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tv   Book Discussion on Just Medicine  CSPAN  April 17, 2016 9:30am-10:31am EDT

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the mac we did that because they wanted to raise money. we thought they could go on and raise the additional money they needed to win. we were like little political venture capitalists. we were going to go out there. there is a kick starter for women. family since her early money is like yeast. they make the dough rise and we've been doing that ever since.
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[inaudible conversations] been that good evening, everyone. good evening. i would like to start by thanking everybody for being here at our very first event at us poison pellets have been thinking collaboration of politics & prose as we embark on our first in a series of many wonderful reading. at this time underminded attractors up on her and invite making devices before because there did. thank you so much. truth will not be dead and there will be a question-and-answer session. raise your hand and i will come
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and give you a microphone. after the question will have to sign in right over here. my name is christopher and i welcome you here in a half for bradley graham and elizabeth magazine, co-owners of politics & prose bookstore and on behalf of our amazing staff. they do over 500 event year, split apart locations like this one, tacoma and our flagship store in connecticut avenue in different venues across the city. classes, literary trips and children's programming year-round. we have c-span tonight. if you'd like to see events like these in the past and going forward, subscribe to our youtube channel. i'd like to begin by saying i am pleased to welcome someone as she discusses her debut type, and care for racial inequality and american health care.
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someone is a professor at university of colorado law school in the colorado school of public health issue served on the faculty at the university of colorado's center for bioethics and humanities and is a cofounder of the colorado health equity project, a medical bitter partnership is mission history bears that the good health to those who are their low-income clients. under academic experience and their expertise to illustrate the implicit race bias that is present in our health system and result in a loss at 84th of them lives annually. the disparities entrenched in the health health care system ae premise of not these impassioned argument for a law-based solutions, not just training programs and cultural sensitivity. they celebrate matthew for having presented a thorough picture of a problem facing minorities in the health care system and for proposing reform
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on specific sections of the civil rights act of 1964 who she claimed to provide illegal and more basis to hold liable those who unconsciously discriminate and would help to establish a new standard of care and medicine. michele goodwin, professor at the university of california irvine has just the racial inequality in american health care is a massively written narrative that was once starving grizzly that claim washingtons page turning an award-winning book medical apart site has there ever been a book that makes medical discourse so captivating. please join me in welcoming dayna matthew. [applause] >> thank you, chris.
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i was an awesome introduction. i would like to package it and take it home to my kids. i want to get to the meat of the matter and talk about unconscious races that affect the health of the united states. i want to pick up on the member chris spoke about 184,000 people, the number of people the 16th surgeon general of the united states estimates died annually because of health disparities in the united states. that's a very big number. 84,000 people. let that sink in and talk a little bit about why they died a minute. my objection on trent objective is to the view is some food for thought. i've developed an acronym. i want to leave you with five and said he will. unconscious racism and health care being morally untenable,
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medically untenable, monetarily untenable, manageable and just massively urgent. so those are what i'd like you to take away. i will trace them out for you in 20 minutes and take us to a conversation love boat. i had an experience when i was nine years old. i remember it clearly because it was my first experience with explicit racism. the explicit expression that i was in area person to the speaker because of the color of my skin. i was on the playground. a 9-year-old girl -- i was nine at the time also, made it or it clear by using the why she would not play with me on that playground. and she made it clear to everybody else who was on the monkey bar where they would not be playing with me either.
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i have no doubt about her motives. i have no doubt whatsoever about my relative position in her mind as to myself for it. that called explicit racism. i remember it well. it was my first time experience in it and that is not what this book is about. however, an unscientific study -- i have three kids in their 20s. i checked with them and i say do you guys remember your first experience with explicit racism? every single one of them does. they are in their 20s which tells us what? the generation between the two of us has not changed the existence and presence of explicit racism and the people of color in this nation today. i want to make that clear because that's not what i'm talking about. i'm not talking about explicit racism. i'm talking about implicit racism. implicit bias, all three of those terms are used interchangeably. let me start by defining them.
