Removing the Blinders - stereotypes of foreign-born physicians
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A look at how foreign-born physicians are changing the workforce - and how to embrace that change!
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Removing the Blinders - stereotypes of foreign-born physicians
- 1. Stephanie Huckel, MS – Diversity Specialist, Office of Diversity & Inclusion, Blue Cross & Blue Shield of Rhode Island Emerson Moses, MBA, FASPR – Director of Provider Recruitment, One Medical Group
- 2. Introductions Emerson Moses, MBA, FASPR, CMSR Director of Provider Recruitment at One Medical Group Senior Physician Recruitment Consultant, Tufts Medical Center, Boston, MA 7 years with Baystate Health, Springfield, MA 3 years in academic medicine & healthcare management at Massachusetts General Hospital
- 3. Introductions Stephanie Huckel, MS Diversity Specialist, Blue Cross & Blue Shield of Rhode Island Formerly, Diversity Specialist, Baystate Health Treasurer, Board of Directors, Jim Collins Foundation Speaker, 2013 DiversityRx National Conference on Quality Health Care for Culturally Diverse Populations “Transgender Health: Improving Care through Collaboration”
- 6. Preference hierarchy US-born & trained MDs US born & trained DOs US born, Internationally trained physicians Foreign born physicians 68% 26% 7%
- 7. What do the stats say? 19.9% 8.7% 5.8% 4.8% 3.3% 2.5% 2.4% 2.2% 2.1% 2.1% Top 10 countries where IMGs received medical training India Philippines Mexico Pakistan Dominican Republic USSR Grenada Egypt Korea Italy
- 8. What do the stats say? 1. New Jersey 45% 2. New York 42% 3. Florida 37% 4. Michigan 34% 5. Illinois 34% 6. Connecticut 29% 7. Ohio 29% 8. Maryland 27% 9. Pennsylvania 26% 10. Texas 24% 11.California 23% 12. Massachusetts 22% 13. Virginia 22% 14. Missouri 22% 15. Arizona 22% 16. Indiana 21% 17. Georgia 20% 18. Wisconsin 19% 19. Tennessee 17% 20. North Carolina 13% Top 20 states where IMGs practice, 2007
- 9. What do the stats say? IMGs within each specialty Internal Medicine – 37% Psychiatry – 31.4% Anesthesiology – 28% Pediatrics – 28% General/Family Practice – 28% General Surgery – 19.8% Radiology – 18.8% Obstetrics/Gynecology – 17.6%
- 10. What do the stats say? IMGs & Performance Dividing the international medical graduates into those who were foreign-born and those who were American citizens who chose to study abroad, the researchers discovered that patients of foreign-born primary care physicians fared significantly better than patients of American primary care doctors who received their medical degrees either here or abroad. (The New York Times, Aug. 12, 2010)
- 11. Culture & Cultural Competence Culture is: Learned, not innate Broad, not just race and ethnicity Changes; is not static Exists within all groups Defines group norms and boundaries
- 12. Culture & Cultural Competence Cultural competence is: The ability of individuals and organizations to effectively understand and address the unique perspectives and health needs of various communities The capacity of a system or of an individual to: Value cultural influences in individual beliefs and practices Take into account those influences in delivering services to diverse populations
- 14. Bias is not a bad word. Bias is a predisposition to see events, people or items in a positive or negative way. Bias is an attitude or belief. Bias is valuable. A 2012 survey found that 79% of HR professionals report unconscious bias as a widespread issue. Unconscious Bias
- 16. “That Calls for Carlsberg”
- 17. Ladder of Inference Observe data Select data Add meaning Make assumptions Draw conclusions Adopt beliefs Take action(s) Our beliefs lead to choices about the data we select
- 18. 1. Observe data: 2. Select data: it’s tall and loopy. 3. Add meaning: tall and loopy = awesome (scary) 4. Make assumption: this roller coaster is awesome (scary) 5. Conclusion: definitely should (not) go 6. Belief: all roller coasters are awesome (scary) 7. Take action: get on! (Run away!) Reflective loop: if you have a great (or terrible) experience, it will reinforce the data you select next time.
- 19. Examples of Bias “Dead fish handshake”
- 20. Examples of Bias India The majority of Indians are Hindu Men customarily do not touch women in either formal or informal situations A Western woman should not initiate a handshake with a man. Most Indian women will shake hands with foreign women but not men. Only westernized Hindus will shake hands with the opposite sex Titles are highly valued by Indians
- 21. Examples of Bias Fashionably late…
- 22. Examples of Bias Russia Always be punctual, but do not be surprised if the Russians are not on time. It is not unusual for Russians to be 15-30 minutes late. Don’t try to be subtle and make “suggestions,” assuming that Russians will “take the hint.” Be factual and include all levels of technical detail It is not customary for Russians to disclose their home phone or other personal telephone numbers.
