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Article 1
Estimating Implicit and Explicit Gender Bias Among Health Care Professionals and Surgeons. Salles A, Awad M, Goldin L, Krus K, Lee JV, Schwabe MT, Lai CK. JAMA Netw Open. 2019 Jul 3;2(7):e196545.
This study uses existing data collected by Project Implicit to ask several questions related to implicit and explicit bias in healthcare workers vs the general population and in then in the surgical specialty in particular. Implicit biases are unconscious mental associations that most people make about roles of men and women in society in the workplace that, unlike explicit biases, may not be in line with one’s stated values, and are believed to result in persistent inequality in the workplace. The question of implicit bias is important to medicine because despite training an equivalent number of male and female physicians since 1999, women still represent a smaller minority of all faculty, 24% of full professors and only 14% of department chairs. Further there is evidence this is a result of biased behavior, as women are offered fewer opportunities for career advancement, lower salary and reimbursement and less mentorship and support, despite equivalent qualifications. The study relies on the results of a test (Implicit Association Test or IAT) performed on thousands of health care professionals, and attendees of the ACS meeting in 2017, that they adapted to specifically address gender. The test uses a computer administered test in which words are sorted by the subject into categories and concepts that are closely associated by the subjects tend to be sorted more rapidly. Additionally, they assessed for explicit biases, asking participants explicitly if they associated career, family, surgery, and family medicine with women vs men. Their results were counterintuitive. Health care professionals showed more implicit gender bias than the non-healthcare population, both male and female health care professionals showed implicit gender bias but female health care professionals showed significantly more implicit bias towards women, associating them with family more than career. With explicit bias the relationship flipped. While both men and women demonstrated explicit bias, men expressed more explicit bias associating men with career and women with family. When gender-specialty bias was associated women and men in the surgical specialty showed similar implicit bias towards men and surgery, and women and family practice, but again, men showed higher explicit bias. This association, notably, did not show any difference among age groups but the authors note their sample of older health care professionals was small.
This study is of particular interest because it is novel for testing gender specific implicit bias among health care professionals. It’s results are consistent with other literature showing bias is universal - both women and men demonstrate implicit bias, although men also express greater explicit bias towards men and career/surgery. Its strengths include a clever experimental design and a large data set; however a fundamental flaw could be the implicit association is a reflection of a perception of status quo, rather than a true gender-bias. The explicit gender bias demonstrated by both men and women would also seem to counter this as a possibility. The general conclusion we can reach is that unconscious or implicit-bias is pervasive in the healthcare field, as is explicit bias, and, as it is amenable to correction, merits attention from surgical societies and healthcare professionals as a whole.
Article 2
Reducing Implicit Bias: Association of Women Surgeons #HeForShe Task Force Best Practice Recommendations. DiBrito SR, Lopez CM, Jones C, Mathur A. J Am Coll Surg. 2019 Mar;228(3):303-309.
Implicit bias is a universal, and is not restricted to a specific gender, sex orientation and health care professionals are not immune from its effects. To help address this, the Association of Women Surgeons #HeForShe Task Force developed best practice recommendations to help correct bias, both in intraprofessional context and in treatment of patients where unequal treatment based on such biases has been demonstrated in the literature. Importantly, evidence suggests implicit biases can be countered and “unlearned” by recognition of the problem and targeted efforts to address them. Thus, the following recommendations are made.
First, and foremost, to Commit to a cultural shift, as while bias can be countered easily in the short term, sustained efficacy requires organizations to change culture towards valuing bias eradication, and require buy in from workers and the institution. As people tend to be unaware of these biases, uncovering bias via Implicit Association Testing is a useful tool to help people understand these biases are universal. This may empower individuals to engage in introspection and unlearning of potentially harmful behaviors without feeling shamed or judged for what is unconscious and universal behavior. In particular, IAT available from Project Implicit at https://implicit.harvard.edu/implicit/takeatest.html is noted. These tests are simple and can be tested over time allowing individuals and institutions to work towards improvement in unlearning hurtful behavior. Further, leadership should consciously develop a program for counter-stereotyping exposure, and make efforts towards professional mentorship, exposure (e.g. invited speakers and visiting faculty), hiring and promotion of women, POC, LGBTQ individuals etc., who are demonstrably invited/mentored/supported less despite equivalent qualifications. The cultural shift necessarily requires commitment from departments to continue to assess and monitor improvement over time, and focus on not making the problem be addressed by the “most diverse” individuals, a common reflexive behavior that will instead make them feel marginalized and unduly responsible for their own acceptance instead of simply being included. Instead, all individuals should feel empowered and responsible for addressing bias and taking steps to improve institutional equality for all people. The institution should also actively pursue monitoring for improvement of processes in admissions, hiring, advancement, and test to ensure those responsible for these processes understand and address their biases so they are not perpetuated.
