How to Recognize and Overcome Unconscious Bias in Healthcare

hi everyone my name is Marina I'm GNA give it just a minute or two to let people get all joined and ready to go here I'm very excited to be here we're going to have a great talk today and I'm hoping that we have some good questions afterwards I'm excited so I'll give it a give it a minute or two okay and just so everyone is aware I am going to go through my presentation just kind of going through the slides I'll be on video over here and then at the end I'm not going to be able to monitor the chat myself and so I have the wonderful Stephanie from our marketing team who is moderating the chat and will be able to kind of pull questions for me which I will then answer just kind of on camera and I'll get rid of my screen and everything and we can just chat at the end of it is how I like to do questions so okay we are about two minutes past so I'm GNA go ahead and get started hi everyone my name is Marina Horiates Kerekes I am the director of medical assessment at osmosis from Elsevier I've been with osmosis and then Elsevier for about four years now and I have had the privilege of being able to get involved in thinking about inclusion and diversity within our content and within the organization as a whole so this has been a subject that I have thought about a lot and I have tried to educate myself on and today we're going to focus specifically on unconscious bias in healthcare and how we personally can recognize own and overcome the effects of unconscious bias so let's go ahead and get into it just as an agenda we'll go through a couple of different things first I want to have a conversation about just kind of setting the tone for this topic and we're going to do a little bit of a vis visualization exercise we'll go through some definitions and then we're going to talk about the effects of unconscious bias or as I like to put it why all of this matters why we're here why we're talking about this why this is important and because it is so important we're also going to talk about taking actions what can we do what can you do in your own life what can you do as an advocate overall to mitigate the effects of the reality that unconscious bias exists so we're going to start off by kind of setting the tone here so first I want to do a visualization exercise so if you're comfortable close your eyes and I want you to imagine you are in the hospital you're in preop for a chis cystectomy you last night came into the hospital with horrible abdominal pain and you found out that your gallbladder was inflamed and now you are waiting for surgery to have it removed so a tech arrives with a rolling cart full of equipment to take your vitals they're mostly normal except your heart rate's a little high you're nervous which is fair soon your nurse arrives checks your IV asks you how you're feeling Pats your arm and says that the surgeon will be over in a few minutes to wheel you back you take a deep breath you close your eyes you're waiting and then the surgeon arrives with a resident and the resident confirms on the computer that all of the data is correct and that yes you signed all the consent forms and then the surgeon nods and shakes your hand and asks you if you have any questions okay now pause I want you to take a second I want you to go back to the very beginning of this imagery first of all the hospital where is it what does it look like is it clean is it crowded is it a well-resourced setting or not and then we're going to go through the people that we just encountered in that story so first the tech what does the tech look like how much do they weigh what is their race are they conventionally attractive how about the nurse what gender are they race do they have any visible disabilities how about the resident what gender are they how old are they and the surgeon what gender are they how old are they what's their race what's their weight are they conventionally attractive all these visual things that we immediately clock in our brain as soon as we perceive something and then you realize a bit later that all of the assumptions that you made in your natural Vis visualization of this scenario that you are imagining yourself in those are assumptions that are potentially the result of unconscious bias so the reason I want to start with this is because this topic is hard to talk about it is hard to sit and realize that yes you have unconscious biases whether you like it or not and I think it's important to come to this with that humility and also with a tone of empathy so in the way that we will talk about empathy in applying it to those around us I think we also can apply it to ourselves we can apply it to people that we perceive as biased and how we are going to take steps to mitigate that effect so I just I just think that this is an important tone that we can set whenever we're having this conversation today and also as you go forward into your into your lives and start to think about some of these themes and the steps that you can be taking in your life just coming at it with empathy and humility okay so let's talk about some definitions what is unconscious bias it's also known as implicit bias you may have heard which would be the opposite of explicit bias or conscious bias biases that you are aware of unconscious bias then is defined as social stereotypes about certain groups of people that we form outside of our conscious awareness so that kind of makes sense it's a lot more prevalent than conscious bias we don't tend to have actually a ton of conscious biases that we necessarily would admit to but unconscious bias is everywhere in our minds and what I think is interesting about them is they're often completely incompatible with one's conscious values so some of the images that you might have conjured for yourself of the surgeon of the nurse you know of these people in this scenario and even the setting you might not actually think that you have any kind of preconceived notions of what those people would look like you have you don't hold any particular belief about what gender what race you know kind of things would be appropriate for those roles and yet your brain made assumptions about them so I think that I think that's interesting to think about now when we think about unconscious bias where do they come from these are learned attitudes that are shaped by years of many things past experiences cultural environments