Cable provider. [inaudible conversations] good evening, everyone. I would like to start by thanking everybody for being here at our very first event at busboys and poet politician and pros as we embark on our first and this is a very wonderful readings. At this tile i would like to remind you to turn off your cell phones, any noisemaking devices. Thank you so much. Feel free to order food or drinks. As of tonights reading there will be question and answer. I will come and give you a microphone and after the question and answer session we will have a signing right over here. My name is christopher gregs and i welcome you on behalf of politics and prose bookstore and on behalf of our amazing staff. They do have 500 events a year spread aupon politics and prose like this one in our store in connecticut avenue and different venues across the city. We have cspan tonight, so if you would like to see events like these that we have done in the fast and going forward, feel free to subscribe to our youtube channel. I am pleased to welcome dana matthew, a cure for racial inequality in American Health care. Professor at the university of Colorado Law School and the Colorado School of public health, she serves on the faculty at the university of Colorado Center for bioethics and cofounder of the Colorado Health equity project, medical leadership chose mission to remove barrierses for those who have verylow income clients. Expertise to illustrate the race bias thats present in our Health Seasonal and results in loss of 84,000 lives annually. Disparities entrenched in the Health Care System are the premise of matthews em passion argument for lawbase solutions, not just Training Programs and cultural sensitive. Celebrates matthew for having presented thorough picture of a problems facing minority on specific sections of civil right acts of 1964 which she claims provide a legal and morale basis to hold liable those who unconsciously discriminate and would hope to establish a new care of medicine. And mitchell goodwin, medicine inequality asthmassively written captivating narrative. One cannot stop reading. Claiming that not since washingtons winning book, america apartheid has there ever been a book that makes medical discourse so captivating. Please join me in welcoming ms. Matthew. [cheers and applause] thank you, chris, that was an awesome introduction. I would like to package and take it home to my kids. [laughter] i want to get right into the meat of the matter and talk about unconscious racism as it affects the health of populations in the United States. I want to pick up on the number that chris spoke about, 84,000 people because thats the number of people that the 16th Surgeon General of the United States david estimates die annually because of Health Disparities in the United States. Thats a very big number. 84,000 people, let that sink in and we will talk about why they die in a minute. My objective tonight is to leave you with some food for thought and so ive developed a sort of acronym, i want to leave you with 5ms, if you will, i want to talk about unconscious racism in health care being morally unattainable, medically unattainable, monetarily unattainable, manageable and just massively urgent. So those are the ms i would like you to take away. Im going to try to trace them out for you in 20 minutes and then take this to a conversation level. I had an experience when i was 9 years old, i remember it clearly because it was my First Experience with explicit racism, the explicit that i was inferior to the speaker because of the color of my skin. I was on a playground, i was 9 also, made it clear why she would not play with me on that playground and she made it clear to everybody else who was on the monkey bars why they would not be playing with me either. I had no doubt about her motive, i had no doubt about my relative position in her mind as to myself worth. That is called explicit racism. I remember it well. That is not what this book is about. However, an unscientific study, i have kids all in their 20s, i check with them and ask do you guys remember with explicit racism, every single one of them does, the generation between the two of us has not changed the existence and presence of explicit racism. I want to make that clear because thats not what im talking about. Im talking about implicit racism. Let me start by defining. Unconscious racism is when you store social knowledge. The information that you take from the music that you hear on the radio, the movies that are presented to you, the television stories, if youve been watching political debate, all of this is social knowledge and stores in the unconscious part of your mind. It is triggered when you encounter a person of another race involuntarily. Involuntarily its triggered. You call up that knowledge unintentionally and informs your decision and conduct and interaction with people of a different racial group unintentionally. Now, lets be clear, the difference is very important because studies show us that most people in the United States today are not going to identify themselves as explicit racism, well, that was before the president ial elections cycle that we are in. [laughter] probably more than we thought would identify as explicit racism. But most people explicit racism is kind of out of style, right . Its not what we do, its not how we identify ourselves as a country and who we are as a people. Even if your explicit preferences are galitarian, are to be a nonprejudice, your implicit biases, will do more to inform and direct your conduct than will your explicit preferences. Why is this important . Its really important in health care and why it i came to write this book that Health Disparities is killing people of color daily. Its causing people of color in this country to live sicker