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Self-Awareness and Cultural Identity as an Effort to Reduce Bias in Medicine

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Journal of Racial and Ethnic Health Disparities Aims and scope Submit manuscript

Abstract

In response to persistently documented health disparities based on race and other demographic factors, medical schools have implemented “cultural competency” coursework. While many of these courses have focused on strategies for treating patients of different cultural backgrounds, very few have addressed the impact of the physician’s own cultural background and offered methods to overcome his or her own unconscious biases. In hopes of training physicians to contextualize the impact of their own cultural background on their ability to provide optimal patient care, the authors created a 14-session course on culture, self-reflection, and medicine. After completing the course, students reported an increased awareness of their blind spots and that providing equitable care and treatment would require lifelong reflection and attention to these biases. In this article, the authors describe the formation and implementation of a novel medical school course on self-awareness and cultural identity designed to reduce unconscious bias in medicine. Finally, we discuss our observations and lessons learned after more than 10 years of experience teaching the course.

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Notes

  1. Daniel Goodnenough, Roxana Llerena-Quinn, Anne Hallward, Linda Barnes, Irving Allen.

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Acknowledgments

The authors wish to thank Nancy Ferrari for her editorial contributions to an earlier version of this manuscript and to Yolanda Bauer for her general administrative and editorial assistance and her constant good cheer. Dr. Heather Logghe wishes to thank her colleague, Dr. Christian Jones, for his important input. Dr. Augustus A. White, III wishes to acknowledge with tremendous gratitude the following support from:

Ms. Lucy Algere

Coach Tommy Amaker

Dr. Mark and Mrs. Renee Bernhardt

Beth Israel Deaconess Medical Center, Department of Orthopaedic Surgery

Blue Cross Blue Shield of Massachusetts

Bristol-Myers Squibb Foundation (John Damonti)

Dr. J. Jacques Carter

Dr. Phillip Clay

Ms. Claudette Hodges Crouse

Dr. Robert Crowell

Culturally Competent Care Education Program, Harvard Medical School

Dr. Anthony D’Amico

Rodger L. and Gloria F. Daniels Charitable Foundation (Richard J. Hindlian, Co-Trustee)

Mr. Kevin and Mrs. Jennifer DaSilva

Mr. Michael Douvadjian

Dr. Daryll Dykes

Mr. Vincent Fath

Dr. John Feagin

Dr. Harris Gibson

J. Robert Gladden Orthopaedic Society

Mr. Fred Green

Dr. Thomas Green

Arthur and Barbara Higgins Charitable Foundation.

Mr. John M. Holliman

Mr. Jamie Hoyte

Dr. Joseph K. Hurd, Jr. & Mrs. Jean Challenger Hurd

Dr. Jesse and Mrs. Beryl Jupiter

Mr. Wendell Knox

Dr. Melvin Law

The Macy Foundation

Massachusetts General Hospital, Department of Orthopaedic Surgery

Mr. John L. McGoldrick

McKesson Foundation

Chancellor Keith Motley

Movement is Life

Reverend Willie and Dr. Anne Naulls

Dr. Michael Parks

Dr. Bendt Petersen

Dr. Preston Phillips

Dr. Roderick Randall

Attorney Macey Russell

Dr. Isaac Schiff

Dr. Thomas P. and Cynthia D. Sculco Foundation

Dr. Manish Sethi

Dr. Randolph C. Steer

Dr. Louis & Mrs. Ginger Sullivan/Sullivan Family Foundation, Inc.

Dr. Samuel Thier

Dr. Michael Watkins

The Augustus A. White, III, MD Family Trust

Dr. Willard Wong

Mr. Lloyd Wright

Zimmer Holdings Inc.

Author information

Authors and Affiliations

  1. Harvard Medical School, Boston, MA, USA

    Augustus A White III, Dan A. Goodenough, Edward Krupat & Roxana Llerena-Quinn

  2. Allies for Health, Reno, NV, USA

    Heather J. Logghe

  3. Boston University School of Medicine and Boston University, Boston, MA, USA

    Linda L. Barnes

  4. Tufts University School of Medicine, Portland, ME, USA

    Anne Hallward

  5. Harvard University Health Service, Cambridge, MA, USA

    Irving M. Allen

  6. Brookside Community Health Center AND Brigham and Women’s Hospital, Boston, MA, USA

    David W. Green

  7. Boston Children’s Hospital, Boston, MA, USA

    Roxana Llerena-Quinn

Authors
  1. Augustus A White III
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  2. Heather J. Logghe
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  3. Dan A. Goodenough
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  4. Linda L. Barnes
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  5. Anne Hallward
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  6. Irving M. Allen
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  7. David W. Green
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  8. Edward Krupat
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  9. Roxana Llerena-Quinn
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Corresponding author

Correspondence to Augustus A White III.

