I'm Dr. John Clark. I'm the Chief Medical Officer and Director of Occupational Medicine for Brookhaven National Laboratory in Long Island. And today I'm going to be talking about bias, implicit bias, and other biases that we have that impact in a lot of ways the way we deal with each other, the way we deal with patients, the way we deal with colleagues, even family. So I'd like to start off with a quick exercise where I want everyone to take a look at the screen and you'll see six models, and I want you to correctly identify the ethnicity of each of the models. And I'm really generous, right, so I gave six clues. One is Israeli, one is Filipina, one is Puerto Rican, one is Indian, one is Iranian, and one is African American. Is everyone ready? So the answers are. Now by a show of hands, how many of us got this 100% correct? And that's the response I expected. I look at this like a board exam. No one's ever gotten a perfect score, nobody ever will, right? I created this and I get them mixed up. In fact, the Israeli model and the Filipina model, I thought they were the same model, but then I said, wait a minute, one of them has blue eyes, the other has brown eyes. About 20 years ago, my wife and I went on a cruise and the cruise left out of the Dominican Republic, so the majority of the passengers were Dominican and spoke Spanish. So one day, we went down to breakfast and as we entered, I asked the worker to be seated at a table for two. And he said, well, today is group seating, so you have to sit at a table with a group of people. So as my wife and I were eating, I noticed that every time a white couple came in, they were actually led to the seats for two, right? So that didn't sit well with me. So I went to the attendant and I said, hey, you know, what's going on? You know, you told me we couldn't sit at the table for two, but you're seating people at the table for two. And his response was, you people like to sit together and eat together, right? My response was, well, what do you mean by you people? He said, Dominicans, right? You like to eat together, you speak Spanish. And I said, point one, I'm not Dominican, and point two, I don't speak Spanish, right? So never judge people based on what they look like. You do not know anything about them other than the observations you make based on what you see, right? Don't assume anything, don't judge. And I picked that sign, wrong way, go back, on purpose. Because once you go down the wrong path of bias, you can't go back, because I'll never go back on that cruise, even though the food was great, the amenities, it was a great cruise line. In fact, my wife and I had done our honeymoon on it, so that's why we went back. But that one incident left such a terrible taste in my mouth that I would never go back on that cruise line. Now what was interesting is the attendant, as he responded, I could tell that he really didn't think he did anything wrong. He had an accent. He was white, but he had an accent as if he was probably from an Eastern European country. I didn't ask, so I don't know exactly where, but because of that, I say, you know what, he probably is not that familiar with American culture to know that, you know, you don't tell a black person, you people, and you would understand that, you know, there's a sensitivity behind treating me different than other people, right? So one of the points I want to make today is it's really not about your intentions. It's really about the impact of your actions, what you say and do on people. So you have to kind of remove yourself from the equation, because sometimes, right, if you're confronted with a situation where you may have offended someone because of something that's biased, you yourself might get offended by the fact that you think you're being attacked because your intentions were good. But it's really about the impact that your actions make. Now, there's a double standard in healthcare. So this is a quote, a VIP is in that room that I would sometimes hear during my medical school and my family practice residency, right? And I always found it offensive, and when I became a resident and I was supervising other physicians and they would say that, you know, the attending said there's a VIP. I said, no, a VIP is in every room. And if you are treating people differently based on their socioeconomic status, you're doing something wrong, right? So a lot of the biases that occur within healthcare actually begin during the training. Because if you're, if you have an approach where because of who someone is, you tailor your administration of healthcare, you are actually treating people different based on socioeconomic status. So the definition of explicit bias is attitudes and beliefs we have that we are fully aware of based on what's being perceived. Explicit biases are usually directed toward a group of people. Unconscious or implicit bias is unintended, subtle and subconscious associations learned through past experiences, thoughts that happen to all of us that we are unaware of on a conscious level. So I've highlighted specific portions of the definition and I'm highlighting unintended because again, the experience on the cruise, I could tell that it was unintended to be offensive to my wife and I. And it's learned through past experience. So the issue with that is that sometimes people have a bias and it is based on actual events. Let's say you live in a certain neighborhood and you've been repeatedly robbed, right? And because of that, you now view certain people in a certain way, right? So I never propose to people that, okay, you have to change your bias, but you have to understand it that way you can control how you allow the bias to manifest. Now in 2007, this study came out, Implicit Bias Among Physicians and its Prediction of Thrombolysis Decisions for Black and White Patients. And this was the first evidence of unconscious racial bias among physicians, its dissociation from conscious bias and its predictive validity. And one of the conclusions was physicians' unconscious biases may contribute to racial and ethnic disparities in use of medical procedures such as thrombolysis for myocardial infarction. In 2014, this study came out, Do Physicians' Implicit Views of African Americans Affect Clinical Decision Making? And the conclusions was there was a strong implicit preference for whites over blacks, significantly greater liking for whites over blacks, and whites were more medically cooperative than blacks, and some conscious biases could influence their treatment decisions. Serena Williams, we all know who she is, elite tennis player, 23 Grand Slam titles. So in 2011, she was nearly killed by a pulmonary embolism. And then in 2017, after giving birth, she had trouble breathing and believed she was having another pulmonary embolism. She alerted the nurse and asked for a CT scan and a blood thinner, but the nurse ignored her, right? The nurse believed that she was confused. So the point I'm making here is sometimes patients who are marginalized are not taken seriously. And I've experienced this myself. Literally every time I've had to go get healthcare on my parents or someone I know, I have to say I'm a physician because each and every time, I recognize I'm not getting the standard care, right? I'm being treated differently because as a doctor, I know what's supposed to be done, right? And it's true. You're not taken seriously. So the doctor did the ultrasound of her legs and it was negative. And this was her response. You know, Doppler, I told you I need a CT scan, right? But guess what? Ultrasound was still nothing, but when they finally did the CAT scan, it showed several small clots in the lungs and she was immediately put on heparin drip and she lived. But they don't always live, right? In May of 2023, Tori Bowie, another athlete, and I'm pointing out athletes because athletes are in peak health condition. So it's not that there's underlying issues that you could say caused this. So on May 2nd, 2003, she died. She was only 32 years old, cause of death, childbirth. So these are the stats from 2021. You know, African-American women are 2.6 times higher rate of death than white women, right? 