in which you grew up Social communities that you exist in the media that you consume etc. and there's a good amount of Neuroscience that's been documented on these so we can think of unconscious biases as something that your brain designed for you as a way of having mental shortcuts for information processing and it is a reflection of our brain's usually helpful tendency to organize the world around us into categories of course in this scenario sometimes the categorization that we automatically implicitly make is biased studies have shown that unconscious bias develops at a very early age typically they've started documenting it kind of middle childhood and develops across childhood and they have real world effects on Behavior throughout our lives but this is my favorite part that the studies have demonstrated our unconscious biases are malleable so we can take steps to minimize the impact of unconscious bias I think this is important because it's easy to have a conversation about unconscious bias and to kind of get to the point of yes I recognize that I have these biases great and then stopping there and saying you know that's a that is a good first step but that's not the whole thing that's the first step in changing and making sure that those biases aren't impacting your behavior so that's what I really want to focus on today is how we can notice them and then enact change there are lots of different types of unconscious biases many of them you have probably heard of course some of the bigger ones that are talked about mostly race or ethnicity gender sexual orientation physical ability but then there are some of some of these other ones I think are interesting that we don't talk about a lot so Affinity bias is something that just kind of as the words suggests it is a tendency to have a bias toward people who are more similar to you so whatever you personally identify within in any of these categories you are more likely to have an affinity for people who are also in those same categories as you and this is as you can imagine important in things like the workplace and hiring and of course also in healthcare and the people that you are caring for another really interesting one that I was reading about is Beauty bias so this is a pretty well documented phenomena that humans people in general tend to have a bias toward people who are more conventionally attractive and those people end up in positions of power more often which is which I think is fascinating because it's not something that we would necessarily ever admit to consciously or at least we wouldn't necessarily want to name bias is another thing we're going to talk about that a little bit later that there is a tendency to bias toward people who have perhaps more white sounding names than people who have more black sounding names and there's been studies that have demonstrated the differences in Behavior according to that this is another interesting one the Halo and horns effects this is kind of talking about the tendency to be biased in our thinking about a person based on one quality for example if I am interacting with someone a patient perhaps and I find out that they went to a very prestigious University I might then end up having that fact color my whole thought about that person and in that case perhaps it's in a positive way I now make assumptions about their level of intelligence about you know their social economic status about their you know their role and jobs and stuff outside of the hospital the setting that I'm currently seeing them and then the opposite of that is called the horns effect so making a judgment about a person overall based on one thing that you might perceive as negative yeah so these are these are all fascinating I think anyway but I think it's most important to talk about then yes those are interesting ideas why do we care what effect do they actually have and to talk about that I want to do a case study here so you don't have to read all this text this is a kind of medical note we'll say it's a fake note and it is talking about Mr. R. Mr. R is a CLE cell patient with a history of chronic left hip osteomyelitis and he's coming to the Ed with pain all everywhere and he is narcotic dependent and we kind of go through his history his usage and now we're talking about he's presenting to the hospital in this pain and he says that yesterday when he was hanging out with friends outside of McDonald's he got dehydrated he's had some stressful events in his life recently and he feels like all of that has contributed to this crisis that he's presenting with right now with 10 out of pain it hasn't been helped by any of the medications that he says he's taken and non-physical exam he seems to be in distress but his vitals are more or less completely normal the rest of the exam is normal though he says that there is tenderness to palpation of the left hip I want to just pay attention to the language that was used in that note so describing Mr. R as a sickle cell patient a lot of this language also doesn't assume that Mr. R is telling the truth for example we have words like stating he has 10 out of 10 pain as opposed to him just having 10 out of pain or in the physical exam you know that the exam is normal although he reports tenderness not you know or saying that he it's an it's a report as opposed to that just being an existing fact of the physical exam you know he saying that he is narcotic dependent he's here in the Ed frequently and then these extra little qualifiers of reportedly he takes 100 milligrams of oxycontin but there's a reference to some other social things about Mr. R that's documented in this note a reference to the Housing Authority moving him to a new neighborhood you know being at outside of McDonald's what are the implications of that and then some of these other moments they quote him you know the pain is all up in my arms and legs he believes that some stressful situations have contributed to his current crisis that sort of thing and what happens when we change some of those words so instead of describing Mr. R as a sickle patient Mr. R is a man with CLE cell disease he's a person and then we kind of change up some of the of the history to have some more objective data he has about 8 to 10 pain crises per year which sounds very different he recently moved to a new apartment it's not actually that important that it involved the Housing Authority some of these details