Cancer Topics - Impact of Implicit Racial Bias on Oncology Patient Care and Outcomes

"What exactly is implicit racial bias? How does it manifest in physician-patient interactions and what is the potential impact of such bias on oncology patient outcomes? In this ASCO Education Podcast episode, Dr. Lauren M. Hamel (Wayne State University) and Dr. Nimish Mohile (University of Rochester) share their insights and perspectives on these topics with host Alissa A. Thomas (University of Vermont). If you liked this episode, please subscribe. Learn more at https://education.asco.org, or email us at [email protected]. Resources: Blindspot: The Hidden Biases of Good People by Mahzarin R. R. Banaji and Anthony G. Greenwald Implicit Associations Test 21-Day Racial Equity Challenge   TRANSCRIPT Dr. Nimish Mohile: We had a patient a few years ago who had presented to our clinic, who ended up having a diagnosis of primary central nervous system lymphoma, and she was a young black woman, and it took about nine months for her to get that diagnosis. She had gone into multiple emergency rooms, she was only 22, had not had prior interaction with the medical system, but based on some of her socioeconomic demographics, her skin color, she was never given the kinds of testing that any other patient I think should have gotten at that time.   Dr. Alissa Thomas: Hello, and welcome to another episode of ASCO Education podcast. Today's topic is, 'Implicit racial bias and its impact on patient care.' My name is Alissa Thomas, and I'm a Neurologist and Neuro-Oncologist at the University of Vermont College of Medicine. I'm delighted to introduce our two guest speakers; Dr. Lauren Hamel, who is an Associate Professor of Communication and Behavioral Oncology at Wayne State University, and the Co-program Leader of the Population Studies and Disparities Research Program of the Karmanos Cancer Institute. Her ongoing research explores racial attitudes in non-verbal behavior of oncology patients and physicians, and how those behaviors influence treatment decisions. Dr. Nimish Mohile is a Professor of Neurology and Oncology at The University of Rochester. He also serves as the Diversity Officer, Associate Chair for Career Development and Leadership, and Neuro-Oncology Division Chief. I'll get us started with the first question, really a definition. What do we mean by the term, ‘implicit racial bias’? Dr. Lauren Hamel: I'm happy to go first. I think understanding what the definition of what implicit racial bias is is really important. You know, for good or for ill, over the last few years, it's gotten a lot more attention. And I think what's important to remember about it is that it's not a cognizant or a conscious bias, and it really is implicit, and it really is more of an association than it is anything else. It's sort of like the built-up associations that we have for anything. You know, could be race, could be gender, any number of demographics, or other factors that make our lives as humans. So, you know, associating certain aspects of people with positive or negative valuations. I think when we're talking about implicit racial bias, it's kind of like the gut associations we have for members of different racial groups. So often, it's kind of paired with "white is good, black is bad." It's a very rudimentary description of it, but that's a real kind of basic association that this kind of definition is built around. Dr. Nimish Mohile: Yeah, I would agree with that. I think that's a great discussion of what this is. I think it's really important for us to remember that these are really ingrained behaviors. It's, based on, you know, how we've been socialized and conditioned. And I think it's helpful to also put it in the framework of knowing that we all have some biases, we all probably have racial biases, and age biases, and other kinds of biases, and there's no sort of good or bad about having these biases. And the important part of this is, how do we recognize some of the biases that we have so that we can be more conscious about how we might fix those or think differently about the patients that we're seeing so that it doesn't result in actions that can be harmful. Dr. Lauren Hamel: Yeah, I agree with everything that Dr. Mohile just added. It is these ingrained associations. Really, it isn't about blaming ourselves for them because it's kind of the result of how our brains are structured. But to his point, it's once we know that we have them, and you know, we have data showing how they affect our behavior, it's then on us to identify them and then work to mitigate them. Dr. Alissa Thomas: Thank you. How do racial biases in patients and physicians influence treatment decisions or ultimately, how does this affect patient outcomes in Oncology? Dr. Lauren Hamel: You know, I think the direct relationship between certain biases and outcomes is still kind of being uncovered and investigated. But there are some interesting patterns that have been uncovered in data, specifically in the Oncology context too, because as you can imagine, a variety of professional organizations and groups examine the influence of bias. But just within Oncology, we see physicians who have higher levels of implicit bias who tend to see their patients who are black as less trustworthy, less educated, and less adherent to treatment recommendations. We also know that higher levels of implicit bias may be associated with less aggressive treatment programs recommended for black patients. We see some associations between levels of implicit bias and verbal dominance. But what was I think, especially