Trainee Evaluations, Reviews, and Confidentiality: Framework to Mitigate Bias

To finish out this blog series on trainee review, confidentiality, and psychological safety, reviewing a framework to help all aspects of academic medicine mitigate bias in our work seemed fitting. Whether it be patient care or candidate selection, Dr. Quinn Capers, IV, Interventional Cardiologist, Professor at UT Southwestern, Vice Chair of Diversity and Equity, and previous transformational leader at the Ohio State University, has given us a robust framework to utilize that I believe easily extends to evaluations, reviews, promotions, extensions, probations, graduation, or non-renewal of contract.  You can read his article in depth here.

I will give you his framework below, but first, a few points about bias.

We all have biases – a preference for or against a person or group. Our brains like to make efficient use of patterns. We form automatic assumptions and categorizations of people based on repeated experiences, influences, and stimuli.

Explicit bias is when we are aware of our bias and choose to think or act in a way based on our prejudgment. Biases can exist in any categorization – such as the federally protected categories such as race and gender that we often think of, but they can also be toward other populations based on things such as size (thin or obese) or personality (outspoken or reserved).

I discussed this with friends last year and asked if they had any easily identifiable biases. One could only think of one characteristic – middle-aged women who color their hair in unnatural colors. She had much prejudgment about why they must choose to do so, and her automatic assumptions were all unflattering to the individuals. But, she was readily aware of the judgment and actively battled it. I have this reflex when it comes to men with heavily tattooed faces – again, it’s one I’m aware of, and I put effort into not accepting my assumptions.

Implicit bias is a positive or negative unconscious thought or act based on an unconscious prejudice.

I remember rounding on an inpatient with a team of residents in Alaska. When I exited the room of an older patient I had just met, I commented something to the effect, “That woman brings a smile to my face.” To which an astute intern, knowing I had recently moved up from Florida, said, “You think it’s her Southern drawl?” Huh, I thought; I hadn’t even realized she had one. But that was it. Her accent, age, and tone were automatically endearing to me and conjured up memories of my grandmother. I was unconsciously positively biased toward her.

Dr. Capers, among others, explains that good people can have an egalitarian view of humanity and still have an unconscious bias resulting in behavioral differences below our awareness level. Verna Myers, a Harvard-trained lawyer, author, and inclusion strategist, gave a TED talk that included her own example of implicit bias that she became aware of on a turbulent flight. Before that, she would have denied having such a bias because it went unnoticed. The key for us to grow and overcome is to uncover and spotlight unconscious preferences and work to treat people equitably.

Framework. So how do we apply this when working with evaluations, reviews, and recommendations for resident and fellow promotion? There are practical activities in addition to listening and reading about bias. We can actively identify what things may stir up bias within a residency training program that we can remove. Some programs have begun publishing resident classes with “Dr. XYZ” instead of “XYZ, MD, or DO.” Some programs leave the schools attended unlisted. These might not be welcomed or important where you are, but consider what may be important for your locale. Using the Implicit Bias Test and working through case studies regularly can help reduce unfair practices based on biases. In addition to those steps, Dr. Capers offers a framework involving four steps to mitigate implicit bias, proven in patient care and candidate selection. I believe we can apply that to the evaluation, review, and promotion process.

My take on applying Dr. Caper’s Four Tactics to our current topic:

1. Consider the Opposite – This counters both known biases and those we may not notice. Focus intentional awareness on your assumptions and judgments. Consider common prejudices, even the ones you feel you do not have (as in Verna Myers’s story – we are often blind to them). Then, think of what preferences or disinclinations you know you have. As you review a trainee, ask yourself, what about this individual that may trip you up?

With those in mind, actively look for evidence to the contrary. For example, do you know that a particular resident comes across as lazy and unmotivated? Actively look for proof that they are putting in effort and being proactive. Do you know you dislike “jocks” because they seem uninterested in intellectual pursuits? Where can you find evidence that this trainee, despite their love of sports, does take pleasure in intellect?

2. Common Identity – What can you find in common with each trainee you are evaluating or reviewing? Briefly review those. Maybe it’s a hobby, heritage, where they grew up, languages they speak, common areas of medical interest, faith, previous jobs, etc. Find something, and give it a little airtime in your mind.

3. Perspective Taking – Pause to consider what their lives may be like now and what they may have been like in the past. Our assumptions automatically prejudge, and considering what it may have been like for them can loosen some negative presumptions.

If they have well-known socialite or academic parents, it’s easy to think of the privilege they had. But think of the pressures they must have faced – whether exerted upon them overtly or internalized from signals growing up.

If the individual is from a marginalized group, imagine the distance traveled to get to where they are now. We want to counteract unconscious negative influences.

4. Counter Stereotypical Exemplars – This is where you review in your mind briefly someone of similar make-up, especially for the things that could trip you up, and remind yourself of those individuals who do not fit the stereotype. 

When reviewing an outspoken woman of color, you know there have been decades of your life where the stereotype has been an angry, black woman approached dismissively. Even if you feel like you admire such women and wouldn’t ‘fall prey’ to the existing biases, you need the counter. Because remember, we are not just trying to avoid conscious bias but implicit bias. Give airtime to reflect on someone you admire who could fit the description but who counters the stereotype - whether it’s Rosa Parks, Maya Angelou, Aretha Franklin, Condoleezza Rice, or Trudi Lebron (someone whom you should get to know if you’re elevating your organization’s culture in DEI/JEDI).

These four actions in the larger setting of reading/learning, self-testing, and keeping the issue of bias at the forefront of our evaluation process will help mitigate our unconscious biases. If done properly, this will NOT lead to unmerited evaluations or promotions. It’s going to make you more objective with the data that you have, both qualitative and quantitative.

5. What do they bring? After hearing how one of my friends, Dr. Ami Shah, a pediatric surgeon, and her group are approaching recruitment and interviews, I want to offer a fifth idea that can also be applicable. When Dr. Shah and her program interview, instead of asking the traditional “Are they a good fit?” they now ask, “What do they bring?” This goes back to being personally invested in that inclusion safety piece. And when using it in an evaluative and review process can add balance. They may have deficits. They may be below the bar. They may need remediation. AND, they may still add something to the program, the patient care, the team dynamics, etc. It won’t change what you recommend for them, but it will make sure you tell yourself and them a more complete story of the individual. Your interactions toward them and regarding them will be improved because of it.

I’d love to hear about your experiences, perspectives, and reflections on the topic. 

I look forward to exploring the next blog topic next week. Stay tuned!

Until then, Have a joy-filled week.  Tonya

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