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unconscious racism is what happens when your stored social knowledge, the information you take for the music you hear on the radio, the movie is presented to you commend the television stories, the discourse you've been watching the political debates and conversations, all of this is social knowledge and then current just part of your mind. it is triggered when you encounter a person of another race involuntarily. you call up that knowledge unintentionally and it informs your decision-making and your combat and interaction with people of different racial group unintentionally. now let's be clear. the difference between explicit preferences and implicit preferences is very important
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because studies show us that most people in the united states today are not going to identify themselves as explicit race. that was before the presidential election cycle that we are in. probably more than we thought would identify as explicit. but explicit racism is kind of out of style. not how we identify ourselves. it's not who we are as a people. this is what the book is about. it is about finding out their dreams and dreams of data that even if you're explicit preference is our egalitarian, even if you're explicit preferences are to be a fair, non-prejudice, egalitarian person come your implicit biases trumpeter x posted preferences. your implicit biases what is stored in your social knowledge will do more to inform and direct your conduct then will
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your explicit preferences. why is this important? it is really important and health care and why i came to write this book was to get help disparity, but we politely call health disparities is killing people of color daily. it causes people of color in this country to live sicker and die quicker because of the color of their skin. so if i were so inclined i could than the rest of the evening running the data on just that fact. in 2003 the institute of medicine published an important seminal work called unequal treatment and a catalog 25 years of data. the fact that infant mortality in the african-american population is twice that of white population, and the fact that you are 75% more likely to die if you're diagnosed with
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coronary artery disease than if you're a person of color than if your way. these are the kinds of data, the kind of statistics replicated a matter what the cause of disease is true for stroke, diabetes. i'm going to posit canned or because i want to make a point. with respect to cancer, whites and blacks diagnosed at the same time have a 33% different gap in their five-year survivability rate. this is not true, however if they receive similarly intend to treatment, education, screening. if these treatment disparities are eliminated, the difference in survival rate disappears. the fact that it's true is morally untenable. morally untenable in the united
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states in my view. it is medically untenable as the medical profession not only agrees to first do no harm, or that if you read closely the hippocratic oath talks about justice. it talks about being a provider and a traitor of an entire patient, a whole patient in context. and when that is not the case, implicit biases change the way people are treated. so let me turn now to the contents of the book, the institute of medicine study done in 2003 positive that it is possible that physician bias may have a causal relationship with help disparities that because physicians themselves as individuals were bias on race,
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ethnicity, socioeconomic, gender , orientation another grounds might actually influence their treatment decisions, but at the same time the institute of medicine said we don't know how the mechanisms work. the point of my book was to try and come up with an understanding of those mechanisms, to understand how it is that physician bias translated into poor health outcomes for people of color as compared to white. so i looked at the empirical literature. i looked at the studies and they are copious. with respect to implicit bias in health care and i organize them into what i call six mechanisms, the bias care model. i'm only going to talk about one tonight. i organize them in a way that's it just there or six different pathways are mechanisms by which
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physician bias translates in to help disparity. one of the most important contributions i hope my book will make us not only to organize work of mechanisms for others to discuss and research, but also the fact that one of those mechanisms become a dirty little secret, both biases that patients hold. if the fact of the matter is we get these biases by her social knowledge, all of a sudden in the united states would get a same social knowledge in the literature tells us that patients as well as providers will have implicit biases. one study in one mechanism for tonight and if you're interested in the other five we can talk about them some more during the q&a. for one study was about mechanism number five comment implicit bias changes their treatment patterns. this is a very direct link where
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mechanism between bias and disparity, and between bias and poor health outcomes. this study is better in the treatment space say this. and they give the fund by alexander green especially. they say that if a patient has a coronary artery disease and we present that patient first as a black woman, then it's a white woman, and next is a black man, then as a white man, but we use a script, we use it predetermined set of data that tells us about the medical indicators. he is a predetermined set of facts about their history and personal background. they are identical to the
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physician vouch for their race and gender. if we do that, we can see race and gender and form of the treatment decision. second step of the study and probably the most troubling for my work and the reason i went to do this work, if we also measure the implicit bias of the physicians making the diagnostic decision, the inverse relationship between the level of implicit bias and the quality of the treatment decision. that is to say the more implicitly bias, the higher on the implicit association. i feel like i can talk about that as. the higher the implicit association test scores, the more likely they are to provide an inferior treatment fidelity to patients of color as compared