that don't actually matter to his care that much in this moment in this initial perception of him but that the language can transmit bias to the person who's reading the chart who next is going to interact with him also talking about you know the pain itself that the physical exam is normal other than tenderness to palpation of the left hip that you know he is an obvious distress as opposed to he appears to be in distress things like this that that make a significant difference when you just change a little bit of it now this this is from a paper that I love to site it is talking about the transition of transmission of bias in the medical record and the impact of stigmatizing language so they did a randomized study of two chart notes the two that I just showed you employing stigmatizing versus neutral language to describe the same invented patient and they measured attitudes toward the patient that the people had read these different notes and then they also took a record of what the pain management decisions of these clinicians who are reviewing these two cases the pain management decisions that they would make and it turned out that exposure to stigmatizing language was associated with more negative attitudes toward the patient and less aggressive pain management less aggressive management of the patient's pain so it had actual clinical outcomes just the language that was used and this quote that I really like that they talk about how language in the medical record it's more than a reflection of attributes it's also a means to transmit these attitudes to others so when we think about the effects of unconscious bias on health that is an example of how you know bias might impact pain management and I think that this this is a quote that I think is very specific toward racial bias but I think it has implications kind of across all types of bias when we think about them so race is a social construct and not a biological category based on innate differences however racism has biological consequences so the idea that the physical biology of some of these things doesn't you know say really anything about a physical difference between people however our by based on those attributes can have real consequences on people's health for example when we there's been a lot of talk recently about differences in maternal mortality according to the CDC the maternal mortality rate for black women in 2021 was 2.6 times higher than that for white women sorry we also think about differences in research funding so and this is this is kind of a thing that I didn't really think about very often until someone pointed this out to me in medical school which is that there is a significantly greater amount of federal funding and Foundation expenditures available for cystic fibrosis which is of course a disease that primarily affects white individuals it's a genetic condition compared with CLE cell disease also a genetic condition that primarily affects black individuals and this was documented in a paper in 2020 another example I went to medical school in Baltimore which is where this is from pediatric asthma so compared with white children black children have a three to fivefold higher risk of asthma related hospitalization and a Sevenfold higher risk of asthma related mortality and this was documented in the Department of Health and Human Services office of minority Health in 2018 so these are different ways that you know there's not necessarily a reason behind these differences in health outcomes except the existence perhaps of bias and the people managing these different health things now of course unconscious bias exists outside the hospital we are having this conversation about bias in healthcare but as I'm sure you know there's plenty of examples of say bias in the workplace this was the example that I was talking about earlier we think about hiring and promotions there's a study that they did where they had fictitious resumés that were sent to help wanted ads and some of them had very white sounding names and some of them had very black sounding names and those with the white sounding names were 50% more likely to get a call back for an interview also things like salary this is an example of potentially gender bias among mentored career ko8 or k23 recipients these are recipients of the NH grant funding which is a mentored program the mean salary of female researchers was ?31,000 less than their male counterparts again there's no there's no fundamental difference between male and female scientific researchers and yet we see the impact of this bias so what do we do I think that of course you're all here you all recognize that this is something that is important that we need to do something about and you recognize probably by now perhaps that you might have your own biases how can you go about kind of identifying those the Harvard implicit association test is a very famous test that was published that goes through you kind of go through a test where you are able to select different topics for example sexual orientation weight gender race and you kind of go through a testing module where you associate those things with more positive or more negative connotations and your results will show kind of what you when you're going very quickly and making snap decisions about these words that are being lined up next to each other you're able to kind of see oh interesting do I tend to have a bias am I more successful at associating white people with positive attributes because I'm better at clicking so it's a really interesting test I would recommend you checking it out and also just generally in terms of recognizing our own bias self-reflection is super important and I think there's a bit more of an active way to go about that self-reflection in terms of actively seeking out perspectives that are different from your own and this is kind of across the board are you what is the content that you're consuming in your daily life what are the books that you're reading both you know non-fiction there's a lot of literature out there about these kinds of topics but also fiction are you when you sit down curl up with a novel on a weekend in the summer on the beach are you only reading works by authors who look like you maybe and in those cases are you missing out on an opportunity to learn more and to see more perspectives outside of the one that you already have other things like you know reading op-eds what