So hi everyone, my name is Lauren Hamill, I am a faculty member in the School of medicine at Wayne State University and the Karmanos Cancer Institute in Detroit Michigan. And today I'm going to talk to you about the influence of patient and physician attitudes on communication in cancer care. And there's a specific focus on interactions between cancer patients who are black or African American and they're non black, non African American oncologists. So today we're going to go over a few things, first, we will describe the role attitudes and communication plays as contributors to health disparities. We're going to examine the communication that occurs between black cancer patients and non black physicians. We're going to talk about physicians implicit and explicit biases and how those biases have been shown to affect patient perceptions and expectations. And then by the toward the end we're going to focus on the last part of the research that we're conducting. Which looks at jointly determined behaviors between patients and physicians and cancer treatment interactions. And then we'll end with some solutions about how to mitigate the influence of patient physician attitudes. And I might contextualize a little bit more just by saying we're focusing on race related attitudes. And in particular, we're looking at physicians implicit and explicit biases of race, but then also patients attitudes of suspicion. And if they're suspicious that they may not be getting as high quality of care due to their racial group, also experienced with previous discrimination. And then general distrust or mistrust of the health care system in the United States. So I'm sure many people in the audience are familiar with the Institute of Medicine's panel on the causes of health care disparities that that text was called unequal treatment. And it came out almost 20 years ago, but it was a really influential text, it provided a lot of information about the roots of disparities in our health care system. But the one that I'm focusing on is what the panel kind of identified as being at the patient and provider level, and that is the source of some of these disparities clearly are complex. And they're rooted in historic and contemporary inequities and they involve both healthcare professionals and their patients. And specifically this panel identified that there were race related attitudes that influenced communication and disparities and treatment immortality. And that was healthcare provider prejudice or bias and minority patient mistrust and refusal, so, of course, there are a number of other causes of disparities biology of tumors. For instance, if we take to the cancer context, socioeconomic factors, access to quality care, the environment that people are raised in, so of course there are many contributing factors. But my research and the research of my study teams focus on these two contributors, which is patient provider attitudes. And then, ultimately, the communication that they have between them, so this gives you an idea of the kind of general model that we use as we conduct this kind of research. So if you'll kind of envision like, pre, during and after the model of patients and physicians meeting to discuss medical care, and this can be applied to a number of medical contexts. As I mentioned, most of my work happens within oncology or within cancer, so that's where the context is, for most of this talk, but it can be applied very broadly. So, we assume that patients and physicians come into an Interaction together, right, one patient, one physician and they're both humans right there, both individuals. So with them come a lifetime of experience, for the patient's side it's a lifetime of experience as being a racial or ethnic minority in our country. For the physician, it's someone who may or may not be a minority, in our work we focus on interactions that happen between black and African American patients. And their physicians who are we refer to as basically non black, not necessarily white, but not of the same race as the patient and they have their experiences and attitudes as well. And so the assumption is that those kinds of attitudes are brought into an interaction and that that will influence the communication that these two individuals have. It will influence how that communication occurs over time in the interaction and it will also influence the perceptions they have of one another. So how, kind of how they evaluate each other, the patient sees the position as being trustworthy. For instance, if the physician sees the patient as someone who will adhere to or tolerate treatment and then ultimately those that communication. And those perceptions will affect outcomes both short and long term, so in the short term, maybe it's a treatment decision, maybe it's a decision to go on a clinical trial for the longer term. It could be treatment adherence, again to use cancer as an example, cancer really isn't something that you treat one time. You treated in a campaign there are a number of treatment visits, a number of follow up appointments and treatment can last for months, even years. So this is the model that we work from, we assume that there's influence from attitudes and communication and then that influences outcomes. And I'm also before I jump in to some of the specific findings, I think it's really helpful to contextualize what we already know about communication in what we call racially discordant diets. Again, as I've been emphasizing patient and physician of different races, all of the work that I'm bringing in today focuses on patients who are black or african american and a physician who isn't. So what we've seen over many studies that observe communication in these interactions, we also ask patients and positions to report on their experiences and their actions is that. We see communication for black patients is frequently of lower quality than clinical communication with white patients and what do I mean by that? So we see on the physician side that on average physicians tend to provide their African American or black patients with less information, they approach them in a less patient centered way. They tend to be more verbally dominant and they tend to be more contentious, on the patient side, we see that flag patients tend to ask fewer questions than white patients. They participate less than their decision making around treatment and they also leave