Advertisement

Culture, Medicine, and Psychiatry

, Volume 37, Issue 2, pp 314–339 | Cite as

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

  • Seth Donal Hannah
  • Elizabeth Carpenter-Song
Original Paper

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.

Keywords

Cultural competence Physician training Health disparities Minority health 

References

  1. Bobo, Lawrence D. 1999 Prejudice as Group Position: Microfoundations of a Sociological Approach to Racism and Race Relations. Journal of Social Issues 55(3):445–472.CrossRefGoogle Scholar
  2. Bobo, Lawrence, James R. Kluegel, and Ryan A. Smith. 1997 Laissez-Faire Racism: The Crystallization of a Kinder, Gentler, Antiblack Ideology. In Racial Attitudes in the 1990s: Continuity and Change. Steven A. Tuch and Jack K. Martin. Westport, CT: Praeger Publishers. Pp. 15-42.Google Scholar
  3. Brubaker, Rogers, Mara Loveman, and Peter Stamatov. 2004. Ethnicity as Cognition. Theory and Society 33:31-64.CrossRefGoogle Scholar
  4. Burgess, Diana, Michelle van Ryn, John Dovidio, and Somnath Saha. 2007 Reducing Racial Bias Among Health Care Providers: Lessons from Social-Cognitive Psychology. Journal of General Internal Medicine 22(6):882-887.CrossRefGoogle Scholar
  5. Burovoy, Amy, and Janet Hine 2008 Managing the Unmanageable: Elderly Russian Jewish Emigres and the Biomedical Culture of Diabetes Care. Medical Anthropology Quarterly. 22(1):1-26.CrossRefGoogle Scholar
  6. Campinha-Bacote, J., D. Claymore-Cuny, D. Cora-Bramble, J. Gilbert, R.M. Husbands, R.C. Like, R. Llerena-Quinn, G. Francis, F.G. Lu, M.L. Soto-Greene, B. Stubblefield-Tave, and G. Tang 2005 Transforming the Face of Health Professions Through Cultural and Linguistic Competence Education: The Role of the HRSA Centers of Excellence. Health Resources and Services Administration, March, 2005, http://www.hrsa.gov/culturalcompetence/roleofcoes.pdf.
  7. Carpetner-Song, Elizabeth A., Megan Nordquest Schwallie, Jeffrey Longhofer 2007 Cultural Competence Reexamined: Critique and Directions for the Future. Psychiatric Services 58(10):1362-1365.CrossRefGoogle Scholar
  8. Carter-Pokras, O., D.A. Acosta, D. Lie, S. Bereknyei, H. DeLisser, P. Haidet, A. Gill, C. Hildebrandt, S. Crandall, K. Kondwani, and S. Glick 2009 Practice What You Teach: Curricular Products from the National Consortium for Multicultural Education for Health Professionals. Focus on Multicultural Healthcare, July 2009, pp. 8–11.Google Scholar
  9. Dovidio, John F., and Samuel L. Gaertner 2004 Adversive Racism. Advances in Experimental Social Psychology 36:1-52.CrossRefGoogle Scholar
  10. Dovidio, John F., Louis A. Penner, Terrance L. Albrecht, Wynne E. Norton, Samuel L. Gaertner, J. Nicole Shelton 2008 Disparities and distrust: The implications of psychological processes for understanding racial disparities in health and health care. Social Science and Medicine 67(3):478-486.CrossRefGoogle Scholar
  11. Gaertner, Samuel L., and John F. Dovidio 2005 Understanding and Addressing Contemporary Racism: From Adversive Racism to the Common Ingroup Identity Model. Journal of Social Issues 61:615-639.CrossRefGoogle Scholar
  12. Good, Mary-Jo DelVecchio 1995 American medicine, the quest for competence. Berkeley: University of California Press.Google Scholar
  13. Good, Mary-Jo DelVecchio, James, Cara, Good, Byron J., Becker, Anne E. 2003 The Culture of Medicine and Racial, Ethnic, and Class Disparities in Healthcare. In Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Brian D. Smedley, Adrienne Y. Stith, Alan R. Nelson, ed. Pp. 594-625. Washington, D.C.: National Academies Press.Google Scholar
  14. Good, Mary-Jo DelVecchio, Sarah S. Willen, Seth Donal Hannah, Ken Vickery, and Lawrence Taesing Park (Editors) 2011 Shattering Culture: American Medicine Responds to Cultural Diversity. New York: Russell Sage Foundation.Google Scholar
  15. Graves, D. L., R. C. Like, N. Kelly, A. Hohensee 2007 Legislation as Intervention: A Survey of Cultural Competence Policy in Health Care. Journal of Health Care Law and Policy 10:339-361.Google Scholar
  16. Greenwald, A. G., M. R. Banaji, L. A. Rudman, S. D. Farnham, B. A. Nosek, and D. S. Mellott 2002 A unified theory of implicit attitudes, stereotypes, self-esteem, and self-concept. Psychological Review 109(1):3-25.CrossRefGoogle Scholar
  17. Hannah, Seth Donal 2011a Clinical Care in Environments of Hyperdiversity: Race, Culture, and Ethnicity in a Post Pentad World [Ph.D. dissertation]. Cambridge: Sociology, Harvard University.Google Scholar
  18. Hannah, Seth Donal 2011b Clinical Care in Environments of Hyperdiversity. In Shattering Culture: American Medicine Responds to Cultural Diversity. Mary-Jo DelVecchio Good, Sarah S. Willen, Seth Donal Hannah, Ken Vickery, and Lawrence Taesing Park, eds., pp. 35–69. New York: Russell Sage Foundation.Google Scholar
  19. Hardy, Kenneth V., and Tracey A. Laszloffy 1995 The Cultural Genogram: Key to Training Culturally Competent Family Therapists. Journal of Marital and Family Therapy 21(3):227-237.CrossRefGoogle Scholar