do you have on your social media what are the accounts that you're following attending workshops kind of like this all ways of actively seeking out additional perspectives outside of potentially your own unconscious bias that you've begun to identify with yourself and then as far as mitigating those in addition to actively seeking out other perspectives I like to think of this as kind of training empathy so unconscious bias is as we've said by definition it's unconscious which means in order to alleviate it in order to reduce those biases and thereby kind of reducing the effect of them hopefully you kind of have to employ a little bit of subterfuge so these examples of kind of what's the content that you're consuming can you be intentional about that so that in your day-to-day life you are consuming more things and you are exposing yourself to more associations that are counter to perhaps the unconscious bias that you initially might have had based on all of sorts of life experiences that have led you to this point someone gave me a good example of a really great way to learn a language is yes you can go through your apps and you can read your books and you know listen to things you know classes go even to that country but one of the best ways to learn a language and to really inhabit that language is to consume media in that language so whether that's music whether that's you know videos movies television podcasts all of those things are attacking your subconscious and are giving you the opportunity to start to input all of that new data into your mind on a subconscious level so that's kind of the thing that we want to do with unconscious bias so paying attention to them and then kind of setting up safeguards for yourself an example here is when you're making decisions you know whether this is in the workplace in a hiring decision like earlier or a clinical decision-making process do we have a diverse range of voices at the table are we making sure that we're considering all of the implications of this decision from multiple different perspectives and that can be you know a diverse range of professions that can be a diverse range of just people with different life experiences but being intentional about the perspectives that you seek out knowing that you might have a tendency to think one way and there's a high probability that getting more perspectives in there can help you to make an a least a less biased decision or outcome I like to think of this too as this is of course an internal dialogue but can also be an external dialogue you know this is something that you can run by hey can you take a look at this hey what do you think about this I've been thinking about this in this way but I want to see you know what are your thoughts on that am I do think I'm missing something now that comes with the caveat that it is not the job of the people against whom you might have identified a personal unconscious bias to educate you about how to reduce that bias that is of course your job so it's not you know something that you're asking okay is this is this bias you know you are doing the work you're doing the research yourself but you're also respectfully finding ways to check yourself oh that got out of order this is a this is these are smaller examples and it kind of goes back to our beginning case that we talked about so as healthcare providers who are I think kind of the primary focus of this talk one way that you can take action in a very day-to-day kind of setting is in your medical documentation so we've seen that the language that we use in the medical record transmits bias how can we in you know just documenting your daily notes make change in that small way for example at Asos we talk a lot about patient identifiers and we want to have a patient first kind of language whenever we're talking in our videos and our practice questions that sort of thing so saying you know instead of saying a diabetic saying a person with diabetes it's like our original case a sickle cell patient versus a man with CLE cell disease putting that person back into the sentence an alcoholic versus a person with alcohol use disorder and then also in that subjective data when you are documenting a history you know things that language that assumes that the patient is telling the truth saying you know she says her pain is 10 out of 10 she has 10 out of 10 pain because that's fundamentally subjective she's the only one who gets to decide that so you don't need to add the additional qualifier that like oh well that's what she said and it's little tiny subtle things like that that can shift the perspective of a patient for when you hand that patient off to the next person in the shift to the next type of Provider who's even accessing their chart and all of those things are very important we have a lot more examples I don't want to take too much time because I want to make sure that I am leaving space for question but as far as inclusive language we have an inclusive language webinar that I completed a couple of years ago and we also have information on our amazing osmosis blog that you can check out more of these kind of specific examples of how can I in my day-to-day life with my medical documentation do little things to kind of be an advocate so coming back to the beginning we talked about the importance of approaching this topic with empathy and with humility and we sort of went through a visualization experiment where we potentially identified some of our own unconscious biases we talked about what those actually are we learned about different types of biases everything from the ones that we talk about quite often in our in our society right now to some of the ones that we don't talk about very often we also talked about some examples of the effects of unconscious bias which is really why we're here why this matters the reality is that these biases that we hold if we're not doing work to address them and to prevent their effects we are impacting the health of people and that's ultimately that that's why we're here that's why we do these jobs is we are trying to help people and recognizing that sometimes these things that you were not intending and probably are not even aware of can impact the health and therefore the lives of people so this is important and then we talked about you know taking some action both thinking about kind of internally how am I thinking about my own biases how am I