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to patients who are white. the reverse is true. the lower their implicit bias measures, the more likely they are. this is a study of coronary artery disease patients who needed the treatment of choice for their coronary artery disease. the more likely a physician scorer was to prescribe the treatment of choice. that tells us there is an empirically evidenced relationship between implicit bias in the quality of treatment that a patient will receive. that results in different health outcomes because different treatment will be afforded to people based on the color of their skin. the other mechanisms has to do with the conversation and communication between physician and patient. i'm interested you've had this experience if you encounter
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someone and they are not looking you in the eye. the information if you're not a person of color. the interviewer sure. they are verbally dominant. not asking our respect while crediting your opinion. these are and their implicit biases kick and also so they think i know what that is. i'm no longer satisfied with a lot of data that tells us what patient satisfaction it was poor health outcomes. what i found out in this book was a series of interviews with those kind of patients is not just low patient satisfaction. it is low patient satisfaction meaning i'm not coming back to you anymore. that's an interruption in my continuity of care. it means if you tell me that i
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need to exercise, i'm not listening to you because you've insulted me. that means my adherence in compliance is so, which translate into low or relatively poor health outcomes. all of these mechanisms work together. it is often the case that you read a book i've been told and you finish a book and you would write another book, a different at the conclusion of that conversation. that firm aegis to have a second project. to let me share with you a couple things. i'm going to read one thing out of the book cannot close telling a little bit about what i would do to fix this and what my next book looks like. in the empirical data i set out to create a new data set to interview patients and
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physicians, interview health care providers and asked them about their lived experience, their own personal interaction with implicit bias or unconscious racism. but i found essentially as i was able to confirm all six of the mechanisms i describe in this book. i choose a different patient to read about and this time i want to choose a first generation chinese men who bears out mechanism number six says patient who feel and perceive themselves as being discriminated against drop out of the care system or at least interethnic care system in a way that impacts their help out and negatively. this is a story of a man who is an engineer by training and profession and the implicit bias
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that he experienced really is emblematic of what i heard for many patients. what i heard for many patients and you will hear it in his story is that his view was discredited, that perceptions about 10 is a foreigner meant that he was not believed or taken serious leg. his complaints were ignored and the treatment he received turned out to be inferior. picking up the middle of the story since 198 i just found i got some clinical disease like re-occurring to me, which caused and came from the countryside back in china. it is mosquito, a very tiny. it's hidden in the liver and can one day show up and have a very high fever. and then you are dead and you go
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to sleep and he describes the scent is good you can't walk. you are lethargic. you can't work. i got that thing he said. it is an asian disease. when i came here, it came back. i went to dr. i knew everything about it for sure. when i got to the hospital, nobody believed me. and then they take my blood and they say you know i can find nothing. there is nothing wrong with you. but this thing is true. you cannot find it in the blood, but if you look carefully at them the. i don't didn't they bother to do that. of course i can't really remember the name of the academic terminology. to the dictionary with me. imagine this meant experience. he goes back and take the dictionary to explain to a stock or they can speak english. i took the dictionary and i
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found what to tell the doctor, but they say no way. i cannot give you any kind of treatment. you can show me what is making you feel bad. come back. and this is done if you don't have symptoms, they only kill the symptoms. they don't treat you for what's really wrong. if you don't speak english very well come you have less of a chance of making them understand. this is not to say they hate chinese. they have some kind of pre-judgment. they say you're wrong because you're not professional. her whole life in the united states is you never met someone like me. it makes you so weak it can kill you. so after 15 years here i got this thing again but i decided i'm not going to the hospital again because it makes me feel
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worse to go to the hospital. i write to my friend and shanghai. i tell them i need the medicine and they bring it to me after a month. i'm a professional in my area. of these taken same well-educated. if i had a psychology degree i could take apart the sense of dignity this man lost in his encounter, defensive is both which he was quick to deny. remember his comment. they are not racist. they don't hate chinese. but i am not going back there anymore he said. his health outcomes are at first sight did that in fact this has happened. i think this is medically untenable. tom the bees to some of the foremost disparities scholars in this country tells us that it
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cost 1.24 trillion with a t. dollars m. loss product to be, preventable hospitalization and increased health care costs. to treat health disparities over a course of his study of six years. it is morally, and medically and monetarily unsustainable not to address this problem of health disparities. the most serious causal factor that we are not talking about his unconscious racism. so what i wanted you to fix? at/singson q&a but mostly i would like to see the law changed. why more of our medicine is concerned. poor doctors are under so much law. i said.for my husband.