69.9 per 100,000. So sometimes, and you know, this is my personal view. I don't like to term people of color. I don't like to term BIPOC, black indigenous people of color. Because to me, what that does is it stratifies people along the lines of you're either white or you're colored, right? You're either white or you're grouped together into, you know, and I was working at an organization where I first heard that term. Like I was like, what is BIPOC, right? And they, and you know, and I said, I posed a question. I said, let's say you're planning an event for the BIPOC population. What food are you going to serve and what music are you going to play? Right? Everyone was quiet. Cause there is none. Cause it's not a culture. It's not an ethnicity, right? But what it does, right, when you're looking at data, is the death rate among the Hispanic population is very similar to the white population. And when you combine the groups as a people of color, right, or BIPOC, the rate is reduced now from 69.9% to 48.9. So as you're approaching healthcare and addressing disparities, it's really important to actually extract the population so you could specifically address it versus grouping everyone together as people of color. And the CDC's statement on this, implicit bias and institutional racism are some of the driving forces behind the high rate of mortality, you know, high death rate among black women. It has little to do with socioeconomic status. And this is why I chose to use the examples of Serena Williams, who has a high socioeconomic status. And a study in California revealed that the richest black mothers and their babies are twice as likely to die as the richest white mothers and their babies. So during the pandemic, I was doing my master's in healthcare policy and research and an MBA. And one day, you know, I went to one of the classes. This was on Zoom now because of the pandemic. And the professor opens up the class by saying, today, we're going to discuss the reasons behind why African Americans are dying much at a higher rate than whites from COVID in America. And we're going to focus on the diet and obesity, but we're not going to talk about race or any other conspiracy theories, right? So I took offense to that because I know differently, right? And I said, professor, we're not sweeping this under the rug today, right? And then I shared two examples, right? This is Kimora Lionel, and she's a nine-year-old girl from Florida presented to the ER with a temperature of 103 with no underlying condition. They did a urine test and they sent her home. Now even lay people in July of 2020 knew that in the midst of the COVID pandemic, the first thing on your differential is COVID. So why would you not test her? And she went home and later died from COVID. Deborah Gatewood, 63-year-old phlebotomist from Detroit, worked at a hospital for 31 years, went to that hospital where she worked four times, right, with symptoms of COVID that were progressively worsening. They never tested her. So ultimately she died from COVID as well. And I use those two examples because they were two geographically distant areas in America. And it was a young child who, at that time, she was the youngest person in the state of Florida to have died from COVID. And then you had an older woman. Now that led to a robust discussion in the class. And the professor ultimately agreed that, yes, race is playing a part in the deaths. And then he even shared that, hey, when I was a resident, you know, people would say stuff like black people don't feel as much pain as white people because black skin is thicker, right? So what was interesting to me, though, so my classmates were comprised of, this was an executive MBA master's program. So you had a lot of leaders in healthcare. Some of the students were politicians. Some of them were chief medical officers, CEOs. And nobody said anything. I was the only one that said something. But a bunch of people texted, you know, the direct messages and said, thank you for speaking up. Thank you for your bravery. I agree 100%. And I didn't view it as bravery. And I wasn't, I didn't feel like complimented. I was actually surprised. And the reason I was surprised is because this was a very vocal group. Whenever we had class discussions, you know, you could barely get a word in edgewise sometimes. But it really confirmed for me how people think. That if something is going on and you don't say anything, a lot of times people think you agree with it. Because I thought my classmates actually agreed with the professor. That's why they were quiet. So a quote from Plato, I shall assume that your silence gives consent. Right? So sometimes when you don't say anything, people believe you agree. And even a step further, that you're actually part of the problem. Especially if you're in a position of leadership or power where you could make a change. Now what is the worst that can happen if you speak up? Right? So people sometimes are afraid. But what I didn't share with my classmates that I'll share today is I got an A plus in that class. I was one of the few people. Because I spoke up. Right? So when you speak up, most of the time people listen. So I learned this when I was a child. Right? As a child I learned how to, why speaking up makes a difference. So I was born in Queens, New York. And when I was ten years old, my family moved to Barbados. My parents are Barbadian. And my father wanted my brother and I to experience life in the Caribbean. You know, education, the culture. So he moved us to Barbados. A few things about Barbados. Beautiful beaches. Right? Some of the best rum. Anyone who likes rum. The oldest distillery, and they still create rum, is Mount Gay. In 1703 it was developed. Some of the finest rum in the world. Speaking of fine, Rihanna is from Barbados. She's probably the most famous person. Right? But another thing a lot of people don't know. So when I lived in Barbados, Barbados had the highest literacy rate in the world. And today it's one of 22 nations that has 100% literacy rate. So between the ages of ten and 13, I had a period in life where I was in a society that did not have American racism. So what does that mean? So I'll give a description of what it's like as a black child, a black male, growing up in America. It's based on the imagery. The media does this a lot. Is your options are, you know, you're going to go to jail. That's the first thing. Right? Second is if you don't go to jail, your options are going to athletics, going to sports. You know, going to entertainment. Because that's what's available to you. Right? So things like that, you know, you'll never amount to anything because you're not smart. All of that. But Barbados' population was 91% black, 4% mixed race, 3.5% white, 1% South Asian, and 0.1% East Asian, 0.4% other. So because of that experience, I had a different perspective. I saw people like myself who supposedly are less intelligent, but performing at a higher rate. When I returned to America when I was 13, I was two years behind in math and science. Right? Academically. And I had to work hard. Or, no, I was two years ahead. I'm sorry. When I went to Barbados, I was two years behind. When I came back to America, I was two years ahead. Because the education system, by the time you're 15, that's the equivalent of being a senior in high school. And once you're 16, you go on to college level courses. So when I returned to New York when I was 13, I'm now, you know, with that mindset. And I'm in the cafeteria. So I was in a school that was in a predominantly white neighborhood. So the black and Latino kids, we were all busted. And the cafeteria was divided into three sections. So one section was us, the other two sections were white and other students. And segregation, you know, I'm not that old. Segregation wasn't legal at this point, right? So but it was natural segregation. I'm sure many people have that same experience where, you know, kids are