Unconscious bias – Stacie Walton MD

Accused of Attempted Murder

Posted on June 6, 2021June 5, 2021 by Stacie Walton in cultural competence, Humanity, Unconscious bias

Part Two

Please read Part One first!

We disembarked from the ski chair, and I led to the left. The gentle slope led me to a run I had skied multiple times in the past; simple and easy. I chose a beginner slope, or so I thought. I remembered an easy grade with minimum pitch and gorgeous terrain. In retrospect, I never saw a trail marker, probably because I didn’t look for one. Taking the lead and moving down the mountain, feeling the cold breeze against my face would offer me the chance to get my head together; I slowly moved forward. I thought I had chosen a simple run, as Marianne had only been skiing a couple of times before. Marianne followed close behind. As I skied over the first ridge, I immediately recognized the steep pitch of an advanced slope. I wondered, where am I. Skiing over the first ridge; I realized I had led both of us onto a double diamond run, difficult for me and impossible for Marianne.
As I coached her down the mountain, falling occasionally and watching her take spill after spill, I realized I had put us both in danger. She could be hurt. We focused on the job at hand. I had forgotten that minutes earlier, my friend had told me the most important fact about her life- who she chose to love.
One hour later, when the danger seemed to dissipate, with skis in hand, walking down in knee-deep snow and crawling over moguls the size of little hills, Marianne laughed at the top of her lungs, smiling at me, ” I’ve come out to a few people, but Stacie, no one else has tried to kill me!”
We tell this friendship story, entitled “When Stacie Tried To Kill Me” at gatherings and between ourselves. My love for her has never wavered, and I have no idea what happened on that ski slope some 30 years ago when I steered her onto a double diamond ski run. Could it have been unconscious biases guiding my actions? Could it have been my need to appear accepting, using up so much brain space, that I had blinders on for the reality surrounding me? I wonder…

Oxytocin and Hugs

Posted on October 23, 2019October 17, 2019 by Stacie Walton in Unconscious bias

Today on a webinar about Unconscious Bias, I was reminded of the power of oxytocin for stimulating good, warm fuzzy feelings.[1] Oxytocin is a hormone produced in the brain. When a breastfeeding mother embraces her infant or when the infant cues its mother into wanting to feed, this powerful hormone is released. Oxytocin stimulates the letdown of milk, while simultaneously opening up the heart of both the mother and infant for feelings of connection and closeness. Oxytocin is released when we give each other hugs, in the first months of a love relationship, and when we have orgasms. I wonder if oxytocin can be released when I examine some of my patients.

My next thought was we need to bring the hug back to public education. Imagine, the child feels welcomed and uplifted as he or she walks into the classroom. And, more importantly, the teacher is filled with a rush of incredible warmth as they scan the room of their daily crew, oxytocin stimulated by 28 different hugs!

I shared this thought with a professor I know, and she said, ” Ah, well, good luck with that!” I know the public is probably not ready to give up the association between hugging and inappropriate touch at school. But , wouldn’t it be inspirational? A hug a day would keep the potential for learning paramount. Many teachers have found other ways to connect with their students that involve touch but not hugging. I imagine connection is happening and oxytocin flowing through daily traditions like – the special handshake, the life-affirming daily hip hop chants, or the affirmations to each student before beginning a lesson. Now let’s take this one step further. What would a medical school classroom look like if oxytocin levels were high or off the charts? What adult behaviors of connection simulate the handshake, the chant, or the affirmation? Maybe, we should just start with the hug!

My thoughts turned to something I have personally pondered a lot. When colleagues or patients would ask, “Dr. Walton, you always seem so upbeat, what’s your secret?” I would think, ” Well, after you see the first patient of the day, it is just uphill from there!” Between getting my children to school and dealing with the commute or starting the day with a contentious morning staff meeting, even after arriving to work frustrated or flustered, by the time I was finished seeing the first patient of the morning, I was leaving that room uplifted and smiling. In that exam room, hugs of greeting were the norm, hugs of compassion when life sucked were accepted. A touch on a mother’s shoulder to say I hear you and I understand. Most encounters included an exam. Wouldn’t oxytocin levels be running high in that room?

