Private session for the DEI Council of a medical group: Bias in Healthcare

NIH seminar July 7 2022

Ted x seminar August 19 2019 Transcript below.

St Scholastica October 22 2019 School of Sciences seminar series

TEDx Talk Transcript

90 years ago, my Canadian grandmother, Margaret – my namesake – was the only woman enrolled at the law school at the U of New Brunswick. She was made to sit outside classrooms and listen to lectures, from the hallway. 50 years ago, my mother, a rare woman pursuing a PhD in genetics at IU, encountered so many obstacles that she left the program.

My sister and I, not having learned the lesson, both achieved our PhD’s and became college professors in competitive, male dominated fields. We both faced more than our fair share of career hurdles – imagined violations of gender based expectations, hazing in school, failure to recognize our real accomplishments, l, and denial of tenure at our first faculty positions.

90 years ago, gender bias was conscious and visible and easy to fix. “Policy change – women can now sit in the classroom with the men.” Today, gender bias is unconscious and invisible, and practically impossible to fix because it’s easy to deny it even exists. But it definitely exists. The same resume is less likely to be considered qualified, if a woman’s name is at the top. The same online class, when taught by a hyp woman instead of a hyp man, generates worse student feedback. And, yes, women professors are less likely to achieve tenure, 25% less likely if you’re comparing women and men who are married with children.

The best way to achieve success in your career is to be rooted in a basis of respect and camaraderie that, frankly, white men are often able to assume, but which often elude the rest of us, #notallwhitemen #definitelynotmyhusband. Members of the transgender community see this clearly, as they are given continuous unearned deference as a man, but their competence is continuously questioned as a woman. I see this clearly, now that I have achieved a position where I am rooted and respected.

My current workplace, for me, is a breath of fresh air, a model of equality, and a stark contrast to every professional position I’ve previously held. I didn’t know what I was missing. My colleagues, men and women, work with me collaboratively, and this is the first place I’ve felt safe to make bold, creative choices. At a dept meeting two years ago, I suggested a curricular change that was, to my surprise, immediately embraced. It’s saving the college tens of thousands of $$ a year, this one idea, resolved an intractable staffing challenge for one dept, and elevated the learning outcomes of several other depts. Obviously, this was a good idea, but it took me probably a year to work up the courage to suggest it, because I’ve consistently struggled to be heard at other institutions.

So, what’s different at my current inst? How is it that my colleagues respect my voice? My theory? 15 People at this college are used to listening to women, because lots of powerful women are already working there. This organization has spent decades investing in the long game of creating a more diverse, inclusive workforce. Today, much of the leadership at the school; all of the academic deans; and fully half of the scientists and mathematicians are women – an increasingly important factor for getting women students through STEM programs.

Society is capable of overcoming its gender bias but it only happens with deliberate work, individual people seeing a problem and acting to overcome biases. I’m interested in that purpose and that action. I’m a neurobiologist, so I approach this from an anatomical perspective. Our conscious beliefs are contained in different areas of the brain than the parts where our unconscious behaviors are enacted. Sometimes, those conscious beliefs and unconscious behaviors don’t agree. Let’s take a look at the anatomy of bias, and the anatomy of deliberate effort that can effectively overcome that bias.

The massive structure on top of the human brain, the cerebrum, is where we engage in our highest level of thought, and especially in the cerebral cortex, a 1⁄2 cm of grey matter that coats the cerebrum like frosting. The cerebral cortex is divided up into functional areas, with each responsible for different functions of cognition – there are dozens of types of cognition that fit into three main categories.

The sensory cortex at the back of the brain processes sensation – vision coming back from the eyes, touch coming from the tips of the fingers up the spinal cord, and sound coming in from the ears. This is how we take in information about the world.

At the front of the brain is the prefrontal cortex, responsible for our highest levels of human thought – will power, personality, judgment, reason ... and conscious decision making.