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Other Disclosures

None.

Ethical Approval

Ethical approval was waived by the Institutional Review Board (IRB) of the Harvard University Faculty of Medicine which determined that the research protocol is not human subjects research as defined by DHHS and FDA regulations.

Disclaimer

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Previous Presentations

Presented by the Harvard Medical School Department of Continuing Education:

“Getting to Equal: Strategies to improve care for all patients”—a course for clinicians, educators and administrators.

Held April 2–4, 2009 at the Fairmont Copley Plaza Hotel, Boston, MA.

Offered by: Culturally Competent Care Education Program at Harvard Medical School.

Under the direction of:

Augustus A. White, III, MD, PhD

Leonor Fernandez, MD.

Lecture

Journey to Self-Awareness: Meeting the Requirements for LCME Educational Directive 22 (Dan Goodenough, PhD, Roxana Llerena-Quinn, PhD, David Green, MD, Irving Allen, MD, Augustus White, MD, PhD).

Workshop

Understanding Dynamics of Class and Race in Doctor and Patient (Dan Goodenough, PhD, Roxana Llerena-Quinn, PhD, David Green, MD, Irving Allen, MD, Augustus White, MD, PhD)

Appendix: References provided by Roxana Llerena-Quinn, PhD

Appendix: References provided by Roxana Llerena-Quinn, PhD

Background Material and Resources for Extensive Study

Session 1. Introduction. Course Overview

Course Rationale-

  1. a.

    Institute of Medicine Report (2003). Chapter 1:“Introduction and Literature Review” in Brian D. Smedley, Adrienne Y. Stith, and Alan R. Nelson, Editors, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Board on Health Sciences Policy. Unequal treatment: confronting racial and ethnic disparities in health care Washington, D.C.: The National Academies Press. http://books.nap.edu/books/030908265X/html/29.html#pagetop (provides an overview of documented health disparities that go beyond access problems)

  2. b.

    US Department of Health and Human Services Agency for Healthcare Research and Quality: 2011 National Healthcare Quality Report. AHRQ Publication No. 12-0006March 2012. www.ahrq.gov/qual/qrdr11.htm

  3. c.

    Physicians for human rights. The right to equal treatment.

    An annotated bibliography on studies on racial and ethnic disparities in healthcare, their causes and related issues.

    http://ignatiusbau.com/2010/09/06/physicians-for-human-rights-the-right-to-equal-treatment/

    *(A resource on health disparities by specialty)

  4. d.

    AAMC: cultural competence education. LCME ED 21 and 22

    https://www.lcme.org/connections/connections_2013-2014/ED-21_2013-2014.htm

    https://www.lcme.org/connections/connections_2013-2014/ED-22_2013-2014.htm

  5. e.

    Lehrman S. (uploaded on September 30, 2007) News as American as America: a report for Knight Foundation. Part 1. “Reflections on the Future,” Part 2: “The Human Factor” (focusing on the media, this section explores the way our own unconscious belief systems lead to dangerous gaps in reporting and in medicine and most important why we need to change).

    http://www.knightfdn.org/diversity/lehrman/013_chap1.asp

  6. f.

    Test on unconscious bias: research from the field of cognitive psychology shows that many forms of stereotyping occur below the level of conscious awareness. Try taking a test. It takes about 10 min. www.implicit.harvard.edu/implicit/demo/index.jsp

  7. g.

    Tervalon M, Murray-Garcia J (1999) Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. Journal of Marital and Family Therapy 25:191–209.

Readings:

  • Beagan BL. (June 2003) Teaching social and cultural awareness to medical participants: “It is all very nice to talk about in theory, but ultimately it makes no difference” Academic Medicine Vol. 78 No. 6/ pp. 605–614.

  • Betancourt J, Ananeh-Firempong O (2004) Not me! Doctors, decisions, and disparities in health care. CVR &R. May/June 2004, pp. 105–109.

  • Burgess DJ, Fu SS, van Ryn M (2004). Why do providers contribute to disparities and what can be done about it? Journal of Internal Medicine; 19:1154–1159.

  • Burgess DJ, van Ryn M, Dovidio J, Saha S (2007). Reducing racial bias among health care providers: lessons from social-cognitive psychology. Journal of General Internal Medicine; 22:882–887.