divided. And what would happen is there were three lunch monitors, these older white women who would patrol the cafeteria. And what they would do every day is patrol us, right? So constantly they'd be reprimanding us, you know, sending us to the principal's office. And one day I had enough. And, you know, as the lunch monitor came over, I stood up and I said, you are racist. I said, every day you come over here yelling at us. And look, the thing you're yelling at us about right now, they're over there doing the same thing. And I said, go over there and, you know, harass them. You know, I'm 13. Her response was nothing. She didn't say anything. She actually turned bright red and then she did go over there. And she stopped bothering us. In fact, I was like the hero because she never bothered us again, at least whenever I was in the cafeteria. So I learned that no matter how young you are, right, your words can have power. And speaking up is sometimes the way that you affect change because sometimes a person doing it may not be aware. Because again, this is unconscious bias. That lunch monitor may not have been a racist, right, but her actions, right, had that impact on us as students. So when you speak up, most of the time, in my experience, people act. But when they don't, right, that might signal that it's an unhealthy environment. It's an unhealthy organization if they don't recognize the need to change something like that. So HR Magazine has an article that came out in 2014. Everyone harbors unconscious prejudice. The trick is gaining enough insight to preventing, to prevent it from affecting who you hire and how you treat people. So that's what it's about. Like everyone, all of us, me, you, we all have unconscious bias. But the real key is to acknowledge it but also control it so that you don't affect people. And I take it a step further. I say we all maintain biases. We have it, but we do things to maintain it. And part of that maintenance is not actually identifying it so you could do something about it. So the first step is you identify biases. You want to own it. You acknowledge the fact that it's there. And then you could proceed to control or manage it in a way where it doesn't impact other people. And yes, we can. We all control our biases, right? How many of us ever hated our boss? Don't say anything because your boss might be at this conference, right? Or your teacher, right? But you want a promotion. You don't want to get fired. You want a good grade in the class, right? So everyone does control biases. I take it a step further. There's a quote from a lyric from Bob Marley. Some will hate you, pretend they love you, and now they're behind, they try to eliminate you. This is the backstabber, right? They're experts at treating you nicely, right? So they could gain your trust. But behind your back, right, they're doing the devil's work. Profanity, there's a lot of people who use profanity. But then when they're around certain people that they respect, they know, you know, grandparents, they don't do it. So people could switch it on and off. But they have to make the effort. And has anyone here worked in a customer service job? When I was in high school, right? I was a cashier at a supermarket. And it's interesting the way you get treated. Like, as physicians and health care providers, we probably don't experience this much. But when you're in those type of jobs, people disrespect you. They're rude. And you have to smile and give them a good customer service. So I'm always extra nice, you know, like in the hospital, the maintenance people. Be nice, because those folks go through a lot. So the definition of prejudice is an unfair and unreasonable opinion or feeling, especially when formed without enough thought or knowledge. Definition of bias, the action of supporting or opposing a particular person or thing in an unfair way because of allowing personal opinions to influence your judgment. So I'm going to talk about bias versus prejudice for a second. So bias starts with preconceived notions, whereas prejudice starts with preconceived judgment. Bias is actions based on one or more of the following, reputation, rumors, group think, which is popular opinion, as well as past experiences. Whereas prejudice is opinions based on insufficient knowledge. So when you look at it, you see that, wait a minute. Bias is about actions. Prejudice is about opinions. Well, you can keep your opinion to yourself, but your actions affect people. So in a lot of ways, bias is worse than prejudice. And what happens sometimes is if someone does something and they're confronted in a way where they're being accused of being prejudiced, sometimes it's very offensive because they're not actually prejudiced. And they say, how could you accuse me of that? But they are biased. So one of the ways to think about it is that you have to address this. You want to focus on a way where the person will receive the input because there are a lot of connotations, negative connotations associated with being accused of being prejudiced versus someone pointing out that you have bias. So fuel for bias. So there's several types of biases. And confirmation is a tendency to trust information that confirms your preconceptions. And at the same time, you ignore or dismiss opinions that disagree with your own, even though they might be factual. Anchoring bias. The tendency to rely heavily on one piece of information, often the first thing you hear when making decisions. So you know the saying, first impressions are the most important. Because anchoring bias is extremely difficult to change. When someone has that, it's very difficult for them to move away from it. Affinity bias is the preference we have for people similar to ourselves. So an example is that cafeteria, where even though it wasn't segregated, it was segregated because of affinity bias. Ethnic bias. Discrimination against individuals based on an ethnic group. And the bandwagon, or conformity bias, occurs when you adopt a belief just because more people hold that belief. This can lead to what's called groupthink, which is a tendency for group members to over-conform to a leader. The halo effect. The halo effect is when you view something, one thing about someone or something as positive, it now transfers over to everything else. It can influence the way you view people, a company, a brand, or a product. And the opposite is the horns effect. If there's one negative thing, you now translate to mean everything else is negative. So the halo effect causes us to overlook negatives. And the horns effect causes us to overlook positive. The quote. You know, this is an example. I know they're a serial killer, but they're so gorgeous. I know the doctor amputated the wrong leg, but I don't want to sue. They're such a great doctor. They're so nice. The opposite. And there's a group of men after interviewing a female candidate. I know she has over 20 years of experience and published 40 articles, but she was five minutes late to the interview. So they're using her being late as reason to, right, cool. He's an occupational medicine physician. He can't be cool. So I use this onion skin view of the way confirmation bias and anchoring bias can actually inhibit you from getting out of bias. So the exterior layer is the reputation. You've never actually met the person, but you have a negative view of them because of what you've heard. The second layer will be a bad first impression. So you actually meet them, but that one encounter was negative. The third is limited personal interaction. You met them, were with them for about 10 minutes. You didn't like them. And in the middle are the true characteristics. So familiarity is one of the key ways to overcome bias, right? Because if you become familiar with someone, you now know their true reputation. You could know they can develop a lasting impression. You get a personal relationship, and you could get to who they are as a person. So familiarity can be a bridge to the truth and actually force the empathy. So it's believed that empathy is actually the root of how you overcome bias. We all have things in common. So the same way we hold biases, patients, colleagues, family, friends, strangers, everyone has biases too. So when you encounter people, it goes both ways. So the fuel for anchoring and confirmation biases are the first thing is appearance. The moment someone encounters you, they first see you. I mean, sometimes they can hear you first if you're yelling and they don't see you. But your demeanor, the way you carry yourself, your actions, and your words. There's something called a 7% rule, which says that only 7% of what you communicate is through the words that you're actually saying. 