IHI Open School Short

Video Transcript: How Can Providers Reduce Unconscious Bias?: A Conversation Between Donald Berwick, MD, and David R. Williams, PhD, MPH

Donald Berwick, MD, Senior Fellow and President Emeritus of IHI
David R. Williams, PhD, MPH, Professor of Public Health, Harvard T.H. Chan School of Public Health

BERWICK: Is there a remedy, if I’m a physician or a nurse, and I believe what you’re telling me, which is, I don’t believe I’m racist or acting in such a way, but there are unconscious biases at work. Can I unlearn them? Can I work my way out of it? And if so, how?

WILLIAMS: There are a number of strategies that have been shown to be effective. I will say two things. The first thing is to realize that that could be me. I had many talks to medical, nursing and other health professional groups after the IOM report came out. And a typical health care provider in the United States would say, I would never do that. I would never provide less pain medication to a black patient than a white patient. Whereas the evidence is clear that black patients get less pain medication with similar level of conditions. So the first thing is to realize, that could be me, and that people who have implicit biases are not bad people. They are just reflecting the culture and the belief that they were raised with. So that’s the first point.

The second big principle is the challenge of focusing on what we call individuation versus categorization. What is normal for human beings as we process information is to put things into categories. So I see you, and I don’t see you as a unique individual, Don Berwick. But I see you as a middle-aged white male. I’ve put you in a category. And in my mind, there are lots of associations that come with middle-aged white male. So it’s, how do you look at a person, at your patient, at your client, and see that person as an individual and try to understand the individual context of that person as opposed to instantly seeing them, which is natural, because that’s how we deal with the complex cognitive information we have to manage every day. We put things into categories. It simplifies life. It helps us to navigate our social world. So it’s normal for us to do that. So that’s one general principle.

There are a range of other strategies that have been shown to be effective. One is trying to put yourself in the shoes of the other. So you have a patient who is an elderly black male. And if you stop and wonder what his life was like, and what was it like for him to grow up in this society, and what are the things he encountered. So the extent to which you try to walk a mile in someone else’s shoes, that is another strategy that has been shown to be effective.

There is also a strategy that’s called counter stereotyping, which means, for example, you think that all women are weak. Well, could you sit back some days and just imagine what a strong woman would look like? And imagine that that women could be strong.

So those are a number, but they’re a broad range of psychological strategies that have been shown in very careful laboratory experiments to minimize the occurrence of it.

I would say two things. One is, processes of implicit bias are more likely to occur when someone is working under time pressure, so you don’t have time to think. You just default to your social categorization processes. It’s also more likely to occur when you are dealing with complex cognitive information. In fact, researchers point out that many of the features of a typical encounter between a patient and a health care provider, the ingredients within that encounter, are some of the very factors social psychological studies show maximize the processes of implicit biases operating.

BERWICK: I’ll guess that fear can play a role in it.

WILLIAMS: Yes, fear, anxiety also play a role, absolutely. Fear and anxiety also play a role.