Article 3
Association of Racial and Socioeconomic Diversity With Implicit Bias in Acute Care Surgery. Zebib L, Strong B, Moore G, Ruiz G, Rattan R, Zakrison TL. JAMA Surg. 2019 May 1;154(5):459-461.
Implicit bias, or the involuntary attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner, can create barriers that impede access to opportunities across many domains, including health care. Prior studies have shown that among medical professionals (including trauma surgeons), implicit bias in favor of white people approaches 75% and bias in favor of the upper class exceeds 90%. In this study, the authors sought to explore whether racial and socioeconomic diversity mitigates the existence of implicit and social class bias in the field of trauma and acute care surgery. They collected demographic data and results of the validated Implicit Association Test from various health care providers and staff at their multicultural urban trauma center. The authors found that implicit bias among healthcare professionals was lower for race (56%) and social class (82%) compared to previous studies of trauma surgeons across the U.S.
This study is an important step in showing that “majority minority” cities may help to reduce overall implicit bias in the acute care surgery environment; however, the reason for this remains unclear. Is it because more immigrants make up their workforce, or perhaps because the study population was comprised largely of non-physician health care professionals and ancillary staff who have less implicit bias? Diversity may in fact be somewhat protective against implicit bias, but racial and class bias are clearly still a problem even in culturally diverse cities such as this one. Unfortunately, the impact of class, racial and ethnic bias on trauma and acute care surgery patients requires further analysis to determine if it leads to worse clinical outcomes.
Article 4
Ensuring Equity, Diversity, and Inclusion in Academic Surgery: An American Surgical Association White Paper. West MA, Hwang S, Maier RV, Ahuja N, Angelos P, Bass BL, Brasel KJ, Chen H, Davis KA, Eberlein TJ, Fong Y, Greenberg CC, Lillemoe KD, McCarthy MC, Michelassi F, Numann PJ, Parangi S, Reyes JD, Sanfey HA, Stain SC, Weigel RJ, Wren SM. Ann Surg. 2018 Sep;268(3):403-407.
While local resources exist specifically for sexual harassment in the workplace, there are limited standardized resources available (particularly for faculty, trainees, and administrators) that address ‘best practices’ when dealing with other forms of exclusion such as discrimination, macro or microaggression, bullying or other exclusionary behavior. The leadership of the American Surgical Association (ASA) therefore appointed a Task Force to create a handbook that directly addresses equity, diversity, and inclusion within the discipline of academic surgery. The task force recommends that academic surgery departments prioritize equity, diversity and inclusion in the surgical workforce. Data from the AAMC and ACGME show that women and racial and ethnic minorities are under-represented in academic surgery departments and face more academic career challenges than their white male counterparts. Departments should make every effort to recruit and retain diverse faculty by promoting transparency in salary, promotion and career advancement, and emphasizing wellness and work-life integration. Increasing diversity and cultural competence among health care providers has been shown to improve access to care for minorities, facilitate physician-patient communication and allow for more equitable patient-centered care.
The white paper goes on to state that recognizing individual and organizational barriers to diversity and inclusion is necessary for identifying opportunities for change. Interventions should be individualized and progress should be measured using validated tools and defined metrics. Explicit and implicit bias can impede progress towards increasing diversity and inclusion, and buy-in from institutional leadership is essential for ensuring accountability and sustained behavioral change. Creating a culture of respect, tolerance, equity and inclusion is imperative and there should be zero tolerance for bullying, harassment and microaggression. Policies must be in place to empower and protect those who report witnessed accounts of bullying and harassment. Once measures have been implemented to address diversity and inclusion among health care providers, ongoing self-assessment at all levels is necessary to track progress.
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