Dr. Jeff Stone has recently expanded his implicit bias training program and is looking to take his expertise beyond the University of Arizona. The Alliance National Program Office reached out to Dr. Stone to learn more about implicit bias and discuss the impact of his intervention.
In Southern Arizona, the largest population of underserved minority patients is of Hispanic descent. Research shows that, even with all other factors being equal, minority patients are less likely to receive adequate health care. A growing body of research suggests that implicit bias may be one of the factors associated with this finding. Jeff Stone, PhD, from the University of Arizona Cancer Center (UACC), has been working with the University of Arizona College of Medicine (CoM) to train first year medical students to recognize their own bias before they start interacting with patients. According to Dr. Stone, “by understanding the psychology underlying their bias, they [medical students] can learn to control it, no matter who they are interacting with.” The training teaches medical students a variety of techniques that have been shown to reduce bias, helping promote equitable care for all patients.
Dr. Stone has recently expanded his training program, introducing additional sessions during the third year of medical school, right before medical students are assigned clinical rotations. The Alliance National Program Office reached out to Dr. Stone to learn more about implicit bias and discuss the impact of his intervention.
What is implicit bias?
I think of it as the automatic negative gut reaction we have to someone who we perceive as being different from us. The gut reaction can stem from a negative emotional response to another person or from a spontaneous activation of the negative stereotype. That gut reaction can influence the way we evaluate the other person, make decisions, assess the person, or it can cause us to interact more negatively with the person than we intend.
Can you explain the difference between implicit and explicit bias?
Some people know that they are prejudiced towards certain groups of people and if the opportunity presents itself, they will purposely discriminate against members of that group. Implicit bias comes from the same source of dislike but in contrast to explicit bias, implicit bias operates so quickly that people do not know they are expressing dislike towards someone or acting in a discriminatory or unfair way. Several studies suggest that implicit bias primarily affects the nonverbal channel of communication.
Do you have an example that would help explain how implicit bias affects minority and underserved cancer patients?
I think a good example of what we are focusing on in our research and in our training occurs when providers meet with patients in a clinical setting. During clinical visits, most providers want to be fair and they want the interaction to go well, so they pay careful attention to what they say and they choose questions and words carefully to communicate fairness – and that is a deliberate conscious act. As a result, their explicit verbal behaviors tend to be guided by their explicit goals to provide equitable patient care.
Implicit bias is a gut reaction to someone; when the gut reaction is positive, then a provider’s physical behavior is to approach and engage with a patient. If that gut reaction is negative, then a provider’s physical behavior is to avoid and disengage from the patient. So as a result, the provider’s nonverbal behaviors – like how close they sit and how much they face the patient, how much eye contact they make, or just how positive they sound in their voice – are all guided by the degree of implicit bias towards the patient. Interestingly, even if providers are saying all the right things, their nonverbal behaviors may communicate that they are uncomfortable or displeased with the patient or the interaction. That sends a mixed message to the patient who they are meeting with.
What happens to the patients getting these mixed messages?
Patients perceive both deliberate behaviors, verbal responses, and the more unspontaneous non-verbal behavior; they read both at the same time. The research suggests that when these two channels of communication are inconsistent with each other the patient can pick up on that, and it makes them feel like their provider is not entirely engaged with them. The non-verbal form of bias tend to influence how a patient feels about the interaction with the provider.
Would you say then that a patient would be less likely to talk to his/her provider and deliver important information?
The research shows that, after an interaction with a physician with implicit bias, patients report generally less satisfaction with the meeting and with the care that they are being offered. They are also less likely to recommend the physician to other people. A recent study with oncology patients showed that, when they interacted with a doctor with high implicit bias, they were less likely to remember the content of the meeting. Implicit bias affected their memory of what the physician was trying to communicate with them.
Can you describe your intervention?
Our intervention has two main outcomes. First, we want providers to understand what implicit bias is, and how it influences judgement and interaction with patients; then we want providers to learn new communication skills that would allow them to control expression of implicit bias. To help providers learn about implicit bias we talk about the psychological processes that contribute to prejudice and discrimination in health care, completing exercises that give them a sense of their own biases. We then discuss the studies done in medicine and other health care settings that link implicit bias to treatment decisions.
What does the next section of the training entail?
The next section of implicit bias training focuses on the clinical skills providers can learn to reduce the expression of their biases. First, we have them watch a video of a provider interacting with a Hispanic patient and have them observe nonverbal indicators of implicit bias. We think that helps them see what the non-verbal expressions of bias look like. Then we have them complete exercises to practice other implicit bias reduction strategies; for example, we have them come up with questions they can ask patients that reveal groups or activities or interests that they share with a patient. We also have them do exercises where they can gain a patient’s perspective on their condition, their treatment, and so on. We believe that it’s important to do more than simply explain these strategies to providers; they need to work through how to use them so that they can apply them, to effectively de-activate the biases during meetings with patients.
How did this project originate and evolve into its current iteration?
The NIH has funded us for about eight years now, and we have been giving the training to the University of Arizona CoM students for the past five years. The training has evolved based on feedback we got from students and the faculty. Right now all our training is done in the first year of medical school, but what we’re going to be doing as part of the Alliance to Advance Patient-Centered Cancer Care is coming back in the third year and doing a refresher training with the students before they go into their clinical rotations. What we are trying to understand is if we come back in the third year and remind them of everything they learned in the first year, does that make them more aware of the strategies? After they are done with their third year of clinical rotations, we will look at how well they are doing with their non-verbal behaviors. This will be the first time we have done that.
Are there any plans to develop an online version of your training?
Implicit bias training has always been face-to-face, in part because we are a little distrustful of online applications of it. We have been encouraged to try to develop more online training, so we have a version of the first part of our training online right now and we are testing to see if it is as effective as the face-to-face version.
Are you looking to expand training opportunities beyond the University of Arizona?
We absolutely are. At the University of Arizona, we have been training students at the CoM in Tucson, faculty in the Department of Family and Community Medicine, and we recently did a training for oncology fellows in the UACC. We have also done trainings for nursing groups outside the University of Arizona, such as the Wisconsin Public Health Nursing Conference in August 2016 and the American Association of Colleges of Nursing Conference in November 2016. We have adapted our training for groups outside of health care as well: for example, we are doing trainings for faculty, staff, and graduate students in the University of Arizona College of Science. I have done similar trainings for faculty on other campuses and for other groups in the Tucson community. We can take our implicit bias training wherever people want to learn about it and adapt it for their uses, including other health science centers, or other Alliance sites, if there is interest.
Jeffrey A. Stone, Ph.D.
Jeff Stone, Ph.D., is a Professor of Psychology in the College of Science, and Professor of Psychiatry in the College of Medicine at the University of Arizona. He earned his B.A. in Psychology at San Jose State University, his Ph.D. in Psychology at the University of California, Santa Cruz, and completed 4 years of postdoctoral study in the Department of Psychology at Princeton University. Dr. Stone has devoted most of his career in experimental social psychology to investigating the mechanisms of attitude and behavior change, and the processes underlying prejudice, stereotyping, stereotype threat, and the reduction of intergroup bias. Dr. Stone’s currently funded research focuses on the intergroup bias processes that contribute directly to ethnic and racial disparities in health.