. You should know it's not the only one, but it is the one that's been maybe the most widely studied and validated. It turns out the results on the implicit association test have been associated with discriminatory behaviors in the healthcare system, in the criminal justice system, and in the education system. So it's not just a fun little computer game. The results of that computer game might have implications, but that is implications if we do nothing, but of course we're interventional cardiologists. We're not in the do-nothing business. We're in the do-something business, right? We see something and we intervene. So these associations that could be negative, I ask you, what do they come from? If I, in my mind, have an association of a certain demographic group with negative characteristics, what does that come from? Where does it come from? All around us. And let me show you some examples, some fun, some not so fun. So the credit for this photo goes to my good friend, Dr. Sharon Hayes, a cardiologist at the Mayo Clinic. She was getting on a flight in Delta, and they were advertising through posters a new app that they have. And this new app allows you to track your flights on a multi-stop flight, but just as importantly, it allows you to track the location of your luggage. So if you wind up in your destination city, maybe this happened to some people in the room this trip, if you wind up in your destination city and your luggage isn't there, you can at least look on your phone and see where your luggage was mistakenly sent. So what is the benefit? What's the benefit of that app? This poster is telling you. The benefit of that app is if your meeting is rescheduled, you can change your flight plans, or if your flight's running late, you can reschedule the meeting. That's the benefit. That's the benefit, apparently, if you're a man. If you're a woman, the benefit is you get to keep an eye on your favorite shoes. So where are they? Where are my Jimmy Choo's? What city did they wind up in? I need my shoes, right? So you know what makes me chuckle a little bit when I see this is that they actually went out of their way to show some diversity, didn't they? So the woman is Asian, across the aisle is an African-American couple, so they were probably patting themselves on the back, saying, oh, we're so woke. You know, we did a good job with this campaign, and they completely missed that they are really reinforcing this stereotype that men are thinking about their meetings, and women are thinking about what am I going to wear? Where do these associations come from? Where do these associations come from? You're looking at here. This is a picture I took from a Twitter page. The Twitter page, the person took the photo in Savannah, Georgia. In Savannah, Georgia, there was a billboard, and I think it's still up. I don't know if it's still up. I've been using this so long, it might have gotten back to me. They might have taken the billboard down by now. But the billboard has on it three white males wearing surgical caps and masks. The only print on the billboard says all cardiothoracic surgeons look like this. So I know you're probably thinking, what? What are they selling? What's the purpose of this billboard? And that's not true. And there's an answer to that. But what I'd rather have you think about is the little girl that lives across the street who sees this every day on the way to school. Or for that matter, the little boy of color who sees this every day on the way to school. It is possible that seeing images like this that send a similar message might result in that little girl, or that little boy of color, the idea of being a cardiothoracic surgeon will never enter because this is what the world has been telling them. Where do these associations come from? Next I'm going to show you a video. And I didn't think about it, does our, can I ask, is our audio piped through these speakers or is it going to come from this laptop? Okay. All right, good. So I'm going to show you a video and I'll set the stage for you. This is an actual news clip from Chicago. Anybody here from Chicago? No? Okay. Well, Chicago's having problems, as we know, with gun violence. A lot of homicide. They're almost number one in the nation. A lot of times, much of it is on the black side of town and it's very often a black person shooting and killing another black person. So there's been a shooting here. This is not a reenactment. This is the news clip. So after the shooting, the journalists are interviewing bystanders. One of the bystanders is a four-year-old little boy. I want you to listen closely to what you hear the four-year-old little boy say. And I also want you to listen to what you hear the anchor say at the end of the clip. Okay? So there's been a shooting. This is a news clip that played on a local news station in Chicago. Meantime, two teenagers are wounded on the city's south side. It happened at East 74th. There's an 18-year-old man and 16-year-old girl were hit while standing on the sidewalk. Male's in good condition while the girl's expecting to recover. And kids on the street, as young as four, were there to see it all unfold and had a disturbing reaction. No, I'm not scared of nothing. When you get older, are you