What do hugs and oxytocin have to do with discussions about unconscious bias? Well, when you feel connected, your oxytocin levels increase, you are happy and stimulate higher brain function. With higher brain function, you are more self-aware and feel expanded. Open to new ideas, creativity is at your fingertips. You are less likely to be dependent on unconscious beliefs and emotions like fear to guide your thinking or your behavior. You are more likely to be open to learning in a classroom or more creative when determining the diagnoses and treatment plan for your patient.

[1] “Oxytocin: The Love Hormone?” https://www.medicalnewstoday.com/articles/275795.php

Wow Your Audience with Culturally Appropriate Presentations

Posted on October 9, 2019October 9, 2019 by Stacie Walton in connections, perspective, Stereotypes, Unconscious bias

You volunteered to provide a presentation on morning rounds or at the monthly quality program. You believe in Health Equity. As you prepare, you ask yourself, “how I can ensure a culturally competent presentation in front of my colleagues?” I will walk you through 4 aspects of your performance that support your cultural agility and models the behavior of skilled physicians.

Number One: DO NOT Leave this aspect of your presentation until the last minute!!

Unless you have a working knowledge of the social determinants of health (i.e., you obtained an MPH degree) or you pay attention to the statistics about health disparities – you may need to do a google search to augment your content.
More importantly, if the nature of the disparity has not impacted you, you may not be versed in the nuances of this problem even with the subject matter you are delivering.
Stated differently, you often don’t know what you don’t know.

Number Two: Acknowledge Health Disparities with every presentation

Be a Rock Star and share the health disparity statistics associated with the disease or public health issue you are discussing whenever you give a presentation.
When we probe deeper and examine the structural reasons that explain particular disparities- from social determinants to implicit (unconscious bias). You not only highlight the work that must be done to alleviate the gap but also remind yourself and the audience that this work is of value in your department or specialty.

Number Three: Choose Pictures Wisely

I cannot emphasize this enough! As the adage says, “A Picture Says a Thousand Words,” stereotypes and discrimination hide
neatly in visual displays. We must be mindful not to perpetuate them in our presentations.
Ask yourself – do the photos reflect the diversity in the community I serve? Do the images mirror my colleagues who are in my audience?
For example, if you are showing photos of pathology, be sure to confirm the pathology across all the groups that this pathology effects. I’ve been to so many lectures about STDs among adolescents and ALL the slides, and I repeat ALL the slides, depicted genital lesions on Black female patients-this is unacceptable! And Most importantly, ask yourself, what is the underlying message that gets transmitted with a slide deck like this?

Number Four: Choose Words Carefully and Avoid Stereotypes

Your hidden stereotypes may perpetuate harmful beliefs in a presentation in front of your peers. There are several ways to mitigate these stereotypes.
Pay attention to how you feel, think, and what your body reveals when you are talking about a group of people or people afflicted with a particular disease. If you feel uncomfortable, reflect on that because it has personal meaning for you and it may be lurking in your unconscious.
Take the Harvard Implicit Association Test. Get some “objective” ideas about some of the beliefs you hold. Save your results and consider interventions to expand your cultural agility. Then, retake the test.
Get feedback on your presentation from colleagues who may be closer to the patient population or community involved.<
Be courageous and ask people how they want to be identified. As cultures, societies move forward, identification changes. Terms no longer used include Oriental and Negro. Preferred identifiers include LatinX and African American or Black. If you can be specific about the country of origin that can be helpful as well.
Keep in mind that no group of people are homogeneous; there will be differences in opinion and belief. Expect “mistakes,” but graciously be open to learning new and different perspectives

Reducing Unconscious Bias in the Emergency Room

Posted on October 2, 2019 by Stacie Walton in connections, perspective, Unconscious bias

Bias is a neutral word. A bias is a belief, a thought, a preference. In and of itself, it has no leaning towards right and wrong, or best and worst. Personal and social judgment assigns the bias a nuanced meaning. In health care, these beliefs can turn into a missed diagnosis, an inappropriate treatment strategy, or a patient’s untimely death. The most critical aspect of bias for health care providers is realizing that our unconscious beliefs guide our behavior towards other people, often unconsciously. We often make decisions about how we interact with people through our biased lens. We choose subconsciously whether we will lead with respect, or with dismissal, or even disdain. It is crucial to recognize whether our biases are reality-based or a reflection of inaccurate assumptions about our patients, our colleagues, or ourselves.