The motor cortex is in the middle, responsible for motion, or movement. This sends info down the spinal cord, for example a command to wiggle your fingers. More than discrete movements though, the motor cortex is in charge of behavior – one way to define behavior is that it’s simply series of movements in a particular order and coordinated in a particular way. I am exhibiting a behavior right now – I am lecturing, and it’s all movement. I am gesticulating with my fingers, my eyes are moving around the room, and I’m moving my teeth, tongue, and lips to create words. Movements are the outward expression of my thoughts, the only way the world knows what’s going on in my brain. Some say, the only reason your brain exists is to move your body, to create behaviors. Sensory, prefrontal, and motor cortices. Information, decisions, behaviors. These areas are physically connected and so, are able to communicate with each other and with other areas of the brain. Now, this is a simplistic model. I describe the command of movement simplistically with a single arrow, when really it looks more like this. The motor cortex works in concert with many different parts of the brain to command behaviors. The physical structure of cognition is difficult to describe succinctly. But since the title of the talk is the anatomy of bias, I guess I’d better try. We want to understand the architecture of conscious beliefs and unconscious behaviors. The anatomy of conscious beliefs is hard to pinpoint - there are at least ten different philosophical models for consciousness alone. Your beliefs live somewhere in connections among the prefrontal cortex, the emotional centers in the medio-temporal lobe, other structures of the brain responsible for understanding past experiences, others responsible for future predictions, and also: the hormonal state of the body, and whatever is happening in the external environs. In short, it’s complicated.

Today, I am focused on unconscious behaviors, the structures of which are fairly well identified. The motor cortex works primarily with the basal ganglia, cerebellum, and thalamus, to create a type of memory called procedural, or skills-based, memory, the memory of tasks.

For example, you know how to button a shirt, and could easily think about something else while doing it. You are unconsciously, automatically buttoning the shirt, and demonstrating procedural memory. But buttoning a shirt is a specific series of actually pretty complicated movements, and if you’ve ever observed a child learning this behavior, they are consciously engaged. Behaviors are first consciously applied, usually involving heavy input from the prefrontal cortex, and then once part of your procedural memory, they can be carried out unconsciously. Do you pay attention to exactly how you push your foot into a shoe, take a bite of a sandwich, input your phone’s password or drive a car? Procedural memory is at work, all the time.

Now - You have to have some sensory input as well – It’s called sensorimotor integration because these two structures work so closely together. When you’re buttoning a shirt, you have to feel if you are dealing with a large button and a small button hole, so that you need to push a little harder to get the button through. When you’re driving, you have to be aware of the color of the stoplight or the sound of an ambulance. So the sensory cortex is always engaged, even in unconscious behavior.

But this procedural memory center can work against your best interests. You can absentmindedly enact a behavior you didn’t intend. Have you ever mistakenly grabbed the wrong set of keys, turned down the road toward your old house, even though you haven’t lived there in two years? When you were a kid, did your mom ever call you by your sibling’s name? When you were in the workplace, have you ever explained something to a woman who didn’t really need the explanation? I’ve certainly done that, and one particular example of this changed my whole outlook in the classroom. One day, my students were working in pairs on a task, reviewing a 20 step physiological process. I had printed out the steps and cut them into strips, and their job was to work with their partner to put the steps in order. After a few minutes, I walked up to a pair of male students. They had stopped talking and their papers were lined up. I didn’t even glance at their assignment. Check, activity complete. I then walked over to a pair of women, who were still talking, and began critiquing their work and fussing with their papers. One of the women called me out for my difference in treatment, pointed a finger at me and said, “You’re sexist!”

I was shocked! And the excuses came pouring out of me. Why, it had nothing to do with the fact that they were women! Their papers were a little messy, they were still talking, and honestly to me, they looked confused. But her words haunted me. Had I interpreted the women’s chattiness as incompetence? More troubling, had I interpreted the mens’ confidence as competence, giving them a pass they hadn’t earned? I realized that, yes, at least in that moment, I was sexist!

In student evaluations through the years, I sometimes got comments that I “played favorites”. But I didn’t know what the problem was, much less how to change it. So I clung to that specific example of my bias and was determined to learn from that painful interaction that day. Since that time, I’ve started implementing a system of equalizing my attention; spending the same amount of time with each group in paired review projects; having a conversation with each individual one of my 72/96 students each semester, and walking each to my office to make sure they know they can visit me there; students often don’t understand how office hours work, and access is important. Access may be the most important aspect of equity. I hope these conscious choices to be more deliberate in my interactions will help me learn to become more unconsciously fair-minded.

Learning creates physical changes in your brain called plasticity. The cerebral cortex contains about 16 bill neurons, which are interconnected via synapses. Synaptic plasticity occurs when molecular changes are made at these synapses, creating stronger connection, and allowing the cells to exchange information more freely. If you have enough inter- connecting cells that have strengthened their communication enough, a neural network forms devoted to that new piece of information. There’s a neural network in your motor cortex, or in your cortico-striatal-thalamo-cortical circuit, devoted to buttoning a shirt.