55% is your body language. And 38% is your vocal tone, how you speak, how you communicate. And we do speak long before we can talk, right? From babies. And what do you think they're communicating? And what's funny is that when I look for these images, I Google angry baby, I didn't think anything would come up. Yeah, well, you think they're saying this? I love you, right? Or are they saying that, right? So this is an example of just the look on your face. If you're angry and you tell someone, I love you, right, you know, yeah. But the issue is, OK, who needs to get hugged, kissed, or fed first? Who should get hugged, kissed, or fed first? Yeah, bias often will decide. Imagine you walk into the nursery and you see that. Which babies? And in all likelihood, those babies need something way more than a happy baby. But you know, for us, as you apply this to health care, we should not let bias decide who actually gets better treatment, resources, and resulting clinical outcome. Bias language in the medical record, right? See, back in the day when I came up, when you use paper charts, if you wrote something crazy, right, it may never go anywhere because it's in a paper chart. But nowadays, everything you document in the electronic record can be accessed and likely will be accessed by others, including the patients, because they're laws now. You know, when you now go for medical treatment, your lab tests are uploaded where the patient can download it before you even can talk to them. So nowadays, information is very accessible. And I can tell you, the last thing you want, like when I've gone to testify in arbitrations and legal cases, the last thing you want as a clinician is to have written something negative or that's biased about a patient. They will use that against you. And it will work against you, because you're the clinician. You're supposed to be above that. You know, you're not supposed to speak negatively of a patient. But you can actually harm the narrative about the patient and communities. You can influence subsequent attitudes, right? Someone reading your note is now going to take on what you say and may formulate an anchoring bias based on that. And you can propagate bias from one clinician to another. So these are some guiding principles. You know, use first-person language. So examples are, you know, some people might say, oh, the person's a sickler, a diabetic. No, you want to say person with sickle cell disease or person with diabetes, right, a schizophrenic, you know, person with. So you don't make the person a disease. You just say the person has the disease. Eliminate pejorative terms, right? Frequent flyer, right? We all use it. But patient well-known to us, right, in the diplomatic way. The drug screen is dirty, right? Drug screen is positive. Cancer sufferer, cancer victim, you know, person living with cancer. I mean, you're communicating the same thing. You're just doing it in a way where there's no negative connotation. You know, drug addict, you know, person with substance use disorder. Someone with a criminal history, you know, convict, inmate. No, you would rather say person who was incarcerated. And gomer, do they use that still? Yeah, when I was in training, yeah, they'd refer like someone who was homeless, who had a lot of complicated, oh, gomer's in there. You know, just call a person a patient, right? They're human. Choose inclusive language. So statements like wife or girlfriend, you'd wanna say something like spouse, partner, significant other. Gay lifestyle, preference for male partners. Instead, you could say sexual orientation. Wheelchair bound, right? No, instead say things like uses a wheelchair. And afflicted with or suffers, you could say lives with. Right? Avoid labels, you know, saying things like patient is non-compliant, right? You're not labeling them as a non-compliant person versus they are not taking their medications. Or patient's a poor historian. No, I had trouble taking a history due to, right? Or difficult, manipulative, unfortunate patient. Just state the facts, right? You don't need to interject your opinion and describe them in a negative way. Don't weaponize quotations, right? You know, patient has stress at home. You know, like when you use quotations, sometimes it suggests there's doubt. Or you think the person's not being truthful. So you could say they have multiple stresses. The patient reports pain so bad, you know, say they have severe pain. Do not lead with race, ethnicity, language, socioeconomic status, and other social identifiers. Now when I was trained, when you presented a patient, you had to say, you know, like 25-year-old black male. And if you didn't say that, right, you were reprimanded. Because that was part of how you had to present. But if those things are not necessary to a clinical case, you should not mention them, right? So examples would be, you know, 65-year-old African-American male presents with chest pain. Instead, you could say 65-year-old presents with chest pain. Now you sometimes need to put the descriptor. So you have to, you know, really connect that to what's the clinical relevance of that. So another example would be 35-year-old handicapped female Chinese immigrant who can't speak English needs transportation, right? Rather, you could say 35-year-old requires a translator who can translate Chinese and needs assistance with transportation due to use of a wheelchair. Her immigration status has nothing to do with anything. The fact is he's a Chinese immigrant, right? So all of the descriptors that really don't have anything to do with the clinical case or relevance, you leave those out. Avoid language that attributes responsibility to patients for their conditions. What that means, you know, like saying something like patient failed outpatient treatment, right? You're kind of blaming the patient. But no, the antibiotics did not work for the infection. Or he's refusing to be admitted. No, they're declining admission. Or like patient's refusing to wear oxygen. No, they're not tolerating oxygen. Avoid verbs that undermine the patient's experience like the, you know, soap notes, subjective, the person's history. You know, you don't want to negate that. So when you say things like patient claims, patient alleges, right? You're raising doubt, right? But instead you state it, they are, right? You know, you state it as a fact, what they say. So how do we identify biases? How many are familiar with the Harvard Implicit Association tests? A couple of people. So there's a program where you go online and it shows a bunch of images. Then it'll show words. And then it times how quickly you click a negative word or a positive word once you see the image. So they say this is effective. You know, with everything, you know, nothing's perfect. So there's some issues. But this is something that's commonly used. But I say there are a number of self-tests, right, that we can use. And I have teenage children and now they're dating, right? So I find myself saying, yeah, I don't want them dating that, you know. Like you rarely, the way you deal with your children, because children, especially when they're the age where, yeah, they may marry somebody. And now, right, you have someone in the family, you know, look at the royal family with Meghan Markle, right? So my cousin, when she was in the third grade, became really good friends with a white girl in her class. And