  • Green A R, Carney D R, Pallin D J, Ngo L H, Raymond K L, Iezzoni L I, Banaji M R (2007). Implicit bias among physicians and its prediction of thrombolysis decisions for Black and White patients. Journal of General Internal Medicine:1–8. Readings:

Session 2. Cultural Meanings and the Culture of Medicine

Readings:

  • Taylor J S (2003). Confronting “culture” in medicine’s “culture of no culture.” Academic Medicine, Vol. 78, No.6.

  • Kumas-Tan S, Beagan B, Loppie C, MacLeod A, Blye F (2007). Measures of cultural competence: examining hidden assumptions. Academic Medicine, vol 82, No. 6/June.

Resources:

  • Definition of Culture

  • Helman C (1994) “Culture, health and illness” England: Butterworth-Heinnemann, pp. 2–6.

  • Culture of Medicine

  • Groopman, L C 1987 Medical internship as moral education: an essay on the system of training physicians. Culture, Medicine and Psychiatry 11:207–227

  • Kleinman A. What is specific to biomedicine? In Writing at the margin: discourse between anthropology and medicine. Berkeley: University of California Press, 1995, pp. 21–40

  • Lazare, A (1987) Shame and humiliation in the medical encounter. Arch. Intern. Med. 147:1653–1658

Session 3: The Cultural Genogram

Readings:

  • Hardy, K V and Laszloffy, T A (1995) The cultural genogram: key to training culturally competent family therapists. Journal of Marital and Family Therapy. 21(3) 227–237

Resources:

  • Keily MK, Dolbin M, Hill J, Karuppaswamy N, Liu T, Natrajan R, Poulsen S, Robbins N, Robinson P. (April 2002). The cultural genogram: experience from within marriage family therapy training program. Journal of Marital and Family Therapy. Vol.28, No.2, 165–178.

Session 4. Power and Privilege

Greene B (2007) How difference makes a difference. In Dialogues on difference: studies of diversity in the therapeutic relationship, Washington, DC: American Psychological Association, pp. 47–63.

McIntosh, P. 1988 White privilege: unpacking the invisible knapsack. Working Paper Series No. 189 Wellesley College.

Recommended:

  • Pinderhughes E. (1989) Understanding race, ethnicity, & power: the key to efficacy in clinical practice. NY: Free Press: 109–146.

Session 5. Gender Privilege

Candib L (1995) Power and relationships. In: Medicine and family: a feminist perspective. New York: Basic Books, pp. 240–74.

McGoldrick, M (1998) “Belonging and liberation: finding a place called ‘home’, in Re-visioning family therapy: race, culture, and gender in clinical practice, McGoldrick. New York: Guilford Press, pp. 215–18.

Mathews V. Special report: ‘the biggest inequality of all: macho beliefs are just part of the problem’ Independent News, March 2002.

Session 6.Straight Privilege

Harrison A E. Primary care of lesbian and gay patients: educating ourselves and our students. Fam Med. 1996; 28:10–23.

Potter, J E. Do Ask, Do Tell. Ann Intern Med 2002, 137:341–43.

http://www.annals.org/issues/v137n5/pdf/200209030-00010.pdf

Film: Growing up gay (by Brian McNaught)

Author, counselor and lecturer Brian McNaught, drawing from his own experience, explains the unique aspects of growing up gay in a predominantly straight world. He discusses his own experiences of growing up gay in America and examines the strictures in the Bible that are frequently quoted regarding homosexuality and put a more realistic light on what was really being said. He makes real the experience through his richly-detailed and thought-provoking guided imagery. This video can easily be used in segments as a powerful educational tool.

For more resources:

http://www.hrc.org

Session 7.Societal Factors: Race and Racism

Film: Race: power of an illusion

A three part series film produced by California Newsreel that investigates race in society, science and history.

Part One—The difference between us

Examines the contemporary science—including genetics—that challenges our common sense assumptions that human beings can be bundled into three or four fundamentally different groups according to their physical traits.

Part Two—The story we tell

Uncovers the roots of the race concept in North America, the nineteenth century science that legitimated it, and how it came to be held so fiercely in the Western imagination. The episode is an eye-opening tale of how race served to rationalize, even justify, American social inequalities as “natural.”

Part Three—The house we live in

Asks, If race is not biology, what is it? This episode uncovers how race resides not in nature but in politics, economics, and culture. It reveals how our social institutions “make” race by disproportionately channeling resources, power, status, and wealth to White people.

