Unconscious bias training module for panel members and their clinic staff

This training aims to increase awareness of unconscious bias so that panel members and their staff can provide a fair and inclusive immigration medical examination service to Immigration, Refugees and Citizenship Canada clients.

Transcript: “Unconscious bias training module for panel members and their clinic staff”

Video length: 32 min 47 sec

Narrator: Welcome to the Unconscious Bias Training module intended for panel members and clinic staff. This training is designed to promote an awareness of unconscious bias and how it can affect our thoughts, feelings and actions.

Throughout our history and still today, far too many people face inequity. The Migration Health Branch at Immigration, Refugees and Citizenship Canada is committed to minimizing bias in its health screening policies and program delivery, including during the immigration medical examination process.

Our call to action is to combat all forms of biases, discrimination and other barriers to inclusion. It is not sufficient to simply equip ourselves with knowledge and tools; we must take action in ways we know will be meaningful in addressing all barriers and disadvantages. Being a leader means taking an active role in ending all forms of discrimination and oppression, consciously and constantly challenging our own biases, and creating an environment in which our employees, clients and Canadians feel empowered and safe to speak up when they witness barriers to equity and inclusion. Inaction is not an option. We are counting on each and every one of you to help us achieve this goal.

By the end of this course, you will be able to

1. better understand what an unconscious bias is.
2. Understand how unconscious bias can impact your work as a health care professional.
3. And lastly, you will be able to develop strategies to tackle unconscious bias.

In order to achieve this goal, we first need to ask the question, what is bias? A bias is a subjective belief or assumption formed without reasonable justification, often based on a social stereotype, which influences the ability of an individual to evaluate a particular group of individuals or situation objectively and accurately. A bias can be positive or negative.

This leads us to another question: what is a stereotype? A stereotype is an oversimplified belief about a group of people, usually based on limited or incorrect information. It is an overgeneralization. Stereotyping happens when we think that all members of a group are the same. Often stereotypes are accepted as facts. However, we must allow for individuality among members of a group. We need to acknowledge that stereotypes may be incorrect and recognize that they may be harmful.

Can we have biases without even being aware of them? The answer is yes! There are 2 types of biases:

1. conscious biases (also known as explicit biases) and
2. unconscious biases (also known as implicit biases)

So, what is conscious bias? A conscious bias is the result of conscious thoughts. It occurs when we are aware that we are being biased and doing it intentionally. Section 1.2: Ethical conduct and conflicts of interest of the IRCC Panel Member’s Guide states that when you conduct an IME for a client, you must carry out your professional obligations with competence, integrity and loyalty. The principle of equal rights applies to all clients; each and every one must be treated with respect and dignity. Conscious biases can lead to actions that negatively impact clients. We ask that you always keep in mind the impact that a bias could have on IRCC clients. Conscious biases can be deliberately regulated. For this reason, conscious biases will not be explored further in this module, and we will focus on unconscious bias. Acting on bias may lead to discrimination. Discrimination is an action or a decision that treats a person or a group badly for personal characteristics which a person cannot change or are only changeable at an unacceptable cost to personal identity, such as race, age, gender, religion, sexual orientation and disability.

Next, let’s look at unconscious bias. Unconscious bias is an unfair belief, assumption or generalization about an individual or group of people based on personal characteristics that occurs without one’s knowledge. They are learned stereotypes that are unintentional and deeply ingrained. Unconscious biases are subtle, hidden, because they are activated automatically without being aware of them. Our unconscious biases are often incompatible with our conscious values. Because we are, by definition, unaware of our automatic, unconscious beliefs and attitudes, we believe we are acting in accordance with our conscious intentions. In fact, our unconscious bias is in the driver’s seat. It is possible for us to treat others unfairly even when we believe it is wrong to do so. Cognitive neuroscience research has taught us that most decisions we make, especially regarding people, are “alarmingly contaminated” by our biases. Our assessments of others are never as objective as we believe them to be. Unconscious biases cause us to make decisions that favour or exclude others. Similar to conscious biases, unconscious biases can lead to discrimination.

