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Swansea University invited me to an Away Day. There was a whole day of lectures planned at a hotel conference suite just outside Swansea but due to clinic commitments I only caught the afternoon session; a ‘workshop’, on how to recognise and prevent what was termed unconscious bias.

I consider myself somewhat in tune with modern thought about socio-political norms, despite living as I do far from the madding crowd at the western fringe of this island, and I love popular psychology programmes on TV as well. So I was looking forward to this workshop. The ostensible purpose was to enlighten us about all forms of bias so that we would be better able to teach medical students without unfairly discriminating against some of them.

The lecturer was from affluent South East England and was very keen to tell us rustics how biased we all were. We were invited to imagine we had just got on a train for a three hour journey and there were only a handful of empty seats in the carriage. One was next to a businessman, another next to a mother and child, another again next to a man with multiple tattoos and so on and so forth. Where would you sit? Whatever answer you chose meant you were biased. Making judgements. Unfair judgements. So therefore we were all biased and bad people and we needed to cleanse ourselves of bias. But there was good news! We were all mostly victims too, discriminated against by others. So we were invited to think about how we felt discriminated against and unfairly judged for a few minutes.

There was considerable pressure to conform to this so people volunteered various features that made them feel prejudiced against, helped on occasion by our venerable leader. A pattern emerged whereby women seemed to be victims just by virtue of their sex, non-white people could volunteer that and some of the men were gay and most of the others claimed some sort of class discrimination. Wales has no class system of note and I have never felt unfairly judged but when I volunteered this the leader tutted and suggested that regional accents might be holding some people back, whilst looking at me. She even brought up a table of how acceptable regional accents were and indicated that the Welsh accent was not at the top of the pile. The woman next to me volunteered how her slightly frizzy hair might make others judge her.

By this point I had realised that this presentation was not overlapping with any part of how I believe the world to be constructed, but I did realise that this was a valuable insight into how certain people do in fact view the world. Micro-inequalities came next. If a person has an uncommon name and it is frequently mispronounced that is an example, it seems, of a microaggression. The sufferer develops an inferiority complex and fails at tasks they would otherwise succeed at and it is the fault of all those people calling them the wrong name. I worked at Moorfields for a year and was called Glen most commonly, but otherwise sometimes Gwen and Glyn. Mrs Lane, an oculoplastic Titan, who worked at Cardiff before she retired, called me Glyn for years and she being so important and me so lowly I just accepted it and shrugged when people sometimes gave me quizzical looks.

I never felt any aggression, micro or otherwise. It was also stated that not making eye contact was an example of microaggression, as was making too much eye contact, or giving various medical students differing amounts of eye contact, as that is discrimination pure and simple. Various people in the audience volunteered certain banal day to day experiences and asked if they constituted a microaggression. They did indeed, almost always. Except when they were a macroaggression.

We were given a list of nine different types of bias and invited to dissect a day-to-day conversation written on a sheet of A4 paper to pick out the different types of bias (including salience bias, attribution bias, affinity bias, etc.) and microaggressions taking place. By the end of the session we were getting so good that each and every word was couched in various terms of hideous discrimination and that a seemingly normal snippet of conversation was transformed into something that Hitler and Mussolini might have said while discussing the New World Order. Getting to know our own biases was the name of the game and an online tool – implicit.harvard.edu/implicit – was promoted that would help us to do that. That tool, for I have tried it, very rarely says that you are unbiased. Perhaps it cannot. In this fresh new world we are all both aggressors and victims, and hopelessly lost to the abyss.

So where does that leave us? I am more aware of my own biases I suppose. I was biased against the leader of the session and perhaps unfairly put it down to her being posh and English and speaking with Received Pronunciation. But knowing that we are all biased does not really advance anybody in any direction. It seemed reminiscent of all the Catholic guilt I remember so well from my own formative years – we are all hopelessly fallen and damaged. But there is no loving God to rescue us anymore; there is instead an online module on how to be a better person. Not perfect, that’s impossible, but better.

Is being biased all that bad though? Why shouldn’t we avoid sitting next to the lunatic on the train? If we see a person sport one of those Love Hate homemade tattoos on their knuckles should we be blind to their potential for making poor life choices? If a person turns up to interview in a scruffy jacket as opposed to making an effort with a suit should we conclude that they aren’t really all that bothered about getting the job? If a person is from Wales is it more likely that he sings and plays rugby?

If your next set of patient notes has an obviously Chinese name and there is only one Chinese person in the waiting room is it microaggression to assume they are the person you want? How does all this help us teach the doctors of the future? I don’t think it can at all. Medicine is full of weighing up the risks of various conditions based on just these sorts of factors, especially in a discipline such as inflammatory eye disease. We ask questions about sexual practices, ethnic origin and travel because they yield important information. The answers bias us toward one course of action over another. And I guess that can be extrapolated all over life itself. But then again I’m biased, I guess.

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Gwyn Samuel Williams

Singleton Hospital, Swansea, UK.

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