Smedley, A. and Smedley, B.D. (2005). Race as biology is fiction, racism as a social problem is real: anthropological and historical perspectives on the social construction of race. American Psychologist (60), 1, 16–26.

Jones, C.P. (2000) Levels of racism: a theoretical framework and a gardener’s tale Am. J. Pub. Health 90:1212–1215

Calman N (2000). Out of the shadow. Health Affairs 19(1):170–174

Gamble, VN 2000 Subcutaneous scars. Health Affairs 19(1):164–169

Tummala-Nara P. (2007) Skin color and the therapeutic relationship. Psychoanalytic Psychology. Vol 24, No 2, 255–270.

Session 8.Modern Racism and Levels of Racial Awareness

Take a test: implicit bias

https://implicit.harvard.edu/implicit/

Test on unconscious bias: research from the field of cognitive psychology shows that many forms of stereotyping occur below the level of conscious awareness. Try taking a test. It takes about 10 min. www.implicit.harvard.edu/implicit/demo/index.jsp

Film Resources:

  • True Colors

    http://www.viewingrace.org/browse_sub.php?subject_id=40&film_id=385

    Subject: African Americans, race relations, racism, Whiteness

    Summary: to test levels of prejudice based on skin color, ABC’s Prime Time host Diane Sawyer follows two friends, college-educated men in their mid-30s, one black and one white, through a variety of everyday situations. Using a hidden camera, the film explores their experiences. Pretending to be new in town, John and Glen separately try to rent an apartment, answer an ad for a job, buy a car, and shop. The video chronicles the disturbing differences in the way they are treated in identical situations. John (white) is welcomed into the community while Glen (black) faces roadblocks of higher prices, long waits, and unfriendly salespeople. In stores, Glen finds himself either ignored or followed to make sure he does not steal. Landlords tell John that an apartment is available and tell Glen that the same apartment is not. A car dealer attempts to charge Glen $1000 more for a car than John. In the end, Glen knows that he would be reluctant to move to this city while John thinks it would be a fine place to live.

  • The Angry Heart. Fanlight Productions

    Addresses the impact of racism on heart disease among African Americans. By Jay Fedigan

    http://www.fanlight.com/catalog/films/331_ah.php

  • Skin Deep: a 53-min documentary film by Academy Award® nominated filmmaker, Frances Reid, tells the story of college students nationwide confronting the reality of race relations in America. The film explores what happens when culturally diverse students from colleges across the USA start talking candidly with each other about the impact of race on their experience and outlook. Brought together for a weekend retreat, the students examine their deeply held attitudes and feelings about race and ethnicity while exploring the barriers to building a society that truly respects diversity and pluralism. Scenes of their participation in group discussions, as well as personal portraits and views of their lives at home and at college, reveal why racial tension persists and suggest ways of overcoming our country’s complex legacy of racial injustice, apathy, and alienation.

    http://www.irisfilms.org/films/skin-deep/

  • Color of Fear: eight North American men, two African American, two Latinos, two Asian American, and two Caucasian were gathered by director Lee Mun Wah for a dialog about the state of race relations in America as seen through their eyes. The exchanges are sometimes dramatic, and put in plain light the pain caused by racism in North America

    http://vimeo.com/40602451

    Multimedia Resources—Understanding prejudice

    http://www.understandingprejudice.org/multimedia/

Readings:

  • Beagan BL. Is this worth getting into a big fuss over? Everyday racism in medical school. Med Educ. 2003 Oct; 37(10):852–60

  • Dovidio J F, Gaertner SL, Kawakami K, Hodson G, (2002). Why can’t we just get along?

  • Sue, D.W. et al. (2007). Racial microaggressions in everyday life: implications for clinical practice. American Psychologist (62), 4, 271–286.

  • McLaughlin, K.A., Hatzenbuehler, M.L., and Keyes, K.M. Responses to discrimination and psychiatric disorders among Black, Hispanic, female, and lesbian, gay, and bisexual individuals. Am J Public Health. 2010 August; 100(8): 1477–1484 doi: 10.2105/AJPH.2009.181586

  • Sue D W & Sue D (2008) Racial/cultural identity development in people of color: therapeutic implications in Counseling the Culturally Diverse (5 th edition) John Wiley & Sons, Incorporated.

  • Sue D W & Sue D (2008) White racial identity development: therapeutic implications in Counseling the Culturally Diverse (5th edition) John Wiley & Sons, Incorporated.

