“Unconscious bias in health care describes associations or attitudes that reflexively alter our perceptions, thereby unintentionally affecting behavior, interactions, and decision-making. Health care organizations need to be actively discussing this subject at the highest level to find gaps and learn where to dedicate resources for improvement, even if it means confronting awkward topics and having uncomfortable conversations. The time has come for organizations to be deliberate in their efforts to improve diversity in their workforce and active in their outreach to improve inclusivity. The problem does not improve if we choose to ignore it, or worse, deny it.”

Brooke Trainer is an anesthesiologist.

She shares her story and discusses her KevinMD article, “Acknowledging and mitigating unconscious bias in health care.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow. Today on the show, we have Brooke Trainer. She is an anesthesiologist, and she wrote the KevinMD article “Acknowledging and mitigating unconscious bias in health care.” Brooke, welcome to the show.

Brooke Trainer: Thank you. Thank you for having me.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Brooke Trainer: Yeah, I’d love to. Thank you for the opportunity. I graduated from medical school at the University of Miami, go Canes, and completed my anesthesia residency training at Yale New Haven Medical Center in Connecticut, after which I went on to complete an active-duty tour with the Air Force in Germany as a critical care air transport physician. I finished my service with the Air Force, which was by far the best job of my life so far, coming to Langley Air Force Base in Virginia as the medical director. I served as the medical director there.

When I finished up, I thought it was a nice transition to come into the VA, a transition to my roots, to keep with the service members. I embarked on a career in both academic and university medicine and kept my position at the VA. I joined the faculty at the Central Virginia VA Health Care System. I started up an acute pain service and then rekindled my interest in critical care medicine. I went back and took a leave of absence to do a fellowship in critical care at the University of Virginia, and now I’m working as an intensivist, an acute pain physician, and an anesthesiologist at both the VA and now VCU.

One of the things that I’ve been very involved in is organized medicine, for my whole career. I’ve held several leadership positions in organized medicine, including president of the Association of VA Anesthesiologists, and I also serve as the alternate director for the Virginia Society of Anesthesiologists to the ASA board of directors, and then as editor-in-chief for my society, the Virginia Society.

I love teaching. I love simulation. I actually have a national faculty position with VHA SimLEARN, which is the Simulation Learning, Education and Research Network, based out of Orlando, Florida, and I teach a course for VA facilities across the nation, which was very timely for COVID, called Ventilator Education for Non-Intensivist Training, the VENT course. These are just a few of the things that I wanted to share with you all that I think are a little relevant to the article.

Kevin Pho: Sure. So you mentioned your involvement with organized medicine. Why is it important for physicians to be involved with organized medicine?

Brooke Trainer: This is a way for us, one, to stay relevant in our profession, up to date, and educated, and also to advocate for our patients, especially for the safe care of our patients. Even if you’re not political, organized medicine is not all political, but some of it has to be. A lot of health care, unfortunately, is policy-based, and a lot of it is relevant in our legislative affairs and political affairs. So even if you’re not someone who is, quote, political, I think it’s still important to stay involved so you can stay relevant on the standards, protocols, and guidelines of your society, stay out of trouble, and keep your patients safe. These are the main reasons.

Kevin Pho: Can you give an example of how you’re involved in organized medicine, or of the organizations that you’ve been involved in? How has that moved the needle in terms of advocating for physicians?

Brooke Trainer: So I do serve as president of the Association of VA Anesthesiologists. One of the things that we are working on in the VA is that recently there was a big push for federal supremacy, which may be relevant. It may be necessary for patients to be able to transfer care across state lines, to move resources, and to enable greater access to care. These are some of the things that we strive for, to make sure that all patients have great access to care. But what becomes concerning is when these things happen at a rate that outpaces the need to safely monitor and care for our patients, in not just an efficient way but a highly effective way that’s in the best interest of their outcomes.

