Medical Residents Explore Implicit Bias at the Penn Museum

August 18, 2017

Looking closely: Marina Di Bartolo, far left, with fellow medical residents, and Program Director Marc Shalaby, MD, examining the seated statue of Ramesses II in the Egypt (Mummies) Gallery.

Fresh Eyes in the Galleries 

It was 8:00 am on a Thursday morning in July, early for most Museum staff, but the special visitors from the Hospital of the University of Pennsylvania—seven medical residents and a program director—appeared wide awake and ready to engage.

The residents had agreed to participate in a pilot program at the Museum, the brainchild of second year internal medicine resident Marina Di Bartolo, developed in conjunction with Dr. Anne Tiballi, an anthropologist and the Andrew W. Mellon Director of Academic Engagement at the Penn Museum. Marina had participated in a similar program as a medical student at Yale, where students focused primarily on training in deep observation, engaging primarily with European paintings from the Center for British Art. The Penn Museum project would include deep observation training, but the goal of the training went a step further: to help emerging doctors recognize and reduce implicit bias, bias that can interfere with doctor/patient communications and effectiveness when working with diverse patients. Marc Shalaby, MD, the Program Director for Primary Care Residency, was excited about the idea of exploring implicit bias, and supportive of the pilot project with the Museum.

The focus of the observation, on this morning, would be a selection, not of paintings, but of culturally diverse objects from the Penn Museum’s international, and internationally renowned, collections.

About Implicit Bias

Implicit bias involves associations outside our conscious awareness that lead to misleading, often negative evaluations of a person based on characteristics such as race, ethnicity, sexual orientation, or gender. Medical professionals are not immune to implicit bias, as recent research reported in BMC Medical Ethics (2017) makes clear. Left unconscious and unexplored, these biases can influence diagnoses and ultimately, treatment decisions for patients.

Before entering the galleries, the group settled into an introductory session in the Museum’s Nevil Classroom. Dr. Tiballi began. She spoke about a decade-plus shift taking place in museums, as traditional collaborations with “the usual suspects”—archaeology, anthropology, and art history students and scholars—are making room for a new model of learning and “skills-based programming,” where the Museum’s rich collections are explored anew as “media” to help new audiences better connect with diverse people and cultures.

Marina shared a bit about her experience with the Yale program, where the art was predominantly from the 18th and 19th century European traditions. She had reason to be enthusiastic about a museum collaboration; there was evidence that even short training in deep observation helped medical students perform better with patients; later tests indicated that the positive results of deep observation practice stayed with them. At the Penn Museum, with a collection of archaeological and ethnographic cultural material from around the world, the objects for the workshop would be very different from European paintings—and Marina was interested in learning how that would change the program.

Dr. Anne Tiballi (middle) talks about an artifact with the residents.

“The Penn Museum has over a million objects from six continents. We had to think of something different for you all,” said Dr. Tiballi, suggesting that the residents could think about the pieces in the collection differently, too.  “Use objects as a window into underserved past lives. Who used these objects? How? Why? Objects are really agents, just as people are.”

The residents shared definitions and thoughts about implicit bias, and its negative associations—usually based on race, gender, or other demographics—bias that can directly affect how a patient is treated, sometimes with negative consequences.

“We are all subject to direct and indirect messages that society blasts at us,” Marina conceded, noting, “as residents, we are much more prone to this because of our cognitive load—we are tired.” She suggested a few tools to use to limit bias: increasing awareness of the pervasive problem; having a desire to change; learning more about the theory, practice of bias, and finally, employing tools, like this workshop, to overcome the tendency towards unhelpful bias.

“Archaeology has had its own embattled history with bias,” Dr. Tiballi said. “Archaeology really wanted to be a science—but we aren’t exclusively a science. And we all come with biases.”

After a warm up exercise—each participant was asked to talk about an object that they happened to have with them, discussing what it meant to them—the group was ready to visit the galleries and see how bias might play a role in their exploration of Museum artifacts.

Exploring the Objects

Once in the galleries, the residents spent time looking closely at three objects, including an eye kylix drinking bowl in the special exhibition Magic in the Ancient World and a colossal seated statue of Ramesses II in the Egypt (Mummies) Gallery. The first object, and the first stop, was in the Native American Voices exhibition.

A girl’s elk tooth dress, from the Crow nation, was one of three objects the residents examined and discussed in the galleries.