  • Tatum B D. Talking about race, learning about racism: the application of racial identity development theory in the classroom. Harvard Educational Review 62, 1. Spring 1992, pp. 1–24.

Boston Globe article: they are sitting right next to us: on college campuses, students continue to struggle with ethnic tensions and racist attitudes. Dec.5, 2007

Session 9. Social Inequality and Social Determinants of Health

Readings and resources

Film:Unnatural Causes

Unnatural Causes is a 4-h documentary series that tackle the root causes of our alarming socio-economic and racial inequities in health. The series crisscrosses the nation uncovering startling new findings that suggest there is much more to our health than bad habits, health care, or unlucky genes. The social circumstances in which we are born, live, and work can actually get under our skin and disrupt our physiology as much as germs and viruses.

The World Health Organization (WHO). The Social Determinants of Health. http://www.who.int/social_determinants/en/

Scott J. Life at the top in America Isn’t just Better, It’s Longer. New York Times. May 16, 2005 http://www.nytimes.com/pages/national/class/index.html

Session 10. Classism in Medicine and Beyond

Film: People like us: social class in America

People Like Us looks at how class really works in America, examining how it affects our understanding of race and gender, investigating the exclusion of class from the national debate, and probing the ways in which class differences shape daily life.

The filmmakers: Louis Alvarez, Producer; Andrew Kolker, Producer

Companion multimedia site: http://www.pbs.org/peoplelikeus/about/index.html

Readings:

  • Beagan BL. Everyday classism in medical school: experiencing marginality and resistance. Med Educ. 2005 Aug; 39(8):777–84.

  • Goad J (2000) Chap. 5: Workin’ hard. The redneck manifesto. Touchstone (Simon and Shuster, NY) pp.101-23

  • Lewis M (1978, 1993) Introduction to the Second Edition and Chapter 1: Inequality and equalitarism: the individualization of success and failure. The culture of inequality. Amherst: University of Massachusetts Press, pp. vii–xvi and 3–19.

Session 11.Immigration and Refugees

Film: Becoming American (unnatural causes, Episode three, 29 min)

In this segment of Unnatural Causes, we learn that recent Mexican immigrants, although poorer, tend to be healthier than the average American. They have lower rates of death, heart disease, cancer, and other illnesses, despite being less educated, earning less, and having the stress of adapting to a new country and a new language. In research circles, this is the Latino paradox. But as they are here longer, their health advantage erodes. After 5 years or more in the USA, they are 1.5 times more likely to have high blood pressure—and be obese—than when they arrived. Within one generation, their health is as poor as other Americans of similar income status. Researchers speculate about initial protective factors and reasons for its expiration date.

Readings

  • Aktar S (1999) Psychosocial variables associated with immigration. In Immigration and identity. Northvale, NJ: Jason Aronson Inc. chp.1, p. 5–39

  • Burck C (2004) Living in several languages: implications for therapy. Journal of family therapy, v.26, n.4, p.314–339

  • Markides KS (2001). Migration and health. International Encyclopedia of the Social & Behavioral Sciences. Elsevier Science Ltd. pp. 9799–9803

  • Perez Foster RM (2001) When immigration is trauma: guidelines for the individual and family clinician. American Journal of Orthopsychiatry, v.71, n.2, p.153–170

  • Schwartz S J, et. al. (2010) Rethinking the concept of acculturation. Implications for theory and research. American Psychologist (65), 4, 237–251

Resources:

Session 12. Religion and Spirituality

Readings:

  • Wiggins Frame (2001) The spiritual genogram in training and supervision. The Family Journal, Vol. 9, No.2, 109–115

  • Zaal M, Salah T, Fine M (2007) The weight of the hyphen: freedom, fusion and responsibility embodied by young Muslim-American women during a time of surveillance. Applied Development Science. Vol. 11, No.3, 164–177.

Session 13. Student project presentations

Students share their semester projects with each other.

Session 14. Closure (multiple identities) and feedback

Students are given an opportunity to integrate the multiple aspects of identity they have explored during the semester focusing on lessons learned since the start of the course and next steps. Student feedback is highly valuable, as it has added complexity to the scope, depth, and processes of the course.

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White, A.A., Logghe, H.J., Goodenough, D.A. et al. Self-Awareness and Cultural Identity as an Effort to Reduce Bias in Medicine. J. Racial and Ethnic Health Disparities 5, 34–49 (2018). https://doi.org/10.1007/s40615-017-0340-6

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