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…
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. 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.  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.
 Schulman et al., “The Effect of Race and Sex on Physicians’
Recommendations for Cardiac Catheterization.”
et al., “The Effect of Diaphragmatic Breathing on Attention, Negative Affect
and Stress in Healthy Adults.”
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 allowedbell hooks
Adapted from the Iceberg Analogy in the 2006 publication by the National Multicultural Institute.