Implicit Bias and Its Impact in Geriatrics, Hospice and Palliative Care

Eric Widera:Welcome to the GeriPal Podcast. This is Eric Widera.

Alex Smith:This is Alex Smith.

Eric Widera:Alex, who is our guest today?

Alex Smith:Today our guest is Kim Curseen who is associate professor of internal medicine at Emory School of Medicine and Director of outpatient supportive and palliative care at Emory Healthcare. Kim, welcome to the GeriPal Podcast.

Kim Curseen:Hi, thank you for having me.

Eric Widera:We start off all these podcasts by a song request for Alex. Do you have a song?

Kim Curseen:Yes. I would like “Closer to Fine” by the Indigo Girls.

Alex sings “Closer to Fine” by the Indigo Girls.

Alex Smith:For the rest of the song, you’ve gotta listen to the end of the podcast. We said I’d try that in a lower octave because I have a little cold, but I ended up going for it. I think I got a few of the notes, here and there.

Eric Widera:Kim we invited you to join us on the GeriPal Podcast because I came upon a CAPC, Center to Advanced Palliative Care, post. Actually on their blog, palliativeinpractice.org, where you discuss implicit bias and its impact on palliative care. I was hoping that we could talk a little bit about that, both how it impacts palliative care, hospice and geriatrics. Thanks for joining us today.

Kim Curseen:Thank you. I appreciate it.

Eric Widera:Maybe we can actually take a step back. What is implicit bias? Is there an explicit bias? How should we be thinking about this?

Kim Curseen:The way I like to think about it, implicit bias is the subconscious thoughts that we have that actually influence our behavior and we do this all the time. We’re not completely conscious or behave in conscious ways about our environments. It’s that first reaction, that first thought or assessment that we make of a situation or a person, that informs the way we behave. The explicit bias is when we’re actually conscious of our assessment of a situation or of a person and then we behave based on what our preconceived notions are, or our thoughts. Everyone has implicit biases and they impact us all the time, 24 hours a day. It’s part of how we function in the world.

Eric Widera:Are there any clinical scenarios for our readers who tend to be sort of more clinically minded, that you come to mind where this has been an issue?

Kim Curseen:Well, you think specifically about your older population. I think it happens all the time. You know you walk into the room and you see a patient and their child, and the natural tendency is to talk to the child. Even though you don’t mean to, you kind of talk to the patient like, “Hi, how are you?”, and then once you get into the meat of the conversation, instead of having this sort of triad conversation, you end up having this diad conversation and the patient’s sort of left out and you don’t mean to, you just assume or you make assumptions about, just subconsciously. If you have a husband and wife there, and maybe they’re an older couple that you end up talking to the man or directing your conversation and you have to be very mindful not to do that.

I said in the blog that I work with a really great male nurse and often when I walk in the room with him, the patients look at him and I see this like fight, they’re like, “Why am I looking at him? She’s the doctor.” They’ll even say, “You’re the doctor.” These are just the things that happen throughout the day that if you’re not kind of mindful of them, impact the way we communicate with patients, cause us sometimes to miss critical points.

Alex Smith: There are all sorts of implicit biases, right? I’ve taken the implicit bias test.

Eric Widera:There’s a test?

Alex Smith:There’s a test. Kim, could you tell us about the test?

Eric Widera:Is it something you pass?

Alex Smith:Right.

Kim Curseen:No, there are lots of different tests for implicit bias, but the test basically asks you series of questions and I’m not sure which test you actually took, Alex.

Alex Smith:I took the one out of Harvard where you have, you hit one key on one side of the keyboard and one key on the other side of the keyboard, associated with an image on the screen. For example, I most recently took the one about young and old people, and it would be young and good on one side of the screen, and old and bad on the other side of the screen. Then you cycle through words that were meant to either good or bad, and then they’d flip them so that you’d have the young and bad, and old and good sort of words together, and they time your reaction between seeing the image and inputting the correct key. It was more, I have to say, I’m in the vision of geriatrics here. I had a strong preference for young people, which conversely stated is a strong preference against old people.

Kim Curseen:Well, that goes along with our culture. I mean that’s what you’re taught, that’s what you’re ingrained with. We to start people got to know the white coat isn’t magical. There’s nothing magical in being geriatrician or palliative care doctor who really feels very important about patient centric care and advocating for your patients so that’s what you do. Your implicit bias is kind of there so you can think what you like and feel the way you like, but it matters how you translate it into what you do. If you recognize that, that’s the case, then you do things very deliberately to try to overcome those biases. You recognize when maybe you are talking to the patient’s family versus the patient. You recognize your feelings about going into a room maybe with a frail elder that’s not able to talk and how you’re going to manage them or how engage or how much you actually try to engage that person in the conversation. We all have these things and the question is, now that we have them, what do we do about it?