- 23. Examples of Bias China Punctuality is very important in China; lateness or a cancellation is a serious affront. Introductions tend to be formal, with courtesy rather than familiarity preferred. Avoid making exaggerated gestures or using dramatic facial expressions. The Chinese do not use their hands when speaking and become distracted by a speaker who does.
- 24. Examples of Bias Lack of eye contact, soft spoken
- 25. Examples of Bias Philippines Staring at someone is considered rude. Speaking in a loud voice is considered rude. Filipinos revere harmony; speak in quiet, gentle tones.
- 26. Examples of Bias Talking/Standing too close!
- 27. Examples of Bias Mexico A warm, somewhat soft handshake is the customary greeting among men and women Touch-orientated, lingering handshakes, touching of arms – all signs of willingness to be friendly Men should avoid putting their hands in their pockets; hands on hips suggests hostility or a challenge. Mexicans highly value the individual dignity of a person, regardless of social standing or material wealth.
- 28. Skills Seven Steps to Identify & Address Unconscious Bias Recognize that you have biases. Identify what those biases are. Dissect your biases. Decide which of your biases you will address first. Look for common interest groups. Get rid of your biases. Be mindful of bias kick back. Source: Diversity Best Practices
- 29. Resources Project Implicit - https://implicit.harvard.edu/implicit/demo/ “Proven Strategies for Addressing Unconscious Bias in the Workplace,” Diversity Best Practices – http://www.cookross.com/docs/UnconsciousBias.pdf Blindspot: Hidden Biases of Good People by Mahzarin R. Banaji & Anthony G. Greenwald The Secret Life of Decisions: How Unconscious Bias Subverts Your Judgement by Meena Thuraisingham
- 30. Thank You! Questions? Stephanie Huckel, Blue Cross & Blue Shield of Rhode Island (stephanie.huckel@bcbsri.org) Emerson Moses, One Medical Group (emoses@onemedical.com)
Editor's Notes
- I was at conference recently where I opportunity to hear Sherman Hu speak – Sherman was the very first employee of LinkedIn’s Hiring Solutions business - #61 – It was essentially his job to recruit recruiters to use LinkedIn to source talent. And in his opening slides he made the following statement: “We are all here because we know how to connect with others better than anyone else.” – not just through technology and social media but also, as recruiters, we connect with people – on a deeper level. We become advocates, partners, best friends?? With our candidates. And when we make a successful placement, it’s not just a professional success but also a personal one. We know, as physician recruiters, that foreign-born physicians are a large piece of the physician staffing puzzle. In my experience, and maybe some of you have experienced the same thing - I’ve experienced a lot of biases – not only in communicating with physician leadership but also, if I’m being truly honest, within myself – pertaining to foreign born physicians and some of the behaviors that we associate with them. What we’d like to do today is talk about this – where do these biases come from? … We don’t believe that anyone in this room is saying ‘absolutely not, I am not hiring foreign-born physicians’ – but how can we take some real-life examples, understand where the biases are rooted, and then apply them back into our work so that we in-turn become more accepting of cultural differences and better champions for our candidates? We want this to be fairly casual. We will ask for feedback throughout the conversation and we want this to be a safe-space for everyone in this room.
- Quick introduction – a number of you know me… Director – private primary care practice group with 25+ offices across six markets. Previously I have worked in physician recruitment at Tufts Med Center and Baystate Health.
- Steph add Board work Diversity Rx conference
- So let’s step back and think for a minute about what we picture in our minds when we think of an ideal or “typical doctor” – both physically - what do they look like – and in a profile – training, experience, communication skills, etc. Well here are some doctors we see or have seen in media that we might be familiar with… Dr. Kildare (who’s this?), Dr. House, Doogie Houser (my personal favorite), Dr. Oz, Dr. Doug Ross - george clooney in ER? These are the images that come up when you do google search of “top tv doctors’ brings up these images… What do we see? They’re all white, attractive – they were all born in the united states, and they all trained in the us.
- Even when we see gender diversity… our image of doctors still fit stereotypes. One of the most popular female doctors of all time – Dr. Quinn – is a beautiful, white, american female. Then again, a consistent pattern of the show was that she was constantly battling to prove that a woman could be a good doctor. This is not to say that television doesn’t have female doctors and doctors of color – Grey’s Anatomy, Scrubs, and of most recent the Mindy Kalig project. But, these demonstrate the message that was imprinted into many of our minds throughout our lives – doctors are white men. And that image really sticks.