interesting, is that we also see patterns of kind of perceptions from the patients that these physicians are communicating with. So, we see some manifestations in behavior, but we also see patients kind of “picking up” on some of these, whether or not they can identify them as bias necessarily. But for example, we see that patients who are seeing a physician with higher levels of implicit bias tend to see their physicians as less patient-centered, and less trustworthy. And I think that's a really important piece to identify because these biases are by definition kind of operating outside of our own consciousness, but they're manifesting themselves in a way that the people that we're communicating with are noticing. Dr. Nimish Mohile: We had a patient a few years ago who had presented to our clinic, who ended up having a diagnosis of primary central nervous system lymphoma, and she was a young black woman, and it took about nine months for her to get that diagnosis. She had gone into multiple emergency rooms, she was only 22, had not had prior interaction with the medical system, but based on some of her socioeconomic demographics, her skin color, she was never given the kinds of testing that any other patient I think should have gotten at that time. That was a real sort of wake-up call for our clinic, because as some of you know, this is a disease that we can really treat, especially in younger patients. So, there's real consequences to these kinds of biases. And some of them are personal, the ways they're ingrained in us, but some of them are built into our systems, and it's based on; what our ERs are designed like, where our hospital systems are, what kind of relationships we have with primary care physicians in different communities, what kind of access some of our patients have to primary care physicians. This patient in particular didn't have great access to primary care, so she didn't have this other team of people to advocate for her and to say, "Hey, you know, this is something really different in this patient, and we need to take this seriously." So, I think it can get complicated as we think about biases in ourselves, in other people, in the whole health system, and then also as we get out of our health system, some of these things are so influenced by what's going on in our communities. Dr. Lauren Hamel: Yeah, I think that's a really important point. At least with my work, I examine kind of at the interpersonal level, but these biases, as Dr. Mohile points out, exist in all levels of our society, and they interact, and they're-- I don't want to say additive, it's probably much more exponential. But yeah, it's a layer, on top of layer, on top of layer problem. Dr. Alissa Thomas: So, Dr. Mohile, you commented earlier that part of it is recognizing these biases in ourselves. Can you discuss how we might approach this with the impact of an anti-racism education program has been in your department and applications for that? Dr. Nimish Mohile: So, we've worked on anti-racism in our department on a couple of levels. One of the main levels is just building awareness for individuals to understand that they have biases, that they have racial biases, and starting to understand why they have those. So, we've gone through exercises like book clubs and talks, for people to really do some of that self-reflective work to understand how they've been conditioned as they grew up. I've personally done that and have found it very revealing and understood some of the biases that I grew up with based on people I was around, and based on my schools, and based on segregation within my school systems. So, I think that that's one piece of it. I think another piece is we don't often get taught about the history of racism in the United States, and how widespread it is. It's a very small part of our curriculums, and I think we have to take it upon ourselves now in our medical systems to go through that education. Education that we probably should have had all through elementary school, high school, college, we have to do that learning now because then we can really start seeing that impact of race on our society. And I think for physicians specifically, what is that impact of racism on patient care in our medical systems and how it's been ingrained in US healthcare. Understanding that we had segregated hospitals right until the 1960s, those are all things that were in the lifetimes of still practicing Oncologists. One of the things we did for our other professional society that I belong to, The American Academy of Neurology, is we did develop an anti-racism education program that focused on understanding this history and this historical lens in healthcare, reviewing the impact that anti-racism has on our colleagues. So, what does that mean for black physicians or physicians from other underrepresented groups and how they interact with our health systems, how they're treated, what does it mean for their roles in academic departments? Then talking about how we can connect being anti-racist with the goals of health equity. So, how can we change the systems that we have control of to have healthcare that's more fair? And then finally, how do we engage trainees and physicians in really developing anti-racism action plans? One of the important things about anti-racism is that you really have to be active, it's not a passive experience. You have to take action to change all these systems around us that are embedded with racism. Dr. Alissa Thomas: Thank you. Along the same line, Dr. Hamel, you recently co-authored a study of a longitudinal implicit