going to stay away from all these guns? No. No? No. What do you want to do when you get older? I'm going to have me a gun. Because I live right here and I don't want none of my family members to get shot. Okay, so what did you hear the little boy say? I'm going to get me a gun. Right? So he just saw a shooting. His response is, I'm going to get me a gun. And did he say it kind of shy and timid and bashful or did he kind of have some swagger? Like, I'm going to get me a gun, right? So think for a moment about, and then, you know, you might have heard the anchor say at the end of the clip, and I think it's more powerful that you don't actually see the anchor, you just hear the voice. He said, that is very scary indeed. So in case you don't know how to feel about it, he's telling you, you should be scared about what you just saw. And I'd like you to think about how that might make you feel, both in your conscious mind and your unconscious mind, about that side of town, right? You want to drive through the side of town with a four-year-old or have guns? And if we're honest, how it makes you feel about those people, right? What's wrong with them? Is it in their DNA? I mean, this little boy just saw somebody get shot. That's not what a white little boy would do. A white little boy would be hugging Mommy, saying, Mommy, I'm scared. But this black little boy is saying, I'm going to get me a gun. Think about that. And as you think about that, let me show you the very same interview, the very same little boy, but this time, a little different perspective. That's why I like the hair. You ain't scared of nothing. Damn. When you get older, you going to stay away from all these guns? No. No? No. What do you want to do when you get older? I'm going to have me a gun. You are? Why you want to do that? I'm going to be the police. Okay. Well, then you can have one. So what he was saying was, I'm going to have a gun because I'm going to protect my neighborhood from this kind of crime because I'm going to be a police officer. But some editor at that news station saw fit to cut it right after he said, I'm going to get me a gun, cut it right there and use that in the clip that's played to, really, millions in the Chicagoland area. And I know you have some feelings about that. I know you probably want to interview that editor, don't you? Me too. But rather than think about that, I'd rather have you think about the impact that has on both our conscious mind and our unconscious mind when we see that over and over and over again. If we see it enough, our unconscious mind will start to tell us this is the truth about the world in which we live. Let me give you one last example. So I'm going to go backwards here, if this will allow me. Yeah. OK. So let's go to New Orleans at the time of Hurricane Katrina, when, as you might remember, much of the city of New Orleans was underwater. And some people who survived the hurricane died of starvation. Because if you remember reading about that, the Federal Emergency Management Administration was very late in coming. So some people were found, had died of starvation in their homes. Some people decided to take matters into their own hands. And what you see here is on the same day, August 30th, August 30th, these photographs went out on the Associated Press with an accompanying caption. The one up top with a black person says a young man walks through chest deep floodwater after looting a grocery store. The one at the bottom says two residents with two white people says two residents wade through chest deep water after finding bread and soda. So think about those verbs, looting versus finding. Aren't they doing the same thing? And think about the impact that has on your unconscious mind. One of the things that I point out here that, again, makes me chuckle, if this weren't so sad, is it says that they found the bread and soda from a local grocery store. They found it at the grocery store. Isn't that nice? Yeah. I'd like to go find the Lexus at the Lexus dealer, but it's described as finding as opposed to looting. Think about the differences in those words and the connotations that they carry. And so the point I want to make is that if you were a newborn child and I was in charge, say, I'm in charge. You're all newborns. I'm in charge of every image you see. You don't get to see any image, but what I decide to show you and what I decide to show you is the images I've just shown you on the loop over and over and over again. What would your unconscious mind think is the truth about the world in which you live? Your unconscious mind would think that men think about their meetings while women think about their wardrobe. Women are not cardiothoracic surgeons. Black people loot while white people find, and that black male equals danger. And here's the most important point that Dr. Smith and I can share with you today. You don't have to be a so-called bad person for your unconscious mind to have these associations. You just have to be somebody who grew up in the United States with your eyes open, seeing the images that are all around us. Well, physicians are not immune. Janice Saban and colleagues showed that back in 2009 when they tapped into that database at projectimplicit.org. That's where