Unconscious bias could be a matter of life or death.
“Doctors aren’t listening to us, just to be quite frank. We’re dying, three times more likely. And knowing that going in, some doctors not caring as much for us, it’s heartbreaking.”
—Serena Williams (2018 post-pregnancy interview with BBC)
In mid-March, Karla Monterroso flew home to Alameda, California, after a hiking trip in Utah’s Zion National Park. Four days later, she began to develop a bad, dry cough. Her lungs felt sticky.
The fevers that persisted for the next nine weeks grew so high — 100.4, 101.2, 101.7, 102.3 — that, on the worst night, she was in the shower on all fours, ice-cold water running down her back, willing her temperature to go down.
“That night I had written down in a journal, letters to everyone I’m close to, the things I wanted them to know in case I died,” she remembered.
Then, in the second month, came a new batch of symptoms: headaches and shooting pains in her legs and abdomen that made her worry she could be at risk for the blood clots and strokes that other COVID-19 patients in their 30s had reported.
Still, she wasn’t sure if she should go to the hospital.
“As women of color, you get questioned a lot about your emotions and the truth of your physical state. You get called an exaggerator a lot throughout the course of your life,” said Monterroso, who is Latina. “So there was this weird, ‘I don’t want to go and use resources for nothing’ feeling.”
It took four friends to convince her she needed to call 911.
But what happened in the emergency room at Alameda Hospital only confirmed her worst fears.
At nearly every turn during her emergency room visit, Monterroso said, providers dismissed her symptoms and concerns. Her low blood pressure? That’s a false reading. Her cycling oxygen levels? The machine’s wrong. The shooting pains in her leg? Probably just a cyst.
“The doctor came in and said, ‘I don’t think that much is happening here. I think we can send you home,’” Monterroso recalled.
Her experiences, she reasons, are part of why people of color are disproportionately affected by the coronavirus. It is not merely because they’re more likely to have front-line jobs that expose them to it and the underlying conditions that make COVID-19 worse.
“That is certainly part of it, but the other part is the lack of value people see in our lives,” Monterroso wrote in a Twitter thread detailing her experience.
In the hospital that day in May, Monterroso was feeling woozy and having trouble communicating, so she had a friend and her friend’s cousin, a cardiac nurse, on the phone to help. They started asking questions: What about Karla’s accelerated heart rate? Her low oxygen levels? Why are her lips blue?
The doctor walked out of the room. He refused to care for Monterroso while her friends were on the phone, she said, and when he came back, the only thing he wanted to talk about was Monterroso’s tone and her friends’ tone.
“The implication was that we were insubordinate,” Monterroso said.
She told the doctor she didn’t want to talk about her tone. She wanted to talk about her health care. She was worried about possible blood clots in her leg and she asked for a CT scan.
“Well, you know, the CT scan is radiation right next to your breast tissue. Do you want to get breast cancer?” Monterroso recalled the doctor saying to her. “I only feel comfortable giving you that test if you say that you’re fine getting breast cancer.”
Monterroso thought to herself, “Swallow it up, Karla. You need to be well.” And so she said to the doctor: “I’m fine getting breast cancer.”
He never ordered the test.
Monterroso asked for a different doctor, for a hospital advocate. No and no, she was told. She began to worry about her safety. She wanted to get out of there. Her friends, all calling every medical professional they knew to confirm that this treatment was not right, came to pick her up and drove her to the University of California-San Francisco. The team there gave her an EKG, a chest X-ray and a CT scan.
“One of the nurses came in and she was like, ‘I heard about your ordeal. I just want you to know that I believe you. And we are not going to let you go until we know that you are safe to go,’” Monterroso said. “And I started bawling. Because that’s all you want is to be believed. You spend so much of the process not believing yourself, and then to not be believed when you go in? It’s really hard to be questioned in that way.”