and die quicker because of the color of their skin. So if i were so inclined i could spend the rest of the evening running the data on just that fact. In 2003 the institute of medicine published an important seminal work called unequal treatment and it cataloged 25 years of data, the fact that infant mortality in the africanamerican population is twice that of white population. The fact that you are 75 more likely to die if youre diagnosed with coronery Artery Disease than if you are white. These are the kinds of data that will be replicated no matter what the leading cause of disease. Its true for stroke. Im going the pause at cancer because i want to make a point. With respect to cancer whites and blacks diagnosed at the same time, 33 difference in the fiveyear survivability rate. This is not true, however, if they received similarly intensive treatment, education, screening, if these treatment disparities are eliminated, then the difference in survival disappears. The fact that that is true is morally untenable in the United States in my view. It is medically untenable because the medical profession not only agrees to first do no harm but if you read closely, the hippocratic talk about justice and when that is not the case, then implicit biases change the way that people are treated. So let me turn now to the content of the book that institute of medicine study that was done in 2003, positive that its possible that physician bias may have a causal relationship with Health Disparities, that because physicians themselves are individuals were bias on race, ethnicity, socioeconomic, gender, sexual whorntation and other grounds, that might actually influence their treatment decisions but at the same time, the institute of medicine said we dont know exactly how those mechanisms work. The point of my book was to try and come up with an understanding of those mechanisms, how to understand how physician bias translates into Poor Health Outcomes for people of color as compared to whites. I looked at the studies and they are copious, and i organize them to six mechanisms, the bias care model. Im only going to talk about one tonight but i organized them in a way that suggest there are six different pathways or mechanisms by which physician bias translates into Health Disparities. One of the most important contributions i hope that my book will make is not only the organized set of mechanisms for others to discuss and research but also the fact that one of those mechanisms, dirty little secret, involve implicit biases that patients hold. So if the fact of the matter is that we get the implicit biases by our social bias, all of us living in the United States are doing to get the same social knowledge and the literature tells us that patients as well as providers will have implicit bias, so one study and one mechanism for tonight and if youre interesting in the other five, we can talk about some more during the q action, but issue study is about mechanism number five that implicit bias changes their treatment pattern, right, this is a very direct link or mechanism between bias and disparities, between bias and Poor Health Outcomes. Why . Well, the studies that are in the treatment space say this, and im thinking of one by alexander green specially. They say that if a patient has coronary Artery Disease and we present that Patient First as a black woman, then as a white woman, next is a black man, then as a white man, but we use a script, we use a predetermined set of data that tells us about the medical indicatorses, we use a predetermined set of facts about their history and personal background and their family connections, so that all of these individuals are identical to the physician but for their race and their gender. If we do that, then we can see that race and gender informed the quality of the treatment decision. Second step of the study and probably the most troubling for my work and the reason i went to do this work, if we also measure the implicit bias of the physicians making the diagnostic and treatment decision, there was an inverse relationship between the level of implicit bias and the quality of the treatment decision. That is to say the more implicitly biased a physician is, the higher on the Implicit Association test, and if you would like i can talk about that test, the higher the Implicit Association scores, the most likely they are to provide an inferior treatment modality to patients of color as compared to patients who are white. The reverse is true. The lower their implicit bias measures, the more likely they are. This is a study, a study of coronar Artery Disease patients which needed, a muchas gracias of a low implicit to prescribe treatment of choice. That tells us evidenced relationship between implicit bias and the quality of treatment that a patient will receive, that results in different, so the other mechanisms have to do with version and communication with patients. Maybe youve had the experience. You know that theyre not looking you in the eye. You know their interview is short that their body language puts zis tans between you and them. And so they say, i know what that is. Since i know what that is i no longer am satisfied with the experience and we have a lot of data lowpatient satisfaction equals poor outcome. What i found out in this book is a series of interviews of those kinds of patients that its not just lowpatient satisfaction equals Poor Health Outcomes. Its lawpatient satisfactions means im not coming back to you anymore. Its an interruption in care. That means if you tell me that i need to exercise, im not listening to you because youve insult today me, that means my adherence and compliance is low which translates into low or relatively Poor Health Outcomes. All the mechanisms work together. Its often the