they do the implicit association test and keep the data, and if you've ever taken one of those tests, you know that they ask you a few things about yourself. It's anonymous, but they do ask you a few things like your demographic. They ask you your occupation. So what they did is they tapped into that database and they looked at the results on the black-white implicit association test. On that black-white implicit association test, you can get three different results. You can get a result that shows you have what's called implicit white race preference, which means unconsciously you associate a white person's face with good things, family, joy, love, et cetera. This is unconscious now. Unconsciously associate a black person's face with negative things, pain, fear, violence, misery, danger, et cetera. All unconscious. So you can have implicit white race preference, or you can have the opposite implicit black race preference, or you can be neutral. So those are the three results you can get on this test. They tapped into this test. They were interested to see the results for those who said their occupation was physician versus everyone else. And if we start with the everyone else group, and by the way, this is millions of test takers, so a lot of data, in the non-physician group, the proportion of people with the result of either moderate or strong implicit white race preference, 70%. So seven out of 10. It's almost ubiquitous. Would you like to guess what proportion of physicians had implicit white race preference? 70%. So there was no difference between physicians and non-physicians in this unconscious association of white people with good things and black people with bad things. Now, again, this is all unconscious. But what you and I really want to know is, does this have anything to do with our decision-making when we're doing what we love doing, taking care of patients? There is some evidence that it does. So here's a publication in 2007 where actually the subjects of this experiment were residents. These were internal medicine and emergency medicine residents at four different programs, two in Boston and two in Atlanta. I don't know if they were thinking let's get some Yankees and let's get some Southerners, but that's how they picked the residents. They had those residents take the implicit association test. And then they had them participate in some clinical vignettes about acute myocardial infarction. They didn't tell them the purpose of the study. They said the purpose of the study is to see if you're up to date on your treatments of acute stimming. Half of those residents, they all saw a vignette. The vignette described somebody having a heart attack. But the vignette came with a photograph. And so half of the residents saw a photograph of a black man having a heart attack. The other half saw a photograph of a white man having a heart attack. But the vignette was the same. And it was that Mr. T is a 50-year-old male smoker with hypertension who presents to the ED having a heart attack. It went on to say, it went on to describe the EKG, ST elevation in the anterior leads. An internal medicine or emergency medicine resident would recognize that this patient's having an anterior stimming. It then goes on to say you do not have access to a cath lab, but you do have access to thrombolytic therapy. Would you give this patient thrombolytic therapy? The residents were less likely to treat the black man with thrombolytic therapy. When the researchers looked at all the data they had on those residents, everything they had in their database, and did some sophisticated statistical analyses to see what was the strongest predictor of the decision not to treat the black man. It was the resident's implicit negative bias about black people. So this is a hint, it's just a hint that what could be happening out there is that you or I see a patient because of what we see. Gender, race, skin tone, obese or not obese, age, our perception of their religion. That if we have a negative association with what this person looks like, it's possible that that could influence how we treat patients. And I know you find that unacceptable. We all find that unacceptable. Sky finds that unacceptable. And that's why we're here today. Let me give you another study because that one was a simulation. Let's take it to real life. So let's, we'll leave the cardiologist's office, leave the emergency room, leave the cath lab, let's go to the office. But let's go, we're going today to see the cancer doctor. So I want you to imagine that you have a diagnosis of cancer and you're going to see your oncologist today. You're already, right, on pins and needles. You're already very anxious. What are they going to tell me? Are they going to tell me that the CT scan shows that my cancer is spreading, that the chemo isn't working? What they did in this study is they had 18 oncologists take the black, white IAT, and then they said forget about it. Now just go on and treat your patients. But in this experiment, they actually, with the consent of the patient and the consent of the doctor, they videotaped the office visits. And they had some, and then they graded the office visits, neutral observers graded them. Here's what they found. And I think