Alex Smith:Right. Right, so much of it is about, in taking this test, we were joking early about can you pass? Like I failed, but the point of the test isn’t pass or fail and it’s not passing judgment on you. It’s really about, I think a lot of this is about, isn’t it about the sort of the environment in which you grow up in and the fact that we pick up all of this sort of cultural residue, which imparts a bias in us against old people and in favor of young people because we’re constantly bombarded with messages that youth is desirable and good, and aging is to be avoided and bad, and that seeps into our subconscious and it comes out and can be actually demonstrated via this test, but it’s not anything that like I should, I get an F for.

Kim Curseen:I mean, it just tells you what it is and so there’s no way for you to ever address anything if you’re not quite sure where you are. Participating in test like that should be a tool for self reflection and you can see, “This is my unconscious bias, so how is that manifesting in my practice or even is it manifesting in my practice? And then what are those deliberate behaviors I can employ to make sure whatever my unconscious bias is isn’t filtering down into my practice and getting in between me and good care plans.”

Alex Smith:I think it’s really common sense that the first step would be awareness of implicit bias. That makes sense.

Eric Widera:Let me ask you about the first step then is. The first step is awareness. What are the common implicit biases that I should be thinking about to be aware from, because I can imagine there, there’s a lot.

Alex Smith:Right, in particular, there are clinical care in geriatrics and palliative care.

Kim Curseen:Sure. Again if you’re helping to work with the population that of course, the larger ones that are different in ethnicity, financial, educational, personal background, religion, political, all of these things that make up all that patients that we’re seeing and because when patients come to the office, we in geriatrics and palliative care, a lot of what we do is talking, sort of getting to know people. As you’re getting to know people, they’re not just sticking to their disease states. They’re letting you into different aspects of their life. If you have a patient that comes in maybe and they are dressed what we would consider shabbily or they come and they have a history of drug abuse or alcohol abuse, or they come and express views, political views. That happens quite a bit in my clinic, about what’s going on in the world because they’re talking to their provider, they feel free to talk to you.

All of those things, we’re developing a natural dialogue so if you’re aware, you understand yourself and you spend some time trying to figure out, what are the things that trouble me? What are the things that are keeping me? When a patient says this or they look this way, what are my responses? We all have those things like there, I always lack because what bothers somebody doesn’t bother another person and even your most wonderful accepting people have that thing, we all have that thing that we have a difficult time abiding. All have that thing that strikes us at our very core whether we are aware of it or not.

Alex Smith:The first step is awareness. Now after awareness, we can try and overcome our implicit biases because we want to strive to overcome them. We believe that we should be treating old and young people similarly. We believe that we should be treating men and women similarly. We should believe we should be treating people of different ethnic, religious backgrounds similarly. Is there any evidence to show that being aware and attempting to overcome it, is effective? In other words.

Kim Curseen:Yes.

Alex Smith:Yeah.

Kim Curseen:There are signs that show that once physicians and healthcare providers are made aware of their biases, that they have the ability to change them. That’s the beautiful thing about in implicit bias, that you can, if you are made aware of it, that gives you the opportunity to employ techniques to change it. There’s this really wonderful test that showed people pictures of African-Americans and when Caucasian people first looked at these pictures, they all looked the same, had very difficult time trying to distinguish, but being shown the pictures repeatedly, they were able to start to pick out specific characteristics. Then it became more personal and so by the end of the exercise, I was able to show that in the beginning, everybody sort of looked the same. By the end of the exercise with repeated exposure with the person actually being aware, they were actually able to make distinctions and it seemed more personal so the idea who you setup the idea of being area, that this could be an issue, gives you the ability to transform and change. When people are doing diversity training or implicit bias testing, that’s the basis.

Eric Widera:As providers, I’m going to give an example. I’ll give an example on a far spectrum. Somebody walks in and let’s say it’s a patient I’m caring for on our palliative care service and they have a tattoo of a swastika on their shoulder.

Kim Curseen:Yes.

Eric Widera:I will have an implicit bias right there automatically the second I see it.

Alex Smith:You might have an explicit bias.

Eric Widera:I will have both the implicit and explicit bias. How should I react to that? I’m going to have an emotion, and that’s probably in the color how I think about this person.

Kim Curseen:Yeah, actually you’re a human being. You get to have those emotions so what I think is really important is to be mindful of it. What are you really upset about, because you walk in, you see the swastika on the patient and do you know at what point in their lives did they got it? What do you actually really know about that patient other than that you see that there? We actually don’t so what we’re reacting to is how that makes us feel. As an African-American woman, if I see that, then that brings up issues of fear and anger and frustration, until I have all of these emotions that have a lot to do with me, but not so much to do with them.