case that you write a book, ive been told, and you finish a book and you would write another book, a different book at the conclusion of that conversation, well, that for me just means i have a secondbook project to go on, right . [laughter] but let me share a couple of things. I am going to read one thing about the book and close a little bit about what i would do to fix this and what my next book looks like. When i finished categorizing the data, i set out to create a new data set qualitatively, interview patients, interviews physicians, Interview Health care providers and ask them about their lived experience, their own personal interaction with implicit bias and unconscious racism, what i found essentially that i was able to confirm all six of the mechanisms that i described in this book. I choose a different patient to read about and this time i want to choose a chinese man, bears out mechanism number six, patients that feel and perceive themselves as being discriminated against drop out of the care system or at least interrupt the care system in a way that impacts their Health Outcomes negatively and this is a story of a man who is an engineer by training and profession and the implicit bias that he experienced really is emblematic of what i heard from many patients. What i heard from many patients and youll hear it in his story is that his view was discredited. That perceptions about him as a quote, unquote foreigner meant that he was not believed or taken seriously. His complaints were ignored and the treatment that she received turned out to be inferior. So he picking up in the middle of the story he says, one night i just found i got clinical disease like recurring to me which caused and came from the country side back in china. Its a mosquito, a very tiny thing. I know that illness. Basely its hid nn the lover and can periodically one day show up and you have a very high fever. And then you are exhausted and then you go to sleep and he describes the symptoms. You cant walk, youre lethargic, you cant work, and i got that thing, he said. Its an asian disease. When i came here, it came back. I went to the doctor, i knew everything about it for sure when i got to the hospital nobody believed me. And then they take my blood and they say, i cant find nothing, theres nothing wrong with you, but this thing is true. You cannot find it in the blood but if you look carefully, its in the liver. But i dont think that they bothered to do that and, of course, i cant really remember the name or the academic terminology so i took the dictionary with me, so imagine this mans experience, hes going back and taking the dictionary to explain to his doctor that he can speak english. So i took the dictionary and i found the word to tell the doctor but they just say, no way, i cannot give you any kind of treatment. When you get this kind of thing again and you can show me what is making you feel bad, come back. In this system if you dont have symptoms, they only kill the symptom, they dont treat you for whats really wrong and if you dont speak english really well, you have a less of a chance to making them understand. This is not to say they hate chinese but they have prejudgment, his words, not mine, they say youre wrong because youre not professional. Remember hes an engineer, ph. D, engineer, plus maybe in your whole life in the United States youve never met someone like me but this thing it makes you so weak, can can kill you, so after 15 years here i got this thing again but decided im not going to the hospital again because it really makes me feel worst to go to the hospital. I write to my friend in shanghai, i tell them i need this medicine and they bring it to me after a month. Im a professional in my area, at least i can say im well educated. Oh, my goodness, if i had a psychology degree i would take apart the sense of deg anity that this man lost in his encounter. The sense of of insult which he was quick to deny. Remember hisment, theyre not racist, they dont hate chinese but im not going back there anymore, he said, his outcomes are adversely affected by the fact that this is happened. I think this is medically untenable, tom who is one of the foremost disparities scholars in this country tells us that it caused 1. 24 trillion with a t dollars in loss productivity, preventible hospitalizations and increased healthcare costs to treat Health Disparities over a course of his study, was six years. It is morally, medically and monetarily unsustainable not to address this problem of Health Disparities and i think the most serious causal factor that we are not talking about is unconscious racism. So what do i want to do to fix it, i will do a lot of things that i want to talk in a q a. Why more law where medicine is concerned . Poor doctors, they are under so much law. I say that for my husband. The social no, maam needs to be changed in this country. The social norm right now tells us that it is okay because it is unintentional to discriminate. That is not true. My fourth m. Unconscious bias is malleable. Theres 25 years of data that tells us we can actually do something about unconscious bias. Some of the most interesting experiments are those in which people who are unconsciously bias as measured by the iat, the Implicit Association test and who are explicitly bias are told in an experimental condition and experimental situation that their biases are not shared by 86 of their peers and then there are subsequent parts of the experiment where theyre asked to sit down on a chair next to people of color, those who believe that their biases are affirmed by their peers sit further from the person of color then those who believe their biases are not the social norm. They sit closer. Thats just one example of social experience. Brown versus board of education. We