their interaction with less understanding of their diagnosis and treatment plan. We also see that clinic visits are often shorter for black patients compared to white patients. Now, it doesn't necessarily mean that attitudes are responsible, but it's a disconcerting pattern to say the least. And I also want to stress here and I bring it up again later is that across medical interactions a patient. A black patient is most likely to interact with someone, a physician from a different race and that's especially the case in oncology. My colleagues and I published a commentary a few years ago which highlighted the dearth of practicing African American or black medical oncologist in the United States. And across the entire country, there were fewer than 200. Practicing medical oncologists who are black so that means when a black patient encounters a physician there likely to be seeing someone who's a different race and likely experiencing lower quality communication compared to their white counterparts. I bring this text into all of my talks when I discuss implicit bias because it's something that it's applicable to a number of settings, not just medical care, but it gives the reader understanding of where our implicit biases come from. This is really important piece of this work the book is called Thinking Fast and Slow, It's by Daniel Kahneman, he's a Nobel prize winner and it really gives you an academic understanding of what implicit and explicit biases are. And especially very recently, the talk of implicit bias has increased and as someone who studies this, of course, I want attention to be given to this construct, especially one that I think is very important, but I also think we run the risk of losing what it really means. And I think it's important to understand as we start talking about this work, but what implicit biases, I'm going to do a very brief summary of what it is. But just to remind everyone that it's not an attitude that we hold consciously implicit biases I think are better to think of them as strengths of associations rather than an attitude that we can hold or foster. It's the strength of association between between two.Excuse me, between two things right, so it's not an explicit bias and these we build associations over time. We build associations by living in our culture with repeated messages from friends, from family, from media and we start to develop those associations. So you know really, common one is women stay home and take care of the home men go out for a living white people have certain kind of jobs, minority people have a different types of jobs. And it doesn't need to be based in evidence, It's just kind of the repetition of messages and the extent to those associations is what is our implicit bias. And it's not really a part of my talk today, but there are a number of implicit association tests available online through the university,excuse me through project, implicit project implicit at Harvard. And you can get a sense of how these biases are measured you can even get a sense of what kind of implicit biases you hold and really to drive the point home that this is implicit biases don't make us bad people. Implicit biases make us people and our brain is really good at associating things and in a lot of ways it's really helpful that we don't have to think very carefully about every step of our lives. But on the other hand, it can become quite dangerous if we start building up associations, especially those that have been shown to be hurtful toward others. So, if you take on Kahnemans text, you'll see that he divides our way of thinking into two modes. All right, so there's the thinking fast or the implicit processing and there's a thinking slow or the explicit processing with implicit processing. It's a lot of unconscious reasoning, there's low effort, it's automatic, not a lot of logic, not a lot of purpose, and our thoughts and feelings are automatically activated and a lot of times are manifestations are hard to control, and they're usually nonverbal. The example that I use in my lectures is if you've ever been accused of having an expressive face, it's not something that's given as a complement, it means that whatever you're thinking inside is being shown on your face. Probably in a way that you don't intend when I was little, my mother told me that if I didn't stop rolling my eyes didn't get stuck that way happily, that didn't happen. But it goes to show you that whatever I was thinking was coming out through my eyes even though I didn't intend them to if you compare that to the thinking slow or the explicit processing, remember like thing to a time where you really had to focus if you were writing a paper or taking an exam. Your reasoning is conscious, your effort is high, your have a logic and purposeful way of thinking, your thoughts and feelings are activated very consciously and it's much more easier to control. And those are your usually are verbal reactions so we know through research that race related thoughts and feelings operate at both levels. But implicit bias is a better predictor of discrimination and discriminatory reactions so that's why we spend a lot of time measuring and studying that particular type of attitude. So hopefully with some context there, let's start talking about physicians, race related attitudes and racially discordant interactions that they have with their patients. So at the explicit level, so right, the very conscious, very focused way of thinking physicians consistently denounced over racial bias in a national Survey, of positions said that they give better care to black patients than to their white patients. However, today's racial bias is often implicit process so overt expressions of explicit prices have declined dramatically in recent decades not to say that that's gone, but it's not the same levels that they use it as it used to be. However, implicit racial bias still exists and this is more difficult to control and interactions. And interestingly, when we examine levels of implicit bias and physicians and compare them to the rest of the public, they actually have higher levels of both implicit and explicit explicit racial bias. These data were published 12 years ago, so they're getting a little bit old, admittedly, but there's no reason to expect that the levels of implicit bias especially have changed very much. So you'll see that the public respondents are in