Once I’m able to recognize them, I’m able to recognize, “Okay, this is my issue and I’m okay to feel like this so am I going to be able to do what I need to do?”, because once you’re able to name it, then you’re able to compartmentalize it and say, “You know what, this is how I feel so I’m going to need to pay in order to take care of them.” I’m going to need to, instead of relying on my natural communication style and the natural, the things that are actually warm- warm and fuzzy and, that’s not going to be automatic so I’m going to have to be very deliberate in my behavior. Deliberate in my questions about asking about concerns, deliberate in my body language and being very aware of myself when I’m talking to this individual to then try to do some perspective taking about figuring it, well, what actually is the story. If I walk in the room, you have a Swastika on your arm, they don’t get up and leave, then maybe things are all right. Maybe that was a time in their life that they regret. Maybe they actually feel that way but they’re in trouble now.

Am I going to be able to do this? Then I also have to be very honest with myself. If I cannot do this, then I need to own that too and be able to get them to a person who can, but none of that happens unless I do the work upfront. I’m realizing number one, what’s tattooed on their arm is what’s tattooed on their arm but what I’m going to through is my issue and has something to do with me, and I need to work that out because that patient can’t work that out right then. Does that make sense?

Eric Widera:Yeah.

Alex Smith:I think it pushes it to yet another level when they make racist comments towards a physician that changes the stakes because then you’re not talking about, it’s not less of a question about, “Well, you know, is it possible that they regret having this tattoo? Was it a mistake? Was it done on a dare?”, whatever, to okay, now this person is really into it and they clearly believe or clearly stating sort of aggressive racist language. Anyway, we digress.

Kim Curseen:You know, but that brings up a very good point and say, like love gum palliative care, not palliative care for super awesome people or palliative care for non-racist people.

Alex Smith:Right.

Kim Curseen:I mean everybody gets this. The qualifications about who the character or the person isn’t in the definition and there’s a lot of time to work out, a lot of time for social injustice, but we’re in a different sphere. Not here, not here, this is the time in people’s lives, depending on where they are that they get care regardless of their background so I kind of think about it everybody walks in clean and you get to have this because you’re a person that exist. That’s the qualification and that’s how I’ve been able to sort of navigate it and get through it because I’d be honest with you, I’ve heard some stuff over the years, I continue to.

Eric Widera:Yeah, so we talked earlier about how culture influences like our implicit biases around age, gender, race. I’m just thinking about research publications that come out, like African-American’s use less hospice care at the end of life and how those publications also potentially influence how I think about a particular group like African-Americans and hospice use. How should I be incorporating that information and thinking about it when I meet individuals of particular groups?

Kim Curseen:Now that’s a really great question. Yeah, you watch things like on CNN and it’s like, “Oh, African-Americans love Cheetos.”, and I’m like, “Oh, gosh, I love Cheetos, I didn’t know that.”, like I’ve been, I know, I go to these lectures and I’m taking notes. I’m like, “Dang, is that what we believe? I did not, nobody told me that in the meeting.”

Eric Widera:I like Cheetos.

Kim Curseen:The larger point is that those studies are trying to help us with cultural competence so giving you maybe some background and the way you should think about them is that when you are interacting with people and you’re getting to your block points and you’re trying to figure out, well, why is it like that? What is it? What sort of the disconnect? What could be the reasoning? How might they be sort of working through these problems when you’re thinking about populations and how to develop educational materials. Things kind of on a macro level, how do you develop services that are going to really serve a community? However, when you get down to person to person, then cultural competence may not be as helpful as something called cultural humility. Cultural humility is the ability to meet another person and despite all the things that you heard, still be able to be open to allowing them to tell their own story and allowing them to define themselves in the way in which they define themselves.

I always use an example, me and my cousin. When you think about how I define myself, if you ask me, “Kim, what are the three things that make you, you?” I’ll probably say, doctor, service and probably now mom, but I might have said African-American.

Eric Widera:I thought you were going to say podcaster.

Kim Curseen:Not podcaster. If you ask my cousin who, we were raised very similarly, she might say Native American, because we belong, we have family that belongs to a tribe and no, I define myself as African American. She defines herself as Native American. She might say, writer or mystic. All the things that are kind of important to her, but we’re both raised the same way so if you come and talk to me and you assume that we think the same way, there are going to be barriers kind of in the way and way we relate. If I’m seeing myself first as a doctor and you’re talking to me about end of life issues, I probably want to know what the statistics are, right? That matters to me. How was this working, and that’s the conversation you could have, the sort of medical detailed conversation about the pros and con, and I might make my decision that way.