changed the social norm of explicit prejudice racism. We have to do three things with respect to the Civil Rights Act of 1964, number one we have to make implicit or unconscious bias unintentional racism actionable under that statute. Number two, we have to reverse alexander versus sandoval, its one of the gifts our dearly departed Justice Scalia left us, we have to three, replace the private cause of action that worked so well with respect to explicit racism so that it is available as a cause of action pertaining to implicit racism and how do we cabin this so that everyone who thinks a negative thought is not sued in the system that im proposing, we import a negligence standard if into the title six regime and the ngz standard simply says that if you as an institution, if you as an individual have done what is reasonably shown to address implicit bias, you have a perfect defense to a title 6 cause of action. This would create institution that would help Health Providers will do with hippa. Hippa is a big law. Institutions became immediately active and proactive with respect to training, teaching and changing the social norms around privacy. If youre a woman like a certain age, you remember, there would be the chart sitting on top of the nurses station, no more. Social norm changed by the law. But i do believe we are going to change the social norm if we do what i propose. Let me end by telling you the book that i would write if i were writing today, i would write a book about more than just the implicit bias that affects the health of populations in the clinical encounter. Im holding up a picture about the boy of American City in flint, michigan, its my believe that its pretty clear from the literature today that your health care alone doesnt make you healthy. So if you are discriminated against in education, you will have a higher likely of experiencing Poor Health Outcomes than those who are not discriminated in education. If your housing is discriminatory, unsanitary, unsafe, when the physician says you need to exercise more, you need to eat better, if i live in flint, i dont have aa supermarket in my city in order to buy fresh fruit and fresh vegetables. The social determ neans of determiminent of health, i cant exercise if there are no sidewalks no parks, no Public Places and theres no safe place for me to dpers. All of this has an influence. Flint is not the only country in this country where they are desperately describ outed by law and that desperate distribution is right with unconscious racism that results in Poor Health Outcomes. Its not the only city, i promise you. I will leave it there because theres so much more to say about unconscious racism. Let me close by saying the two last things. Governor rick snyder assured us that there was no racial motivation behind his decision to ignore the leadcopper rule. Completely ignore democracy and replace the democratically elected officials in flint with Emergency Managers by his decision to ignore the outcries of patients of people of citizens in flint who explain that the orange slush that was spilling from their tap water didnt smell right, didnt look right, didnt safe to drink for them or safe for them to wash their babies in. I will give you that Governor Snyder didnt think he was making a decision based on the race or poverty of that population. That would be explicit racism. That would be explicit bias, but i will also give you assurance whether admitted or not, Governor Snyder would never make that decision with respect to a population that looked like him that had the financial wherewithal that he had, that didnt give him an unconscious reason to believe this group of people were somehow less than, somehow different than or somehow not entitled to the same treatment as a population of his own children. Thats implicit bias and thats how massive my last m, the problem is in my view. So thank you for taking the time to listen to me. I look forward to your questions. [applause] if you have a question, please raise your hand, i will do my best to make myself around the room. I have two questions. One is reading the book i was impressed with how much i didnt realize the copiuosness of the research, i had problems reading back and forth because i had to look at that, why is it that so much has been out there before and its just now coming through . Second point is, you talked about title six, using the negotiate standard, can you speak a little bit about how it would apply to individuals because in showing, e guess the burden of proof would be on still the plaintiff but showing implicit or even the demographics, can you speak on that point . Let me take the second one first because i will forget that one. I would like to see impact return on the title 6 regime, reversing sandoval so i that i could statistically show are case for having the evidence that there was actionable discrimination at play, right . [inaudible] same standard would be my view. Same standard. A compete defense would be negligence. I acted reasonably to take the stems that steps that are in the literature, what would make implicit bias malleable. Why is it just coming to the floor . I was been studying Health Disparities for about a decade at this point. And dont get me wrong, i came to washington, d. C. Because i believe firmly in the Affordable Care act, firmly that this is the step we need today take in order to expand health care in these United States to at least 80 million more people. Having said that, if we had universal health care and universal access was to inferior and discriminatory care you would still end up with disparity that is im describing in this book. Access has been the focus for the past 25 years, the first generation of documenting Health Disparities and understanding the extent of those Health