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washing the social norm needs to be changed in this country. the social norm right now tells us that it is okay because it's unintentional to discriminate. unconscious bias and its unconscious bias. those in which people are measured by the ict, the implicit assist haitian test and/or explicitly biased are told in an experimental condition and situation that their biases are not shared the 80s x% of their peers and then there are subsequent parts of the experiment where they are asked to sit down on a chair next to a person of color. those who believe their biases are affirmed by their peers step further from the person of
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color. those who believe their biases are not the social norms that closer. that is one example of several at. that's what bush tells changing the social norm matters. we changed the social norm about explicit prejudice, racism in this country. we need to change the social environment that implicit unconscious, unintentional racism. we do three things with respect to the civil rights act of 1964. number one we have to make implicit or unconscious bias unintentional racism actionable under that statute. number two we have traversed alexander versus sandoval, one of the guests that are dearly departed justice scalia left us. we have to replace the private cause of action that worked so well with respect to explicit racism so it's available at the cause of action pertaining to
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implicit racism and how we cap in this so everyone who thinks the negative thought is not suited in the system i'm proposing and import a negligence standard into the title vi regime the negligence standard simply says if you as an institution, if you as an individual have done what is reasonably shown to address implicit eyes, you have a perfect defense to a title vi cause of action. it would create a system where the providers will do it it done with hepa. if it does it to law. it changed everything with respect to privacy. institutions became immediately active and proactive with respect to training, teaching and changing social norms around privacy. if you're one of a certain age like that i am, you remember
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television market used to walk up to the nurses station and there would be the chart. no more. social norms changed by the law. i do not think we will dedicate course to ourselves out of the implicit bias and its deadly impact on health care. but i do think will change the social norm if we do what i propose. the book i would write if i were writing today, i would write a book about more than just the implicit bias that affects the health of populations in the clinical encounter. i'm holding up a picture about the poisoning of american city in flint michigan. it's my belief is social determinants of health in flint michigan are rife with implicit bias. it is pretty clear from the literature today that your health care alone doesn't make you healthy. so if you are discriminated
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against in education, you will have a higher likelihood of experience in poor health outcomes than those who are not discriminated against in education. if your house soon is discriminatory, unsanitary and unsafe, physician tells you you need to exercise more, eat better. if i lived in flint i don't have a supermarket in my city in order to buy fresh fruit and fresh vegetable. ..
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we could get at the implicit ties that touches these issues if we change a discrimination actions that are available. how could flint happen? it is not the only city in this country where the social that covers of health are distributed by law and that distribution is rife with unconscious racism that results in poor health outcomes. it's not the only city i promise you. having said that, we will leave it there because there is so much more to say about unconscious racism. let me close by saying these two last things. governor rick snyder assured us there was no racial motivation behind his decision to ignore the lead and copper rule, behind his decision to completely
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ignore democracy and replaced the democratically elected officials conflict with emergency managers, by his decisions to ignore the outcry is a patient's of people, citizens conflict who explained the orange sludge that was spewing forth from their tap water did not spell what, didn't look right, didn't seem safe to drink for them or safe for them to wash their babies in. what could be further from the clear, honest to goodness truth than that this predominately black population and those that were not predominately poor population were the victims of unconscious racism? i will give you that governor snyder didn't think he was making a decision based on the race or poverty of that population. that would be explicit racism. that would be explicit bias, but
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i will also give you an assurance that whether he would admit it or not, governor snyder would never make that decision with respect to a population that looked like him, that had the financial wherewithal that he had, that did not give him an unconscious reason to believe this group of people were somehow less than or somehow different than or somehow not entitled to the same treatment as a populatiopopulatio n of his own children. that's implicit bias and that's how massive the problem is, in my view. so thank you for taking the time to listen to me. i look forward to your questions. [applause] >> if you have a question please raise your hand. i will do my best to make my way around the rim.
