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William Hua, PhDStaff Psychologist | San Francisco VA Health Care SystemAssociate Clinical Professor | University of California San Francisco*Special Acknowledgement to Kelly Koo, PhD
Unpacking Microaggressions and Biases and its Impact on Health CareAsian Health SymposiumOctober 10, 2019
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Disclosure
I have no relevant financial relationships with any companies related to the content of this course.
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MICROAGGRESSIONS:Real examples from Asian providers and patients
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“When asking about preventative measures for a given health condition, a provider commented that “Orientals rarely have that problem…” and suggested that “I shouldn’t worry” (but did not elaborate further on my initial question).
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“I don’t have the range of affect that is ‘typical’ in western culture or the depth of expression expected to express extreme of emotions. Because of this, I am often asked over and over again if I understood something, even though I repeatedly nod and say yes.
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“I was demonstrating a mindfulness exercise to a client and his response to me was, ”It’s like you’re Mr. Miyagi from the Karate Kid.” I tried to take it as a complement since he did enjoy mindfulness, but it was hard to knowing that he never remembered my actual name throughout our work together.
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What are Microaggressions….and why does it matter?
§ “Everyday verbal, nonverbal, and environmental slights, snubs, or insults, whether intentional or unintentional, which communicate hostile, derogatory, or negative messages to target persons based solely upon their marginalized group membership.” (Sue, 2010)
§ Microaggressions = occurs at individual, person to person, levels
§ Microaggressions ≠ micro impacts
§ Microaggressions explained: Mosquito Bites
ds
https://www.psychologytoday.com/us/blog/microaggressions-in-everyday-life/201011/microaggressions-more-just-race
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Microaggressions in Everyday Life
§ “Your English is good! You look exotic.”
§ Locking the door when you see a person of color.
§ “Do you have a girlfriend?” to a gay man.
§ Having just female or male on intake forms.
§ “Can I speak to the doctor?” to a woman doctor.
§ You are a foreigner. You are not American.
§ You are a criminal/you are dangerous.
§ Straight is standard; heteronormativity.
§ Transgender persons as “other” or as “not normal”.
§ Women are not doctors.
Microaggression Message Conveyed
Adapted from Sue et al, 2007
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Have you had a microaggression directed toward you in your role as a provider recently?
A. Yes, in the past week
B. Yes, in the past month
C. No
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Getting Personal
Pay attention to where microaggressions and individual and systemic biases occur in this narrative
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"I don't really work with a diverse population"
§ Multicultural humility as an APPROACH to clinical work, vs. tied to one identity.
§ Blindspots à bias
§ Emphasis on approaches to working with the patient that includes:- Individual experiences- Intersectional Identities- Context- System
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Implicit Bias
Implicit (unconscious) bias: unconscious, unintentional, and/or automatic mental process in which individuals may hold negative beliefs about others
E.g. having a general rule about not seeing a patient if they show up more than 10 mins late, but then being more likely to bend this rule if the client is ____ (often not in awareness)
Devine, 2012; Gaertner & Dovidio, 1986
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Bias and Impact
§ Implicit bias is not inherently “bad”; we all have them, even when we don’t want to believe that we do
§ Because they happen on a subconscious level, want to examine what happens when biases remain unchecked à
- Impacts our interpersonal interactions - Biased decisions, unintentional slights - Increase in microaggressions
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Impact on Health Care
How does bias impact health care?
1. Interpersonal interactions (with patients)- Treatment adherence- Treatment follow-up/dropout - Perception of quality of care
2. Internal dynamics (within the system, among staff)
3. Costs/Waste (money, time)
https://www.youtube.com/watch?v=ze7Fff2YKfM
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Unpacking Bias and Its Impact Discussion of Bias and Impact (15 minutes) • In groups of 4-5, provide as many examples as you can of bias that
providers might have about Asian patients who have a particular concern e.g. beliefs that Asian patients are less/more likely to smoke cigarettes)e.g. believing a patient would be healthier if they just ate less of their cultural food
• Discuss the possible impact of these biases on patient care
Strategies to Mitigate (5 minutes)• Discuss strategies to identify the biases and better keep our biases in
check
Debrief & Share (5 minutes)• Pair with another group and briefly share what your group discussed
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Commitment to Action § What is one action you will commit to that will help
you to better examine and address your unconscious bias? How can you help keep yourself accountable?