they became best friends until the girl's parents found out that their daughter was friends with a black girl, and they came to the school and demanded the school switch her into a different class, right? So when you observe children, right, a lot of the biases, we put it on them, like parents say things and do things that teaches the children to be biased, right? Another self-test would be next time you're driving, someone cuts you off, what are the additional descriptors you use before the curse word, right? And if that has nothing to do with their driving, that might be a bias, right? And this applies like if you're out at a store, someone offends you, you know, what do you add? That has nothing, you know, what does their gender, race or whatever have to do with the way they're driving? But for you, it does because that may be a bias that you're interjecting, right? Another self-test is do you assume good or bad intention with certain people? Why or why not? Who do you give the benefit of the doubt to, right? Would you make a different clinical recommendation for your family member or loved one, right? That's a good test as a clinician to remain grounded. You know, this like, I'll give an example, group of guys might be at a restaurant, right? A waitress does a terrible job, oh, but she's hot, right, so she gets a good tip, right? So they're biased because they find her attractive where if there's someone they don't find attractive, right, they're now complaining. So factors outside of race, ethnicity and gender do influence bias. I'm going to shift a bit and talk about that. So bias, back to the definition, is the action of supporting or opposing. So you actually can gain support through other variables outside of race. So I have a confession. I specifically wore this outfit, these colors, this suit to actually create positive biases, anchoring as well as confirmation biases of me and the halo effect for my presentation. So I'll explain what I mean. Prototype bias and color theory. So to explain prototype bias and what it is basically is people categorize people to fit certain roles based on how they look, right? So my story goes back to, you know, when I was a kid, when I was eight years old, I heard rap music and I loved it. Started writing rap lyrics and I actually wanted to be a rap artist, right? My parents hated it because, again, I'm from Barbados. You're not supposed to be a rapper, right, go to med school. In fact, I have one brother, he's older, he's also a physician and that's what you do. But their prototype bias for their child was no. But I was serious about it and the reason they were nervous is because I actually did get a record contract. So when I was in my junior year, I had a decision. Either go to medical school or you pursue a music career. But I chose medicine, you know, and you all heard about the Puff Daddy story, right? Part of it is that, you know, the entertainment industry is crazy, like the lifestyle and all of that, right? So prototype bias. So when I became a resident, I actually found a way to combine the two and I created Health Hop, which is health-related hip hop. So I wrote, you know, I've written a bunch of songs and performed. So early in my career, I used to get hired by drug companies like Glaxo, Sharing Plow, Pfizer to do health events, right, on asthma, allergies and different topics. And they'd have me speak and then I would perform the song. And it was a good way to connect with certain audiences, right? But what would happen is sometimes after the performance, people would come up and say, are you really a doctor, right? Because I'm here rapping, right? So prototype bias, right? So for me, like, anytime I'm at a conference or presenting, I'll always be dressed very formally, right? Because biases do affect you and how you behave. Because for me, the experience was, you know, I always have to maintain credibility as a physician, right? So I need to look that way. So that's the prototype bias. Now, the flip side of this is, you know, from the perspective of the rap community, rappers aren't supposed to be doctors. So I'll give an example. I'd done a project for the Long Island Railroad called the Gap Rap. So they had an issue where people were falling between the platform and the gap. So I wrote a song called Gap Rap. And it got a little buzz in New York. And Howard Stern caught a hold of it, right? And on his show, he was like, I don't like this because doctors are not supposed to be rapping. It's not professional, right? And the rap artists comment. There was an interview where a reporter who had interviewed me about a song I did on allergies played it for Common. And Common said, no, you know, doctors aren't supposed to be rapping. So throughout my career, I've had both, you know, the impact of prototype bias that, you know, a doctor's not supposed to rap and a rapper's not supposed to. In fact, I met some folks yesterday and someone was telling them that, hey, he has a talent. And they couldn't guess what it is, right? So she's here, Dr. Alexander. And she told them it was rap. And they couldn't believe it. Because again, I don't look like a rapper. I don't have tattoos and, you know. So color theory, right? So when I, you know, I was producing a lot of songs and I put out a series of compact discs. And I didn't have a budget to do the graphic design. So I took some courses, read some books, and taught myself how to design CD covers. So one of the things I learned about was color theory. So color theory is the science behind how colors interact. But also, the psychological impact that colors have on you. When people see certain colors, they make certain associations. So navy blue. Navy blue is the most preferred color in the world. If you have a group of 100 people, the majority will say blue is my favorite color, right? So if I'm wearing your favorite color, I'm now trying to create an affinity bias, right? You like blue, you might like me, right? But blue is associated with authority, calmness, serenity, intelligence, confidence, loyalty, wisdom, truth, and heaven. The sky and the ocean are blue, always there, constant, reliable. And again, this is about subconscious bias, right? So these are things that you don't realize. But when you wear blue, right, it conveys that. But when you dress formally, formal dress, a suit, also is associated with authority, intelligence, and wisdom, right? So wearing a navy blue suit is giving a two-fold effect. White. So white is associated with truth, honesty, purity, innocence. So I want you guys to believe me, right? So I'm wearing a white shirt. So as I'm speaking, you're seeing me in a white shirt, the blue suit, right? Brides wear white, right, to signify commitment, honesty, faithfulness. Then red. Red is the color of passion and excitement. So a good example would be if you're going for a job interview and you have a really, like, strong personality, might not be a good idea to wear red. Because as you're speaking, you might come across more strong, and they may not like you because of that. So you may want to tone it down, you know? But if you're a little more laid back and reserved, you may want to wear red, because that's now going to project more energy. I'm not the only one. And when is the debate? June 27th? And I can guarantee you that the both of them are going to be wearing this outfit. They might deviate and wear a different tone of blue, but they're both going to be wearing navy blue suits, a white shirt, and a red tie. And the reason they're going to do this is because of what I just described. The other impact is it says I'm patriotic. Those are the colors of the flag. So without them having to say it, without them having to verbally say I'm patriotic, everyone looking at the screen will make that association because of the colors of the flag. So there's a movie called Adjustment Bureau. Has anyone seen that? Well, this movie has a, you know, it's about Matt Damon plays a politician. And there's a great scene where he goes into some of this of how politics and politicians