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thank you. >> thank you for a brilliant presentation. i have two questions. what is 100 the book i was impressed, i didn't realize the copious miss of the research, i mean, i have problems as we go back and forth because i had to look at this. why is it that so much has been out there before and it's just now coming through this book? second point is you talked about title vi, using the negligence standard which i can see for institutions. could you speak more about how it would apply to individuals because showing i guess the burden of proof would be on plaintiff, but showing implicit or even the demographics, could you speak about point? >> they take the psycho first because i will forget that one. i would like to see disparate impact return to the title vi machine. i can reversing sandoval.
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so that i could statistically show that health outcomes in an institutional level or on an individual level which are biased are a prima facie case for having the evidence that there was actionable discrimination at play, right? same standard would be my view. so a complete defense will be negligence, right? a complete defense was that i acted reasonably to take the steps that are in the literature showing what will reverse, what makes implicit bias valuable. that's th to ever do that from a legal standpoint. why isn't just coming to the fore? i have been studied health district for about a decade at this point and most attention leading up to the 2003 report have to do is ask us. don't get me wrong i came to washington because i believe
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firmly in the affordable care act, from in fact this is the step we needed to take in order to expand health care in these united states to at least 18 million more people. having said that if we had universal health care and that universal access was to answer your and discriminatory care you would still end up with the disparities are described in this book. access has been the focus for the past 25 years. it's the first generation of documenting health disparities and then understanding the extent of those health disparities. that's the work that had to go before so the all of the statistics i quote about cancer disparities, diabetes disparities, the death rates for infants. they are copious but that took 25 years in order to unmask that literature just to describe the problem. without once we describe the problem and get people access to health care it would change these disparities and inequalities. it has not. a deep% of the disparities nation for health quality and
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exit have not moved in 25 years. pardon me, but some of my best friends are conservatives but conservatives like to point to the fact that we are narrowing the life expectancy gap. it's still the case if you are a black man in this country you're going to die five to seven years earlier depend on where you live. in some parts of the country your life expectancy is like that of someone from haiti. so the fact that we have narrowed the life expectancy gap a little bit doesn't change that death rates for infants, to the diabetes, due to cerebrovascular disease, heart disease, cancer, you name it, asthma, people of color die quicker and live sicker in these united states than white people do. we haven't moved to new and so now we're just turning to this question of what might be the mechanism. last part of the answer i would
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give is that this is a sticky topic. i had to start my talk by saying i want you to all the i'm not talking about explicit racism. i don't want to offend anybody and make them think i'm pointed health care profession, people who are dedicated to caring for populations, who are trained to be objective are themselves racist. i shut down the conversation if i would do that. i want to be clear that although this is tough, we are talking about a ubiquitous problem and we're just getting to that conversation. >> good evening. i think you may have already answered this but i wanted to bring it up anyway i want to bring up a three-point. i think i will start backwards and energy focused just now, i am a nurse and so i've been a nurse for 18 years and over
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again acute-care setting so i've witnessed a lot of what you have discussed. and i've not read your book. this is always a healthy discussion for me and some of my peers. i wanted to talk to you about health care is very diverse, it's very diverse in the ethnicity of the clinicians that care for our population. and so, and you spoke to clinicians being trained as a comes like cultural sensitivity. i don't know if the due diligence has actually occurred in the address of that. and i think it speaks to what you talked about, like this implicit unconscious belief that people have. i went to south africa recently and i have some conversation with some folks there and asked have ever come to america. know, but i watch b.e.t. i want to say that several
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america from african-american standpoint but again it speaks to that unconscious thought of what to believe it to be. the same is true for health care clinicians. i wanted to ask this. how do you think the business of health care helps to promote this implicit unconscious belief? because health care facilities now especially with the new affordable care act and the way that hospitals are reimbursed, like there's a heavy competition on being number one, on meeting benchmarks, i'm getting the quality faced reimburses and being number one with a strokes and/or trauma center or cancer center, that it almost, it stumps you ca and want you to provide a level of care that you want to because you're constantly having to meet those benchmarks. even though there's going to be work and recommendations to try to work towards this we have to talk about the way that the