Disparities, thats the work that had to go before so that all of the statistics i quoted about cancer disparities, diabetes disparities and death rate for infants, their copious. We thought that once we described the problem and got people access to health care it would change these disparities and inequalities, it has not. 80 of the disparity measures for Health Quality havent moved in 25 years, right, so pardon me, but some of my best friends are conservatives, but conservatives like to point thoth fact that we are narrowing the Life Expectancy gap, right, its still the case if youre a black man youre going to die five to seven years earlier depending on where you live and in some parts of the country your Life Expectancy is like that of someone from haiti, right, so the fact that we have narrowed the Life Expectancy gap a little bit that doesnt mean that death rates for infants, death rates for heart disease, cancer, you name it, asthma, people of color die quicker and live sicker in these United States than white people do, right, we havent moved the needle and we are now turning to the question of what might be the mekism. Last part of the answer i will give you is that this is a sticky topic, right . I had to start my talk by saying, i want you all to know im not talking about explicit racism. I dont want to offend anybody to say im pointing to the Health Care Profession people that are dedicated to caring for population who is are trained to be objective are themselves racist, i shut down the conversation if i do that, right, i want to be clear that although this is tough we are talking about implicit bias and unconscious racism and we are just get to go that conversation. Good evening, my name is didi, i think you may have already answered this. I want to bring up three points and i fall backwards, i know you spoke just now about i am a nurse, okay, ive been a nurse for 18 years and worked in the cute care setting so i have witnessed a lot of what i have discussed and i have not read your book, this is a healthy discussion for me and some of my peers, but i wanted to talk about the health care is very diverse and its diverse in absentee of clinicians. And you spoke about clinicians to be trained of cultural sensitivity and i dont know that that Due Diligence actually occurred to really address that. And i think it speaks what you have talked about, the implicit unconscious belief that people have, you know, i went to south africa recently and i had some conversations with some folks there and asked if they had come to america and no, but i watch bet. Thats not really america from african standpoint. The same is true for health care clinicians, but i wanted to ask you this, how do you think the business of health care helps to promote this implicit unconscious belief because, you know, Health Care Facilities now specially with the new Affordable Care act and the way that hospitals are reimbursed, theres a heavy competition on being number one, on meeting benchmarks, on getting qualitybase reimbursements and being number one with stroke center, trauma center, Cancer Center that it almost it almost wanting to provide that level of care that you want to because youre constantly trying trying to meet those benchmarks, we have to talk about the way that the health care is afforded to the people who need to provide the health care. Didis question with lots of discussion and i want to go to the last point, i think it has a heavy influence on the operation of implicit bias because remember implicit bias is automatic thought. Its what we use to organize very complex chaotic situations into manageable bites, essentially, right . So think about what a differential diagnosis is, a physician takes possibilities and very quickly underscore bold will come back to the word quickly, tries to decide what is wrong and what can be done for this patient, right . That exercise is a exercise of judgment that invites the kinds of categorization and shortcuts that implicit bias reflect, right . Thats thats exactly the kind of setting that implicit bias thrives, we have very complex, large decision that is are subject to great amount of discretion. Add to the fact that the business of medicine has made those decisions, have to speed up. You have to speed those decisions up, right . We have to perform according to metrics, we have to get the patient in, get this patient out. Ive got so many that i have to see. I have quality measures i have to meet. The fact is we created an environment where shortcuts are necessary and, in fact, shortcuts are how we cross the street safely. Fast cars will hit you faster than slow cars will and you walk across the street based on those judgments. Everybody uses them, but in health care they can be exacerbated, when the level of discretion provides connection with provider and the amount of time to make those decisions are short and when the level of discretion is too broad. I heard tom and others suggest that if we were to standardize some patient decision making, here is where i know my husband will go patient, standardize patientdecision making, there are ways that what you said certainly have a bearing on the prevalence of implicit bias. Hi, first of all, thank you for the awesome talk. My question is about so, i guess, the identities of the doctors effect the interactions . Shes going to make me go there. The goal is to help promote or encourage youth from lowincome communities of color to go into medicine, so i was wondering, does that have any affect due to those programs, is that based, that would address implicit bias . The answer is yes and no. Yes because one of the things that makes implicit bias malleable by stereotypes. If you prime someone with pictures of people of color in positions of power, not just, you know, the