HLOL Podcast Transcripts

Health Literacy

Implicit Bias: A Factor in Health Communication (HLOL #146)

Helen Osborne: Welcome to Health Literacy Out Loud. I’m Helen Osborne, President of Health Literacy Consulting, founder of Health Literacy Month and your host of Health Literacy Out Loud, albeit with a bit of a cold.

In these podcasts, you get to listen in on my conversations about health literacy with some pretty amazing people. Today, I’m talking with Dr. Winston Wong, who is a practicing physician who also serves as the Medical Director of Community Benefit at Kaiser Permanente. His work includes developing community and organizational partnerships to eliminate health disparities.

Dr. Wong has won numerous awards and serves on a number of national advisory boards, including the Institute of Medicine’s Health Literacy Round Table.

I’ve been Dr. Wong’s fan from afar for a long time, taking note of his thoughtful and thought-provoking comments at the Institute of Medicine’s Health Literacy Round Table.

Welcome to Health Literacy Out Loud, Dr. Wong.

Dr. Winston Wong: Thanks, Helen. It sounds like it’s been a great series of podcasts and I’m looking forward to sharing some thoughts with you this morning.

Helen Osborne: That’s great. You and I did a little ahead-of-time planning and we were talking about the work that you’re doing in eliminating health disparities and particularly about the role of bias, whether we’re aware of bias or not. It sounds like an important factor in health communication. Tell us more.

Dr. Winston Wong: A lot of this work stems from my being a physician for nearly 30 years and most recently a physician at Kaiser Permanente where we’ve been looking at things like blood pressure control among our African American population group.

Many things come out in that regard relative to whether physicians really focus on what the right therapy is for their patients when they listen to their patients. I think health literacy comes into play in this regard.

Helen Osborne: You’re talking about blood pressure. That sounds as objective as anything could be. What’s this role of bias in there?

Dr. Winston Wong: I think, as you know, blood pressure control has been a problem for America across the board for decades. When we look at African American population groups, the control rate of blood pressure among African Americans continues to lag maybe about 10 percentage points behind Caucasian Americans across the country.

Here at Kaiser Permanente, we seem to do a pretty good job. Our rate of control among everybody is well above the national 90th percentile. Among African Americans, it’s above the 90th percentile, but we still have about a 5% discrepancy rate that we’re trying to address.

Helen Osborne: Between people who are African American and Caucasians?

Dr. Winston Wong: Yes, between members who are African American and our Caucasian membership.

Helen Osborne: How do you account for that difference?

Dr. Winston Wong: There are a lot of different reasons. Among them is a lack of trust between the healthcare system and the African American population in general.

Of course, every individual is different, but I think some of the historical legacy with regards to how African American communities have perceived how the medical system has treated them does play a factor.

Helen Osborne: You’re talking about people’s follow through and the instructions. You take their blood pressure and it’s high and you know something needs to be done.

This role of bias or the concern and the embracing of our healthcare system, is that where it comes in, when you make recommendations? Or is it in your diagnosis?

Dr. Winston Wong: It’s a little bit of both. One is being very persistent in diagnosing people with high blood pressure and defining that in terms of how they understand the condition of blood pressure.

Then, as you say, I think there’s a lot that comes into play with regards to how people are able to relate to the instructions, the directions and the guidance of physicians and clinicians that care for them.

This factor becomes even more so in certain populations that either don’t understand the directions and guidance that their clinicians are providing to them or have a different definition of how that plays.

Helen Osborne: That falls under the rubric of what health literacy is all about, that we’re talking in ways that others necessarily cannot understand. Where would the bias fall in?

Dr. Winston Wong: I think what we’ve tried to explore is how clinicians and healthcare systems actually understand the kinds of conversations that their patients are having with them.

Bias comes into play and there have been some studies to suggest that there is even bias that plays a reflexive process within our brains.

Because of survival, they connect at certain stereotypes if you will almost beyond their level of consciousness. It works at a very automated level deep within the neuropathways within our brains.

This has been documented with regards to certain researchers that have looked at how people react to certain images based upon facial types, skin color, etc. in a series of objective tests.

Helen Osborne: Do you mean people like me, people who think I’m just doing good deeds? Me too? You too? Do we all have bias?

Dr. Winston Wong: This particular feud has been called implicit bias or unconscious bias because it doesn’t come into play as we process information in our frontal lobes and how we understand people.

It’s really at a much deeper neurologic pathway process that makes connections for our brains to be able to function in a world that has so much information coming at it at any given time.

