Communication in Healthcare: Mindfulness: Mindfulness & Reflection, Implicit Bias

The Diagnostic Process: Step 5

*Explore Possible Diagnoses Using H&P Findings* (after talking w/ the pt) ×Look for clinical clues that point towards the MOST LIKELY Dx ×"Fingerprint" findings (exact - knowing only one or two things can cause a certain dx)

The Diagnostic Process: Step 2

*Frame the Differential Dx (DDx)* -Use a Problem-Specific Framework: Organize the possible diseases/conditions subcategories (Examples of problem-specific frameworks - anatomic, organ/body system, physiologic, pivotal points. *Start broad and work to narrow!*)

The Diagnostic Process: Step 1

*Identify the Problem* -You MUST be CERTAIN that you understand what the patient is telling you. ("I'm tired" - mentally, physically, emotionally, sleep-deprived? Have a precise handle on what the problem is)

Emotions

*LESS EXAMPLES* 1.Amusement 2.Anger 3.Contempt 4.Contentment 5.Disgust 6.Embarrassment 7.Excitement 8.Fear 9.Guilt 10.Pride in achievement 11.Relief 12.Sadness/distress 13.Satisfaction 14.Sensory pleasure 15.Shame

The Diagnostic Process: Step 4

*Limit the DDx* ×Tailor DDx using pivotal points to create a PATIENT SPECIFIC DDx (common dx in this group? Don't waste time or resources)

Feelings Starting with Letters A-D

*MORE EXAMPLES* ×Abandoned - Afraid - Aggravated - Agitated - Alienated - Alive - Alone - Amazed - Ambiguous - Ambivalent - Amused - Angry - Annoyed - Anxious - Appalled - Apprehensive - Ashamed - Astounded - Astonished - At ease - Awed - Awkward - Bad - Bashful - Betrayed - B!tchy - Bitter - Blamed - Blissful - Blocked - Blue - Bored - Bothered - Bugged - Bummed-out - Burdened - Calm - Captivated - Cautious - Challenged - Charmed - Cheated - Cheerful - Clever - Combative - Comfortable - Committed Compassionate - Cooncerned - Condemned - Confident - Conflicted - Confused - Consumed - Contented - Contrite - Controlled - Creative - Crummy - Crushed - Curious - Deceitful - Deceived - Defeated - Defiant - Degraded - Dejected - Delighted - Depressed - Despair - Destructive - Determined - Devastated - Different - Dirty - Disappointed - Discouraged - Disgusted - Disoriented - Dissatisfied - Distracted - Distraught - Distressed - Distrustful - Disturbed - Dominated - Doubtful - Down - Downtrodden - Drained - Driven - Dumb...........

The Diagnostic Process: Step 3

*Organize the DDx* ×Utilize pivotal points (list out, come up with a top 3)

The Diagnostic Process: Step 6

*Rank the DDx* -Possibilistic approach -Probabilistic approach -Prognostic approach -Pragmatic approach (By the end point, we shouldn't have more than 3 possible options!)

The Diagnostic Process: Step 8

*Re-Rank the DDx Based on New Data* (maybe we are right/close & need more labs and tests to confirm!)

The Diagnostic Process: Step 7

*Test Your Hypotheses* (Labs, imaging, testing)

The Diagnostic Process: Step 9

*Test the New Hypotheses* (w/ more supportive tests and labs)

2 Types of knowledge needed for clinical competence

1. "Tacit" knowledge (depends on experience, how we explain it) 2. "Explicit" knowledge (what can be easily explained, actual data)

Summary - "Unlearning" Implicit Bias

1.IDENTIFY your specific implicit biases --- When we fail to learn about our blind spots, we miss opportunities to avoid harm. 2.Practice MINDFULNESS 3.Be AWARE of patient groups at greater risk for implicit biases 4.LEARN about other groups of people to balance your similarity bias 5.RECOGNIZE implicit bias demonstration if it is happening around you ---- because IT IS happening all around you 6.Practice COUNTER-STEREOTYPING 7.Above all, be FAIR 8.Understand that this is a LIFE-LONG process

Empathy Skills: NURSE Technique

Naming Understanding Respecting Supporting Exploring

The EveryONE Project

Advancing Health Equity Through Family Medicine: -implicit bias training -practice leadership for health equity -assessment and action -community collaboration and advocacy

How Does Implicit Bias Operate in Healthcare?

Clinician & Patient (Prior Experiences & Implicit Bias) Leads To Attitudes & Behaviors Brought into the Clinical Encounter, Differential Treatment and Adherence, Differential Outcomes

Perspective-taking

Consider experiences from the point of view of the person being stereotyped. This can involve consuming media about those experiences, such as books or videos, and directly interacting with people from that group.

Availability Bias

Considering easily remembered diagnoses more like irrespective of prevalence

Reflective Questions

Designed to help clinicians doubt their initial impressions, disrupt habitual patterns of thought and behavior, see a familiar situation in a new way and discover the uniqueness of each situation "How might my prior experiences affect my actions with this patient?" "What am I assuming about this patient that may not be true?" What interfered with my ability to observe, be attentive or be respectful with this patient?" "Were there any points at which I wanted to end the visit prematurely?" "What would a trusted peer say about the way I managed this situation?" "Were there any points at which I felt judgmental about the patient - in a positive or negative way?"

Check your messaging

Embrace evidence-based statements that reduce implicit bias, such as welcoming and embracing multiculturalism.

Individuation

Evaluate people based on their personal characteristics rather than those affiliated with their group. This could include connecting over shared interests or backgrounds.

Introspection (Table Definition)

Explore and identify your own implicit biases by taking implicit association tests or through other means.

