Messy moments: Unconscious racial bias

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You notice two attendings talking in the hallway of your practice. Rebecca Rice MD tells Anthea Wellstone MD, an African-American, that that she heard Wellstone telling a patient the wrong thing the wrong way.

“You should never tell a patient that you’re unsure of the diagnosis. You should never waffle with a patient. If you are unsure, tell them little or nothing. Go figure it out before saying anything.”

Wellstone responded - choosing her words carefully, talking slowly. She explained what she discussed with the patient and why. You sense Wellstone hesitating. She may be afraid.

As managing partner, what if anything do you want or need to do?

As head of your practice, you really want Wellstone in your practice. She gets great “patient experience” scores! She likely feels threatened here.

Race may be at play. Rice needs to understand how her words and tone affect others. They are particularly insidious if they come from unconscious bias.

Wellstone may feel unsafe. You know that psychological safety proves critical in medicine. Without it, people will not tell one another crucial information or possible errors. Psychological safety means everyone believes they can offer without worry about reprisal or humiliation. This conversation may silence Wellstone.

That jeopardizes patient safety.

Your job as leader is to pave a path for them to communicate constructively. You depend on their cooperation.

But you don't feel ready to handle race issues. You’re afraid anything you say will blow up your practice’s peaceful coexistence.

First, put yourself in Wellstone’s shoes. Rice criticized her. She may feel undermined or unsafe. Black clinicians constantly face seemingly small race-based insults. They attack MDs’ rank, skill and autonomy. It’s vital to preserve Wellstone’s right to speak with safety.

You want both physicians to feel valued, yet you fear that your words will upset someone.

Your Inner Game

Always when the situation is hot or saturated with emotions – attend to yourself.

How can you lower your own feeling of your leadership being threatened. It’s hard to respond wisely.

1. Breathe deeply and slowly 3 times. Focus your attention on where you touch the environment – feet on the floor, hands in your pockets, etc.
   1. Take your own temperature – including its intensity.
   2. Lower your own feeling of threat:
      1. Label the source of the threat you feel, perhaps to your rank
      2. Reduce the strength of that distress. Tell yourself a strength of who you are, what you offer:
         1. I’ll be kind to both of them,
         2. I’ll say I value each of them,
         3. I’ll be curious and ask them how they see things, or
         4. I’ll let them know I care that each of them feels safe
      3. How do you feel now?

Now decide your intentions for talking with each of them.

Lead to foster psychologically safety and belonging:

Arrange private meetings with each of them.