use this in order to try to get people to vote for them. I don't have time to show it, but you can go on YouTube and find the clip. Now, this is an article from 2016, Hillary Clinton. Americans don't trust her, but why? As of the latest New York Times poll, 67% of registered voters have doubts about her trustworthiness, right? I don't remember much about that election, but I do remember her nickname, Cricket Hillary, right? That was all that was being said. Well, color theory might provide some insight. For some reason, she liked to wear green. She wore it to the Benghazi hearings to Iowa immediately after announcing for president and as Secretary of State at the G-12 Summit. Well, never wear a green suit. That's actually a quote from my father. My father was a real estate broker and an insurance broker, and he was pretty successful, right? And he used to tell my brother and I about power dressing, right, the way you dress actually can impact your level of success, especially in sales. Never wear a green suit. He didn't explain why, and I only started to understand why after studying color theory. So, some people have negative associations with green, and that's because of money. Some people have bad relationships with money, right? So, they may view you as untrustworthy, possessive, envious, greedy, and selfish. So, never wear a green suit to a job interview, right? So, Hillary Clinton, no matter what she was saying during her speeches, her outfit was speaking, right? And look at this, right? So, when you contrast that to the male candidate who's wearing the blue-red tie and the white shirt, you're basically endorsing him, right, against you. Prototype bias, so the tendency to habitually think of the same people for choice assignments, right, in the HR world, and it's embedded in medicine. It's called the match, right? It's all about affinity bias and prototype bias. Most of the people who apply for residency, they're qualified, but I don't know if it's the same now, but when I was in medical school, for example, orthopedics, the athletes who were tall men, right, in my class, two women went into ortho. One was athletic. The other was very attractive, right? So, the prototype bias actually impacts, you know, training. And this is why some people might slip through the cracks, the outsider, and may not last in the residency, right, where they're not accepted or welcome. They struggle and eventually leave the program. But this is, yes, embedded in our system of how we develop physicians and training, right? So, prototype bias, people's mind tells them what good and bad people look like, what people who are supposed to be something look like. Now, a question to the audience. What other prototype bias may have influenced her electability? Anyone? Not smiling yet. I didn't notice that. Gender. Okay. Anything else? Height. Good. Only five foot five. So, height. So, this graph depicts the trajectory of the average height of presidents, from George Washington all the way up to Donald Trump. As you can see, it's an upward slope, right? George Washington was six foot two. The shortest president was Madison, five foot four. Lincoln was six foot four. And Joe Biden is six feet tall. Now, this is the last 12 presidents. And I use red for the Republican, blue for the Democrat, because it really doesn't matter, right? Ten of the last 12 presidents were six feet or taller. JFK was six feet tall. Obama's six foot one. Biden's six foot three. I mean, Biden's six feet. Trump is six foot three. Clinton was six foot two. It goes on and on. Now, when I saw Carter's numbers, 5'10", and Nixon, 5'11", I said, hmm, I'm 5'10 and a half. Maybe I should run. I'm already dressed, right? So, put me on a ticket this fall. So, the fashion model industry has certain standards where women must be between five foot eight and 5'11". Men must be between 5'11 and 6'3". Do you think it's a coincidence that 11 of the last 12 presidents fell within the range of what the fashion industry considers the height men should be in order to be fashionable? So, prototype bias of height. So, often people equate height with authority. We literally look up to tall people. We look up to God from a child. You look up to your parents. You look up to teachers. You look up to authority from the time you're a child as you grow. So, height is associated with leadership. The average American male is 5'9", but 58% of Fortune 500 CEOs are six feet or taller, whereas the adult male population, only 14.5% are six feet. When it comes to six two or taller, 30% of Fortune 500 CEOs are six two or taller, whereas you only have 3.9% of men in America that tall. Height is equivalent to the appearance bias and lookism, and there's a halo effect. If you're attractive or you're viewed as attractive, people translate that into you're good or you're better at certain things, right? Girls, you know, tall, dark, and handsome, right? That's what you hear. They want someone who's tall, dark, and handsome. Tall, see? I got two of them, but. Then there's the obesity bias, right? This article, research demonstrate wage discrimination due to weight is real. So, who do you think are the worst offenders, right? What profession do you think are the worst? Yeah, us, healthcare, right? Obese people working in healthcare experience the largest wage gap on average, 12% lower compared to non-obese colleagues, right? You know, physicians, healthcare providers, we're good people. We like to think we're good people, but, right? We have biases, too, and it translates to, yes, obesity bias. And this is serious. Mayor Eric Adams about a year ago signed into effect intro 209A, which actually prohibits height and weight discrimination as it applies to employment, housing, access to public accommodations. Now, there are exemptions, and this is where it might affect us, because this is something that might now become national. We have started in New York, right? So, employers can consider height or weight in employment decisions only when required by federal, state, or local laws or regulations. And when height or weight may prevent performance of essential functions. So, you know, a good example is if you're dealing with commercial driver's exams. You know, you don't want to now document things like not qualified because of obesity, right? You really must identify the specific factors because this may come into play where height and weight become a protected class similar to race, gender, and age. Now, does unconscious bias training work? A big question. Does it actually work? A Harvard business review, it was a meta-analysis, more than 490 studies involving 80,000 people, concluded unconscious bias training and awareness alone did not change behavior. They concluded that the most effective unconscious bias programs do more than just increase awareness. Participants learn to manage the bias. They learn to change their behavior as well as track progress. So, some of the examples they cited was Starbucks has a program as well as Microsoft. But if anyone's interested in developing, you know, an effective strategy, that's a good article to get information. So, the million-dollar question is can we actually overcome bias? And I say the answer is yes. And I'll share my personal journey with bias. Now, my bias was actually worse than the average bias because I hated dogs. I didn't care what color. You could be white, black, brown. I didn't care where the dog was from, any part of the world. I didn't like dogs. I didn't grow up with a dog. I did not like dogs. Truth be told, my bias was actually rooted in fear. I was actually afraid of dogs. And as I give this example, you know, you could think of the similarities that bias people have against other people. Right? A lot of biases are driven by fear. Right? And that fear comes from, again, a lack of familiarity. Right? Because I was so afraid of dogs that I would never get close enough to one or, you know, learn dog behavior. And of course, Hollywood did not help. Anyone remember Cujo? So, Cujo was this dog that gets rabies and goes crazy