person who is in the room changing the bedpans, right, but in positions of power, positions of authority, decision makers, right, across the spectrum of healthcare providers, the counterstereotypes are likely to reduce the extent to which explicit bias, i have a Pipeline Program and i take reasonable steps to provide counterstereo tapes to recruit and retain providers of color i would have a defense to the implicit bias action. Now here is the dirty little secret and the way i said you are making me go there. If you live in these United States, if you grew up in niece United States, it doesnt matter in your brown, black,yellow, purple, same social knowledge at everybody else. All reflect the bias levels as the major population, sorry to say so. Its true. Hello, i work in quality measurement and we spend a lot of time on whether we should adjust different quality measures and im curious what your thoughts are in whether adjusting measures base on race help where those exist or allows implicit biases where you might only focus on Patient Outcomes on white patients or other patient that is have higher advantages . So i think i understand your question about Data Collection and whether Data Collection helps or hurts . My view is you cant fiction what you cant measure, right . If its not really clearly articulated in the data, i dont think any of these problems are easy to solve. I dont think even the Solutions Proposed in the book are full story, i know that theres a large conversation going on about whether we should risk by socioeconomic status, risk factors or reimbursement. Theres a conversation about whether we should allow Precision Medicine to address racial differences and ethic differences. We have been afraid of those for a very good reason, you cant fix what you cant see. We have to be able to measure it and we have to address. I would say Data Collection such as Affordable Care act helps. Pay for performance being weve got to hospitals want to look at how many readmissions they have and how helling think are patients when they leave. How do you think its going to play into access to health care when pay for performance is now the model, and now some doctors and Health Care Providers in general, their salary is dependent on the health of their patients. And if were all being fed the same information, Important Information about social determinants of health, how does that affect setting up private practices and other sort of health care outputs . Thats just a great question. First of all, thank you for being cognizant of implicit bias, the change in the delivery model and reimbursement models as a medical student. I think the longterm prospects for you doing your part to eradicate Health Disparities is greatly increased by your awareness and your conscious effort to educate yourself. So congratulations to you. In a word, i think it helps, right . I think it helps to move the Health Delivery model in a way that will charge physicians with more than treating disease, but treating entire outcomes, treating entire patients. Indeed, one of the most moving presentations i have heard since i came to washington was a quote that dr. Nicole laurie made, and she said i have failed as a doctor to my patient if i am not a doctor to my patients whole community. Right . So i would suggest that moving away from fee for service into reimbursement models that look at value return as opposed to just the fee for the service that was provided are more likely to produce doctors like dr. Mona who looked at the elevated blood levels in her patients in flint and said something is amiss in the entire community. Something is amiss in the entire population. I have to look at what these patients are living with in terms of housing, in terms of food, in terms of their educational access, in terms of their medical access. And i have to look at their whole picture. I think that kind of physician perspective is much more likely to result from a departure, if you will, from fee for service to more collaborative and outcomesbased medicine. We have time for two more questions. Hi there. My question is kind of two parts. Can you hear me . My question is two parts. The first is, im a medical student as well. What can i do to kind of check my own personal bias and to ameliorate it in whatever way possible . And the second question is in the reading that you gave the patient said that we have a system that takes away the symptoms, and in what ways do you think our Current Health system kind of exacerbates or allows for the implicit biases that youve discussed, and how can we approach it on the individual provider level and also on the Health Systems level . Yeah, great question. Im going to answer it in two parts as well. As a medical student, you have the, you have the fortune of not yet having been indoctrinated, if you will. Theres only one study, but its a very potent study, its a study about medical students over three years. In this study medical students Nursing Students, pharmacy and dental students had their implicit biases measured in their first, second, third and fourth year and correlated with their decisions. In short, medical students like you had the same level of implicit bias as, generally, the population does, but your implicit bias clearly, it wasnt you, but medical students in the study did not have the same correlations between their biases and their treatment recommendations. So they held the biases, but the bias withs did not affect their treatment decisions in the first year. Less so in the second, less in the third and by the fourth year of student, medical students biases affected their treatment decisions in the same way that their attendings and physician trainers affected, right . So the medical student, one of the things you can do is start