bias training curriculum. And can you tell us something about this project and what’s come of it? Dr. Lauren Hamel: Yeah, so it came about a little more than a year ago and kind of coincided happily with an executive directive made by our state’s governor requiring implicit bias training, so we were able to kind of design it so it met those requirements. But really what the goal is, is to approach implicit bias with a 360 view. So, what are all of the issues related to it? What are the scientific underpinnings? What are the measurements? What are the pros and cons of those measurements and what we’ve used, and what they’ve shown in terms of influence on our individual behavior, our decision-making, kind of how we relate to people who might be different than us. And certainly, expanding beyond racial groups — we’ve looked at gender, we’re looking at age, things like structural racism. So, we’re trying to kind of have a comprehensive view of it. And I think, you know, one thing, and it sounds like Dr. Mohile and his group have done a really nice job of tracking what happens after those. Because, you know, I think one-off sessions are better than nothing, certainly. Awareness is critical, but also, tracking like, what does this do for our attitudes, perceptions, and behavior? And that’s not easy. And so really, you know, trying to invest in tracking how things change. So, we’ve had a full year of assessments, we’ve seen some improvements in people’s attitudes and perceptions. But now what we really need to start doing is tracking certain behavioral aspects, and I think that’s where the next step needs to be. Our next year is just about to kick off in a couple of weeks. So, I think that that’s where we need to start putting our effort where it’s—okay, we’ve gotten kind of institutional support, the leaders of both the University’s School of Medicine and also the Cancer Institute have been encouraging this, which I think is really critical, because even though it’s a lot of individual work if you want these changes, you really have to have the support and buy-in from the leaders of the institution. So, we’ve got that, we have interest, you know, we’ve established a really consistent and impressive participation in terms of each session. We’ve had upwards of 200 people attending each session, so people want this information. Now, according to the state, they also are required to have it. So, I think building up on that now, we’ve established a lot of good pieces of it, but now let’s start doing a better job of tracking how does this affect long-term perceptions, attitudes, and behavior. Dr. Nimish Mohile: Every cancer center and department should be doing what Dr. Hamel is doing. The risk of the one-off trainings is that people come out of an implicit bias workshop and think, “Well, I’m fixed. I don’t need this anymore, now I can go on and take care of patients without bias.” And you really need that time to really work on those things and start to fix some of those attitudes that we have. Dr. Lauren Hamel: Yeah. Because the associations get built up over a lifetime. You know, that's not something you're going to fix in an hour. It's a campaign, it's a marathon, to be sure. Dr. Alissa Thomas: So, you've both touched on something that a lot of this is about perception, and it's not just what we say verbally, but non-verbal behavior. It plays into implicit racial bias. Dr. Hamel, can you talk a little about your study of non-verbal synchrony, and can you describe differences between non-verbal behavior with doctors and patients of the same race compared to those of different races? Dr. Lauren Hamel: Yeah, absolutely. And you know, a lot of my work focuses on nonverbal behaviors. On the study you referenced, we were looking at something a little bit more kind of in line with how implicit bias acts. It sort of manifested unconsciously. So, this whole idea of non-verbal synchrony is kind of this non-conscious coordination of movement that happens between two people. And this is a construct that's been studied for decades in a number of settings, but we were the first to be able to examine it in an oncology setting, and also comparing diads of different racial makeup. We were able to take like real video-recorded data of naturally-occurring treatment discussions. We had a set of videos that included black patients in a similar set with white patients. And we used automated software to track their behavior and determine how coordinated they were over time. We actually observed more coordinated behavior between black patients and their physicians compared to white patients and their physicians. Some literature is non-verbal synchrony is sort of seen as always good, and there's also some new data showing that maybe it could be evidence of trying to repair a relationship. We’re very early phases, I'm not in a position to offer kind of a best practice with this, but I think the point is, is that we do see differences. There is a coordinated behavioral difference between dyads. We're also starting to look at how that level of coordination is influenced by attitudes including implicit bias. So, I think identifying a difference is important, but now I think it's on us to now figure it out. Like, what is that the result of? And then, what does that do for the patient in terms of short and long-term outcomes? So, does that affect their perceptions of their physician? Does it affect their perceptions of the recommended treatment? Does it affect adherence to that treatment? Dr. Alissa Thomas: How can we do better? How can doctors improve