This is really important: Whenever you’re making decisions at the highest level on efficiency and access, you always have to maintain that level of safety for patients. And so we’ve been really vocal in our opposition to some things that we think went too far or went too fast and maybe compromised safe care for patients. So this is our opportunity to stay a collective voice and to be heard as a collective voice, not just as an individual, but as someone who’s advocating for the safe care of our patients, especially our veteran patients, who are one of our most vulnerable populations and who obviously deserve the highest quality of care.

Kevin Pho: All right, let’s transition into your KevinMD article, titled “Acknowledging and mitigating unconscious bias in health care.” Now, for those of you who get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Brooke Trainer: Yeah, so this is something that’s near and dear to my heart. It came about after 10 years of practice, when I didn’t even recognize some of my own unconscious bias and wished that I had heard something or had some training in this as a student, as a medical student, even in residency. Acknowledging and mitigating unconscious bias in health care is especially important because we need to better care for our patients. There’s compelling evidence that increasing diversity in our health care workforce improves health care delivery, especially to underrepresented populations, and we know that the diversity of the U.S. population is increasing, and this isn’t reflected in the patients that we treat.

The problem, unfortunately, is that this diversity is not always represented by the demographic characteristics of the health care professionals themselves, and this mismatch can lead to unintended health care inequities due to cognitive biases, whether you’re aware of them, or unconscious biases, whether you’re unaware of them. We need to learn how to recognize, acknowledge, and mitigate these unconscious biases that can negatively impact our understanding and our actions, our decision-making, when we’re taking care of these patients.

I will say that over the past few years, more organizations, fortunately, are recognizing the importance of fostering this culture that includes diverse perspectives, and more and more organizations are having pointed and deliberate conversations on DEI topics. I know that the ASA, the American Society of Anesthesiologists, as well as the Association of VA Anesthesiologists, is having pointed conversations about diversity, equity, and inclusion topics. But we need to be discussing these at the highest level to find gaps where we can learn and dedicate resources for improvement. It’s necessary, even if it means confronting awkward topics and having uncomfortable conversations, that we be working toward efforts to improve diversity in the workforce and be active in our outreach. The problem doesn’t improve if we choose to ignore it, or worse, deny it.

Kevin Pho: So what are some examples of unconscious biases that physicians may have, and can you give further examples of how those biases can affect patient care?

Brooke Trainer: Absolutely. So this is something that I came across, again, like I said, a decade into my practice, and I learned a crucial characteristic about myself. I think that, having been unaware of how implicit bias can play into your decision-making, I actually don’t know what impact I had on patients, and now I am much more aware of it.

I mentioned earlier that one of my roles in organized medicine was serving as our state professional society’s journal editor. A few months ago, I proposed that we publish an issue themed on DEI, and I wanted to recruit diverse speakers to write for the issue. I really had sincere intentions and genuinely wanted to do the right thing. But one of the racially diverse authors that I approached, whom I was considering for writing an article about maybe her perspectives, or really choosing whatever topic she wanted, opened my eyes and changed my perspective on how I was approaching the subject. I want to thank her for this, genuinely.

Her first question to me was, “Why are you only now asking me to contribute an article?” I was like, “Oh, she’s right.” Up until now, I had never thought to reach out to her to write an article. And her follow-up comment to me was, “Why does every white person think they need to ask an underrepresented minority how to fix or resolve this issue?” I could see that, obviously, she was frustrated. She made a valid point, though, and this was likely not the only encounter she had experienced on this subject. But rather than get turned off by her contempt, it actually challenged me. So I wanted to investigate further why she felt compelled to explain, and I was grateful for her explanation.

She gave me the example of how unconscious bias likely contributed to the poor representation of minority trainees in her program, and she challenged me, whom she considered a leader in our specialty, to write about the issue and come up with solutions on my own. I hadn’t thought of this before. I didn’t think it was appropriate, honestly. I didn’t want to claim to be an expert in something that I don’t know much about, and I certainly didn’t know what to say. But she helped me to understand the issue and see her perspective.