going about identifying and then alleviating some of those is based on the content that I'm consuming in my life the research that I'm doing you know going in and doing tests like the IAT to identify and start to take action on your own and also thinking about some external things that you can do that helps prevent the transmission of bias to other people whether that is the language that you're using in your medical documentation or you know even in things of decision-making with team hiring that kind of thing being an advocate because you're recognizing the impact of bias both your own and that of people around you and you are becoming someone who is advocating for being mindful of that and making small and big changes to implement policies and procedures that can actually alleviate the impact and the effect of that unconscious bias on the health of the people that we care for that's all that I have thank you so much for coming thank you so much for your interest in this topic I we could we could go on and on this is a very rich and challenging topic to talk about again my name is Marina Horiates Kerekes you can find me on LinkedIn if you have questions or you want to email further discussion I love thinking about this I love talking about it I love learning about it I think that one of the biggest things for topics like this is to remember that we are all still students and that we're never going to know everything and so I am hoping to continue learning about this to continue sharing what I learn and I hope that you can do the same okay from here I'm going to stop sharing my screen and take a look at our chat to see what questions that we have see okay so our first question here is if you find yourself in a situation where you feel that the provider is exhibiting bias toward you good question how best can you frame The Narrative to diffuse it without further downgrading the level of care o wow that's a great question so I think that that goes back to kind of what we were saying at the beginning is that all of this I think that you know we can give people the benefit of the doubt I think approaching that kind of concern with humility and with empathy is a great way to get started on opening a conversation like that about kind of saying hey can we take a moment here's how I'm feeling here's what I'm perceiving in this interaction I know that probably isn't your intention because it's probably not but it's something that I don't know if you're aware of and just putting it in a non-confrontational way like that can be very helpful in terms of diffusing a really tense kind of thing to try to bring up with someone but doing it in an empathetic way of like hey I think we're missing each other can we can we take a pause and make sure that we're hearing each other and remaining kind of calm and empathetic and again giving that person the benefit of the doubt allows them to respond positively to that kind of confrontation if you will that would be my thoughts on that let's see what other questions do we have thank you for that question it's a really good one okay just scroll through all of these if you'll give me give me a moment okay another question here is what's the best way to convince senior doctors who adamantly believe that there are racial biological differences and the new native narrative is just political rhetoric yeah I've come across a lot of senior doctors who think that black people have thicker skin or that women exaggerate pain yeah lovely this is a really good question I my best advice I think is to be arming yourself with data because the data exists and I think that if you can come back and you have kind of articles in your back pocket I have a couple of those that I like to talk about when people ask me this question leaning on the objective data that has been extensively documented about this kind of thing and I think also again approaching with empathy and saying you know you know I know that we practice evidence-based medicine I know that following evidence is a priority and here's evidence that you know contradicts what you might be claiming there so I think arming yourself doing a lot of research ahead of time and continuing to learn about these topics on your own keeping that data in your back pocket so that you can come out and defend against some of these biased opinions is I think the best start to at least have some power there just coming through again I have to kind of keep scrolling I don't know what's happening to my scrolling okay question yeah this is a really good question so your content on unconscious bias for this webinar focused largely on race and ethnicity you are completely right disability is often left out of this conversation as such how can practitioners within Healthcare do a better job at recognizing ableist bias and meaningfully listening to patients individuals with bias with disability and conditions of Aging so that they receive high quality care and support yeah I think this is a fantastic example I think that but when I was designing this webinar you run the risk in something like this of covering everything and therefore nothing at all or trying to dive into a specific topic as a framework for how you can address multiple topics so I again will stress that there are so many different types of biases some of which we may not even be aware exist and something like disability is a huge one so thinking about you know both Health Care Providers with disability do we have unconscious bias against the ability of those healthcare providers to provide care and also on the other end of healthcare providers exhibiting bias against patients who are coming to them with various concerns and also have a visible or not visible disability or also you know you the question kind of puts Aging in there as well and that's I think an important and also sort of separate source of bias that I think is really important to talk about so I think that as far as how do we do a better job how do we recognize these things how do we take steps to ensure that you know the that bias is being mitigated in some way and that these folks are still receiving high quality Care again I think that doing the research learning about your own bias and also being an advocate what are small ways that you can share information in again kind of an empathetic and humble way about your experiences about your own knowledge because I think that we're all coming to this