yellow and the physicians are in blue and in both in terms of explicit and implicit bias we see that physicians have higher levels now, as I mentioned previously. Why is it so important to study these types of medical interactions? So specifically the interactions that occur between black patients and a non black physician? Importantly, because the majority of the black patients, medical interactions are likely to be racially discordant. I met mentioned earlier about a commentary that we published a few years ago in the Journal of Clinical Oncology that showed very few black medical oncologists, the United States. In fact, there's only 177 which was less than 2.5% of all medical oncologists in the United States. We also know that black people as a population bear a greater cancer burden than white people or really any other racial or ethnic group. There's higher levels of incidents and lower survival rates and the greatest disparities we find are in survival for the most treatable cancers, so we're not talking about no rare, difficult to treat cancers. We're seeing these disparities in cancers that we know how to treat and treat well. And ultimately, I think it's important to remember that the interactions that occur between patient and physician depend on both of them depends on both of them to agree on a recommended treatment to adhere to a treatment. So on the one side you have a you may have a patient that may want treatment, but a physician may decide that the patient is unlikely to adhere to tolerate or benefit from that treatment. On the physician side, he or she may recommend treatment, but the patient may decide that the treatment benefits aren't worth the cost of receiving treatment. And that could be cost like out of pocket costs. But it also could be cost like paint could be suffering, specifically in cancer. Treating cancer is not an easy thing to do. It makes people feel sick, and if a patient doesn't trust or believe their physician has their best interests at heart, they may be unwilling to take on that kind of thing. And race related thoughts and feelings could be especially salient in racially discordant interactions. And any treatment decision that's driven even in part by racialated thoughts or feelings rather than objective medical factors are preventable racial healthcare disparities, which is why it's critical to examine these interactions. So let's talk a little bit about patient perceptions. Interestingly, we found some really interesting patterns with how patients perceive physicians based on their levels of implicit and explicit bias. So let me orient you to this graph because it's a little bit complicated. Now, just to remind everyone, we did talk about implicit bias as something that operates outside of our control. So I think that's important to remember as we start looking at these data. So a set of physicians is given to measures one of their explicit racial bias and one of their implicit racial bias. And then they see their patients and patients are then asked if they're satisfied with that position. What's very interesting about the pattern of findings here is that we see patients are least satisfied with physicians who are low on explicit bias, but high on implicit bias. So that particular profile has been coined the aversive racist. So if somebody who if they were told that they had implicit biases would be horrified. There are explicit biases are one of being egalitarian equality, but their implicit biases are different. But I find particularly fascinating if that this profile with a group of people who are unaware of their level of implicit bias are seeing patients. And the patients are less satisfied with that particular type of physician. So they're encountering some type of behavior that they can identify that is less satisfying than a physician who is low on implicit and also low on explicit. Interestingly, we also see patients that are more satisfied with this subversive racist profile than they are with a physician whose high in both explicit and implicit bias. So physician that has higher than average explicit biases is actually perceived as more satisfying with patients. And there's a lot of conjecture around what that might be. I have some ideas and I started to take on this particular research question in my own work, which we'll talk about a little bit as we move through. So we also see the same pattern of findings when we talk about trust. So again, if you look at this bar right here, here are patients with the lowest amount of trust and it's that same aversive races profile. So you have low explicit, but high implicit bias and similarly it's physicians who don't know what their level of implicit biases because again, by definition it operates outside of our awareness. But physicians are acting in some way that patients are noticing, and that some way is something that I spent a lot of my time trying to figure out. And this type of research has led shed some light into this particular question. So we don't know the kind of pathway right of implicit bias behavior outcome, but we are beginning to see some interesting trends in how in certain behaviors that associated with implicit bias. So this summary slide here shows some work that have examined physicians who are hired implicit bias, favoring white people tend to have shorter interactions, communicate more negatively. Are more verbally dominant, are less supportive, and more likely to describe side effects of treatment as miles with their black patients. So this isn't physicians community, we're not comparing interactions with black patients and white patients. What we're doing is comparing physicians who are hired implicit bias to positions that are lower and implicit bias. And I think another element not ensuring that implicit biases understood correctly is that often the biases that we have are favoring our in group. So it's often more about favoring the group of people that you identify with more than it is about discriminating against or hurting kind of your out group. And that in group can be anything, it can be raised, it can be gender, it can be professional associations, it can be religion, it can be political ideology. So in this case we're looking at that kind of continuum of bias toward white people. So this is where we see some really interesting observations about the link between that level of implicit bias and how physicians are