this will move you. They found that if the doctor had implicit white race preference, the duration of their office visit with the black patients were shorter than with the white patients. The second thing they found is that if the doctor had implicit white race preference, their communication style with their black and white patients were different. With the black patients, it tended to be more what we call verbal dominance, which means I'm doing all the talking. This is what you have. This is what we're going to do. See you next time. Not this more participatory way that we teach our trainees to talk to patients. What do you think of this therapy? What questions do you have? And then finally, they had the patients fill out patient satisfaction surveys and probably not too surprising. There was an inverse relationship between the doctor's implicit white race preference and the black patient's satisfaction with that office visit. So this is really important and it's fascinating because it's not that those black patients knew, you know, I didn't appreciate this visit with Dr. Jones because he has implicit white race preference. I mean, they don't know. They don't know that. But there's something happening. When you and I are speaking with somebody that's from a group that we're unconsciously negatively biased against, there are vibes that we're giving off. There are things that we do and those patients can sense it. And here that is shown graphically from another study. This is another study with family physicians who took the implicit association test and their patients then filled out patient satisfaction surveys looking at patient satisfaction in four different domains. And I forget the domains. One was communication. One was how much are they asking me to participate in my care. But four different domains of patient satisfaction. What they found in this study is again that inverse relationship. This is the clinician's implicit preference. Black preference, white preference. And as you can see, as the physician's implicit white race preference scores went up, the satisfaction of those black patients with the office visit went down in the four different domains. So what I want you to think about is have you ever had a time when you interacted with a patient and you came out of the room and you were thinking to yourself, I'm not sure what happened, but somehow we just weren't connected. I mean, I tried my best. I went in there with the same pure heart that I always do, but somehow we were talking past each other. I just had this uncomfortable feeling. I don't know. We just didn't connect. It could be that that was because you were interacting with somebody who's from a group against which you don't even know it, but you are unconsciously negatively biased against. So social psychology research tells us how you and I interact with somebody if we are negatively biased against them unconsciously. You've already heard about some of that. We tend to over talk them. We tend to stop them and talk over them. We tend to not ask them as many questions. We tend to not give eye contact as much, and we tend to not smile as much. So think about that. Think about interviewing for medical school or residency or interventional fellowship, and your interviewer isn't smiling, isn't looking you in the eye, and is cutting you off. Think about being a patient, and your doctor is not smiling, not looking you in the eye, and keeps cutting you off. You know, one problem we know we have in all of cardiology and interventional cardiology especially is a lack of diversity in our clinical trials. Well, imagine if I come to you, you're the patient, and I say, there's this device that we want to put in your chest. We're not sure it works, but that's what the study is for. And as I'm talking to you about that, I'm not smiling, I'm not looking you in the eye, and I'm cutting you off when you try to ask questions. Are you going to consent to be in that study? So what's the worst that can happen if you and I are interacting with patients, and we are unconsciously negatively biased against them? Well, I'm going to show you something now, something really incredible, and I want to give proper credit to a fantastic physician. Aubrey Grant is a cardiology fellow. He's finishing up his cardiology fellowship at Georgetown. He's headed to Harvard University, the Brigham, to do a super fellowship in sports cardiology. He and his colleagues have put together a virtual reality experience to teach about implicit bias where you actually put on the goggles, and you are the patient, and you're going through the patient encounter experiencing implicit bias against you. We don't have the goggles to pass out to you today, but we do have the clip to show you. So what I want to set this up this way. I want you to suspend belief right now from whoever you are and become the patient. So you are the patient. I want you to feel what this patient is feeling. This case that I'm going to show you is an actual case that Dr. Aubrey Grant participated in, and so they wrote it up and made it this vignette. So suspend belief. You are this patient. I want you to experience this. Oh God, this pain is so bad. Good morning, how can I help you today? I'm having this