Alameda Health System, which operates Alameda Hospital, declined to comment on the specifics of Monterroso’s case, but said in a statement that it is “deeply committed to equity in access to health care” and “providing culturally-sensitive care for all we serve.” After Monterroso filed a grievance with the hospital, management invited her to come talk to their staff and residents, but she declined.
She believes her experience is an example of why people of color are faring so badly in the pandemic.
“Because when we go and seek care, if we are advocating for ourselves, we can be treated as insubordinate,” she said. “And if we are not advocating for ourselves, we can be treated as invisible.”
Unconscious Bias in Health Care
Experts say this happens routinely, and regardless of a doctor’s intentions or race. Monterroso’s doctor was not white, for example.
Research shows that every doctor, every human being, has biases they’re not aware of, said Dr. René Salazar, assistant dean for diversity at the University of Texas-Austin medical school.
“Do I question a white man in a suit who’s coming in looking like he’s a professional when he asks for pain meds versus a Black man?” Salazar said, noting one of his own possible biases.
Unconscious bias most often surfaces in high-stress environments, like emergency rooms — where doctors are under tremendous pressure and have to make quick, high-stakes decisions. Add in a deadly pandemic, in which the science is changing by the day, and things can spiral.
“There’s just so much uncertainty,” he said. “When there is this uncertainty, there always is a level of opportunity for bias to make its way in and have an impact.”
Salazar used to teach at UCSF, where he helped develop unconscious-bias training for medical and pharmacy students. Although dozens of medical schools are picking up the training, he said, it’s not as commonly performed in hospitals. Even when a negative patient encounter like Monterroso’s is addressed, the intervention is usually weak.
“How do I tell my clinician, ‘Well, the patient thinks you’re racist?’” Salazar said. “It’s a hard conversation: ‘I gotta be careful, I don’t want to say the race word because I’m going to push some buttons here.’ So it just starts to become really complicated.”
A Data-Based Approach
Dr. Ronald Copeland said he remembers doctors also resisting these conversations in the early days of his training. Suggestions for workshops in cultural sensitivity or unconscious bias were met with a backlash.
“It was viewed almost from a punishment standpoint. ‘Doc, your patients of this persuasion don’t like you and you’ve got to do something about it.’ It’s like, ‘You’re a bad doctor, and so your punishment is you have to go get training,” said Copeland, who is chief of equity, inclusion and diversity at the Kaiser Permanente health system. (KHN is an editorially independent program of KFF, which is not affiliated with Kaiser Permanente.)
Now, KP’s approach is rooted in data from patient surveys that ask if a person felt respected, if the communication was good and if they were satisfied with the experience.
KP then breaks this data down by demographics, to see if a doctor may get good scores on respect and empathy from white patients, but not Black patients.
“If you see a pattern evolving around a certain group and it’s a persistent pattern, then that tells you there’s something that from a cultural, from an ethnicity, from a gender, something that group has in common, that you’re not addressing,” Copeland said. “Then the real work starts.”
When doctors are presented with the data from their patients and the science on unconscious bias, they’re less likely to resist it or deny it, Copeland said. At his health system, they’ve reframed the goal of training around delivering better quality care and getting better patient outcomes, so doctors want to do it.
“Folks don’t flinch about it,” he said. “They’re eager to learn more about it, particularly about how you mitigate it.”
It’s been nearly six months since Monterroso first got sick, and she’s still not feeling well.
Her heart rate continues to spike and doctors told her she may need gallbladder surgery to address the gallstones she developed as a result of COVID-related dehydration. She decided recently to leave the Bay Area and move to Los Angeles so she could be closer to her family for the long recovery.
She declined Alameda Hospital’s invitation to speak to their staff about her experience, concluding it wasn’t her responsibility to fix the system. But she wants the broader health care system to take responsibility for the bias perpetuated in hospitals and clinics.
She acknowledges that Alameda Hospital is public, and it doesn’t have the kind of resources that KP and UCSF do. A recent audit warned that the Alameda Health System was on the brink of insolvency. But Monterroso is the CEO of Code2040, a racial equity nonprofit in the tech sector and even for her, she said, it took an army of support for her to be heard.