actually acting with their patients. And I should also emphasize while we work through some of these findings, is that these aren't self report data. So it's not just patients reporting on their physicians, but iwe've had the opportunity to video record a number of these interactions. So before a patient and physician meet to discuss treatment, we've been able to assess physicians levels of implicit bias. We've been able to assess patients levels of suspicion, experience with discrimination, levels of mistrust in the health care system. And then observe how they communicate with each other and then use those video recordings to you know more objectively assess the behavior of the individuals, but then also the diet. So we're able to time interactions, were able to code the type of communication they have. Assess it using validated scales in terms of how negative or positive they are, how dominant they are, how supportive they are. And also to the extent to which they talk about very specific things related to treatment. We also see some really interesting findings in terms of what patients expect from their treatment? So certainly it's one thing to observe and describe the different types of behaviors that occur in exam rooms between different patients and different physicians. It's quite another to walk away with some understanding of what that communication could mean for the individual patient. So we actually see some really interesting patterns where physicians with higher implicit bias. Again, favoring whites, have lower patient centeredness or lower patients under communication. And that leads to patients having less confidence in their treatment outcome and greater expected difficulty in completing treatment. So of course this is their perceptions and expectations. We don't know whether or not this influences treatment necessarily, but if you can imagine a situation if a patient is maybe suspicious, maybe not so trusting. Maybe has been discriminated against in the past, either in a medical setting or not. And they encounter a physician who's not very patient centered. Maybe they observe some of the physicians behavior as being slightly odd that they might have reduced confidence in the treatment and not want to take it on. Or if they think it's going to be harmful, maybe they won't adhere to it. So, this is it's a disconcerting pattern for sure. And I think with every step we get a better sense of the nuances. But of course this is one that looked directly at what patients are experiencing. So, I think kind of just to reiterate that this implicit attitude that theoretically we're not aware of. However, physicians with this level of bias or acting, they have patients who are less satisfied and less trustful. They're noticing patients are noticing or picking up on, which is not a very scientific term. But they're noticing the behavior of physicians with higher and implicit bias, so physicians aren't even aware of it. But the patients truly are. So before I move into kind of where this research has moved, at least for me, I want to talk a little bit about patient attitudes and perceptions because so far we've been focusing mostly on the physician. But if there's two people in that room and patients have their own attitudes and those do things to their communication and their perceptions as well. So we actually see as I mentioned, we spent a lot of time measuring patients levels of suspicion that they may not be treated as well given they're given their race or ethnicity. We also look to see how trusting patients are of medical institutions in general and also if they have experienced discrimination. And I don't have a slide devoted to this. But there's been some really interesting trends coming out where if someone experienced discrimination in one setting education or housing or criminal justice, that those that experience can have an effect in a medical setting as well. So maybe patients haven't experienced discrimination in medicine, but there are other experiences can influence their medical interactions subsequently. So our data,, also shows some really interesting trends with patients. So we found that highly suspicious black patients are perceived to be less educated and less intelligent by their physicians. And that's when we control for things like education. So the difference is that physicians are perceiving aren't real, they're noticing something else. But the suspicious nature of a patient is being assumed to be something about their education and intelligence. We also see that black patients lower and trust of medical institutions and who have previously experienced discrimination tend to talk more and interactions with their physicians. And we've interpreted at last finding their as potentially a way for patients to control the interaction. So if they have experienced discrimination previously, they may be working to prevent that from happening again by maintaining control of the floor. And trying to guide the interaction in a way that they think will benefit them. So, I think when what I really want to stay with these findings and I know we kind of covered a lot relatively quickly. But it's that racial attitudes exist for both patients and physicians. We know that they're persistent and they're influencing communication and in some cases outcomes. Of course, there's more work to do. There's always more work to do. But over 10, 20 years worth of research,, we're seeing these patterns persist. And the more nuanced our methods become, the better we are identifying what exactly is going on in these interactions of course with the goal of mitigating them right? So again, studying to understand and describe is excellent, but the endgame should always be the intervention. So what do we need to do to make this communication more productive for these patients and physicians? So, before I end, I just want to take a few minutes to talk about the area of research that I've taken on over the last few years, which is focused on kind of jointly determined behaviors. So so far we've talked about behaviors and perceptions of the individual positions do this patients do that physicians perceive this patients perceive that. But, if there's a die yet, right? And I think I've said that a few times already, there's a it's the diet is the unit of measurement in these interactions. And happily, I've made some strives to advance our methods as we look at