topic and we're all kind of coming from very different perspectives and I have found that the best way to convince others of perhaps a new opinion that they haven't thought of on their own is to meet them where they are and also recognize that these are people who went into Healthcare these are people who purportedly care about caring for people and so coming at those conversations from that lens of I know this is an important thing for you I know that you care about making sure that you're fully hearing your patience and you're not missing things have you considered you know XYZ based on and even that if that's something like debriefing if there's a patient interaction that you witness that might have had you know some just didn't sit right with you might have exhibited some kind of bias is that something that you can sit down afterwards if there if it doesn't appropriate or if you don't feel comfortable saying something in the moment is that something that you can pull the provider aside and say here are my thoughts this is something that landed with me I don't know if this is even something that you noticed but I just wonder have you thought about X and that I think applies for things like disability in particular because it's something that you know bringing up afterwards hey was that even a reasonable interaction and even during the interaction is that even a fair question to be asking are we assessing this full picture of this situation keeping in mind the disability that this person might have so that that kind of thing I'm a big fan of having those conversations and again doing as much as I can to read and read and learn constantly and then share those perspectives as I can okay let's see okay oh this is okay so this next question I am a faculty at a dental school hi welcome the students in one of my courses were required to do one of the Harvard I was too in mid school one of my first years how would you respond to students who say that incorporating conversations on bias is bringing politics into the classroom it's a good question it's a hard question we live in a world right now that is excruciatingly divided along really complicated political lines and unfortunately this this kind of question is common I think that when I am approached with a question like that again Healthcare is in some ways a helpful framework for starting those conversations for saying you know we're all we're all here for the same goal we're all here to take care of people and to provide people with care right so in doing that we also all recognize that evidence-based care is what is what this is all founded on we all agree that science moves us forward and provides the best care which is something that we care about because we are all here so I think that coming to that conversation with evidence as much evidence as you can pull to say look there are actual biological consequences of bias this is something that we have noticed differences in the care of people who otherwise there are no biological differences between that means this is impactful and this is important to talk about and it's our responsibility to make sure that we're considering all angles of factors that can be impacting the health of the patient in front of us so I think a reminder of what the goal is and a reference always to as much literature as you can find you know if that's specific I think specifics are always very help helpful so if that's specific to say a lecture that you might be giving in your dental program bringing examples from that is helpful you know again like I said you know I wasn't able to kind of get into full examples of everything so I kind of used the framework of that paper that goes through those examples of that one patient with sickle cell and the pain management and all of those kind of things but there are examples that abound and I just encourage you to continue reading continue learning and then bringing that as helpful evidence to kind of counter those points okay looks like we have two more questions before we close today so one is how do we reconcile what we've been taught with in terms of documentation in the medical record so we indicate what the patient says rather than what we surmise versus you know what you're talking about taking out the patient states language I think it depends on what you're talking about so for something like rating pain or describing where pain is none of those are things that you are going to surmise because they are fundamentally subjective and those are pieces of information that you have to get from the patient now of course if you have a patient who's not responsive you might be surmising where their pain is based on the physical exam but that's a different that's a different part of the documentation when we're talking about kind of that subjective data some of these things are just simply they are going to come from the patient she has 10 out of 10 pain so adding in that extra qualifier isn't actually necessary it's honestly just kind of extra words and brevity is the old wit so things like that I think I think that just thinking about specifically what you're talking about and is there is it important for me to add this extra context on whatever I'm reporting in the record is that important if not can I take it out is how I like to think about that because I know I know that the language that we are taught in medical documentation is very formulaic and pushing against that and normalizing other ways of documenting things is challenging but I just question at every turn is this necessary is this important for the care of this person and sometimes the answer is just no is how is how I would think about that okay last question here I find that the medical treatment I receive at a public New York City Hospital although rich in medical knowledge lacks logic and rationality when I question my doctors at that level they agree with me my concern is that as I think that might mean to say as a care member how to best present this experience with the general population how do how do you present that overall the populations that served there I'm not sure I think I might have missed a couple of words in in this so please if that was your question please go ahead and send that in the chat if there's anything that you want to clarify there if I'm not answering your question correctly but it seems that you know having conversations with providers and the care