“Ninety percent of the people that are going to come through that hospital are not going to have what I have to fight that,” she said. “And if I don’t say what’s happening, then people with much less resources are going to come into this experience, and they’re going to die.”
This story is part of a partnership that includes KQED, NPR and KHN.
KHN (Kaiser Health News) is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.
Eight schools were honored for their efforts to recruit and retain male students at the virtual gathering for this year’s 45th annual American Assembly of Men in Nursing (AAMN) conference.
The number of men entering the profession is definitely on the upswing. Lewis University College, one of the schools honored, noted, “the percentage of men working as registered nurses has continued to rise. In 1970, only 2.7 percent of registered nurses were men while in 2017, it is estimated that 11 percent of registered nurses were men (U.S. Census Bureau, 2017).”
During the October 14-16 meeting, the AAMN placed the following schools at the top of the list, based on increases in male applicants, admissions, retentions, and/or improved program evaluations from male graduates:
At Johns Hopkins, JHSON Dean Patricia Davidson, PhD, MEd, RN, FAAN responded, “We are proud of our efforts to build a diverse pipeline of nurses, particularly for our support of men who bring needed perspective and experience to our profession. Especially now, our world needs competent and credentialed nurses across all genders, backgrounds, and experiences in order to provide the best health outcomes for the populations we serve.”
Duke also celebrated their 2020 AAMN honor. “Our organization thrives on the presence, engagement, and contributions of individuals from diverse backgrounds. Men who are nurses enrich our profession, bringing a wealth of experiences to the collective excellence our school strives for,” said Marion E. Broome, PhD, RN, FAAN, dean and Ruby Wilson Professor of Nursing at Duke. In a recorded acceptance speech, student Nikolas Silva said: “On behalf of the Duke Chapter of the American Association for Men in Nursing, thank you. Thank you to the Association for handing us this award, and thank you to our amazing faculty supervisors for all the hard work and guidance they’ve given us over the past year. But most importantly, thank you to our members. It is because of them that our organization is able to promote diversity and inclusivity in both our immediate community at the Duke School of Nursing and the surrounding community as well.”
Nurse of the Week Michael King has been dedicated to both nursing and the law for 15 years. His latest challenge—as Commander of the New York City Police Department’s Special Victims Division—calls for him to draw upon both of his professions.
The Jamaican-born officer/RN emigrated to New York at the age of 16, and enrolled in an emergency medical technician program after he entered college. After four years of training paramedics, King joined the NYPD as a beat cop in 2000. As a rookie policeman, he attended nursing school and worked in city hospitals during his off hours. By 2005 he was a licensed RN. King eventually became a forensic nurse, and spent his off-duty time as a coordinator at the Wyckoff Heights Medical Center’s sexual assault response team. Meanwhile, he pursued his NYPD career as an investigator, a crime scene commander, and later as the executive officer of the Joint Terrorism Task Force.
John Miller, the NYPD’s Deputy Commissioner of Intelligence and Counterterrorism, who recommended King for the Special Victims command, says “If we didn’t have Mike King, I am not sure we could have invented him. At SVU he can combine his experiences of helping people in trauma, his knowledge of science, forensics and investigation and his sense of justice in a way no one else — at least no one else I know — could.”
King’s understanding of the close relationship between forensic nurses and police sex crime units makes him keenly aware of both the wide picture and the details behind the operation of an SVU. He also has first-hand experience with rape kits from his stints as a nurse at hospitals in Long Island and Brooklyn. King says his team uses a “science-based technique that encompasses compassion, sensitivity, and the knowledge of psychological trauma.” He wants to extend training in this area toi patrol officers as well, as “they are usually the first ones at a scene to interview a survivor of sexual assault.”
For an interview with Michael King, see this video at PIX11. More details on King’s background and career are available in this story from AM New York.