1. Attend to yourself. Prepare yourself with 3 slow deep breaths and the check-in above: How do you want to show up?
2. Attend to Wellstone:
   1. State your intentions: What do you want to offer or ask from Wellington?
      1. I value you in our practice. It’s important for you to feel safe fully participating knowing that fear of humiliation or reprisal.
   2. Ask: “I’d like to know what you experienced in your recent conversation with Rice about your patient. Please tell me about that.”
   3. Listen: Notice any emotions and their intensity.
   4. Acknowledge: Tell her what you’re understanding from her - “I’m hearing that you….” Ask if you ‘got’ it.
   5. Make it right: “I bet these kinds of things happen a lot.”
      “I want you to feel safe and to bring your best to your patients.”
      “I’ll speak with Rice so that she understands that we work together with respect and kind candor. All of us must support safety from reprisal so anyone can comment, question, even challenge. It’s critical for us to get all needed information for quality care. It’s important to me that we talk together knowing that we are all valued members of the practice. Our intentions, words, and tone must reflect that.”
   6. Make yourself her ally: “What can I do to enable you to feel safe in this practice?” Recap together her ideas. Ask her to choose the one most important to her. Then discuss how you might do that.
   7. Arrange to meet again in two weeks to discuss what has happened.
3. Enlist Rice in your safe culture wish:
   1. Aim to reduce the threat Rice likely feels.
      1. She may feel threatened by someone not in her “clan” (ie, very different from herself) or
      2. She may feel her autonomy is threatened if another way of handling patients takes over.
   2. State your intention for the conversation: your desire to learn what matters to her as a valued member of the practice and to state your expectations for everyone’s contribution.
   3. Ask: “What would you like to see in our practice to improve care of your and our patients?”
   4. Listen to learn what matters to her. Recap to her what you understood as her wish or concern.
   5. Reframe: articulate a mission or intention that all three of you share – Wellington, you and Rice. Use that frame for the rest of this and future conversations.
   6. Step into the other’s shoes. Ask: “What do you think Wellington wanted for her patient?” See if that offers Rice any insight. Then ask: “What do you think Wellington got from the hallway interaction with you about handling the diagnosis uncertainty?”
      1. Recap any insights Rice has.
      2. Tell her your expectations of Wellington, Rice and everyone in the practice:
         1. “We know uncertainty is a pervasive. It also makes physicians really uncomfortable!”
         2. “There are many ways of dealing with patients in uncertainty.”
         3. “Wellington may have felt threatened by your criticism. Research shows that Black physicians feel ‘hyper-scrutinized.’ They continually receive criticisms that judge them poorly in contrast to peers. They believe that people jump to judgment about them because they are Other. Wellington may have felt hurt or disrespected.”
         4. Say (if it’s true): “I want everyone here to feel part of the practice and valued for their contributions.”
   7. Ask: “How might you talk with Wellington about patient encounters without triggering a threat?”
      1. Recap her suggestions.
      2. Ask: “What one small thing will you try the next time you talk with her about her work?” Repeat it back to her.
4. Make yourself Rice’s ally too. Tell her you appreciate that she (Rice) cares about the practice. Tell her something you value about her contribution to welcoming, collegial conversations and relationships. Tell her you know she can do this new step to nurture safety for all.
   1. Ask: “How might I help you enjoy the practice?”
   2. Arrange to meet again in 2 weeks to see how she’s doing.

Benefits for you and your practice

• Reduce medical errors and near-misses. People afraid of being belittled or humiliated will “keep their heads down” and remain silent. It’s critical for everyone to be willing to speak up to perform well in an uncertain world.
• Improve the quality and consistency of care. Candid communications also improve patient safety, outcomes and staff commitment… because this enhances staff wellbeing.
• Gain better ways of doing things. When everyone feels safe reporting mistakes, it speeds up learning and innovation.
• Retain clinicians. Clinicians who feel valued in the practice tend to stay! This minimizes the disruption, difficulties, potential errors and huge costs of replacing them.

This is about who you want to be as a leader as well as what you want for your patients and staff.

• You clarify your expectations of behavior.
• You show them you value them and you see them as professionals with needs and aspirations who deserve respect.
• You bring them together despite differences in the intentions and values that you all share.
• You make it clear that fostering a culture of safety and respect is everyone’s job.
• You demonstrate how you can work together better.

It takes time and practice to communicate expectations and win staff commitment. And you’re trying to change perceptions about those who have been marginalized. Changing perceptions and behaviors is hard! Our brains like established habits, attitudes and thoughts and resist new approaches. After decades of stress, distrust and fear in medical workplaces, it’ll take repetition and time for people to trust you…and each other.

Small changes – no matter how small – can build the base for a safer environment. For example,

• Try out a short phrase or question that leads with curiosity and caring to use in hot moments – when it’s really difficult to know what to do. And carry it in your pocket
• Ask what matters to them and show you actually hear them
• Advertise widely that people can come talk with you any time they are unhappy about interactions or uncertain about productive next steps

I’d love to hear what you tried and how it worked. I always respond!

Nance.goldstein@post.harvard.edu

Nance Goldstein, MDc, ACC, PhD, partners with physicians as a leadership coach to find ways through today’s tough times and enjoy medicine more. She’d like to hear what troubles you in your practice.