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health care is afforded to the people who need to provide health care. >> that is rich with lots of opportunity for discussion. i want to go to the last point, and that is she's asking of the basis of health or influence his implicit bias. i think it has a heavy influence of the operation of implicit bias. remember implicit ties is an automatic spot. is what we use to organize very complex, chaotic situation into manageable bites essentially, right? think about what a differential diagnosis is, a physician takes a universe of possibility and start eliminating those which are not descriptive of the patient and very quickly underscore bold italicized will come back to the work quickly, very quickly tries to decide what is wrong and what can be done for the station. that exercise is an exercise of judgment that invites the kind of categorizations and shortcuts that implicit bias reflects.
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that's exactly the kind of said in which implicit bias fries. when we very complex, large decisions subject to great amount of discretion, after the fact the business of medicine has made those decisions have to speed up your you have to speak the decisions of the we've got 112 minutes to get with the station is, perform according to these metrics, it these metrics, detestation in, out, so many i've got to see. i've got measures i've got to me. the fact is we have created an environment where shortcuts are necessary. and infection because held across the street safely. you categorize and you walk across the street based on those judgments the everybody uses them but in health care they can be exacerbated. when the love of discretion prevents the kind of interaction that connects patient to provider, when the amount of time given to make those
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decisions be sure and and truncated come when the love of discretion is too broad. so i've heard others suggest if we were to standardize some patient decision-making. here's what i know my husband would go crazy. standardized some patient decision-making, we eliminate that discretion which is so vulnerable to implicit bias. there are ways what you said certainly have a bearing on the prevalence of implicit bias. >> thank you for the awesome talk. my question is about, so i guess those of the identities of the doctors affect the interactions between them and -- >> don't go there pics that i've been involved with a couple programs where they're goal goal is to help promote or encourage like the wind come communities of color to go with the madison
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pitts i was wondering light liks it have any effect in those programs? >> thank you for the question and the answer is yes and no. yes, because one of the things that makes implicit bias malleable by the lecture we already have, the study we have counter stereotypes. counter stereotypes mean simply of studied, if you prime someone with pictures of people of color in positions of power, not just the person who was in the room changing the bedpans, but in positions of power, positions of authority, decision-makers across the spectrum of health care providers, those counter stereotypes are likely to reduce the extent to which implicit bias operates. that's true so yes, diversifying the workforce. if i make it an independent lawsuit on describing would be actionable. if i said eithe i do robust outh program, a pipeline program and i've taken race will steps to provide counter stereotypes to
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recruit and retain providers of color, i would have a defense to the implicit bias action. here's the dirty little secret into what i said you are making me go there. if you live in the sky may, if you grew up in these united states it doesn't matter if you're black, brown, yellow, purple or orange. your subject to the same social knowledge as everybody else. so black physicians, latino physicians and white physicians all reflect the same implicit bias levels as the major population, sorry to say so. >> i work in quality measurement and we spend time think whether we should risk stratified a risk that just different quality measures. on trees which are thoughts are on whether adjusting measures based on race helps to point out where this is parties exist or if instead it allows implicit
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bias we might want to focus on improving patient outcomes for white patients are other patients who have higher advantages? >> so i think i understand your question about data collection and whether stratification and data collection helps or hurts. my view is you can't fix what you can't measure. if it's not really cleanly articulated in the data i don't think any of these problems are easy to solve. i don't think even the solutions i proposed that we have in the current literature or a full story. i think in a word that stratification by race and ethnicity helps. i know that there's a large conversation going on about whether we should risk adjust by socioeconomic status and other factors. there's a large conversation going on about whether or not we should allow precision medicine to address racial differences and ethnic differences. we have been afraid of those for very good reason but again you
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can't fix what you can't see. we have to measure it, look it in the face and we have to address it forthrightly. i would say that stratification, data collection such as the affordable care act requires i race and ethnicity helps. >> first off i would like to thank you for adding your solutions to this. i'm a medical student and we had a whole day of talking about this those that entire day and was no solution provide at the end of the day and all walked away scratching our heads. hello? base of the osha saying thank you for providing some of the solutions you provide. i'm going to look at alexander versus sandoval and whatnot. we been talking about reimbursement and that's come up in the conversation.