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Presentation Title17
To Review Later
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Cultural Competence à Cultural Humility
An ability to understand and interact with people from various cultures and belief systems; a skilled application of cultural knowledge
“One problem with this definitional approach is the assumption that cultural competence necessarily leads to efficacious outcomes when applied to minorities.” (Huey et al., 2014)
“It is a process that requires humility in how physicians bring into check the power imbalances that exist in the dynamics of physician-patient communication by using patient-focused interviewing and care.”(Tervalon & Murray-Garcia, 1998)
“…is a process of openness, self-awareness, being egoless, and incorporating self-reflection and critique after willingly interacting with diverse individuals.” (Foronda, Reinholdt, & Ousman, 2015)
Cultural Competence Cultural Humility
GOALS“I will apply this skill with my client”
“I will attend the Asian Health Symposium”
VALUES“I view learning as a continual process”
“I commit to ongoing reflection on my biases”
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Implicit Association Task (IAT)
§ Help to increase awareness of implicit biases that could impact our work
§ Measures strength of associations between concepts and attitudes and beliefs that people may be unwilling or unable to report.”
- E.g. “Belief that women and men should be equally associated with science, but your automatic associations could show that you (like many others) associate men with science more than you associate women with science.”
§ “Results…show that members of stigmatized groups tend to have more positive implicit attitudes toward their groups than do people who are not in the group, but that there is still a moderate preference for the more socially valued group”.”
https://implicit.harvard.edu/implicit/
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Medical Bias and Impact
Medical Bias: Why Doctors Make Mistakes https://www.youtube.com/watch?v=8wlq7-v3-bc
Devine, 2012; Gaertner & Dovidio, 1986
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Resources
Social Justice Syllabus https://www.div17.org/scp-connect/scp-news/scp-social-justice-syllabus/
Diversity Toolkit: Guide to Discussing Identity, Power, and Privilegehttps://msw.usc.edu/mswusc-blog/diversity-workshop-guide-to-discussing-identity-power-and-privilege/
One Size Does Not Fit All: Meeting the Health Care Needs of Diverse Populationshttp://www.jointcommission.org/assets/1/6/hlconesizefinal.pdf
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ReferencesDevine, P. G., Forscher, P. S., Austin, A. J., & Cox, W. T. (2012). Long-term reduction in implicit race bias:
A prejudice habit-breaking intervention. Journal of Experimental Social Psychology, 48(6), 1267-1278.
Foronda, C., Baptiste, D., Reinholdt, M. M., & Ousman, K. (2015). Cultural humility: A concept analysis. Journal of Transcultural Nursing, 1-8.
Gaertner, S. L., & Dovidio, J. F. (1986). The aversive form of racism. Academic Press.Greenwald, A. G., & Banaji, M. R. (1995). Implicit social cognition: attitudes, self-esteem, and
stereotypes. Psychological Review, 102(1), 4.Greenwald, A. G., McGhee, D. E., & Schwartz, J. L. (1998). Measuring individual differences in implicit
cognition: The implicit association test. Journal of Personality and Social Psychology, 74(6), 1464.Greenwald, A. G., Poehlman, T. A., Uhlmann, E. L., & Banaji, M. R. (2009). Understanding and using the
Implicit Association Test: III. Meta-analysis of predictive validity. Journal of Personality and Social Psychology, 97(1), 17.
Hays, P.A. (1996). Addressing the complexities of culture and gender in counseling. Journal of Counseling & Development, 74, 332-338.
Huey Jr. S. J, Tilley, J. L., Jones, E. O., & Smith, C. A. (2014). The contribution of cultural competence to evidence-based care for ethnically diverse populations. Annual Review of Clinical Psychology, 10, 305-338
Sue, D.W. et al. (2007). Racial Microaggressions in Everyday Life: Implications for Clinical Practice. American Psychologist, 62(4), 271-286.
Tervalon, M. & Murray-Garcia, J. (1998). Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. Journal of Health Care for the Poor and Underserved, 9(2), 117-125.
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Thank You!
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