With regards to unconscious bias in terms of how race plays into this, there have been studies to suggest that people do process information based upon some very deeply imprinted neurologic pathways that they associate with features that are associated with different races and nationalities.

Helen Osborne: That’s interesting that this can be part of who we are even if we don’t think it’s who we are.

When I think of a medical encounter, not the primary one but if you’re just going in for emergency care, you have those quick appointments, or you’re treating somebody you’ve never seen before. You have to make some snap judgments. Is bias from the clinician a factor in that?

Dr. Winston Wong: I think when clinicians have been asked, “Does bias play a role in terms of how you make decisions?” studies have pretty much suggested that virtually 90% of clinicians say, “I treat my patients all the same and bias does not play a role.”

On a conscious level, I don’t think it really factors into people’s decision making, but at a subconscious level and how we process information very quickly, I think it does. I think it plays a role in terms of health literacy as well.

Helen Osborne: Tell us more about that.

Dr. Winston Wong: I think when clinicians ask their patients to describe their problem, how they perceive a problem or how they understand a chronic disease, within the first few seconds there is processing that’s occurring with regards to listening to the patient enunciate, the patient’s vocabulary and the patient’s rhythm and tempo to how they speak.

Those associations start to form a path in terms of how we understand the best way to treat that patient within our frame of understanding.

Helen Osborne: We are making those snap judgments even if we want to be as inclusive as we possibly can. How is that different from making a reasoned assessment of how the other person learns and listens?

Dr. Winston Wong: I think one example would be if you were to care for a patient that’s a stranger and as soon as that patient said something you picked up that patient had a British accent and was using some very college-level vocabulary. You would probably assume that that patient can very well assimilate your instructions as a trained health professional.

Conversely, I think if a person just started to utter some words, they used very basic language and maybe they had an accent that suggested they were from a rural or southern part of the country, you probably would have a different set of parameters in which you start thinking about, “How could I best treat this patient?”

Helen Osborne: That’s part of that bias that you talked about, that hidden or implicit bias. Is that different from issues such as stereotyping, prejudice or discrimination? Those seem like such strong words, especially in this era of rampant xenophobia when people tend to be afraid of others. Are those all the same?

Dr. Winston Wong: I would say that what I’m suggesting here is still an area worthy of investigation and research. This has been a test that’s been applied to millions of people across different nations that are associated with visual cues with regards to how people start to frame an individual in their interactions.

With regard to audio and verbal communication, that research has not been done, so I’m actually theorizing that there is some aspect of how we process communication between individuals as soon as we start talking to them. That also impacts our ability to communicate effectively and relate effectively with patients.

Helen Osborne: This is fascinating and this is very humbling, but for me, for you and for everybody listening to this podcast, we want to communicate in ways that are respectful, informative, inclusive and appropriate.

Putting on your health literacy hat right now, what do you suggest we do about this inherent bias that may or may not be there all the time?

Dr. Winston Wong: Let me give you an example. Often, if we’re speaking to an individual who doesn’t speak English, there’s almost a reflexive attempt to speak louder.

There’s some sort of suggestion in our head that if we speak louder, even though this is not the person’s primary language, somehow the communication will be more effective.

It must be some aspect of our training that goes way back before professional training. It goes back to perhaps when we were children and how our parents spoke louder as well as slower if they wanted us to listen to their directions.

Therefore, we think that if we do this for a person that doesn’t understand our language, whether it’s because they speak a different language or because they have a different health literacy level, somehow that’s going to get through to that patient.

I think that assumption is at its core probably wrong. What we need to do is to really ask ourselves, “Are we assuming that this person can’t understand or doesn’t have the same intellectual capacity as me because they use a different parlance of communication?”

Helen Osborne: We have to look inside ourselves right away.

Dr. Winston Wong: Yes. One suggestion I have is that when we communicate with patients, and immediately if we see that this person doesn’t use the same parlance as we do, we have to ask ourselves very consciously, “What am I assuming about this patient?

“Am I assuming that this patient isn’t ‘as smart as me?’ Am I assuming that this patient has less ability to care for his or her needs? Am I assuming that this patient doesn’t understand the impact of their disease?”

If we’re making all those assumptions, we’re probably not doing that patient a service.

Helen Osborne: I did take that test about bias and I was humbled by some of the results. Even though I didn’t like what I had read, I’ve been thinking about it since and saying, “Whoa, I guess I have to pay more attention to certain things.”