Claiming that it will “effectively reverse decades of progress in combating racial inequality,” the American Nursing Association (ANA), the American Medical Association (AMA), and the American Hospital Association (AHA) have called upon the White House to rescind Executive Order 13950, “Combating Race and Sex Stereotyping.”
Scheduled to take full effect in November, the September 22 EO directs that federal funds be denied to federal agencies, companies with federal contracts, and recipients of federal grants that sponsor any program that “promotes race or sex-stereotyping or scapegoating.” Any company found to be defying the order is threatened with cancellation of all federal contracts or funding. Non-exempt contractors are expected to start complying by November 21, but federal agencies were immediately affected by the order. The Justice Department has already suspended its diversity and inclusion training, and the prohibition has provoked a tumult at colleges, hospitals, government offices, non-profit organizations, and other institutions dependent on federal monies.
Citing “the pernicious and false belief that America is an irredeemably racist and sexist country; that some people, simply on account of their race or sex, are oppressors; and that racial and sexual identities are more important than our common status as human beings and Americans,” the EO is a widespread condemnation of the standards underlying most mainstream diversity initiatives. The order describes the concepts espoused in recent federal training programs as a “malign ideology” and claims that “research… suggests that blame-focused diversity training reinforces biases and decreases opportunities for minorities.”
The October 14 ANA/AMA/AHA letter states that “as providers of care to diverse communities throughout the country, we urge the Administration to immediately rescind EO 13950 and allow for our continued work on inclusion and equity.” The three signatories warn that Executive Order 13950 will “stifle attempts at open, honest discussion of these issues [e.g., sexism, systemic racism] in the public and private sectors” and argue that “prohibiting federal agencies from conducting and funding trainings that promote racial reconciliation is counterproductive to addressing racism.” Noting the disproportionate impact of the pandemic upon Black and Brown Americans, the letter argues that “vital research conducted at the National Institutes of Health and academic centers to comprehend the effects of structural racism and implicit bias on health care and health outcomes is needed right now more than ever before.”
The Association of American Medical Colleges also spoke out against the order, and in a September 24 letter, stated that “The AAMC, and the academic medical institutions that comprise our membership, are committed to being diverse, inclusive, equitable, and anti-racist organizations. We believe this training is needed now more than ever. The AAMC intends to continue our trajectory of pursuing and even increasing such training. We urge our member institutions and other affected organizations to do so as well.”
While the academic world is largely seeking to challenge the order, two colleges, the University of Iowa and John A. Logan College, have already announced that they are shuttering their diversity programs, at least on a temporary basis.
Nurse of the Week Marie Manthey is a very busy 85-year-old nurse, entrepreneur, advocate, and activist in the anti-racism movement. After the American Academy of Nursing presented her with a Living Legends award in 2015 for her pioneering work in developing the Primary Nursing model, she did not retire to rest on her laurels. Manthey continues to host her Nursing Salons (regular gatherings in which nurses meet to share conversations and support), works with the company she founded and is still an active advocate for nurses suffering from substance use disorder.
Manthey is also a leader among nurses in the anti-racism movement. After the summer wave of anti-racism protests, she met with DailyNurse to talk about what it means to take action against racism, her journey as a White ally, and her latest Creative Nursing article, which takes a look at trailblazing Black nurse Frances McHie (pronounced “mic-hye”) and the struggle to overcome racism at the University of Minnesota School of Nursing.
DailyNurse: How did you first hear about Frances McHie?
Marie Manthey: “The school of nursing at University of Minnesota has long had a group of very strong volunteers who have a very extensive collection and data [on the history of the nursing school]. So this group of alumni volunteers—who care passionately and energetically about the history of the school of nursing—are responsible for managing historical documents.
And in that documentation area, we found that our first African-American student, Frances McHie, had only been admitted by demand of the legislature. (We recently celebrated the centennial of her admission, which was attended by some of her descendants).”
DN: How did you become involved in the anti-racism movement?