Representativeness Bias

Ignoring atypical features that are inconsistent with the favored diagnosis

Learn to slow down

Pause and reflect on your potential biases before interacting with people of certain groups to reduce reflexive reactions. This could include thinking about positive examples of that stereotyped group, such as celebrities or personal friends.

Take 2

Practice cultural humility, a lifelong process of critical self-reflection to readdress the power imbalances of the clinician-patient relationship.

Mindfulness (Table Definition)

Practice ways to reduce stress and increase mindfulness, such as meditation, yoga, or focused breathing.

Institutionalize fairness

Promote procedural change at the organizational level that moves toward a socially accountable health care system with the goal of health equity.

Base Rate Neglect Bias

Pursuing "zebras"

Confirmation Bias

Seeking data to confirm rather than refute the initial hypothesis -Only doing tests to rule in, not out

Premature Closure Bias

Stopping the diagnostic process too soon

Mindlessness & Delusion

The opposite of mindfulness

Mindfulness

focusing attention on your thoughts and feelings in the moment

Self-awareness

knowing your gifts, areas for improvement, assumptions, prejudices and biases

Habits of Mindful Practitioners: Presence

shut off your own mind and focus on the pt/client

Habits of Mindful Practitioners: Critical Curiosity

×A mindful clinician's response to the unexpected -willingness to learn

Habits of Mindful Practitioners: Beginner's Mind

×Being willing and able to see a familiar situation with new eyes, setting aside biases, categorizations and pre-conceived ideas -we see it differently than someone doing it for a while

Closed-Ended Data-Gathering Skills

×Closed-Ended Questions - primary use is to confirm or refute specific detail ×Types: ×Questions producing yes/no answers ×Questions producing brief answers ×Multiple choice questions -"Are you having diarrhea? How many episodes have you had today?"

Questioning & Relationship Building Skills

×Open-Ended Data-Gathering (get a better/bigger picture) ×Closed-Ended Data-Gathering (quick yes/no) ×Emotion Seeking ×Empathy Skills -"What brings you in today?"

General Communication Skills

×Self-awareness - know your limitations and seek counsel when needed (strengths, weaknesses, biases, & know when to ask for help!) ×Objectivity (describing the facts, not what we THINK about the facts) ×Interpretation vs Observation •Precision (make sure what we hear from the pt on what is going on; they will often use vague terms) •Sensitivity (RULE IN DX: all pt's w/ pneumonia will have a fever) & Specificity (RULE OUT DX: not all fevers mean you have pneumonia; test is not specific for pneumonia) •Reliability (make sure our interview and all tests done are reliable and consistent)

Habits of Mindful Practitioners: Attentive Observation

×The capacity to observe our own behavior while simultaneously being attentive to the patient

Implicit Bias

×Unconscious bias ×Implicit social cognition **×Attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.** -NOT intentional; stored info. based on past experiences (this is what the brain uses when it makes quick, rapid decisions) -can be unlearned, but difficult to do so

Clinicians are...

×vulnerable to errors in communication due to a lack of self-awareness

Implicit Bias Is Not:

•Always negative •Activated voluntarily or intentionally •Accessible through introspection •Always consistent or aligned with our declared beliefs •Always consistent with our own ingroups •Mutually exclusive •Something you should feel guilty about

The Diagnostic Process (Clinical Reasoning)

•Complex process •Diagnostic errors arise from: -Faulty knowledge -Faulty data gathering -Faulty information processing (Tunnel vision) •Dual Reasoning Processes (be aware of your biases in both) -System 1 reasoning (pattern recognition, looking for patterns to recognize the diseases w/ and remembering specific dx's) -System 2 reasoning (slower, specific analytics)

Empathy Skills

•Emotions maximize human communication and connection thus allowing for the development of the therapeutic relationship -Needs can be expressed through emotion as the only for of communication -Emotions are CENTRAL to effective decision making -Patients can express feelings verbally &/or emotions nonverbally or kinesthetically •Once you understand WHY the patient is feeling the way he/she is feeling you MUST then EXPRESS your understanding with verbal empathy •Empathy skills are ESSENTIAL for developing a positive clinician-patient relationship -Doing this shows you understand how they're feeling! -Pt's will often be closed off to HC workers who don't empathize with them

Open-Ended Data-Gathering Skills

•Encourages the patient to freely express what is on his/her mind -Non-focusing: patient alone decides what topics go "on the table" for discussion -Focusing: clinician picks things up "off the table" to learn more about them -"Can you tell me more about your family history?"

Bias Against People of Color in Healthcare

•Fewer prescriptions for pain medication •Fewer bypass surgeries •Less likely to receive kidney dialysis or transplants •More likely to undergo lower limb amputations for diabetes

Non-Verbal Communication

•Kinesics - movement •Proxemics - the space between patient and clinician •Paralanguage - pitch, tone & volume of speech (as well as the melody of your speech*) •Autonomic changes - physiologic changes caused by ANS -See blushing, hives, sweating, crying, etc.

Emotion Seeking

•Once the patient's symptom has been described in appropriate detail the clinician MUST focus on the IMPACT the symptom has on the patient's personal life • •The impact of the symptom will cause an emotional response from the patient. •This should prompt the clinician to respond with EMPATHY -Feelings, Ideas, Concerns, Impact, Expectations *-Patient-first verbiage!*

Implicit Bias Is:

•Pervasive •Predictive of behavior in the real world •Distinct from conscious stereotyping or prejudice •Expressed indirectly •Related but distinct from each other (some reinforce each other) •Malleable - can be unlearned •Hard to teach