If you talk to my cousin and you start talking to her about the pros and cons, she’s like, “No, the universe is going to take care of it. No, I understand what you’re saying, but it’s very important to me to do it this way. All the medical information, the world, not going to make a doggone difference.”, because that’s not the way she defines herself. Then, oh, my gosh, if you start talking about just deviant and maybe there’s a mistrust. That’s a reason why she wants you to do everything then you’ve really missed the boat because she doesn’t even define herself as African-American, but we’re very close. This happens a lot with religion. All kinds of things.

I always laugh, if you speak to my brother, my younger brother in Ebonics, you’re the coolest person alive. You speak to my other brother, he’s offended. The question is, we can all be, even people who look like you. People in your neighborhood. It depends where we belong to a lot of different cultures and a lot of different groups and throughout our lives. The importance of these things shift and change, and even when we’re stressed, how we might define ourselves when we are well, what’s important to us when we’re well like maybe logic and science and money and status, and then you get sick. Then maybe religion and spirituality is more important. The conversation shifts and the way that person that you’ve been taking care of all this time, is now making decisions that you don’t understand. You don’t understand them because we’re being competent and be culturally competent, this is how they should make it according to the book of, their book of ethnicity.

I read the chart and that’s how they should do it, but right now, they are defining themselves differently. Their ethnicity is moved down and something else has taken its place and the only way you’re going to know that is by talking and asking questions and being open, to recognizing that you don’t know everything about a culture, how somebody even views it. Even people within the same culture or the same religion or the same political views, hear things from the pulpit or read their topics and interpret them slightly differently because they have different meaning. One thing I think is really important that sometimes people will use the different cultures or the different way they identify themselves, just sort of cope with situations. We sometimes think that here’s the culture and then you’re going to behave the way because of the culture versus this is how I feel. Now I’m going to take my culture and wrap my culture around that to help me deal with what I’m feeling at the time. Do you guys have time for a quick story?

Alex Smith:Yeah.

Eric Widera:Yeah.

Alex Smith:Tell us a story, Kim.

Kim Curseen:This is one of my favorite of all times because I learned a lot, that he was taking care of a Muslim family from Yemen and the father had Jakob-Creutzfeldt Disease and it was moving very, very fast and the hospital was amazing. They allowed him to stay in the hospital. They took great care. They didn’t want to rush the family but it was clear that he was declining and that we were not, this was going to, we were not going to be able to save his life and everybody desperately wanted. This is three months in the hospital. Everybody desperately wanted to make him comfortable. People were worried that he was suffering. The hospital had been very lenient because they were trying to be respectful so they had, finally we were going to have this big family meeting. The wife kept saying, “No, we need to keep going. I don’t want him to leave.” Even her children were saying, “Mom, maybe we should.”, and she’s like, “No, no, no.”

They got an imam to come and very prominent person in the Muslim community to come into this family meeting with his wife and his sons and the imam said to her, “It’s okay. I think we should make him comfortable.” I mean you would have to see what we were looking at, and everybody was just assuming that she was going to say, “Yes, okay then it’s fine. I’ve heard from my religious leaders. I’ve heard from the men in my community. My son believes this.” Do you know what she said?

Alex Smith:What did she say?

Kim Curseen:She said no. She sat there and listened, because that was not the point. The point was, and we had been listening, was that was her husband and they’d been married over 50 years and she didn’t know what she was going to do without him and she wasn’t ready. When she was ready, then we took him home with hospice and it wasn’t until then. You know, that’s a basic thing that we all kind of understood but we functioned on and we behaved as if that the only thing she was was a Muslim woman and we forgot that yeah, she’s a Muslim woman but she’s also a wife and she’s also a mother and she wasn’t ready to lose the love of her life.

Eric Widera: What do you think we could do as geriatricians, palliative care, hospice providers to actually make sure that we have room to talk about all those things that influence how they make decisions, all those things that they care deeply about?

Kim Curseen:The biggest thing is to ask and when we were doing the social history, when you first meet somebody, the beautiful thing about doing outpatient is that you end up, you have time and you have time to get to know people so when you are discussing all their medical issues, finding out, “Tell me about yourself. If you were feeling better, what would you be doing?” All the things you can learn in palliative care, geriatrics to ask what’s important to you but in a conversation away, you share the pictures, you learn about the children, you ask about the family. You ask, you make a concerted effort to find out who they are but the deal is you also have to show a little bit of yourself as well. We work really, really hard in medicine to kind of come up with checklists and protocol and if we come up with the right checklist, this is all I’m going to do well, but the true magic I think in palliative care and in geriatric care is really the care. What people are responding to is at the end of the day, it’s just two people in the room and they need help and you’ve got help and it’s a relationship.