non-verbal and verbal communication methods with our patients? Dr. Nimish Mohile: I can speak a little bit about verbal communication. I think this work on non-verbal communication is fascinating. I'd love to hear where that comes out because it's something I think we're not really thinking about very much, and I'm not surprised that there's differences there. I think sometimes with communication, just having an awareness in that you might be communicating differently with someone can be helpful. In many of our institutions, we sometimes go through coaching with our communication, particularly with Oncology patients, where you have someone witnessing how you're interacting with that patient, and what kind of verbal and non-verbal cues you're giving, how you make eye contact. I think there's models there that we could really be thinking about, not just focused on some of the stuff that oncology has been focused on, like, delivering bad news or end-of-life discussions, but also on these issues of racial bias or age bias, and see what we could do differently in those areas. Dr. Lauren Hamel: Yeah, I completely agree. And I think decades of research have shown that patient-centered communication skills are something that can be taught, learned, and improved upon. Maybe not just regarding the issues related to racial bias and other racial attitudes, but you know, for helping to improve a number of outcomes for patients. So, I think, that kind of focus, I mean there are very clear, well-established frameworks and methods around that, I think that was just, you know, something we already have in our toolbox that we can use. But I think also things like building up trust within a community, I think is critical, for really any kind of medical institution that operates within a community should be, you know, trusted by the community it's in. And there's a number of strategies that can be implemented to build up that level of trust. So, you're kind of looking at like the outside going in. A lot of these the data that I'm referring to right now are coming out of the primary care setting. But I think people like us that are in an Oncology setting are certainly well poised to start testing these in Outpatient Oncology clinics. And I think just like what we're doing right now, making the topic of race, racism, implicit bias, something that we can have in a number of settings. And I think Dr. Mohile made a really good point. Like, we're not taught this like we're taught like grammar, and, you know, math. This is a part of our lives too, and you know, it's having big effects on huge swaths of our population. So, I think normalizing these conversations is a really important step, too. Dr. Nimish Mohile: In the United States, we're particularly uncomfortable talking about racism. Even within our medical teams, we don't know how to do that. So, what do you do if you're on rounds and you see another provider have some kind of verbal or non-verbal communication that, you know, might not be appropriate, or you think that there's a racial bias in the way we're treating or talking to a patient? That's not something we know how to deal with. We don't know how to bring that up. And so, I think that that's something that within health systems, we need to start working on. We have great models for this. When we think about the transitions we've made over the last 20 years in patient safety, we have elevated these conversations about patient safety. If there's a medical error by anyone on a team, it's something we're open to discussing, not blaming, and then really having a conversation about how can we fix this next time. You know, can we work towards doing that with something like racial bias? One of the things we've started doing in our department is that one of our mortality and morbidity conferences each year is focused on racism. So, a scenario where we think that there might have been differing treatment to a patient based on race, and then having an open discussion about that, going through some of the literature about that, and just practicing some of those conversations with each other as faculty, and medical providers, physicians, nurses, advanced practice providers, of being able to name racism as one of these problems. And then we really try to model that behavior on teaching rounds, so that with our medical students and residents, and fellows, we're also having these conversations about how could racism be at play in this patient's story, and how they got to their diagnosis, and in their outcomes, and an acknowledgement that racism is having some effect on this patient's ability to get screened for cancer, and potentially, their ability to have the same survival as another patient. Dr. Alissa Thomas: Thank you. That's so helpful to think about how to elevate this through departments and people who may be less aware of the issue and raising awareness. You both have touched a lot on communication between patients and providers, and there's a theme here that it's not just the doctor-patient relationship, but also the patient's community, and the medical team, that support that physician. Can you elaborate a little bit more about that, about how we communicate to the patient and the community they represent, and the provider and the team that they represent? Dr. Lauren Hamel: Having active, mature, genuine involvement of community members within a cancer hospital or cancer institute, I think is really important. I know my work has benefited from those who have come before me that established really strong connections with people who are, either