Have you noticed that younger people have an easier time learning things? It’s true, both of facts and of tasks! I’m 45, and it took me a solid week to learn the first step of juggling, a simple task of tossing a ball from one hand to the other with accuracy. My 10 year old son, Carter mastered this in an hour. There is a biological reason why adults take longer to learn or why old folks sometimes get set in their ways. Synaptic plasticity is mediated by an NMDA receptor, a protein which is comprised of four subunits, some of which are variable. More NR2B subunits make learning easier, and these are proportionally higher at a younger age. The famous Doogie mice, where the young NR2B subunits were genetically overexpressed, experienced enhanced learning capabilities throughout their lifetime.

While we’re on the topic of answering lofty questions with science, here’s a doozie. Why is it that a woman who encounters bias in her career, would turn around and treat other women with bias? This is likely due to cultural plasticity, the idea that embedding yourself in a culture and being barraged by constant, consistent messages, begins to effect implicit changes in your own behavior. Cultural plasticity is correlated with at least two physiological changes of the behavior center, the motor cortex. First, there are cells in the motor cortex that respond when witnessing other people enacting behaviors –it’s called mirroring behavior. Second, cross modal plasticity means that some level of learning can occur in two places at once. If a pianist hears a piece of music, the auditory area of the sensory cortex is activated, which would be expected– simultaneously, the motor cortex is activated – the musician is imagining playing the piece. With enough information causing changes to the sensory cortex, change occurs as well in the motor cortex, pretty much bypassing the conscious route through the PFC. This is cultural plasticity.

If you find yourself embedded in a community imbued with intolerance, a shortcut to bypass your cultural experiences is simple: choose more tolerant behavior and practice it, consciously. It’s the same as any conscious learning. A child learns to button a shirt by ... buttoning many shirts. My seven year old son Grayson learns a piece of music on the piano, not by hearing it, but by playing it repetitively. The doing, the movement, is important, if you want to cause plasticity and change the underlying neural networks of the motor cortex, thus changing your behavior.

So, how does bias play into all this? The brain absorbs information best when it is interesting or familiar. The activation of the fear center, the amygdala, or the reward center, the ventral tagmental area, either one will enhance plasticity. And, it’s easy to embed data in networks when similar connections already exist. In other words - if new information resonates with what you’ve already experienced, already believe to be true, or if it pings your emotions, you are more likely to remember it. It takes more effort to learn something outside your world view. It took me years to realize that my students’ concerns about my bias meant that I needed to take a hard look at my own behavior, and still longer to figure out how to start making change.

So, here’s my prescription for change. One, we must admit that we all exhibit biased behaviors sometimes, usually invisibly and unconsciously. Two, once one of those invisible biased behaviors pops up, you have to face up to your bias, no excuses. And you are unlikely to perceive it yourself, so this is where you need to listen to truth tellers – you might hate what they’re saying, but they’re not lying to you. Three, once you recognize that your behavior was biased, find a replacement behavior and practice it. Importantly, you must make yourself physically DO something. Reading books, going to seminars, simply thinking about bias, will only incrementally change your biased behaviors. You must act your way to true change.

Here’s an idea if you’re not sure where to start – do your part to help more women become rooted and respected. Amplify women’s voices in meetings; call it out, on the spot, if you see a woman condescended to, interrupted, or silenced. (And, in these situations, direct your comments to the interrupter – don’t direct advice to the woman – telling a woman to lean in puts the burden on her, and doesn’t make any sense unless the culture is ready for her.) Vote for women! March with women! Promote women! Hire women! Don’t talk about it, do it! Hiring practices matter, and even if you get mixed results at first – keep trying, the results will come. The dominance of US women’s soccer underscores the importance of Title IX, but that law was passed almost 50 years ago. In the major orchestras of the US, a decades long policy of blind auditions slowly improved the proportion of women from 6% to finally, now, about 50%. It takes patience to create a culture of inclusivity. And maybe, it takes policy change. But isn’t it worth it, to know your pool of talented people is including as many people as possible?

My mom, Anne, and my sister, Helen, are here today – two of the smartest people I know. But I wish my grandmother was still with us. I stand on her shoulders, a true pioneer of feminism. My grandmother was the first woman to pass the bar in the province of NB. But she never practiced law. Nobody would hire her. In her 80’s and 90’s when I knew her, she was smart and bold and funny and opinionated and brokered no nonsense. Who knows what ideas she had in her prime, that were never heard?

Imagine sitting outside a classroom, straining to listen, longing to contribute your voice to important discussions. In an allegorical sense, this is still the lot of many women to this day. We have an opportunity to improve that. We all carry on implicit behaviors, etched into our brains, that sometimes don’t correspond with our best intentions toward equality. But we can change our brains. When you purposely engage in actions to back up your highest beliefs – your conscious values and your unconscious behaviors will begin to align. Thank you.