- We all have biases & we all have preferences – conscious or not – that have been shaped by our environment. So beyond the physical, when we think of our ideal doctors we also have a profile in mind. In my experiences as a recruiter, both with physician leadership and also within myself – I admit that when reviewing candidate’s CV I have my own hierarchy or order of preference mind which may resonate with some of you. My top choice is… next would be… followed by… From a numbers perspective, what does that mean? If we’re ruling out foreign born or foreign trained physicians, we’re cutting already cutting out 25% of our physician pool. Source: http://www.kevinmd.com/blog/2011/03/osteopathic-medicine-growth-graduates-physicians.html Practicing in the US – 68% MDs, 7% DOs & 25%
- Where do the come from? What’s their country of origin? Top 10 countries where IMGs practicing in the US received their degrees - Who do we see most in New England? Source: http://www.ncbi.nlm.nih.gov/pubmed/20679648
- Where are they practicing?? Top 20 states based on percentage of practicing IMGs to total physician population. Source: http://www.ama-assn.org/resources/doc/img/img-workforce-paper.pdf
- http://www.ama-assn.org/resources/doc/img/img-workforce-paper.pdf So now let’s look at what specialties IMGs are practicing in… this is by percentage of all physicians within that specialty - top specialty is Internal Medicine. Secondary is Psychiatry. IM, Family Medicine, Pediatrics , Ob/Gyn – all have significant IMG presence making up their total population. Almost 30% of Family Practice physicians are IMGs. . According to Jordan Cohen, MD, and Fitzhugh Mullan, MD, 25.8 percent of total physicians are in patient care (Jordan, 2006) (Mullan, 1995). Within the IMG physician population, 77.5 percent are in patient care Of all practicing physicians, 243K or 26% are IMGs. 27.8 % of residents were IMGs and also interestingly, 58 % IMGs were in primary care medicine (versuse USMGs at 26%). % of IMGs in residency in 2000 vs 2010 is exactly the same. Perception is there are more. Reality is that they are just more visible. “Regardless of whether they are United States citizens, all international graduates must go through an arduous regulatory process before practicing in this country, a process that includes verification of medical school diplomas and transcripts, residency training in American hospitals and the same national three-part licensing exams and specialty tests that their medical school counterparts in this country take. Many go on to choose specialties or work in the rural and disadvantaged geographic locations that their American counterparts shun”
- So who’s better? http://www.nytimes.com/2010/08/12/health/12chen.html?_r=0 http://content.healthaffairs.org/content/29/8/1461.full.pdf+html Though these doctors have filled an important national health care need for over half a century, doubts regarding the quality of care they provide have continued to plague them. Studies initially revealed that international graduates tended to score lower, while more recent research shows that they routinely outperform their peers on training exams in areas like internal medicine. And it turns out that contrary to certain individuals’ worst fears, accent or nationality did not affect patient outcomes. Rather, the main factor was being board-certified: completing a full residency at an accredited training program, passing written and, depending on the specialty, oral examinations, and having proof of experience with a defined set of clinical problems and technical procedures. Dividing the international medical graduates into those who were foreign-born and those who were American citizens who chose to study abroad, the researchers discovered that patients of foreign-born primary care physicians fared significantly better than patients of American primary care doctors who received their medical degrees either here or abroad. We THINK that someone's culture and accent is going to impact their patient satisfaction - but they don't.
- Stephanie I just want to mention briefly what we’re talking about when we say “culture.” Culture is learned, not innate. We’re not born with culture. It’s something that we experience and develop within and adopt. Culture is broad, not just race and ethnicity. Each dimension of diversity has its own culture. The culture of women, the culture of our organizations, the culture of youth. Culture changes; it is not static. As an example, think of the culture of your organization. Has it stayed the same, or has it changed over time. Think about the culture of women. Is it the same now as it was 50 years ago? Culture exists within all groups. Culture defines group norms and boundaries. It is the unwritten rules of a group.
- Stephanie (CEO Resources, 2003)
- Stephanie Let’s shift gears a little. This is the Hulk rollercoaster at Universal Orlando: Islands of Adventure. In this picture, you can see a little less than half of the ride. Raise your hand if you think this looks like a blast! Who thinks that those people are crazy and this looks terrifying? Thank you. For the record, it was awesome. So some of us have bias in favor of roller coasters and some have bias against roller coasters.
- Steph Bias is valuable – it allows us to quickly make decisions all day. 79% stat – kudos to them for their honest! Bias can be tricky though. Our bias doesn’t always provide us with the best information. Let’s look at that.
- Stephanie Bias can effect how we interact with people. As soon as Susan stepped out on stage and started talking, we saw what people were thinking, didn’t we? It was all over their faces – the laughs and eye rolls… Aren’t you glad that they didn’t just send her away at that point?