Where do unconscious biases come from? Everyone holds unconscious beliefs, as these biases stem from one’s tendency to organize social worlds by categorizing. The human brain is very good at capturing large amounts of information through media exposure, social media, lived experiences, and so forth. Given the infinite number of stimuli, it is almost impossible for our brain to take the time to digest and analyze all that information, so the brain will take shortcuts by sorting stimuli (for example, people, objects, experiences) into categories. When faced with situations or people, we use mental maps and patterns to classify them by making a number of automatic associations. Biases are shortcuts our brain forms based on our own culture, lived experiences, things other people tell us, institutional influences or other external influences such as the media.

How does unconscious bias work? Unconscious biases affect our judgment without us realizing it. For example, the tables displayed to the right appear to be different sizes. However, in reality, they are the same size. This is an example of how our brains form shortcuts, and how an unconscious bias occurs.

What do we know about unconscious biases?

• Unconscious biases operate outside of our awareness.
• Unconscious biases can be in direct contradiction with our beliefs and values.
• Unconscious biases are universal: everyone has unconscious biases.
• Unconscious biases influence all human interactions.
• And lastly, unconscious biases influence our actions, which can lead to discrimination.

Almost all of an individual’s characteristics can be subjected to bias, such as one’s ethnicity, gender identity, sexual orientation, disability, skin tone, language or religion. Can you think of other characteristics subject to bias?

In order to minimize the effect of our unconscious biases, we first need to be able to recognize them and then disconnect our automatic associations.

The next 2 sections will describe:

• how unconscious biases can impact us, and
• how unconscious biases can be shaped, and ways to minimize the impact of unconscious biases

Unconscious biases have real-world effects on behaviour and people around us. A substantial amount of research has been published demonstrating impact of unconscious bias in various domains, including health care. In a health care setting, unconscious assumptions could naturally seep into patient–provider communication. Let’s explore examples of unconscious bias in the health care setting and how it may shape your daily activities.

First, let’s look at gender bias. Gender bias is the tendency to favour one gender over another. In the context of the health care setting, biases about gender may affect how patients and their illnesses are treated. For example, studies have shown that pain is a field in medical care that is affected by gender bias. Women’s pain is not taken as seriously as men’s pain. Furthermore, a variety of examples have been presented in which men and women have been treated differently for the same disease, medically unmotivated. Note that gender is based on how someone identifies, while sex refers to biological characteristics, such as genitalia. People can have biases about both sex and gender. Canada protects the rights of an individual to identify in the gender of their choice and express their gender freely. As a panel member, you are required to show the same respect for IRCC clients. This includes using proper gender pronouns and preferred names when addressing a client.

Next, let’s look at age bias. Age bias is the tendency to favour people based on their age. Ageism is age-related bias, usually negative. It is often held against older people, but it can also occur with people in their younger years, teenagers and children. For example, a health care professional could believe that an elderly client may not understand, so turns their head away to talk to a family member, even if the client is completely aware and able to answer questions on their own.

The next example is racial bias. Racial biases are assumptions made solely on an individual’s race, colour or skin tone. It has been identified as one of the most common ways racialized people experience unequal treatment. There are many examples of subtle forms of racial biases, which have real consequences. In health care settings, this has negative consequences for patients, in some cases leading to lower standards of care for people of colour and individuals with darker skin tones. For example, a study suggests that physicians are less likely to diagnose alcohol addiction in Asian Americans compared to white people, even when they have the same symptoms. This may occur due to the “model minority” stereotype, which frames Asian Americans as successful and self-reliant. The implicit bias this creates may lead physicians to overlook signs that Asian American patients require help. Some minority groups are prone to experience more racial biases. As a panel member, you and everyone in your office are always expected to conduct yourself respectfully towards all clients, regardless of their race, nationality, ethnic origin, colour, skin tone, culture or religion.

Another type of bias is weight bias. Weight bias refers to negative attitudes and views about obesity and people with obesity. Studies suggest that health care professionals can view people with obesity as lazy, weak-willed, lacking self-control, unwilling to follow recommendations and unlikely to stick to treatments.