MM: “My awareness began when, 4 or 5 years ago, the Dean of the University of Minnesota School of Nursing, Connie Delaney—who is a phenomenally transformative leader—brought in a speaker to talk about white privilege. That was the first time I had heard that term. She also brought in a university-wide task force on diversity and equity, and I attended some of their open discussions about what is happening to African-American students in our school today.
The next step for me, was I became friends with an African-American person. Her name is Tammy, and she’s a nurse in an administrative position at a local hospital. Well, we met at a statewide leadership meeting, where we made a commitment to develop our relationship and became friends. Tammy started to come to the nursing “salons” I had formed earlier—where we would have dinner, and talk, where the question would be asked, “what’s on your mind about nursing?” and at the end of the evening we would go around and respond to the question “what’s on your mind about nursing now?” After Tammy joined us, we often found ourselves discussing issues affecting nurses of color, and Tammy went on to open a Black nursing salon. We held the first one at my house, and mine was the only white face there. That was part of my leap to a different level of understanding because I listened to what these nurses were talking about. And as I’m listening to them, I’m hearing about what systemic racism really looks like! I had not understood it before; I thought it was about the way we individually deal with racism.
[At the Black Nurses’ Salon] I began to understand what the system has done. It was a big breakthrough. I could finally see where I was in the system as a nursing leader. I could see where some of the decisions I made that involved a person of color versus a White person going for a promotion or better hours, and my decision would sometimes be ‘well, it would work out better if we give this to a White person; she’ll get along better.’ And I didn’t see that until I heard these nurses talk about what it’s like to apply for better hours or something, and despite equal education, equal experience, the white nurse will get it. Also, until now, I didn’t really understand White privilege. Now—at the age of 85—I finally get how being born white has affected everything from my thought processes to my life experiences. It’s very clear to me that action is the only solution.
Tammy and I are going to start another Salon on diversity in nursing with an equal number of nurses of color and nurses who are white. To get us talking to each other.”
DN: It’s complicated. On one hand, it’s not the job of Black people to tell Whites, “this is what you need to do to stop being racist,” but at the same time, we can only learn by communicating in an open, willing dialogue.
MM: “I had to learn how to listen without judgment. At the Black Nurses Salon, I went in ready to just accept what everyone was saying without deciding whether I agreed with everything that was being said.”
DN: One of the biggest obstacles we face is that we are living in an age of “I’m not a racist” racism.
MM: “That’s very true. I discuss that in some detail in a piece I wrote on my journey toward becoming an anti-racist. I went from proudly saying, “I’m not racist!” to actually taking on responsibility for taking steps to dismantle systemic racism and acknowledging that my people with my skin color have been building this system for 400 years At the salons, I began to accept responsibility for what happened. I didn’t ask for it or personally cause it to happen, but it was part of my culture. People of color certainly didn’t ask for it either…..and both of us have experienced the impact of systemic racism.
After taking responsibility, I began to understand that the only solution—I’m a big follower of Nelson Mandela and the idea of reconciliation; it’s a big part of my value system—is reparations. I don’t necessarily mean financial, but the way I am in my world, how I present myself, how accept what other people are saying to me.”
DN: That brings us to the Frances McHie nursing school scholarship, which is a form of reparation, right?
MM: “Yes. When the idea of a scholarship in Frances McHie’s name came up, we found a relative of hers who was a nephew and began putting some flesh on the idea. And with his help, we established the Frances McHie Scholarship for nurses of color [at the University of Minnesota School of Nursing]. That was an action step following a public apology to the McHie family. Dean Connie Delaney made a public statement reflecting that the Frances McHie scholarship was a step in reparations and in accepting the school’s responsibility for racism.”
DN: What other actions are nursing schools taking to reduce the effects of systemic racism?
MM: “Some are changing admissions criteria from a hard GPA requirement, and are taking a person’s story into account as well. I think that’s a good idea. There’s no doubt that people of color don’t have equal opportunities. I have a book that was published in 1933, [Carter G. Woodson’s] The Mis-Education of the Negro. It tells the story of how Jim Crow schools started. It says they were teaching them at a lower level, and that’s been carried on through the years.”