survivors, care caregivers, advocates, you know, people who are very devoted to their particular neighborhood, community, that work really closely with us and provide feedback on a lot of the interventions that we design. So, one thing that I work in with all of my research is, as I'm developing an intervention that I think will improve either communication with a physician or another care provider, I certainly would never implement that without getting that thoroughly vetted by the people who it's going to affect. My clinician colleagues are always really generous with their time. It's a little bit more challenging to get community member feedback, but I do believe that it is, I mean, not just worth it for my own research success, but also for the mission and the purpose of what we're trying to do here. So, if you seek out feedback from a community group or community members who are willing to give you their honest opinion, and you know, you have to be in a position to receive that feedback with grace and professionalism, I think that's an important piece of it. Like, you want to have that connection, you don't want to just kind of have a checkbox. You know, you really want them involved in what you're doing. I'm using my own personal experience, but I'm sure there's far greater levels of, you know, system-level issues where something similar could be implemented. Dr. Nimish Mohile: I agree with that. I think this is really hard, and I think our medical systems are just starting to learn how to do some of this work. So, I'd echo what Dr. Hamel said about really getting input from members of those communities. I think many cancer centers are trying to do more outreach into communities, and that's not that easy. We have to really start by kind of building that trust, and building a philosophy where it's really about helping that community, as opposed to getting more patients from that community, or getting more trial participants from that community, or being able to check off boxes for our NIH grants from those communities. It really needs to be a genuine approach of, what does this community need? Because we don't often know that answer. And so, we have to start with that curiosity, and then determine how can we help those communities with the resources that we have. And I think cancer centers can do this optimally if the entire health system does that, that's where you can really start building some of that trust. Dr. Alissa Thomas: Thank you. For those of us that want to know more, would you be able to share some practical tools or resources that are available for healthcare professionals who want to learn more about implicit racial bias, either on an individual or institutional level? Dr. Lauren Hamel: I think one of the first things someone can do is take an Implicit Association Test, or an IAT, as it's often referred to. They're all housed at Project Implicit, at Harvard's website - google IAT, it'll take you right there. No identifiable data are collected from the individual test taker, but it gives people a sense of what's being measured. You know, it's not a character assessment, it's a measure that's designed to test your associations. And I think just having that experience makes you a much more informed consumer of this kind of science because I think it's important to keep a critical eye. You know, if we're scientists, we have to be critical. And I think this really helps people kind of get to a point where they can understand the science a little bit more effectively, but maybe also can reduce a little defensiveness that inevitably comes up when these kinds of data are discussed. So, I would do that. And then the second thing would be, there's a wonderful book called, Blindspot: Hidden Biases of Good People, it's written by Doctors Greenwald and Banaji, and they are basically credited for creating the Implicit Association Test, as we know it. It's a relatively easy read, and it can really give you a sense of how these kinds of associations affect our decision-making and communications. I would take those two, as a way to start. Dr. Nimish Mohile: I agree with both of those. I'd say that many of our health systems have implicit bias workshops and trainings, and sometimes they're online, sometimes they're in person. They do have varying sort of quality. I encourage people to just look at those trainings a little bit differently than they look at all of the other trainings that we're forced to do. To go into those with a little bit of an open mind and a learning experience, rather than one to just sort of check boxes and move on. I think you can learn some things about yourself from them. One of the things I encourage folks to do if they're interested in more information about anti-racism is to do something like the 21-day Racial Equity Challenge - you can Google that. Kind of small bite-size openings, and then there's talks about biases, but also helps you sort of understand some of the foundations of racial inequity in this country. Dr. Alissa Thomas: Thank you so much. That's all the time we have for today. I really want to say thank you to Dr. Hamel, and Dr. Mohile for sharing your perspectives on addressing implicit racial bias in oncology, and tips for improving communication with patients and providing culturally-sensitive care. And thank you to ASCO for providing this platform for us to discuss. Thank you to all of our listeners, we appreciate you turning into this episode of ASCO Education podcast.   Thank you for listening to the ASCO Education podcast. 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