awful chest pain. It just won't seem to go away. I really need to see a doctor. Okay, let's get you back to triage. Thank God. Hey dear, I'm Nurse Jackson and I'll be your nurse for today. Hmm, now you look familiar. Weren't you just here two weeks ago? Yeah, I'm back. I keep having these chest pains that won't seem to go away. And nobody seems to want to do anything about it. Okay, okay, okay, let's get you calm and settled. I'm going to take a quick set of vitals. Okay, your vitals are looking okay, but your heart rate is a little fast. Ma'am, you really have to try and calm down. Let me check your chart and then grab the doc. Calm down? Oh my God. How can I be calm when my chest is hurting so bad? Can I please get something for this pain? Okay honey, calm down. Jeez, it's super busy here tonight. Hey doc, this is Ms. Little. She's one of our frequent flyers. She stumbled in here from the parking lot. She's a daily smoker and a heavy drinker. She came in here a few weeks back with the same type of chest pain. She was a little drunk when she came in, so we let her sleep it off and then we sent her home. Her troponin and EKG were fine. She's back now saying she has the same chest pain and is now asking for pain meds. She's pretty anxious right now and won't seem to calm down. Okay, let me chat with her and we can grab some labs and EKG and she can just sleep off whatever's in her system. Maybe she's withdrawing from drugs. It's pretty busy in here tonight, so we can just keep her in here for a few hours so she can rest. Hello Ms. Little, I hear you're having a little chest pain? Yes, I told the nurse about these pains. It's been bothering me. I just can't seem to get rid of it. I need something for this pain now. I know my body. Something just doesn't feel right. Okay, let's just try and keep calm. Let's get some labs and an EKG and we can let you rest. Yeah, I think I agree with you. She seems like she's drug-seeking a bit and she's not the most pleasant patient. Let's just get those labs and the EKG to make sure. I'm going to hold off on giving her pain meds for now due to her drug history. So let's also get a urine drug screen too. Okay doc, sounds like a plan. Just a heads up though, she was pretty rowdy the last time she was here. Alright, looks like we've got a trauma coming in right now. Let me go check it out. Come grab me if the patient starts to act up. Something just doesn't feel right. My chest is just aching so bad. The pain has never been this bad before. Why won't this get any better? Alright, let's draw some labs and get this EKG. What about my pain meds? I'm really struggling here. My chest, it hurts so bad. Oh, last time they gave me some Dilaudid and that really helped. Calm down sweetie. Once we get these labs and check your urine, then we can talk about pain medications. Okay. This isn't getting any better. I know they said it's probably nothing, but this just doesn't feel right. I feel short of breath now too. Something isn't right. Where's my nurse? Nurse! Nurse! Where's my nurse? You have got to calm yourself. What's wrong with you? I can't catch my breath. I feel a little nauseous. It's probably just the drugs coming out of your system. Let me check if your lab results have come back yet. In the meantime, I'll give you some oxygen. Let's see if that helps. Your lab results are back and everything looks okay. One of your liver enzymes is elevated, but that's probably from all the alcohol that you drink. They always tell me it's because of my drinking, but I'm telling y'all, this feels different. I know I drink a lot, but this doesn't feel like my normal drinking pains. Something's off. I think I'm having a heart attack. Please, please just get my doctor. Okay, sweetie, I'll go get him to come talk with you. Hi, ma'am. Sorry it's been really busy in here tonight. How are you feeling? The chest pain is still killing me. Now I can't breathe. Someone grab the code card. Hard to watch, huh? So I've shown this to several clinical departments, and I appreciate it. I'm not going to ask you the questions here, but when I ask those departments, I ask them two questions. I say, number one, how many of you feel that that doctor and nurse, that they're really bad people? Raise your hand. And nobody raises their hand. And then the second question I ask is, how many of you think it's possible that on a given call night, when you're multitasking, when you're sleep-deprived, when you're pulled in different directions, that that could be you behaving that way? And slowly several hands go up. And that really is the important point. You don't have to be a bad person for these unconscious biases to take hold and express themselves and how we treat each other. That was a real case. So a follow-up, as you saw, she did code. She went to the cath lab. It was a STEMI. Her right corneal artery was occluded. They got it open. She didn't die. She survived. But she survived with a severely damaged heart. And, of course, now the rest of her life will deal with severe congestive heart failure. So that goes towards answering the question, what's the worst that can happen?

implicit bias

patient care

inclusive workplaces

unconscious biases

differential treatment

patient satisfaction

health outcomes