that in a more dietetic way. And happily, I've had some research funding to move that along. So I have a background in nonverbal communication and studies of non medical interracial interactions have found that attitudes like bias and suspicion. And other relational level factors are more likely to be expressed through less deliberate nonverbal communication, like our facial expressions and our posture then through more deliberate verbal communication, the words that we speak. So as an example, you can imagine a time when there is discrepancy in the words that a physician speaks and how they're spoken. So, perhaps the physician is using comforting words, supportive words. But doing so without finding or maintaining eye contact or speaking very quickly as if in a hurry to be done. And it kind of goes back to an old saying in my discipline, which is, you cannot not communicate. So even when your words are appropriate or correct, you're accompanying nonverbals may say otherwise. And in fact the disconnect might even be what heightens suspicion or attention. So my team and I just published a paper in the journal cancer that came out in print just last month. And we employed network analyses to investigate discreet nonverbal behaviors between physicians and their black patients. And this helped shed more light into the dynamic interplay of their nonverbal behaviors. And it's a good step forward certainly you'll see an example of the network analysis in the upper right hand corner showing how discrete behaviors work with each other. However, this lacked a white comparison group. So my entire patient sample were black and African American cancer patients. But I think if you really want to understand the difference is you need to kind of have a head to head comparison. So what I'd like to do is take a little bit of time to talk about my newer project in this area. And that includes a comparison between interactions with white patients and interactions with black patients. And it's a construct in the nonverbal communication world that's gained a lot of research attention, especially in clinical settings. And that's nonverbal synchrony, which is a non conscious coordination of physical movement that occurs between individuals during an interaction. And the reason why I have fred and ginger in this presentation and I always have is that nonverbal synchrony was first measured using ballroom dancers as two people that were about as in sync as to humans could be. In fact, research has taken this on to examine how this construct works in interpersonal interactions. And what we found is that nonverbal synchrony is both predicted by pre interaction attitudes and has post interaction consequences. So we see people synchronize their behavior more with others whom they have a positive relationship with people with. That they want to develop a positive relationship with and people they trust. We also see that nonverbal synchrony reflects positive affect, liking, similarity, closeness, and rapport. And perhaps more specific to our context. We also see that synchrony influences the therapeutic process, cooperation, obedience, and memory. And you know, I should say I have the word obedience there and that comes from a lot of European literature and I think the American word we probably would want to use would be treatment adherence. [COUGH] So not only is this examining dynamic behavior, it's also very subtle. We're looking at attitudes that are like subtle. And so the argument that I kind of have is that nonverbal synchrony is subtle, unintentional, automatic, and affect laden and the expressions of racial attitudes are likely subtle, unintentional, and affect laden. So this could potentially be an important indicator for relationship quality in a clinical interaction, especially as we examine the influence of racial attitudes. So this study is currently ongoing. I published my protocol a few years ago in the BMJ Open as a secondary analysis that we use videos that we had already collected from a few other and CIA funded grants. And just to kind of give you a sense of what the methods are, is rather than using human coders to observe and track and rape behavior. We used this motion energy analysis software, which automatically tracks behavior over the course of a video reporting. So I have a screen grab here. Now the people that you're seeing in the video are actors, they're not real patients and physicians, but it gives you a sense of how we were able to code these data. So we submitted all of our video recordings, we had more than 200 in total. We had a sample of black patients, and sample of white patients and we were able to track that synchronized behavior in all of those interactions. Now this is one of the first studies to examine the reciprocal nature of naturally occurring communication using a dynamic and jointly determined measure. So it's not, the physician smiled these many times. The patients smiled these many times, the physician ask these many questions. The patient ask these many questions. It's something that they mutually contribute to. And I think that's really critical as we start looking at the diet more than at the individual. Before I move on to the end of the presentation, I will say our findings are being written up on the verge of submitting the first paper from the study for publication. But just to say, we are finding some really fascinating racial differences. So physicians are coordinating differently with their black patients compared to their white patients and we are seeing some influence with attitudes. So I'm hopeful that if we're able to reconvene in the setting again at that point, I'll be able to share our published work in that area. So as I finish, there's kind of the, there's the research part of it, right? Like if you're curious and inquisitive, there's always another question to ask and it's a fascinating area to work, but I spent a lot of my time working with my clinician colleagues to who say okay, so now what? Like we appreciate that there's attitudes, we appreciate that a lot of these attitudes are operating outside of our awareness. What can we do about it? Which I think of course is a really important question because as I was saying earlier, the end game should be, what do we do to intervene? What do we do to improve the communication? What do we do to improve patient trust, satisfaction, adherence? I'll start by saying