What she told me was that when she came to interview at her current training program, she was one of the top graduates of her program, and she’d been looking forward to this day, albeit she was very nervous and wanted to make a good impression. But she was dismayed on the day of her interview when she was met by an all-white, all-white male interview panel. She tries to recall and thinks there may have been one Indian female, but she didn’t meet her or have a chance to talk to her. She further explained that though everyone was very nice and professional, she never felt like she connected to anyone. And to make matters worse, the evening after her interview, all the interviewees were taken out to dinner at a restaurant that was decorated in Confederate Civil War memorabilia, and she wondered if it was almost a subtle message that they were trying to send her away, or to stay away.

In the end, she was surprised to learn that she did end up matching into the program. But she explained that though it was one of her top choices prior to interviewing, it was one of her last, bottom choices after the interview. Ultimately, she confessed that she was happy to match there and realized afterward that all of those, quote, white men who interviewed her were in fact genuinely good people and cared about her, and they promoted her. In fact, they nominated her to chief of her residency class. But why was she one of the only minorities in the class?

Both of us started wondering, and postulated that if they had better diversified that interview panel, as well as chosen an alternate restaurant to take them to, with less offensive decor, perhaps the composition of her training class would have been more diverse. We both agreed that it was highly likely that these unconscious biases turned away a lot of really high-quality diverse candidates from this program. And so I did feel compelled to write about this and say that, just as much as we want to recruit diverse people into our programs, we need to be putting diverse leaders on these panels for these selection committees and considering these unconscious things. So that was my aha moment during my conversation with her. She really opened my eyes to this.

Kevin Pho: What would be some of the immediate next steps that you would take to help solve this issue of unconscious biases?

Brooke Trainer: I think I go back to my fundamentals, and anyone can do this: the fundamentals of “What can you do now?” That kind of thing. I’m super passionate about teaching and mentoring, and everyone’s different. I haven’t discovered any new drugs or fancy devices, but I think that I’d still like to leave behind a legacy with my children, with my family, and then also with the folks whom I am teaching and mentoring along the way.

And so I think by passing on this wisdom, by writing about it, by talking about it, by teaching, and then by helping attain leadership positions where you can actually directly influence these decisions, this is how we can, with small steps and individually, even take little bits of opportunity to think differently, constructively, and creatively, and then influence and advocate for things that are right and for our beliefs, stand up for our convictions, and be authentic. Try to be, like Mahatma Gandhi says, the change that you want to see in the world, step by step, little by little.

Kevin Pho: We’re talking to Brooke Trainer. She’s an anesthesiologist, and she wrote the KevinMD article “Acknowledging and mitigating unconscious bias in health care.” Brooke, what are some of your take-home messages that you want to leave with the KevinMD audience?

Brooke Trainer: Well, I think I’ve stressed a lot about making sure that when we are interacting with patients, or interacting with employees or colleagues, or even in leadership positions in these organizations, we are deliberate in our actions and we reflect on them. And so I hope that the audience takes away from this interview the importance of diversifying interview, selection, and promotion panels. Hiring great candidates is a two-way street. They have to want you as much as you want them.

The second lesson I hope clinicians, particularly leaders in health care, take away from this discussion is the need for health care organizations to seek and recruit a diverse health care workforce. Like I said before, we know that increasing diversity in the health care workforce strengthens our ability to care for culturally sensitive and diverse patient populations. Patients want to connect to their providers, and in order to connect, they have to find that relationship and have some similarities with them. That builds trust, and I talk about that a lot in the article: being able to build trust in your provider, trust in your patient-provider relationship.

I think efforts should be made to not only select the best candidates but also the best people to interview those candidates. One way we can achieve this is by being intentional in our diversification of these panels, especially during the hiring process and recruitment process, and they should be comprised of people of varying backgrounds who represent the demographics of not just the organization but of the patients they treat. I think this exemplifies an organizational culture of diversity, one which prioritizes inclusivity and aims to ensure fair and equitable selection of candidates from diverse backgrounds.

Kevin Pho: Brooke, thank you so much for sharing your time and insight. Thanks again for being on the show.

Brooke Trainer: I appreciate the time. Thank you so much.