and terrorizes the owner and her son for like two days. So that was my impression. Every dog was Kudro. And then on the news you hear about the pilt bull attacks and you know. But I was exposed to positive media. In fact, one of my favorite books was Clifford the Big Red Dog and we all know about Lassie. But the war, right, no matter what positive I heard, my anchoring bias, confirmation bias, horns effect kept me from, you know, ever wanting to deal with dogs. Roots of my bias also is misinterpretation of dog behavior. I literally believe that if a dog was wagging its tail, it's because it wanted to bite you. If a dog was running towards you, it's because he wants to bite you. If a dog sniffs you, it's because he wants to smell the food, right? Everything a dog wanted to bite. That's how I literally thought. And I didn't understand dog owner culture, right? How could you let an animal lick you, right? How could you let an animal in your house? And you know, bias will make you come up with some crazy thoughts. You know, my wife would tell me, you know, dogs lick you. That's their way of showing affection. It's like a kiss. I said, no. Dogs lick you because they like their food moist before they take bites. And there's a special enzyme that softens the flesh so it's easier to tear. So this is the kind of craziness that occurs where I made this stuff up, but sometimes people who are biased might hear something like that, especially on the internet, and now that's fact. Yeah, dogs have this enzyme. They'll kill you. So my biased behavior did not extend beyond labeling. Like I wasn't cruel to dogs. I was too afraid to get close enough to doing it, you know. And I didn't do anything to dog owners except like stay away from them and thought they were crazy. But I labeled, right? My label was dog people, right? And I show a picture of a person with a dog in her car because that example of driving, like if I was driving and someone had a dog in their car, they can't drive because they're a dog person. Look at them, right? So for me, a dog person was a derogatory term that I came up with for people who own dogs. And labeling actually helps to maintain and fuel your bias because it's confirmation bias. So when you label someone, everything that you're experiencing, right, the interaction is being filtered through that label, right? So you're interpreting everything in a negative way. So confirmation of the first impression, you ignore conflicting information. You see everything by a fixed set of expectations. And you conjure up stories like, yeah, the whole licking thing. So can we get a dog? This was 10 years, my wife and children asking for a dog. And of course the answer was no, not getting a dog. But then COVID hit. So COVID hit and things changed for us, right? So this article, when her parents fell ill with COVID-19, nurse began a wrenching mission of mercy. It was in USA Today. That nurse is my wife. So on April 10th, right, fairly early in the pandemic, both of my wife's parents died from COVID on the same day, right? So for my family, we were hit particularly hard. And some of those things I shared about the disparities in healthcare as it relates to COVID personally affected me and my family. Now that's a clip from a video. So using HealthOp, you know, the natural thing to do is I made a rap song about COVID. And it got a little buzz. And, you know, that's how the article came about. And what was crazy is that, you know, I wrote the song at the beginning of March. And then, you know, mid-March filmed the video. And by the time I started the project and finished it, my wife's parents had, they were fine when I started. They caught COVID and died. So at the end of the video, I have a tribute to them. And the reporter found that intriguing. She was like, oh, they both died. So anyone who's interesting, it's an interesting read where you see what she went through and the whole way things unfolded. So because of that, right, you know, seeing my wife grieve and dealing with the craziness of four kids in the house during the pandemic, I said, okay. Because they kept saying, can we get a dog? I said, okay. All right, we'll get a dog. And that's Bentley, Bentley Clark. And I joke and I say, I told you I would get a Bentley someday. So that's Bentley. So for me to change, right, to overcome this bias, I realized that change wasn't necessary. Like I had to do something. You know, my wife's grieving. The kids are going nuts. They want a dog. So I was open-minded because of that. Like I was motivated to now change. You know, I gained familiarity. And it wasn't easy. Like this is a fox, Red Labrador. When they're puppies, their teeth are very sharp. And they like to nip at you. So I thought the dog was Kujo. I'd be like, ah, we're taking him back. This dog's crazy. But, you know, I studied, read articles and learned that, okay, that's puppy behavior. They get over that. So the dog is totally, you know, I recommend the Labrador. You want a dog that is like friendly and never will bite you? Like that's the perfect dog for me. And now I've overcome the fear. Like I'll go to the dog park. There'll be pit bulls. And I'm standing in there like I'm a normal person. I'm not running. I used to run from poodles. I mean, it was bad. I lived in this apartment, you know. And there was this other tenant who had this little poodle. And he would walk with it off the leash. And I would run like the dog would bark, like a grown man running. Yeah. So I now understand dog behavior. Right? And I understand dog owner culture. And I now call myself a dog person. Because I am. I like dogs. Dogs are actually cool. Right? So the parting words are, you know, when it comes to bias, the first element is to identify it. Right? Try to find ways to identify if you have a bias. Understand change is necessary. So for me, I was motivated by the family tragedy. So sometimes if there's not a strong motivation, you may not act on it. But if you, you know, be open-minded. You have to be open-minded. You'll gain familiarity, develop empathy, understand behavior, understand culture. So that's what it really is about, you know, understanding people. And so that's pretty much what I have today. All right. Thank you. And we have some time if anyone has questions. Oh, she's asking me to rap. I'm supposed to rap. I'm supposed to rap. Well, do people want me to rap? Yeah. Yeah, go ahead. All right. I have a question. One, two, one, two. Mm-hmm. Yeah, you can film. I got to go from MD mode to MC mode, so. So now we're ready. All right, so this song is called The Rules, The Rules. Can you hear me? And it's about diabetes, type 2 diabetes. All right, so we're ready. I don't have my music, so I didn't come to the conference thinking I would perform. But. Well, you have to have your sunglasses with you. Well, I wore them over here, yeah. Okay. Ready? All right. Sitting in the waiting room spot, watching the clock, thinking do I need to bounce or get results from the dot. Took out my walker when this old man came walking and he looked kind of cool, so I figured I would talk with him. Anticipating some sort of complication said his leg was feeling numb. He might need an amputation. Feared the situation, but he shouldn't be complaining. Many years he didn't exercise or take his medication. A diabetic that regretted the truth that he really wasn't careful in the days of his youth. Diagnosed at 18, he thought he was straight. Didn't care about his weight and all the junk that he ate. Was in denial for a while, thought he felt great. But at night, like five, six times he'd urinate. Kept him awake, vision blurry and his head it would ache. Faced with the fate of a careless diabetic's mistake. Because he took it lightly, was likely that he might be getting kidney failure and becoming slightly blind with his leg cut off above his right knee and his wife injecting insulin into him nightly. He had to share a story because he'd been blessed. He was supposed to die a year ago from all this mess. He was glad that I heard what he got off his chest and he had