a solution that probably won't work, which is simply telling physicians or other health care providers to just control their biases. That may actually cause physicians to become self focused and more oriented toward monitoring their own performance, then toward learning about the particular needs and concerns of the individual patient with whom they are interacting. So imagine if someone tells you okay, control your biases, all of your attention is going to go to you, to your brain, to your body, to your face, and doesn't make for a very productive interaction. As I said already implicit biases by definition are operating outside of our awareness. So it's not helpful to ask people to do this. In fact it could make things worse. And a lot of medical settings that does happen unfortunately. So to be candid, the evaluation data on implicit bias training is sparse and not very encouraging. Some of my colleagues and I in the school of medicine at Wayne State have been working very hard to build a comprehensive curriculum to address a variety of implicit biases not just race based. But you know, it's a marathon, right? So it requires a comprehensive effort. But I have some suggestions for solutions based on the available data and I have them divided into a few kind of different buckets. There's a physician focused approaches, patient focused approaches, approaches that focus on the patient physician relationship, and then finally the system level. So for position focused approaches and really this could go provider focused. You can remove the medical context completely and just say in person focused if this is something that you want to take on just as an everyday communicator is encouraging physicians to individuated their patients. So unique person, not a representative of a group. Of course that can be accompanied with teaching patient centered communication skills, which is helpful for all patients. Not just patients that are different from us, are different from you but working to become more patient centered and there is skills, many skilled curriculums like that. And there's something that people can take on and get better at and would likely mitigate the influence of any biases. There's patient focused approaches. Now I spent time building and testing interventions for patients. I don't think it's the patient's responsibility to have to undo or work through the awful history that are an awful is an understatement of our country's healthcare system. But I do believe in being your own advocate. So teaching communication skills and strategies for patients to help them illicit important information. One tool that my group and others as well have had a lot of success with is building question prompt lists for patients. So providing them to patients just before they meet with the provider to make sure that they're asking questions that other patients have said are useful. So they can get the kind of information they need. That's just one example, of course. Can also focus on the patient-physician relationship, working to build an alliance using relational communication, creating a sense of common in-group identity using psychological principles. And a previous study that my group did they kind of induced patients and physicians to consider themselves part of the same team. So the physician is the expert in the medical care, the patient is the expert in his our own health history, and preferences, and goals. And what they consider to be important for quality of life. And that working together is what helps you determine what treatment is best, and then also helps the patient adhere to it. And then finally your system level approaches. If you're in the position to have kind of a higher view of whatever the organization is, whether it's a clinic or a hospital or a cancer center. Using aggregated data to provide feedback on disparities. So if you are able to assess our certain patients getting different treatment, are they having differential outcomes? Do we have disparities in our own center and then using that to feed back to your providers? And then of course working to increase treatment standardization. And I think if I could leave everyone with a final thought, implicit biases are not something that we can cure. There's no vaccine for implicit biases. So, what you might want to do is focus less on rewiring yourself and more on creating an environment where implicit biases are less likely to be activated. So things like I mentioned, individualizing the patients, reducing distractions to the best that you can. There's some really interesting data on what activates are implicit biases. And one of them is having limited ability to process information, if you are time pressure, if you're having competing demands in the moment. And of course our lives are full of distractions. But working to reduce those to the extent that you can, giving patients time to speak so that they're able to convey their concerns and their worries. I appreciate that we're all pressed for time, especially clinicians, but creating an environment where a patient is able to speak their mind about their current concerns can go a long way. And then also giving your time for your own self to question your assumptions. And this is something that we can do not just in the moment with a patient or a client. When you're speaking with somebody else, if you have an assumption about them, give yourself a few extra heartbeats to wonder why did I make that assumption. Did I know that because of something objective or did I assume that? And why did I assume that? And is that affecting this relationship? So, this is not something that happens overnight, it requires commitment in a campaign. But I think again, having the environment where a bias is less likely to be activated. I think is an important goal. And before I finish, in addition to Daniel Clemens book I also want to mention the Kerwin Institute based in the Ohio State University and their state of of Science implicit bias review, published in 2014 is a great text. It's got a lot of information about the summaries of implicit bias research in all areas including health care. And before I finish, I just want to say thank you for having me again. My name is Lauren Hamel. I'm basically in State University and I'd be happy to take any, I guess questions after the fact. This is my research world, so I love talking about it. Thank you so much.