Word choice matters

My last post talked about how failure to address our basic physiological and psychological needs can lead us (all of us) to less than ideal behavior.  At times, this failure can lead us to do things that we normally wouldn't do.  I used a few examples and provided a few studies (there are many more) that supports this assertion (see an additional one that even has a name for it - "the Valjean Effect" named after the main character in Victor Hugo's powerful story, Les Misérables).  I cited a recent study showing that residents who were experiencing burnout were more likely to demonstrate signs of implicit bias.  I probably need to better define "implicit bias" in more detail, so here I go.


I talked about this topic a few times in previous posts (see for example, Do we need a "National Women Physician's Day" - one year later" and A life of privilege - part III), but one of the most important topics in medicine today is the issue of implicit bias, defined by the Ohio State University's Kirwan Institute for the Study of Race and Ethnicity as the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.  The definition goes on - these biases are activated involuntarily and without an individual's awareness or intentional control.  Implicit bias is generally used in the context of gender, race, ethnicity, and sexual orientation. 


One of the best examples of implicit bias in regards to gender issues in medicine comes as a result of a study first published in the journal Critical Care Medicine ("Influence of Gender on the Performance of Cardiopulmonary Rescue Teams: A Randomized, Prospective Simulator Study").  In this case, I would argue that the study's conclusions were an example of explicit bias, but you can judge for yourself:


We found important gender differences, with female rescuers showing inferior cardiopulmonary resuscitation performance, which can partially be explained by fewer unsolicited cardiopulmonary resuscitation measures and inferior female leadership. Future education of rescuers should take gender differences into account.


The study has generated a number of editorials and at least one follow-up (and I would say a study with a much, much better design) study ("Female Physician Leadership During Cardiopulmonary Resuscitation Is Associated With Improved Patient Outcomes" with the exact opposite conclusion:


In contrast to data derived from a simulated setting with medical students, real life female physician leadership of cardiopulmonary resuscitation is not associated with inferior outcomes. Appropriately, trained physicians can lead high-quality cardiopulmonary resuscitation irrespective of gender.


However, as well-intentioned as the authors of the second study were in showing that female physicians can lead resuscitation teams and do a great job, the conclusion as written above (copied verbatim from the abstract) is a great example of implicit bias (credit some of my colleagues in pediatric critical care for pointing this out in a recent editorial).  Take a second look at the conclusion ("female physician leadership...is not associated with inferior outcomes") and contrast with the conclusion from the first study ("...with female rescuers showing inferior cardiopulmonary resuscitation performance, which can partially be explained by...inferior female leadership").  Can you see the difference? 


The first study clearly points out and emphasizes that outcomes from a cardiopulmonary resuscitation were worse when females led the team and that this was due to the fact that females were not as good at leading the team.  Conversely, the second study suggests that females might be just as good as males when leading resuscitation teams - at least they are not inferior.  Some experts would justify this working because this is how study results have to be interpreted with respect to study design and principles of evidence-based medicine.  I disagree - there is a clear difference in wording, and clearly implicit bias is playing a major role here.


Diversity and inclusion are important - I would even say the most important - issues for leaders to address today both inside and outside health care.  Diversity and inclusion doesn't happen on its own - it takes significant (and dare I say, explicit) effort.  However, study after study after study shows that diversity and inclusion pays significant dividends in the end.  Teams with inclusive leaders function much better than those without (see a great article in the Harvard Business Review here - credit my daughter for sending me this one).  So, how do you become an inclusive leader?  The authors of the aforementioned Harvard Business Review article conducted a survey of over 4,100 employees and asked them specifically about the behaviors and traits that separated inclusive leaders from those who are not.  Here were the six behaviors that inclusive leaders consistently demonstrated:


1. Visible commitment to diversity and inclusion (these leaders were authentic about their commitment to diversity and inclusion and clearly made diversity and inclusion a major priority).


2. Humility (There is nothing wrong with being confident, but it is also important for leaders to recognize that they don't know everything.  Part of being an inclusionary leader means being able to admit your mistakes, recognize that everyone has something to contribute, and learning from different perspectives).


3. Awareness of bias (This is a big one!  Inclusionary leaders are aware of implicit bias and take steps to eliminate them.  Recognizing the important link between addressing basic needs - there's Maslow's Hierarchy again - and implicit bias is clear here).


4. Curiosity about others (Inclusionary leaders seek out opportunities to learn and grow about different cultures, different perspectives, and different ways of approaching life in general).


5. Cultural intelligence is a natural consequence that follows from having a curiosity about others above.


6. Effective collaboration (Inclusionary leaders empower others, delegate often, and provide opportunities for professional growth and development).


Implicit bias is so prevalent in our world today.  It's just as important to address implicit bias as it is to address explicit bias.  Word choice matters.  Inclusionary leadership requires it.