Stephanie Mach, a member of the Academic Engagement Department and PhD student in Penn’s Anthropology program, directed the residents to avoid reading any explanatory text, instead looking closely at an object in the corner of one large case, and describe what they saw. The residents grew uncharacteristically quiet. One resident broke the silence: “I will say, I find it very difficult to look at this object and not make any assumptions.”

“Yes, you want to make these initial jumps into interpretation,” Dr. Tiballi acknowledged, offering a suggestion: “Just start by describing what you see.”

The answers came more quickly: “Three feet by two feet garment made of cloth, with teeth, or bone, or shell, sewn on.”

The residents added detail to their growing group description, noting beadwork, condition of the fabric and colors, vibrant red and some blue. After some time, Ms. Mach filled the group in on what was definitively known about the piece—and what some research into the time, place, and provenance of the object suggested about the item.

There was general surprise when she noted that the clothing was designed, not for a woman but for a little girl, from the Crow nation living in Montana, circa 1880. It was an Elk Tooth dress, and as the residents had surmised, the quantity of elk teeth richly decorating the dress spoke to its value.

Dr. Tiballi noted that the Crow culture frowns upon bragging about one’s wealth and prestige. One way around that cultural taboo would be to let a child’s clothing express a family’s wealth and status.

Ms. Mach presented some of the context of the piece, noting that though we don’t know the name of the girl who owned this dress, we can piece together a story from the cultural context in which it was made and worn, and by examining the material clues of the dress itself. The trade materials (woolen cloth and glass seed beads), imitation elk teeth made of cow bone, and designs that compose the dress expressed Crow identity, wealth, and pride during a time that was especially difficult for Crow families.

During the period from the late 1800s until 1934—when the dress was made— the US government policy of forced relocations and reductions in Native landholdings made daily life tenuous. Many American Indian children were sent to Indian Boarding schools during these years. This dress, then, is material evidence of Crow resiliency and the importance of maintaining Crow traditions. Wondering about the girl who wore the dress, it is possible, Ms. Mach surmised, that the family decided to sell her traditional clothing because this was such a difficult time to be Indian in the United States. Knowing, too, how fast little girls grow, it may have been too small and the family needed the money made from the sale.

The group visited an ancient Greek “eye kylix” drinking bowl in the Magic in the Ancient World exhibition.

In-depth conversations and collaborative discussions ensued as the group moved to the other objects. Conversations gravitated towards the residents’ working experience. Dr. Tiballi noted: “The discussion at the eye kylix included note of the fact that it had been broken, and that the pieces were put together in Conservation with missing pieces filled in in a way that harmonized with the rest of the object, but also made it obvious that it was incomplete. This was seen as a metaphor for the ways that doctors and archaeologists ‘fill in’ missing pieces in the stories they create about their patients and the past.”

The take home from the experience? “It is impossible to get rid of bias completely,” Dr. Tiballi said, “but we can be more aware of the ways in which our own experiences influence the stories we create. We can become more rigorous in understanding and counteracting negative bias.”

When the residents finished their tour, they were asked to give feedback on the pilot program. Responses were enthusiastic:

“This was great. Every resident should have to go through something similar.”

“We need to have further discussions about our experiences with implicit bias in the hospital.”

For her part, Marina Di Bartolo was happy with the morning program: “Sessions like these can help to raise awareness among young medical trainees that these biases exist, and can be a first step to addressing them.”

Acknowledging that “despite our efforts to avoid them, we all bring biases into our interpretation of art, artifacts, and medicine,” Program Director Marc Shalaby saw potential benefits to the program: “I am hopeful that the skills that we learned will translate to better care for our patients and more satisfying careers for ourselves.”

Future residents and medical students may have opportunities to visit the Museum. “The exercise at the Museum was part of a curricular series that Marina and I—mostly Marina, actually—are developing to try to better understand how residents think and how to help them decide when they should rethink and re-frame their approaches to patient care.”

A special thanks to the seven medical residents who took time out of their busy schedules to join the pilot program: Patrick Sayre, Lindsey Merrihew, Katie Anderson, David Lieberman, Louisa Whitesides, and Daniel Kim. Thanks to Marina Di Bartolo for initiating the discussion and plans, and Marc Shalaby, MD, for his support, interest, and engagement with the project.