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Patrolling Your Blind Spots: Introspection and Public Catharsis in a Medical School Faculty Development Course to Reduce Unconscious Bias in Medicine

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Abstract

Cultural competence education has been criticized for excessively focusing on the culture of patients while ignoring how the culture of medical institutions and individual providers contribute to health disparities. Many educators are now focusing on the role of bias in medical encounters and searching for strategies to reduce its negative impact on patients. These bias-reduction efforts have often been met with resistance from those who are offended by the notion that “they” are part of the problem. This article examines a faculty development course offered to medical school faculty that seeks to reduce bias in a way that avoids this problem. Informed by recent social–psychological research on bias, the course focuses on forms of bias that operate below the level of conscious awareness. With a pedagogical strategy promoting self-awareness and introspection, instructors encourage participants to discover their own unconscious biases in the hopes that they will become less biased in the future. By focusing on hidden forms of bias that everyone shares, they hope to create a “safe-space” where individuals can discuss shameful past experiences without fear of blame or criticism. Drawing on participant-observation in all course sessions and eight in-depth interviews, this article examines the experiences and reactions of instructors and participants to this type of approach. We “lift the hood” and closely examine the philosophy and strategy of course founders, the motivations of the participants, and the experience of and reaction to the specific pedagogical techniques employed. We find that their safe-space strategy was moderately successful, largely due to the voluntary structure of the course, which ensured ample interest among participants, and their carefully designed interactive exercises featuring intimate small group discussions. However, this success comes at the expense of considering the multidimensional sources of bias. The specific focus on introspection implies that prior ignorance, not active malice, is responsible for biased actions. In this way, the individual perpetrators of bias escape blame for their actions while the underlying causes of their behavior go unexplored or unaccounted for.

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Notes

  1. One of the instructors is the author of the companion essay.

  2. This course, and our ethnography of it, is part of the large contemporary research literature on pedagogical strategies for bias reduction that involve notions of self-awareness and the development of cultural competence in medicine. See the recent special issue of Transcultural Psychiatry (Kirmayer 2012) and the recent work of Shapiro et al. (2006) and Yan (2005) who explicitly connect cultural competence education with notions of self-awareness.

  3. The official structure of the course, as reflected in the syllabus, did not map directly onto the way the course ran in practice. The topics outlined in the syllabus were covered, however, there was little focus on application to teaching.

  4. The course took place at a prominent medical school in the Northeastern United States. The data collected for this article were part of a larger project, under the direction of Professor Mary-Jo DelVecchio Good, and were funded by the Russell Sage Foundation, Grant Number 87-05-03. The project had full IRB approval from the relevant institutions.

  5. The problems we observed during large group discussions occurred despite efforts of the course directors, who were all experienced instructors with training in discussion leading, to maintain order during the discussions. The course directors were equally skilled in managing large and small group discussions, yet the small group discussions were more effective.

  6. “Totem” is a descriptive label we use to describe the exercise. In the course it is referred to as the “Cultural Object” Exercise.

  7. According to Hardy and Laszloffy, “pride/shame” issues are aspects of a culture that are sanctioned as distinctly negative or positive and derive their meaning from the basic organizing principles of a culture. They are similar in that both organize the perceptions, beliefs, and behaviors of group members. However, the critical distinction between the two is that pride/shame issues punctuate behaviors as negative or positive, while organizing principles do not (1995, p. 229).

  8. The description of the genogram exercise on the course syllabus was introduced by the following quotations: “The consciousness of what one really is entails ‘knowing thyself’ as a product of the historical process to date which has deposited in you an infinity of traces, without leaving an inventory” (Antonio Gramsci), and “To the extent that this tacit knowledge is not open to self-reflection, we are unable to talk about our own culture. We do not see it unless we are in a cross-cultural situation that makes us visible in our differences…through the eyes of others” (Marcelo Pakman).

  9. The very notion of what constitutes “safe space” must also be considered as deeply culturally informed. The spaces that one considers to be “safe” ones in which to share shameful, embarrassing, or personal experiences will be affected by cultural norms.

  10. Tervalon and Murray-Garcia (1998), Good et al. (2003), Taylor (2003), Campinha-Bacote et al. (2005), Shaw (2005), Carpenter-Song et al. (2007), Smith et al. (2007), Graves et al. (2007), Lo and Stacey (2008), Burovoy and Hine (2008), Murray-Garcia and Garcia (2008), Ring et al. (2008), South-Paul and Like (2008), Carter-Pokras et al. (2009), Willen et al. (2010), Jenks (2011), Shaw and Armin (2011), Kirmayer (2011), Like (2011), Good et al. (2011), Hannah (2011b), and White (2011).

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Authors and Affiliations

  1. Department of Sociology, Harvard University, 33 Kirkland Street, Cambridge, MA, 02138, USA

    Seth Donal Hannah

  2. Department of Community and Family Medicine, Dartmouth Psychiatric Research Center, Dartmouth College, 85 Mechanic St. Suite B4-1, Lebanon, NH, 03766, USA

    Elizabeth Carpenter-Song

  3. Department of Anthropology, Dartmouth Psychiatric Research Center, Dartmouth College, 85 Mechanic St. Suite B4-1, Lebanon, NH, 03766, USA

    Elizabeth Carpenter-Song

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  1. Seth Donal Hannah
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Correspondence to Seth Donal Hannah.

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Hannah, S.D., Carpenter-Song, E. Patrolling Your Blind Spots: Introspection and Public Catharsis in a Medical School Faculty Development Course to Reduce Unconscious Bias in Medicine. Cult Med Psychiatry 37, 314–339 (2013). https://doi.org/10.1007/s11013-013-9320-4

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