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i want to talk about something specifically. what i'm learning is we've got, we had a fee-for-service model and we are moving toward pay-for-performance. and pay-for-performance being hospitals want to look at how many revision revisions they haw healthy our patients when they leave. so my question is how do you think implicit bias is going to play into access to health care went pay-for-performance is now the model and now some doctors and health care providers in general, their salaries are depend on health of their patients. if we are all being fed misinformation, important information, how does that affect kind of setting up private practices and other sort of health care outputs? >> that's just a great question. first of all thank you for being cognizant of implicit bias, the
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change in come the delivery model and reimbursement model as a medical student i think the long-term prospects for you doing your part to eradicate health disparities is greatly increased by your awareness and your conscious effort to educate yourself. so congratulations to you. in a word i think it helps. i think it helps to move the health delivery model in a way that will charge physicians with more than treating disease but treating entire outcomes, treating anti-patients. indeed, one of the most moving presentations i have heard since i came to washington was a quote that dr. nicole lurie may dr. nicole lurie may come issues that i have failed as a doctor to patient if i am not a doctor to my patients whole community, right? so i was a just submitted a way from fee-for-service into reimbursement models that look at value return as opposed to
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just the fee for the service that was provided are more likely to produce doctors like doctor mona who look at the elevated blood levels innovations in flint and said something is amiss in the entire community. something is amiss in the entire population. i have to look at what these patients are living with in terms of housing come in terms of food, in terms of their educational access, in terms of their medical access and i have to look at their whole picture. i think that kind of physician perspective is much more likely to result from a departure if you will from fee-for-service to more elaborate give an outcomes-based medicine here. >> we have time for two more questions. >> my question is two parts. can hear me? the first is, i'm a medical
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student as well. what can i do to check my own personal bias and to emulate it in whatever way possible? and the second question is in the reading you gave, the patient said that we have a system that takes away the symptoms. in what ways do you think our current health system kind of exacerbates or allows for the implicit biases you discuss? how can we approach on the individual provider level and that also on health systems level? >> great question. i'm going to enter it into parts as well. as a medical student, you have the fortune of not yet having been indoctrinated, if you will. there's only one study but it's a very potent study, a study by medical students over three
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years. in this study medical students, nursing students, farm assistance and dental students had their implicit biases measured in the first, second, third and fourth years as they were correlated with their treatment decisions. in short, early in the grammatical students like you had the same level of implicit bias as generally the population does but your implicit bias appointed to clear it wasn't you but medical students in the study did not have the same correlations between devices and the treatment recommendation. so the hell the biases of the biases did not affect the treatment decision in the first year. less so in the second, less in the third, and by the fourth year of training medical students the biases affected the treatment decisions in the same way that they are attempting and physician trainers affected, right? a medical student, one of the
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things you can do is say wait, i can be internally quietly i know you need in a comment you want to do well, i can internally question why might attending on brown's introduces the patient as a 53 year old black woman, if she doesn't have sickle cell or anything that's related to her race. why is that racial monitor important to the description of the patient, other than to convey information that is nonclinical, nonmedical, not helpful and perhaps packed with implicit biases? you can ask yourself that question. it if you are a medical student you can also ask yourself why in the same study, although physicians in training have the same level of correlation between their treatment decision and their implicit biases by the fourth year? nursing students do not. pharmacy students did not and dental students did not.