Health care professionals were also prone to attributing a person’s symptoms to their obesity. A health care professional may therefore recommend that a person lose weight rather than providing treatment for their condition.

Lastly, let’s look at culture bias. The socio-cultural environment we have been brought up in can greatly impact the way we think and act. Cultural bias is the interpretation of situations, actions or data based on the standards of one’s own culture. Cultural biases are grounded in the assumptions one might have due to the culture in which they were raised. For example, some cultures perceive certain hand gestures or prolonged eye contact as a sign of disrespect, but from other cultures, it is assumed that those who do not shake hands or look into someone’s eyes are being rude or evasive. Assumptions that one set of norms is correct may lead to cultural bias when interacting with people from a different culture. When conducting IMEs, you must be mindful of clients’ cultural practices. You should accommodate personal and cultural sensitivities.

Let’s reflect. Think about a particular person or situation and ask yourself these questions:

• What are my biases?
• Are my biases automatic thoughts?
• How do they make me feel?
• What will help me understand my biases?

Remember: having a bias towards someone means having a prejudice against this person. This does not automatically mean discrimination, but it can lead to it.

We ask that you remain aware of biases when conducting IMEs. Unconscious bias can occur at any time in the IME process, for example

• booking an appointment
• receiving the clients
• performing examinations
• grading the results or
• referring the client back to their usual physician

The following section will explore situational scenarios where unconscious biases could be at play.

A physician’s office welcomes 2 women. One of the women is a new client who is there for a check-up and the other woman is the chaperone. Here are some observations:

• The client is 30 years old, according to her intake paperwork.
• Both women have dark hair, but the chaperone’s hair is slightly greying and she has wrinkles on her face.
• The client nods but does not smile when the physician greets her.
• While making some small talk, the physician realized that the chaperone does not speak the dominant language fluently.
• The 2 women smile at each other following the chaperone’s comments.
• The chaperone puts her arm around the client’s shoulders as they sit next to each other on chairs in the exam room.

What unconscious assumptions might the physician or office staff make when observing the 2 women? In this scenario, 2 things may come to mind instantly. What possible assumptions were made when looking at this scenario? First, the relationship of mother and daughter could be assumed, because of the age difference, similar hair colour, and the physical gestures. Second, the older woman is not educated because she does not master the language. These unconscious leaps may affect behaviour towards the client. It is important to separate what is being interpreted versus what is being observed. Reflect on the following statements and identify the statements that are observations—that is, something a camera would capture.

• The client brought her mother with her.
• Two women came into the exam room together.
• Someone who speaks in a grammatically incorrect way isn’t very educated.
• The client is unfriendly.
• One woman put her arm around the other woman.

Now let’s look at the facts:

• The 2 women are spouses. As a couple, they have been together for 3 years.
• The chaperone earned her PhD in her country of origin. She has higher education.
• They recently moved to another country, where they have to learn a new language.

Incorrect assumptions may be hurtful to the client. The unconscious bias regarding the educational level of the chaperone may create an unwelcoming environment and make the client and chaperone feel excluded. This interaction also includes a bias based in heteronormativity.

Let’s look at another example. Two children arrive at a clinic for a medical appointment, accompanied by an adult. Here are some observations:

• The parent, Sam, has very short hair.
• Sam appears to be of African descent. So does one of the children, Emma.
• The other child, Justin, appears to be of European descent.

Reflect on the following statements and identify the statements that are observations—that is, something a camera would capture.

• A dad brought his daughter for their medical appointment.
• An adult and 2 children came into the office.
• A child brought her friend to her medical appointment.
• The adult has short hair.

When the panel physician sees the group, they first welcome the adult: “Hi sir, how are you doing today?” Then, they welcome the children by asking Emma, “Is this your friend?” Emma responds with exasperation: “No, Justin is my brother!” Remember, separate what you are interpreting versus what you are observing. We observed that an adult and 2 children came into the office, as well as that the adult has short hair.