- Stephanie What did people think when they walked into the movie theater? Wow, look at all of these scary guys! What was scary about them? Was anyone in the middle of a fight? Was anyone screaming profanities? No, we have this preconceived notion…this cultural bias…that guys with this look are scary or bad. What happened when a couple pushed past that bias and settled in? They got free beer! Let that be a lesson to you – pushing past bias may bring you free beer.
- Stephanie Video for background, not for inclusion in presentation: http://www.youtube.com/watch?v=K9nFhs5W8o8 I’d like to introduce you to the ladder of inference. This is how we break down and explain the process that goes on in our brains in a split second. We observe something. We select data from what we’ve observed. Why? Because there’s so much going on, that we can’t take it all in, so we have to narrow our focus and ignore the rest. We add meaning. This is the cultural and person stuff that we’re raised and socialized with. This is where fight or flight kicks in. Is this good or bad? This seems… We made assumptions about the other person’s perspective based on the meaning that we’ve added. This must be… We draw conclusions. This is the story we tell ourselves about our observable data. This is… We adopt beliefs based on those conclusions. These beliefs may be new, or they may reinforce the beliefs we already have. We take action based on our beliefs.
- Stephanie Let’s take a look at our roller coaster again and see how the ladder of inference plays out. About slowing down & checking our brains – why do I think that, and does it make sense? And this happens with people all the time… so let’s take a look at real-life examples.
- What are some things that might make “us” uncomfortable as recruiters? Limp, soft or what I’ve heard referred to as “dead fish handshakes”… You go to greet a candidate when they arrive at the clinic or hospital, reach out to shake their hand hello, and you feel like you’ve just shaken… well… a dead fish. what are the messages that we have in our head this happens. Ask the audience - what does it mean to you as a recruiter? What do we think of when someone shakes your hand like this?? What does it say to you about the individual? Great, so let’s look at this from another lense…
- Steph
- How about this situation – You’ve FINALLY identified the pcp doctor or cardiologist, arranged a full day of visits, back to back – every detail is orchestrated down to the minute. And the doctor shows up 15-20 mins late with no apology or even acknowledgment that you’re now running behind by half an hour in your schedule? What would this situation say to you about the candidates?? I know in my experience I’d be frustrated and annoyed… annoyed that I spend all this time an effort arranging the schedule for the day and the doctor seems to not care at all. It feels disrespectful
- Again, from another lense…
- On the flip side - Punctuality is very important in China, as well. Lateness or a cancellation is a serious affront. Never exaggerate your ability to deliver, because the Chinese believe humility is a virtue – and also because they will investigate your claims. Introductions tend to be formal, with courtesy rather than familiarity preferred. Avoid making exaggerated gestures or using dramatic facial expressions. The Chinese do not use their hands when speaking and become distracted by a speaker who does.
- You’re sitting down with a candidate, reviewing benefits, etcs. And the physicians will not make eye contact with you… they’re looking at the table, at their hands, over your shoulder but not directly in your eyes. On top of that, they’re also mumbling or talking so quietly that you have trouble even understanding them. How many of you have had that experience?
- Philippines – staring at someone is considered rude. Lack of eye contact, or eyes looking down. Speaking in a loud voice is considered rude. Speak in quiet, gentle tones. Filipinos revere harmony. The only time you are likely to hear loud Filipinos is when they are boisterously happy.
- I recall this one physician I had brought in for an interview on Boston once and we were standing outside my Chair’s office waiting for him to wrap up a previous meeting… and the candidate was standing so close to me that it was uncomfortable. He wasn’t touching me that there was clearly this invisible line of personal space that he was invading because it felt uncomfortable. So close that you could smell the salad on his breath from lunch… Has anyone else experienced something similar before?
- Mexicans highly value the individual dignity of a person, regardless of social standing or material wealth. It is important not to full rank, publicly criticize anyone, or do anything that will cause an individual to be humiliated. Men should avoid putting their hands in their pockets. Hands on your hips indicate that you are making a challenge.
- Steph This is what these interactions look like – let’s talk about what we do about it. How do we address it? First step is recognizing & identifying. Go beyond ‘this person isn’t going to be a good fit’ – and what does that mean? Sondra Thiederman, PhD has done a great deal of work around bias-reduction strategies. She’s the author of Making Diversity Work. She advocates a three-question “Bias ID Test”: Would I feel the same way about this person’s behavior if he or she were of a different group? Have I had a memorable positive or negative experience with this group during which the characteristic that find came to mind was seen? What do I do when I learn that an individual does not conform to my first thought?
- Stephanie