If you’re going to approach it that way, it gives you valuable information about the person. When you’re not sure, ask. Hey, you’re deciding to do this. Help me understand why.

Eric Widera:Right, don’t assume.

Kim Curseen:Right, and when you ask that question and then usually I say, “You know what, please help me understand why because I want to support you and if this is how it has to be, I’m never going to lie to you if I don’t think it’s a great idea but at the end of the day, I’m here to help you reach your goal whatever that goal is.” Sometimes, I say, “I’m down.”, depending on who I’m talking to but that’s really what it is to create a relationship. They know that push comes to shove, you have their back whether they choose what you want or not. You’re willing, you’re open to it. It doesn’t mean you have to agree, but you would have, if you’re going to practice this kind of medicine and be true to what you say you are, you have to be willing to practice when it’s easy and when it’s more difficult, when it goes against your grain sometimes and if a person’s a lot, or how you want it to be.

Eric Widera:I can imagine in the case that you described is sometimes just asking how does your religion make you think about your husband’s care or what you should get? Just throwing out a tester.

Kim Curseen:Yeah, and people will answer you. One thing people love to do is talk about themselves. If you are sincere and authentic and you are asking, they’ll tell you.

Alex Smith:Yeah, and curious.

Kim Curseen:Yeah.

Alex Smith:I got one last question for you. What you told us to do a thing about implicit bias, like being mindful of it, naming it, working kind of through how you want to respond, it feels like a lot of work too. Do you have a ritual or something that you do before you go into a patient’s room to help you remind yourself to kind of do that work?

Kim Curseen:Yeah, yeah. Right before I’m able to go into a patient’s room, especially if I’m worried that maybe it might be somebody that pushes some internal buttons because of my own baggage, I’ll often stop and take stock of how I’m feeling and all the things in my head I want to say, I say them. Outside, I look really quite calm but I’m saying this, I’m actually arguing, I’m definitely down and I get all that out. Then I take a few seconds to know, to think about what am I really mad at and I think that’s really important. You do have to take a minute to sort of get your mind right, “What am I really upset about?” If I can’t walk in the room, then I don’t walk in the room right then. That’s hard because we all have time pressures, but if you take all that in there with you and it goes wrong, you know how hard it is to sort of in our profession to kind of recover from that if the interaction was bad.

I do that. When I’m actually inside of the room, I spend a good portion, a lot of time and energy in being very aware of my body and my body language, so if my inclination is to pull back, I actually lean forward. All the opposite things that I’m to do, like I’m in Bizzaro World, I end up doing the opposite. One of the things I like to do is if I’m really uncomfortable, I’ll sit but I’ll put my hands under my thighs and I can gauge that when they’re starting to say something and I’m about to pull back, I can feel the pressure and that tells me to move forward.

It sounds like it’s a lot of prep work but for me, it allows me to be conscious and aware and I’m constantly checking. I’m checking and I’m going through, almost like going back to palliative care one on one, do this, are you doing this, are you doing that. After a while, if the behavior’s deliberate, then I can start to relax. The other thing, the mental exercises, what is the thing we have in common. You’re about to walk into a room, what is the thing we have in common? I know. We all want, who’s ever in the bed or who’s ever sat in the chair to feel better. Okay, so we have something in common.

Now we may not agree with how to get there but we got that in common. If you’re there working for that purpose and I’m working for that purpose, there has to be a middle ground. There has to be a middle ground and that allows me to open my mind. If I walk in there with an agenda that it has to be a certain way, it fails, but if I walk in with an open mind that we have to get somewhere and I’m willing to give, and it’s a negotiation and it’s a partnership, then all that pressure that I feel to get them to my side, all that kind of goes away and now, I’m aligned with the patient or the family to reach a purpose.

It doesn’t have to be my way but it has to be a way and then make the decision. Whatever that way is, then we’re invested and no matter what it is, we’re going to do what we can to make it work.

Eric Widera: Well, I want to really thank you for joining us today.

Alex Smith:Thank you so much, Kim.

Eric Widera:I encourage our readers, go to the CAPC palliativeinpractice.org website to read a little bit more. We have some other great stories and tips on that blog site. Alex, do you want to finish this off with a little song?

Alex Smith:Let’s do it.

Eric Widera:Okay.

Alex sings ìCloser to Fineî by the Indigo Girls.

Kim Curseen:That was great.