saying, wait, i can be internally quietly i know you need an a, and you want to do well i can internally question why, for example, my attending on rounds introduces a patient as a 53yearold black woman if she doesnt have sickle cell or anything thats related to her race. Why is that racial moniker important to the description of the patient other than to convey information that is nonclinical, nonmedical, nonhelpful and perhaps packed with implicit biases, right . You can ask yourself that question. If you are a medical student, you can also ask yourself why in this same study although physicians in training had the same level of correlation between their treatment decisions and their implicit biases by the fourth year, Nursing Students did not. Pharmacy students did not and dental students did not. I dont have the answer for why that is. I have a hypothesis about why that is, right . The Nursing Mission is to advocate for the patient as an individual. The Nursing Student sees the patient not as a category, but as an individual. I dont have the data to prove that im right or wrong, but you can ask yourself as a medical student what it is thats happening in your training that might lead you to change your, who you are, frankly, and how you treat people as individuals. And you can combat that. The reason i think thats not a fools errand is because a third part of the shulman study that i talked about rather, the green study that i talked about was that he took out of the 6700 students 703 students he examined, 60 of them it was disclosed to them that this was a race study and what the differences in treatment were between them. Just the disclosure changed the treatment pattern, right . Just the disclosure. Just knowing that one is susceptible. So i applaud you, because the first part of your question was what can i do about my biases, which suggests to me selfknowledge, selfawareness and having the kind of Critical Thinking that will, if that study is correct, will result in you being much more vigilant about offering care equally to patients of color as to white patients. Those are the things i can think of. Last question. Hi. Its just sort of a curiosity. Im wondering if you see less implicit racism with pediatrics . I would assume kids would be sort of a great equalizer yeah, good for you. Yes, we do. So theres a study done out of wayne state, michigan. Yea, michigan. That is, actually, a series of studies that shows a couple of things. Pediatricians have lower biases than other physicians, slightly lower biases than other physicians. Foreigntrained medical graduates have lower biases than other physicians. People who grew up in Different Countries with different sets of social knowledge and social inputs have lower biases. Theres a lot of work yet to be done on implicit biases, right . I thought that this was a conversation starter. I thought and felt strongly that this problem is too deep, too broad, too wide, too important not to talk about even given the state of the research as it is right now. We dont have a lot of information about um police sit biases implicit biases beyond blackwhite and latinowhite pairings. Thats a shortcoming in the literature. We dont have a lot of information about implicit biases and what it does beyond the Physician Group with the exception of the one study pertaining to students. We dont know what p. A. S, clinical pharmacists, nurse practitioners, we dont know about their biases and the inannounce on their influence on their treatment. If anybodys been to the dentist and had the receptionist treat them ugly, they dont go back, right . So what about people who are administrators in the Health Care System . What influence do their biases have . So i do believe that even though were doing cultural competency today, even though were spending lots and lots of money on making sure people know that differences exist, weve got to go further and deeper and do the type of stereotype negation that changes the habit of being implicitly biased, that changes the habit of thinking automatically and letting your automatic thoughts override what your preferences are. I want to close by saying that ever since i was a little girl, my mom would have to pull me back from trying to make justice happen when i saw that it wasnt happening. What we see in the Health Care System is not just disparities. Thats a sterile term. Its not just automatic. Its not just ubiquitous and, therefore, acceptable. Implicit biases are not a given. And the problem that they create is fundamentally a problem of injustice. And these United States cannot continue to tolerate the injustice that results in people of color dying and living sicker than whites just because of their color. Thank you. [applause] just being here, i feel informed. I want to encourage you to get a copy of just medicine. Before you leave we ask that you fill out i see some of you are these surveys. These surveys [inaudible] please take the time to fill that out. Please make your way to the signing line. Thank you so much. [inaudible conversations] youre watching booktv on cspan2 with top nonfiction books and authors every weekend. Booktv, television for serious readers. Next, the communicators with fcc chair tom wheeler. Then Vice President biden and former House Speaker john boehner honored by the university of notre dame. After that filmmaker and activist spike lee is the Commencement Speaker at Johns Hopkins university in baltimore. And live at 9 a. M. , a forum on how to improve the effectiveness of civic groups. Speakers include consumer advocate ralph nader. This week the communicators goes to the intx show in boston, the internet and Television Expo sponsored by the National Cable and telecommunications association. We interviewed fcc chair tom wheeler. Host as a regulator and a