Julia Przedworski was getting a routine checkup when the doctor started going through a standard sexual health questionnaire.
“Are you sexually active?” the doctor asked. “Yes,” Przedworski said.
“Are you using contraceptives?” the doctor asked next. “No,” Przedworski said.
“Are you trying to become pregnant?” was the question that followed.
Przedworski, who uses they/them pronouns, identifies as queer and doesn’t have sex with people who could get them pregnant.
But the doctor didn’t know that and, from Przedworski’s perspective, appeared to assume they were heterosexual. Eventually, Przedworski disclosed to the doctor that they are queer, sparking what they described as a visible discomfort and anxiety.
“That’s when we almost had a rupture in the doctor-patient relationship,” Przedworski recalled. “There’s always a risk when coming out,” they added, explaining that this is a big reason queer people often shy away from seeking health care.
Another thing the doctor didn’t know: Przedworski was working as a researcher focused on LGBTQ+ health equity.
That uncomfortable exchange took place about 13 years ago in Boston. Today, Przedworski is still a researcher, now specializing in the study of hidden or implicit biases that affect judgment and behavior, including in health care, in her work at Diversity Sciences. The Clackamas-based company offers training, assessments and consulting to health care institutions and other companies to prevent situations like the one Przedworski experienced.
Studies show that implicit biases based on race, gender, sexual preference and income are widespread in health care. In Oregon, according to a recent report, most people of color rely on community-based organizations, religious figures or traditional healers rather than Anglo-centric providers because of their experiences with racism, discrimination and cultural insensitivity.
As the pandemic and the Black Lives Matter protests fueled national discussions around structural racism and disparities in health care, states and the health care industry have turned to organizations like Diversity Science for help. Five states — California, Maryland, Michigan, Minnesota and Washington — have passed laws requiring at least some health care workers to take implicit bias training. But Oregon has no such law.
Diversity Science has played a role in either implementing or developing the laws in California, Washington and Minnesota. The organization’s clients span the country, though employees work remotely in the Portland area.
The founder of the public benefit company, Michelle van Ryn, brought her consulting business to Oregon in 2017 when she was appointed to serve as the Grace Phelps Distinguished Professor at the Oregon Health & Science University’s School of Nursing. Before that, she served as director of the Research Program on Equity & Inclusion in Healthcare at the Mayo Clinic, a prestigious academic medical center in New York.
Van Ryn’s company develops training that relies on what she refers to as “mind hacks.” With the unconscious mind controlling the majority of our thinking, mind hacks are strategies to intercept those automatic thinking patterns before they impact interactions.
For example, Diversity Science teaches providers to take a moment to consider their patients’ perspectives and to humanize them, rather than stereotyping them by their identity. It also teaches providers to think of themselves as being on a team with the patient, trying to achieve the same goals of good care, among other strategies.
“If you go see a doctor, you don’t want them worrying about their gender bias, but you want them worrying about whatever it is you came in for,” van Ryn said. “We do training that helps (providers) understand structural discrimination and racism but in a way that engages people so that they’re motivated to act versus making people afraid to act.”
Oregon: A Patchwork System
Most of Oregon’s larger health systems require, or strongly suggest, that at least some of their employees take implicit bias training, an informal survey by The Lund Report has found. But the training programs vary widely, and not every employee who provides health care directly to patients is required to take implicit bias training within some systems.
The systems offering specific implicit bias training include Oregon Health & Science University, Samaritan Health Services, Kaiser Permanente, PeaceHealth and Providence Health & Services.
It’s unclear if Legacy Health offers any such training. A spokesperson for the system declined to provide The Lund Report with any information because their teams were “focused on caring for patients,” according to their email response.
Kaiser rolled out its implicit bias training, called “[email protected],” in March 2021 after years of development. According to Ruth Chang, the chief people officer for Kaiser’s northwest physician group, the training was the product of years of development. It employs the SEEDS model of bias to help clinicians and administrators build a shared language about biases.
“It is powerful to have this level of group awareness, knowledge and shared understanding,” Chang told The Lund Report.
At OHSU, a two-hour implicit bias training is highly suggested for all employees, and individual departments can choose to make it mandatory. Since starting four years ago, more than 12,000 employees have taken the training, according to Derik Du Vivier, senior vice president for diversity, equity & inclusion.
“Our training focuses on evidence-based practices and mitigation strategies highlighted in the literature and in current research regarding the impact of implicit bias in health care settings,” Du Vivier said in an email.
Anthony Herrington, the chief diversity, equity and inclusion officer for Providence Oregon told The Lund Report that all seven regions of his hospital system have rolled out virtual instructor-led implicit bias training.
“In the Oregon region, we have added completing implicit bias training as a 2022 performance management goal for all,” he said.
Salem Health offers “cultural competence and bias training” to staff, according to spokesperson Lisa Wood.
But at St. Charles Health System in central Oregon, “as of right now we do not offer any specific implicit bias training, though we hope to do so in the future,” spokesperson Lisa Goodman said in an email.