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i don't have the answer for why that is. i have a hypothesis about why that is, right? the nursing mission is to advocate for the patient as an individual. the nursing student sees the patient not as a category but as an individual. i don't have the data to prove i'm right or wrong but you can ask yourself as a medical student what is that's happening in your training that might lead you to change who you are, frankly, and how you treat people as individuals are you can combat that. the reason i think that is not a fool's errand because a third part of the study i talked about was that he took at of the 700 physicians that he examined, 60 or so were actually, it was disclosed to them this was a race of study. it was disclosed this is a study about patients of color versus patients who were white what the
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differences in treatment were between them. just the disclosure changed their treatment pattern. just the disclosure, just knowing that one is susceptible. so i applaud you because the first part of your question was what can i do about my biases, would suggest to me self-knowledge, self-awareness and having the kind of critical thinking that will, if the study is correct, will result in giving much more vigilant about offering typically to patients of color as to why patients. those are the things i can think of the. >> just sort of a curiosity. i'm wondering if you see less implicit racism with pediatrics? i would assume kids would be a great equalizer. >> yes, we do. there's a study done out of wayne state, michigan, that is
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actually a series of studies that shows a couple of things. pediatricians have lower biases than other physicians, slightly lower biases than other physicians. foreign trained medical graduates have lower biases that other physicians. people who grew up in different countries with different sets of social knowledge and social inputs have lower biases. there's a lot of work yet to be done in implicit biases. i thought that this was a conversation starter. i thought and felt strongly that this problem is too deep, too broad, too wide, too important not to talk about, even given the state of the research as it is right now. we don't have a lot of information about implicit biases beyond black and white and latino-white parents. that's a shortcoming in the literature. we don't have a lot of
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information about implicit biases and what it does beyond the physician group with the exception of the one study pertaining to students. we don't know what clinical pharmacists, nurse practitioners can we do know about their biases and influence on their treatment the if anybody has been to the dentist and had the reception take the ugly, they don't go back. so what about people who are administered in healt in the hee system? what influence do their biases have? i believe in the we're doing cultural competency today, even though we're spending lots of money on making sure people know that differences exist, we've got to go further and deeper into the type of stereotype negations that change the habit of being implicitly bias, that changes the habit of thinking automatically and letting your automatic thoughts override what your preferences are. i want to close by saying that
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ever since i was a little girl, my mom would have to pull me back from trying to make justice happen when i saw that it wasn't happening. what we see in the health care system is not just disparity. that's a sterile term. it's not just automatic. it's not just ubiquitous and, therefore, acceptable. implicit biases are not a given, and the problem that they create is fundamentally a problem of injustice. and these united states cannot continue to tolerate the injustice of results in people of color dying and living sicker than whites just because of their color. thank you. [applause]
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i feel informed and i could've went to get a copy of "just medicine." please give dan and opportunity may quit over to signing table. before you leave we ask you fill out a survey. please take time to fill that out. thank you so much. >> welcome to tuscaloosa, alabama, on booktv. located on the black warrior river it has a population of about 90,000 residents and is home to university of alabama.
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with help of our comcast cable partners, over the next 60 minutes will explore the history of the city and state with local authors including a look at what's known as a black belt. >> a black belt is unique in the state of alabama. it is different from anywhere else, anybody in alabama will to you that the anybody and a black belt will tell you that. it's come a point of pride. >> what about the legal battles as they fight this is to a local employer monsanto. >> if i can prevent this from happening to one of the community, i'm going to tell you what i know and what i experienced. >> but first we speak with other earl tilford about university of alabama in the 1960s. >> the name of my book is "turning the tide: the university of alabama in the 1960s." i put this book because i was a student at the university of


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