#KeyLIMEPodcast 200: When professional ideals meet human fallibility

Reference:

Sukhera J et. al.,  Striving while Accepting: Exploring the Relationship Between Identity and Implicit Bias Recognition and Management Acad Med. 2018 Nov;93

Reviewer: Laura Varpio(@LaraVarpio)

Background

First, the authors provide some definitions:

• Explicit bias: conscious attitudes or intentional discrimination towards certain groups
• Implicit bias: associations, attitudes or beliefs that exist and exert powerful influence over individuals outside of their conscious awareness

The authors contend that implicit biases can perpetuate health disparities by widening inequities and decreasing trust. Given that, medical educators need to address our implicit biases. But that is more complicated than it seems. Once we become aware of our implicit biases, it creates a tension within us — between (a) who we want to be and (b) who we are. We need to reconcile our biases with our personal and professional identities. But before you can get to that work, first you need to recognize your implicit biases.

Purpose

In this study, the authors set out to study how learners and faculty reconcile identity tensions that are evoked during the process of implicit bias recognition and management.

Key Points on Method

Methodology: Constructivist Grounded Theory

The population: faculty and residents working in psychiatry. N = 21

The bias studied: Dangerousness (Justification for that selection: psychiatrists often view part of their professional mandate a need to de-stigmatize mental health, and so hold explicitly positive biases towards their patients. Any implicit biases against those very patients would conflict with their professional identity and also likely their personal identity)

Processes:

1. Each participant completed an on-line version of the mental illness implicit association test. This test asks participants to associate words and assess automatic associations between different concepts. By doing the test, participants find out of they held strong, moderate, mild, or no dangerous implicit bias.
2. With this new information, participants then engage in a one-on-one interview. In that interview, they were asked open ended questions about the experience of taking the test, and were asked to draw a rich picture which they discussed as part of their interview.

Key Outcomes

3 key findings:

• There is a tension experienced within participants between their professional and personal identities, a tension they manage by compartmentalizing the two. Participants held an idealized, confident, un-biased professional ideal. They also held an actual identity of being vulnerable, and not ideal / having bias. The unbiased, confident professional ideal was something to be sought after, a constant goal to strive towards.
• To recognize and manage their biases, participants described 2 processes. One is constant striving for self-improvement which the authors described as intrinsic to most participants’ identity. The other process was the acceptance of the fact that we’re never going achieve that unbiased, professional ideal.

• Participants reconciled these tensions through relationships—they acknowledge that implicit bias wasn’t something that they could manage on their own. Faculty members tended to view themselves as role models for learners of managing implicit bias. Residents needed mentors to help them learn those managing skills. Residents noted that the faculty role models weren’t always around, and some mentioned that there were only a few faculty who were really role modeling how to reflect on biases.

Key Conclusions

Healthcare providers have a predicament: we want to achieve the professional ideal of having no biases BUT everyone has biases, therefore we can never achieve the ideal. Learning that we are not living up to professional ideals can lead to feelings of inadequacy, imposter syndrome, even shame.

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