During the night shift in the Emergency Room internship year, I had an experience that illustrated my bias towards “inconsiderate” people. It would become an AHA moment for me, with a conscious decision to do better. As an intern, I managed the non-urgent side of the emergency room. The night unfolded into the typical frantic evening with a stream of patients, procedures, multitasking and plenty of decisions to make. A grandmother came in with her 10-year-old grandson for the evaluation of a rash. I’d been up all night; I was tired and impatient. As I entered the exam room, I thought to myself as I read the chief complaint on the front page of the chart, why would anyone be coming into the emergency room at three in the morning for a rash? Immediately, I smelled a distinct body odor. The child was visibly dirty, wearing tattered clothes and avoided making eye contact. His grandmother dressed in office attire that was upscale and clean shared the history. I began to lecture the older woman about coming in at three in the morning for a simple rash, and I scolded the boy about his hygiene. She watched me jot down my notes and let me finish with my tirade before she informed me that her grandson lived with his mother, and that they were homeless. She shared that daily hygiene became challenging without access to water, and family relationships remained strained. She was doing what she could. She worked during the day and could not afford to take time off. She searched my face for empathy. She said calmly, “Doctor, could you please stop scolding us . . . and just help us?” A rush of warmth filled my cheeks, and I felt ashamed. When had I become so insensitive? Why hadn’t I been curious about their situation instead of judgmental?

Discussions about unconscious bias in healthcare decision making started in 1991 with the seminal article by Shulman et al.[1] Unconscious bias is more likely to guide behavior when we are tired, hungry, multitasking or experiencing acutely stressful situations. It is at these moments when our sympathetic nervous system activates to ensure “our primitive need for survival.” Any strategy that can bring our parasympathetic system on line will help us to make better decisions, maintain awareness, and remain creative in the chaotic moments. [2] So, what would I have done differently had I known what I know now? Before moving from each exam room and encountering a new patient and their family, I would have taken one extra minute to engage privately in three mindful breaths. I would have taken another 30 seconds to prime my brain with positive intentions for providing the best care possible to the next patient waiting for me. Both of these actions would have decreased the chance of my operating through my unconscious bias and provided a better experience for my patient and his family.

[1] Schulman et al., “The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization.”

[2] Ma et al., “The Effect of Diaphragmatic Breathing on Attention, Negative Affect and Stress in Healthy Adults.”

The Iceberg and the Mirror

Posted on September 4, 2019September 4, 2019 by Stacie Walton in Higher thinking, implicit bias, Stereotypes, Unconscious bias

Self-Reflection Exercise

This activity will take 10 minutes. You will need a piece of paper and something to write with and a mirror. If you have a journal, use it.

As you look at the picture of the iceberg above, you should notice that about 10% of the ice mountain sits above the water line. This is the part of the iceberg that you normally can see. About 90% of the ice mountain is below the surface of the water and usually not seen. Now draw a picture of an iceberg on your piece of paper.

Now look at yourself in the mirror. What do you see? What do other people see when they encounter you? Imagine someone who has never met you before – how would they describe you? Your skin color, your gender, your height…Write your observations about what you see on a piece of paper above the surface of the water line. This is important, so write down what you see.

Now think about all the personal characteristics that are NOT readily apparent to others who encounter you. Write those characteristics on the piece of paper below the water line. You might include your education, your employment, your religion, your relationships, etc.

Questions to ask yourself:

Where do most of your characteristics about yourself fall – above or below the line?
Where do the characteristics that have the most importance to you fall – above or below the line?
Do people ever make assumptions about “who you are” using characteristics that they can only see? If so, how does that make you feel?
What skills do you use to reveal what lies below the surface of the water in your relationships?

Stereotypes abound when there is distance.
They are an invention, a pretense that one knows when the steps that would make real knowing possible cannot be taken or are not allowed bell hooks

Adapted from the Iceberg Analogy in the 2006 publication by the National Multicultural Institute.