Sam feels out of place because the physician addressed her as “sir”, which is not uncommon due to her short hair, but can be upsetting. Furthermore, the panel physician’s unconscious bias negates the diversity that families can embody. This could have been prevented by using neutral terms and open-ended questions.

Let’s look at one last example. A physician welcomes a client for a medical exam. Here are some observations:

• The client is 75 years old, according to his intake paperwork.
• While making some small talk, the panel physician realizes that the client is not well spoken.
• The physician conducts an assessment of cognitive functioning, as per usual. The client declines the assistance of a chaperone or translator to overcome the language barrier.
• The client receives a cognitive functioning score of 24/30.

Reflect on the following statements and identify the statements that are observations—that is, something a camera would capture.

• The client does not master the language.
• The cognitive functioning assessment results graded B is a result of client not mastering the language.
• The client is cognitively impaired.

Remember, separate what you are interpreting versus what you are observing.

We observed that the client does not master the language, but this is not indicative of his cognitive abilities. The physician’s unconscious bias may lead to an incorrect assessment. The physician should take into account mitigating factors such as the client’s educational attainment, literacy and cultural considerations while conducting the cognitive functioning assessment.

Unlearning our biases is a journey. If biases can be learned, they can be unlearned. Our unconscious biases tend to be ingrained. It takes some work to shape them, but it can be done through active reflection and practising inclusive behaviours. Now that we have seen how unconscious bias can affect our work, we should be eager to know how we can diminish its effects.

The next section focuses on things we can do every day to tackle unconscious bias.

Certain interventions can be used to address unconscious biases:

• Accept the existence of unconscious bias
• Hold ourselves accountable
• Hold others accountable
• Get to know others better
• Learn from mistakes

The camera exercise is a good way to stay aware of our thought processes. Let’s pause and examine our interpretations.

It is important to acknowledge and accept the existence of unconscious biases. Accept that everyone has unconscious biases, including ourselves. Bias is a normal part of human functioning, even among health care professionals. Furthermore, accept that biases influence our day-to-day interactions and can negatively impact the services provided to clients. Lastly, accept that there are solutions to address the complexities of unconscious bias.

What steps can we take to hold ourselves accountable?

• Be self-aware: Engage in self-reflection and self-assessment. Write a list of our beliefs that can lead to biased thoughts and behaviours toward others. Analyze biases to identify their source.
• Reflect on whether and how our beliefs negatively impact relationships with clients and their families. The key is to identify your unconscious biases and to make them conscious, so that you can change your thoughts and behaviours.
• Make a personal and professional commitment to combat those biases that compromise the care delivered to clients and their families.
• Participate in development and training opportunities about unconscious bias.

Once we reflect about our own biases, we look at how to hold those around us accountable. It is important to support one another in making better decisions. Call in people, not call out. This encourages people to learn more rather than alienating them. We are all responsible for preventing unconscious bias and for getting an understanding of what it is and how it affects our work.

Get to know others better. Incorporate cultural and linguistic competence in our work, especially when supporting diverse populations. Invest time getting to know people better and become curious about others’ perspectives. Learning about others and understanding their viewpoints will help you build respectful, stronger and safer relationships.

Learn from mistakes. Accept that we may occasionally fail to recognize unconscious bias. We are not bad people if we make a mistake. Putting too much focus on guilt and blame may interfere with our efforts to address unconscious bias. Apologize sincerely. But do not over apologize. Once, or maybe twice, is enough. We can focus our energy on intentional actions to recognize and combat your biases on a consistent basis.

Lastly, practise the camera exercise. Pause briefly throughout your day to try the camera exercise. This exercise will help you to differentiate between facts and assumptions in situations encountered. Pause and examine your assumptions. Perhaps ask a colleague, with whom you have a relationship of trust, to join you in this exercise. Catch and correct each other’s interpretations and help each other focus on facts.

The objective of this training was to increase your awareness and understanding of unconscious bias and to affirm the importance of providing our clients with the highest standard of service, exempt of bias and discrimination. We hope that this course has opened your mind to a new way of thinking. Thank you for your valuable contributions to our clients and IRCC’s mandate.