Other States Legislate
In 2019, Oregon lawmakers mandated cultural competency training for all health care professionals. Though it’s not always the case, cultural competency training can focus on implicit biases. At Diamond Law, another Portland-based group that offers implicit bias training, its cultural competency training includes discussions of implicit biases.
But requiring more training is still a step in the right direction, according to Maribeth Guarino, a health care advocate at the Oregon State Public Interest Research Group (OSPIRG). While there may be some overlap between the cultural competency requirements and implicit bias training, she said mandating implicit bias training explicitly could help improve the patient experience.
“Cultural competency may help physicians and other providers adjust the way they run their practice and interact with patients, while implicit bias training focuses just on that patient interaction and making providers more aware of their own biases,” she said.
While Oregon lawmakers haven’t introduced a bill mandating implicit bias training for health care workers, they did pass a similar law related to mortgage loan originators. In 2021, a bill to mandate implicit bias training for police officers failed to become law.
Oregon is lagging behind other West Coast states, which have begun to standardize implicit bias training for health care workers. In response to studies that show widespread disparities in maternity care between Black women and non-Hispanic white women, California passed a law in 2019 that requires implicit bias training for all perinatal care providers. And in Washington, officials are currently working to develop training requirements for all health professionals starting in 2024.
Diversity Science has worked with organizations in these neighboring states, as well as Minnesota, to develop training. But, according to van Ryn, these laws still have a long way to go: She said they are “a start” but she wishes they included more funding resources and relied more on evidence-based criteria.
“Most of the work in the field is not at all responsive to what we know about what actually works,” said van Ryn, who is considered a leading researcher on implicit biases.
A lot of training backfires, she said, making people aware of their biases but failing to give them concrete strategies on how to interrupt those biases in the first place. In practice, these trainings can be punitive and make providers more anxious and avoidant when treating people with certain identities.
A state mandate could be powerful in Oregon, said Przedworski, the researcher who works with van Ryn. “If you give trainings to enough people, it can shift a culture,” they said.
But laws requiring training are not enough, they said, and training is “necessary but not sufficient.”
Vesper Stein, a trainer at Diamond Law, agreed. As an openly queer and transgender mixed-race woman, Stein has trauma from her experiences in the medical system. She thinks that while a law mandating implicit bias training in Oregon is a start, larger systemic flaws in the medical system also need to be addressed. Requiring medical students to take humanities courses that touch on implicit biases, for instance, could be a more effective way of addressing the root problem, she said.
“I think that implicit bias training is just a first baby step in repairing the cracks in the foundation of health care and how health care professionals treat marginalized people,” she said. “You can’t implicit bias train your way out of a broken medical system and a broken education system.”
Van Ryn agreed, saying organizations shouldn’t stop with implicit bias training and need to take other steps to make institutional change, addressing more subtle dynamics that create exclusion.
Gender Bias Hits Close To Home
In the meantime, van Ryn said she continues to see how the lack of such training and policies impact people she knows in Oregon. This past spring, her 24-year-old offspring, Zoe, experienced poor pain management following an appendectomy at a Portland hospital.
Zoe, who uses they/them pronouns and prefers to keep their last name private for medical reasons, experienced what they described as excruciating pain following the surgery, which occurs in at least 20% of appendectomy patients. Although not unusual, Zoe was practically paralyzed for an hour following each time they got out of bed and was unable to breathe deeply, they said. So, they went back to the surgeon for help.
But getting relief for the pain was harder than Zoe anticipated. The surgeon was dismissive of the pain, they said, and directed comments at their male partner instead. Zoe has grown up learning about implicit biases through their mom’s work, so they easily attributed this to gender biases.
“While I was interacting with the doctor and watching how he interacted, I was sitting there being like, ‘If I was a man, I would be treated differently,’” they recalled.
Zoe’s partner picked up on this as well. After Zoe expressed concerns about the pain, the doctor turned to him and said, “Wow, she’s much more talkative today, isn’t she?” the partner recalled, saying it was “disturbing” that his partner’s doctor “was that dismissive.”
Zoe also noted poor informed consent practices and a lack of trauma-informed care. Exhausted from this experience, they worry about what could be happening to others who don’t have their knowledge about biases and social standing, as someone who’s white, affluent and has a mom in health care: “How many worse things are happening to people that don’t have what I have?”
On May 6, van Ryn sent a letter to the health care provider on Zoe’s behalf, urging the organization to invest in better training in trauma-informed care and implicit biases — specifically gender biases.
“Trauma-informed care creates better experiences and outcomes for all patients but is a major part
of addressing health care and outcome inequities,” van Ryn wrote in conclusion of the letter, obtained by The Lund Report.
Van Ryn also asked the surgeon and other parties at the organization to listen to a recording Zoe made about her experience and provide an apology. The surgeon eventually apologized, van Ryn said, but the system did not make a commitment to providing additional trauma-informed and implicit bias training. It’s unclear whether Zoe’s doctor had taken the training the system provides.
This story is just one of “millions,” van Ryn said, and this isn’t likely to stop happening without serious interventions.
“You can have a minor surgical procedure, be treated dismissively, have your pain dismissed, and it has a huge impact,” she said. “And even though you go home, it was a minor procedure and you heal, will you go back to the doctor … if you have trauma?”