Dr. Winston Wong: Again, that test was with regards to potentially racial and gender bias.

Helen Osborne: I certainly don’t see myself as a biased person, I just don’t, but the results were inconsistent for how I understand myself. Maybe there’s some truth to it and maybe not. I have no idea.

Dr. Winston Wong: I encourage our listeners to explore whether they want to take this particular test around unconscious implicit bias for gender and race.

Helen Osborne: We’ll have that link on your Health Literacy Out Loud web page.

Dr. Winston Wong: That’s great.

What you’ll find is when the test is done, individuals are flashed different images and then they were asked to respond with a click in terms of associations with that image.

Just the milliseconds of reflexive action for certain different adjectives associated with different visuals is an indicator that there’s a neurologic pathway that’s actually imbedded that’s not in our conscious realm but in our subconscious realm.

Helen Osborne: Take the test and be more aware of the issues. This podcast is certainly helping move that forward. Be more aware and don’t make as many assumptions ourselves.

What can we do in the moment? You’re talking to somebody of a different color or different background from you and he or she has high blood pressure, going back to that example in the beginning. What would you do to improve the situation?

Dr. Winston Wong: I think one needs to be conscious of what potential pathways I’m already assuming are occurring in my head and use a conscious approach to try to subjugate what is an automatic processing of that individual.

I think this effectively means you need to be very explicit with regards to your communication with your patient.

In the case of blood pressure for let’s say a patient that has a different social background or certainly a different racial, social or perhaps educational background, you need to ask the patient, for example, “Mrs. Jones, tell me what high blood pressure means to you.” She could say anything.

Then say, “Tell me, how is this important to you?” That person needs to articulate how it’s important to him or her.

You can say, “What do you think would be important for you to say that you want to take control of your blood pressure? Is it important for you and why?”

That patient is able to articulate her values, understanding and framework. You as a provider need to muster all the assets you have and armamentarium you have to support that patient’s framework while developing a therapeutic plan.

Helen Osborne: That sounds like health literacy. That sounds like what we’ve been talking about, the teachback, those open-ended questions and finding out the other person’s values, beliefs and assumptions in there.

It sounds to me as though this research is furthering what we have been talking about and believing in health literacy, to communicate in ways everybody we care for and care about can understand.

Dr. Winston Wong: I think effectively that health literacy means “how are we as clinicians and how are we as part of a healthcare team more effectively able to connect to people who are our patients who are relying on us to provide them with the most information and to help them make the effective therapeutic decisions?”

It boils down to what the value proposition is to that patient to take up any therapeutic plan, whether it means taking a pill every day or changing their lifestyle in terms of increasing their exercise or eating differently.

That patient is going to have to decide at home, in their workplace, when they’re just having fun and recreation or any given time, “Why should I change something based upon a conversation that I had with my provider?”

The conversations are at the middle of what really changes the value proposition for any given patient.

Helen Osborne: Dr. Wong, as always, you are providing so much to think about and do as we all move forward to helping eliminate those health disparities.

Thank you so much for all you do, all you shared and for being a guest on Health Literacy Out Loud.

Dr. Winston Wong: Thanks very much. I hope the listeners have an opportunity to try some of these activities in their clinical practice because I think it will make a real big difference.

Helen Osborne: As we just heard from Dr. Winston Wong, it is so important to consider bias, who we are and what we bring to all health communication. But it’s not always easy to do so.

For help clearly communicating your health message, please visit my health literacy consulting website at www.HealthLiteracy.com. While you are there, feel free to sign up for the free monthly e-newsletter, What’s New in Health Literacy Consulting.

New Health Literacy Out Loud podcasts come out every few weeks. Subscribe for free to hear them all. You can find us on iTunes, Stitcher Radio and the Health Literacy Out Loud website, www.HealthLiteracyOutLoud.org.

Did you like this podcast? Even more, did you learn something new? If so, tell your colleagues and tell your friends. Together, let’s tell the whole world why health literacy matters.

Until next time, I’m Helen Osborne.

Listen to this podcast.


"As an instructional designer in the Biotech industry, I find Health Literacy Out Loud podcasts extremely valuable! With such a conversational flow, I feel involved in the conversation of each episode. My favorites are about education, education technology, and instruction design as they connect to health literacy. The other episodes, however, do not disappoint. Each presents engaging and new material, diverse perspectives, and relatable stories to the life and work of health professionals.“

James Aird, M.Ed.
Instructional Designer