DN: What sorts of things can individuals do to fight racism, on an immediate level?
MM: “We can look at big-picture issues—who we elect as our representatives, our senators, etcetera, but we also have to work on a personal level. We need to make deliberate, conscious, intentional choices about the way we live our lives. What is my circle of responsibility and control, and how do I want to be in those areas? I have to look at the way I interact with my children, my friends, my family, my associates, and ask “what are the things that I can influence?” For me writing—for instance, the article [on Frances McHie] and my personal story about my journey—can help me to influence others to work toward change. I just feel that that is what I need to be doing at this point in my life. This is a personal choice we make: are we going to continue to be the way we’ve been, or are we prepared to step into an area where we can’t predict what people’s reactions will be?”
DN: Are more people sincerely examining their own views and trying to move forward?
MM: “I feel very hopeful because so many people are having these conversations. I have these conversations with a lot of my friends. A lot of [other White people] are talking to me about racism. And my company is creating a task force; we are engaged in looking at everything we do.
I’m also the chairman of the board of Directors of the Nurses Peer Review Network, which helps nurses who have been struggling with addiction and are trying to regain their licenses. I’ve been asking people, “can you help me find African-Americans or other people of color for our board?” We recently added our first Black board member, and we have two more we are considering for our [organization. And I think that I’m not the only person who is doing this. Best Buy is looking for enough people of color and women to make up 30% of their new hires. A number of companies are taking action, and I think that’s a hopeful sign.”
Marie Manthey is the author of the award-winning book, The Practice of Primary Nursing, and is a co-founder of the journal Creative Nursing. Manthey’s recent article on Frances McHie—the nurse, activist, and entrepreneur who broke the color barrier at the University of Minnesota School of Nursing—is available here.
Founded by nursing pioneer and award-winning author Marie Manthey, Creative Nursing has been a quarterly journal for health care thought leaders and innovators since 1981. The journal is edited by health care professionals who love our professions and have a vision for their future.
The 2020 Higher Education Excellence in Diversity (HEED) Health Professions awards are recognizing some of the nation’s top nursing schools for their efforts to recruit and support a diverse student and faculty population. Sponsored by INSIGHT Into Diversity, the oldest and largest diversity magazine and website in higher education, the Health Professions HEED Awards are the only national awards that honor schools in the health professions for outstanding commitment to diversity and inclusion across their campuses.
“The Health Professions HEED Award process consists of a comprehensive and rigorous application that includes questions relating to the recruitment and retention of students and employees and best practices for both; continued leadership support for diversity; and other aspects of campus diversity and inclusion,” said Lenore Pearlstein, co-publisher of INSIGHT Into Diversity magazine.
The nursing schools among the 2020 winners are all notable for their commitment to inclusive education; many are receiving HEED honors for the third—and in some cases, fourth—consecutive year.
Nine schools of nursing are receiving 2020 Health Professions HEED Awards:
At Johns Hopkins School of Nursing, which is being recognized for its second consecutive HEED Health Professions award, Gloria Ramsey, JD, RN, FNAP, FAAN, associate dean for Diversity, Equity, and Inclusion commented, “We hope that the experiences we provide at the Johns Hopkins School of Nursing prepare our students to be leaders for change. Amazing things happen when we, as a growing group of nurse leaders, speak up and work together as we serve our diverse communities. We must stand as a community while striving for inclusion and embracing change.”
Frontier Nursing University is celebrating its third HEED award since 2018. President Dr. Susan Stone remarked, “Amidst the current social justice movement in our country, it is imperative that FNU serve as an agent for change. We know that culturally competent care improves health outcomes and begins with a more diverse healthcare system. We are proud to be taking a leadership role in this movement by educating an increasingly diverse student body, but fully recognize that we have much to learn and areas in which to improve. The HEED Award confirms that we are continuing to move in the right direction and to make meaningful progress.”