four rules that he had to stress. Rule one, always maintain your weight. Rule two, never try to pile your plate. Rule three, avoid sweet carbs and cake. Rule four, exercise and keep in shape. I wished him well and thanks for the advice that he shared. He was sincere and said he hoped my life would be spared and I would listen, be healthy and always prepared because diabetes is preventable and not to be feared. The physician called me in and said, listen, please pay attention so I may mention. I have your results that I got to give. Your test for diabetes slightly positive. Remember, your mother's diabetic, it's genetic. So here's a plan I think you better get with. Avoid obesity exercise frequently. Watch what you eat and be careful with the calories. Watch the starch, don't eat the sweet. Decrease the grease, fatty food and the meat. Drink water, eat some fruit and vegetables if you wanna. Bring your health to a better level. I left the office with a lot on my head thinking I'm still young and I don't wanna be dead. I exercise and 30 pounds got shed and I never forgot what the old man said. Rule one, always maintain your weight. Rule two, never try to power your plate. Rule three, avoid sweet carbs and cake. Rule four, exercise and keep in shape. Yeah! Thank you. So we do have some time for questions and answers, if any. So I'm just going to say, Dr. Clark and I go back a long way. I always love the fact that people that I used to supervise far exceed me in every single way. I'm so proud of you. Thank you. And I also want to say that he does music, his own music, his own studio. He's incredible. So he goes way beyond just being a physician. Really impressed. Thank you. Thank you for an excellent talk. My name is Rupa Das, and I'm the chair of the JEDI committee of our Western component. I wanted to first say that bias, harking back to the comment you said about medical-legal evaluations and how we're supposed to rise above it, we've had some examples of our qualified medical examiners documenting biased opinions in their medical-legal reports, which is really disappointing and has been noticed by the judge. And now the training, the new revised training for QMEs includes a little bit about raising awareness for bias. So at least we're making a little bit of progress. A little more facetious or maybe serious comment is about clothing. I'm probably not dressed like a doctor, I guess. You didn't talk about pink, but I'm wearing some green here. So throughout my career, I've probably gotten more and more conservative in my dress to remove attention from my ethnicity and when I had an accent and all that. So are you saying that we should dress a certain way to maintain respect and our physician status? Or we should be the way we want to be and then help people overcome their biases? Well, what I'll say is this. So when I'm at work, I wear a white lab coat, right? And that's not just because I like wearing it. It's because of what you just said. So I'll give some examples. So in many of my roles, I've supervised other physicians and there'd be cases where, you know, when there was a disgruntled patient, they would say, I want to talk to your supervisor, you know, get Dr. Clark. And then when I walk in the room, they would say, I thought I told you to get Dr. Clark. I thought I told you bring your supervisor, right? So I developed the mechanism of, hey, if I'm in a white lab coat, there's no question that I'm the physician, right? There's no question. And there's studies that show that doctors who wear white coats are perceived as smarter and better doctors, right? So the yes, I'm saying, and you can do what you want. Like I'm not telling anyone to not be who you are, but I'm just telling you, and this is like, okay, some people love green, but enough people don't that it could affect how people view you, right? So it depends on the results you want, right? The impression you want to set, but yeah, I, you know, I wear the white coat and I have people address me as Dr. Clark, right? Instead of my first name because of that, you know, you go to meetings and this is with staff and they'll be like, oh, are you the doctor? You know, I got tired of that. So I'm Dr. Clark. When I write my emails, it's Dr. Clark. Now with my boss and other people, when we're in a one-on-one, call me John, right? But when we're in a group setting, and I've had workers like employees in the place where I work specifically call me John as a form of disrespect to take away my credential as a physician. It's kind of part of my personality and actually it worked against me with my parents. I was that kid, right? If you told me to do something, I'm asking you why. So it's a natural thing, but my father did teach me to speak up because as we would go through things, but he would write letters on my behalf. Like I went through a bunch of stuff in college, medical school, and he would write letters. So he always taught me that, you know, you speak up and it's effective. But you have to do it in a diplomatic way. Like I said, I was 13. You don't want to go, you know, I don't want to get a call from someone a week from now saying, hey, I went to the job. I told them they're racist. By the way, you have any openings? I'm looking. So you have to, you know, know the climate and know how to do it. And sometimes, yeah, you may not want to speak up and you may just want to leave the organization. Yeah. I'm just going to ask a really quick question. Well, first of all, thank you very much for sharing your experience, your very personal experience, and you gave us a lot of food for thought. And one of the questions I have was about the future of medicine. Yeah. So recently in NPR, I heard about keloid classification. And apparently, I don't know if you guys heard all this, but they said, for example, you know, when I was in medical school, I was told that keloids are more often in African-Americans. So the person went to look at the source of it. And apparently, after like one year, she found out it came from the DRC in the 1960s where it was the colonizers classified it based on counting. So it was very bogus data that's now used in all our medical text. So what I'm thinking is about the future of medicine and what we've learned, because now we're like senior, we're no longer junior, and we're teaching the new generation. So how do you think we can put that for the new generation, essentially? Because a lot of the learning has to be unlearned, essentially. The things that they've told us as facts may not be. And then the other part of that question, do you think there's a role for technology that's neutral? Because, you know, in, for example, risk gratification, in diagnostics, AI, is there any role in technology to be colorblind if it's coded by neutral coders? Yeah, they issue great questions. I mean, I think people learn by example more than anything else. So I think the first step is we set the example. And things like when people are referring to the VIP in the room, you know, you say something. You teach them differently. Now, AI is emerging as a potential problem with bias, where they show data. And in the HR world, they've seen that AI is going based on what's information. AI uses information. And a lot of it is biased. So what's happening is, yeah, it is biased as being perpetuated through AI. And it's actually kind of scary, because you don't even have, like, a human to regulate it, to say, you know what? This is a problem. It's biased here. Whereas the machine is going to do what it's programmed to do. So that's a great point. But I'm nervous about that, that the future of AI actually influencing decisions. You know, and those decisions are based on how it's programmed and who's programming it. And then the data is getting, you know, from the internet, basically. Any other questions? Thank you. All right, well, thank you.

Dr. John Clark

Chief Medical Officer

implicit bias

self-awareness

empathy

inclusive language

Harvard Implicit Association Test

decision-making

introspection

prototype bias

AI and technology