that is being provided or at least the care that is seems to be mandated to be provided sometimes just doesn't make a lot of sense and how do you disagree how do you question things how do you know advocate for different ways of thinking and different perspectives so I think that when I think about looking at kind of the way a provider might recommend an umbrella recommendation that maybe doesn't make sense for this specific person for example because that person you know may maybe the provider is recommending going for 20 minute walks daily and getting that kind of physical activity because it's good for your cardiovascular health that's true that that's definitely true that that would be good for your cardiovascular health however what if you have some disability that prohibits you from doing 20 minutes of walking per day that's something that you know being able to be flexible and being able to be empathetic and to push back and to say yeah but does that make sense in this case because I think we recognize in medicine that yes there are guidelines there are clinical trials that have very specific definitions of what they were applicable to and then we have a tendency to generalize them but recognizing that clinicians always think about individualizing their care sometimes times however they just need to be nudged in the right direction and so I think that you know making sure that we have all of the possible perspective represented at the table making sure that if you are someone who has a voice that isn't well represented in whatever Community that you are also figuring out ways to be an advocate to share your perspective what do that means writing an op-ed or you know having a conversation having a really simple debrief that doesn't call somebody out aggressively in front of a bunch of people because then that person is just more likely to go on the defensive but pulling someone aside and having an empathetic conversation can you do that can you share as you're kind of going along and noticing these irrational moments like that I think that's kind of what I would recommend but I don't know if I fully answered your question so if you want to throw more information in the chat feel free ?Music? okay how do I okay this is a good question that we can I think end on this last one is how do I as a future nurse hi congratulations welcome spread awareness of diversity equity and inclusion so your voice is an extremely powerful thing as you move through your training you will have more and more opportunities to use your voice and to use your power for all of those who may be coming up behind you or who you may find along the way who don't have a voice that is potentially as loud as yours can be for various reasons so I think that recognizing your own bias doing your own research and really thinking critically about your environment and what might be lacking and where your own perspectives might be lacking that's the first step of course but as far as being an advocate I think that coming up with specifics is always going to be very helpful so whether that's providing specifics on actual statistics on whatever thing that you're noticing needs to be looked at a little bit more critically or if that's being an advocate more broadly does that mean that you know you are attending seminars are you going to conferences on this kind of topics are you thinking about bringing these kind of concerns questions thoughts perspectives to the leadership of whatever position you're at whether that's you know as a nurse maybe that's bringing something to the charge nurse hey I I'm wondering how we think about XYZ when we have patients who present with this or if that's a higher level is that if that's within Clinic admins or Hospital Administration coming to those forums and speaking out when you feel comfortable and even if it's not speaking out in person can you write can you write and share your perspective all kinds of ways of just continuing to learn and then continuing to share I think that something that I am working on is recognizing that I'm never going to have all of the answers I'm never going to come to a talk like this and feel like an expert and feel 100,000% qualified to even be talking about this but the point is doing work and coming and starting the conversation sometimes speaking before maybe you feel 100% ready is a helpful thing that you can do because it brings people like all of you together in the chat asking these hard questions and reading these amazing links that are being shared from so many different people including Steph thank you I think that that is the point so as far as being an advocate yourself I recommend you know just kind of get out there and do the thing whether or not you feel whether or not you feel ready there's a there's a quote that I really love about speaking up always even if your voice is shaking so that's kind of what I the perspective that I come at this kind of thing with okay with that we are basically at time I want thank you all so much I know that you know a conversation a webinar presentation like this is a little bit self-selecting the people who are going to sign up for this kind of thing are probably the people who are already thinking about this kind of thing and are looking for ways of incorporating this information and perspectives into your lives already so I thank you for being one of those people who's already here and I want to encourage you know we all we all have different perspectives that are so immensely valuable and there aren't enough voices at the table most of the time so figuring out ways that you can be a voice but that you can approach things at osmosis we like to say start with the heart approach things with care and empathy is what I have found to be the best way of changing someone's mind or offering someone A New Perspective and getting things to meaningfully change at osmosis you know I've had conversations about how we approach a hiring process is it possible that this question leads to some bias it's little things like that of just making your voice known that is how we're going to step by step make important changes and continue on this journey that we've all started on so thank you really appreciate all of you and please feel free to contact me if you got more questions concerns feedback I'd love to hear it cool thank you helping current and future clinicians Focus learn retain and Thrive learn more