  20. Hirsch, Jennifer S. 2003 Anthropologists, Migrants, and Health Research. In American Arrivals: Anthropology Engages the New Immigration. N. Foner, ed. Santa Fe, NM: SAR Press.Google Scholar
  21. Jenks, Angela 2011 From “Lists of Traits” to “Open-Mindedness”: Emerging Issues in Cultural Competence Education. Culture, medicine and psychiatry 35(2):209-235.CrossRefGoogle Scholar
  22. Kang, Jerry, and Mahzarin Banaji 2006 Fair Measures: A Behavioral Realist Revision of “Affirmative Action”. California Law Review 94: 1063-1118.CrossRefGoogle Scholar
  23. Kirmayer, Laurence J. 2011 Multicultural Medicine and the Politics of Recognition. Journal of Medicine and Philosophy 36(4):410-423.CrossRefGoogle Scholar
  24. Kirmayer, Laurence J. 2012. Rethinking Cultural Competence. Transcultural psychiatry 49:149–164.CrossRefGoogle Scholar
  25. Lamont, Michèle, and Virág Molnár 2002 The Study of Boundaries in the Social Sciences. Annual Review of Sociology 28(1):167–195.CrossRefGoogle Scholar
  26. Like, R. C. 2011 Educating Clinicians About Cultural Competence and Disparities in Health and Health Care. The Journal of Continuing Education in the Health Professions 31(3):196–206.CrossRefGoogle Scholar
  27. Lo, Ming-cheng M., and Clare L. Stacey 2008 Beyond cultural competency: Bourdieu, patients and clinical encounters. Sociology of health & illness 30(5):741–755.CrossRefGoogle Scholar
  28. Metzl, Jonathan 2012 Structural Competency: New Medicine for the Institutional Inequalities that Make Us Sick. Symposium held at the NYU Department of Social and Cultural Analysis, Friday, March 23.Google Scholar
  29. Murray-Garcia, J.L., and J.A. Garcia 2008 The Institutional Context of Multicultural Education: What is Your Institutional Curriculum? Academic Medicine 83(7): 646–652, http://www.ncbi.nlm.nih.gov/pubmed/18580080.
  30. Ring, J. M., J. G. Nyquist, S. Mitchell 2008 Curriculum for culturally responsive heath care: The step-by-step guide for cultural competence training. Oxford/New York: Radcliffe Publishing.Google Scholar
  31. Shapiro, Johanna, Desiree Lie, David Gutierrez, and Gabriella Zhuang. 2006. “That never would have occurred to me”: a qualitative study of medical students’ views of a cultural competence curriculum. BMC Medical Education 6:31.CrossRefGoogle Scholar
  32. Shaw, Susan J. 2005 The Politics of Recognition in Culturally Appropriate Care. Medical Anthropology Quarterly 19(3):290–309.CrossRefGoogle Scholar
  33. Shaw, Susan, and Julie Armin 2011 The Ethical Self-Fashioning of Physicians and Health Care Systems in Culturally Appropriate Health Care. Culture, medicine and psychiatry 35(2):236–261.CrossRefGoogle Scholar
  34. Smedley, Brian D., Adrienne Y. Stith, and Alan R. Nelson 2003 Unequal treatment : confronting racial and ethnic disparities in health care. Washington, D.C.: National Academy Press.Google Scholar
  35. Smith, W. R., J. R. Betancourt, M. K. Wynia, J. Bussey-Jones, V. E. Stone, C. O. Phillips, A. Fernandez, E. Jacobs, and J. Bowles 2007 Recommendations for teaching about racial and ethnic disparities in health and health care. Annals of Internal Medicine 147(9):654–665.CrossRefGoogle Scholar
  36. South-Paul, J. E., R. C. Like 2008 Cultural competence for the heath workforce. In From education to regulation: Dynamic challenges for the health workforce. D. E. Holmes, ed. Pp. 123–152. Washington, D. C.: Association of Academic Health Centers.Google Scholar
  37. Taylor, Janelle S. 2003 The Story Catches You and You Fall Down: Tragedy, Ethnography, and ‘‘Cultural Competence”. Medical Anthropology Quarterly 17(2):159–181.CrossRefGoogle Scholar
  38. Tervalon, M., and J. Murray-Garcia 1998 Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education. Journal of Health Care for the Poor and Underserved 9(2): 117–125, http://info.kaiserpermanente.org/communitybenefit/assets/pdf/our_work/global/Cultural_Humility_article.pdf.
  39. White, A.A. III 2011 Seeing Patients: Unconscious Bias in Health Care. Cambridge, MA: Harvard University Press.Google Scholar
  40. Willen, Sarah S., Antonio Bullon, and Mary-Jo DelVecchio Good 2010 Opening up a huge can of worms: reflections on a “cultural sensitivity” course for psychiatry residents. Harvard review of psychiatry 18(4):247–53.CrossRefGoogle Scholar
  41. Wimmer, Andreas 2008 The Making and Unmaking of Ethnic Boundaries: A Multilevel Process Theory. The American Journal of Sociology 113(4):970–1022.CrossRefGoogle Scholar
  42. Yan, Miu Chung 2005 How cultural awareness works: An empirical examination of the interaction between social workers and their clients. Canadian Social Work Review, 22(1), 5–29.Google Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Department of SociologyHarvard UniversityCambridgeUSA
  2. 2.Department of Community and Family Medicine, Dartmouth Psychiatric Research CenterDartmouth CollegeLebanonUSA
  3. 3.Department of Anthropology, Dartmouth Psychiatric Research CenterDartmouth CollegeLebanonUSA

Personalised recommendations