Healthcare portraiture and unconscious biasBMJ 2019; 365 doi: https://doi.org/10.1136/bmj.l1668 (Published 12 April 2019) Cite this as: BMJ 2019;365:l1668
- Karthik Sivashanker, Harvard Medical School fellow in quality and patient safety1,
- Kathryn Rexrode, chief2,
- Nawal Nour, chief diversity and inclusion officer for faculty, trainees, and students3,
- Allen Kachalia, director4
- 1Department of Psychiatry, Boston University School of Medicine, USA
- 2Division of Women’s Health, Brigham and Women’s Hospital, Harvard Medical School, USA
- 3Department of Obstetrics and Gynaecology, Brigham and Women’s Hospital, Harvard Medical School, USA
- 4Department of Medicine, Johns Hopkins School of Medicine and Armstrong Institute for Patient Safety and Quality, USA
In 2018 a decision to take down from our primary hospital auditorium the portraits of 31 past department chairs, all of whom are male and 30 of whom are white, ignited a fierce reaction in our hospital and surrounding community. Local media articles were flooded with comments accusing the institution of reverse discrimination, with many pledging never to return to our hospital. This incident presents an opportunity for us to examine how the symbols we consciously choose to honour and display can also unintentionally convey unconscious biases in race and sex. Finding the right balance requires that we honour people’s achievements, while also acknowledging the systematic advantages given to some over others.
Many healthcare institutions choose portraiture as a way to celebrate the contributions of past presidents, department chairs, and physician-scientists. With little variation, however, portraits in healthcare and academia have been of white men.12 Many of those responding to the articles in the media thought that the decision at our institution to disperse the portraits in the name of inclusivity was an affront to these people and their accomplishments. They did not see the lack of diversity as evidence of racial or sex bias in healthcare, but simply a reflection of the contributions, accomplishments, and merit of those being honoured.
Without doubt, these leaders deserve recognition for their dedication, excellence, and sacrifice. Healthcare portraits are intended to elicit a sense of institutional pride; they remind viewers of the people who shaped the identity, history, and mission of that organisation. Such images can inspire others to make meaningful and important contributions.
It is also true, however, that many of these leaders benefited from structural and systematic advantages along the way, yet this dichotomy is rarely, if ever, acknowledged on our walls. This omission is critical to understanding why healthcare portraits can reinforce harmful racial and sex stereotypes when they are displayed without their full context. It is also why people on both sides of the matter may experience them as a form of white male superiority. To argue that healthcare portraiture is a reflection of merit based achievement and nothing more is to tacitly affirm such stereotypes. The only plausible explanation for the homogeneity seen in healthcare portraits is that they reflect both individual achievements and structurally derived group advantages.
Studies have consistently shown that people’s initial judgments around likeability are grounded, in part, in the frequency of exposure (that is, familiarity) to a particular racial prototype.3 Repeated exposure to faces of the same race can lead to in-group favouritism and decreased judgments of likeability for faces of people from other races.3 Such exposure effects are not trivial, as mere exposure to a racial prototype has been shown to increase a person’s willingness to help people of that race, and to agree with their judgments. It even affects their tendency to smile at people of that racial group.3
Therefore, when the people depicted are almost exclusively white and male, the implicit message conveyed is that women and people of colour do not fit the mould. It is no surprise that many women and people of colour see metaphorical walls, rather than ladders of opportunity, when surrounded by these portraits.4
Importantly, acknowledging this experience for many women and people of colour is not the same as saying it is true. Nor does it mean that the people honoured are undeserving, as their contributions are undeniably important to advancing healthcare. Rather, it represents an appreciation for how symbolism and art can contribute to marginalised groups being perceived as the “other.”
Conveying the right message
In this regard, healthcare organisations have opportunities to instil a feeling of belonging and comfort for all their employees and patients. A simple but critical step is to examine the effect that their use of all imagery, as exemplified by portraits, has on their constituents. Are these portraits sufficiently conveying a message of social justice and equity? Do they highlight the achievement (as with a picture of a petri dish), or the person (a picture of Alexander Fleming without sufficient acknowledgment of his contributions)? Further still, do these images reveal the values of the organisation or its biases?
At our institution in Boston there was no question that the leaders depicted had made meaningful contributions to our hospital and healthcare. After soliciting feedback through listening sessions, open forums, and inbox feedback from our art committee, employees, clinicians, and students, however, our institution agreed to hang these portraits in their respective departments. This decision aimed to balance a commitment to equity with an intent to honourably display these portraits, which have inspired generations of physicians and scientists to be their best. It also led our social justice and equity committee to tackle problems like unconscious bias and diversity in hiring. In doing so, we are acknowledging the close interplay of symbolism and policy making in perpetuating racial and sex inequities, and the importance of tackling both together.
The thoughtful and respectful dialogue among our employees served as a stark contrast to the toxic discourse that unfolded in our local community. Much work remains to be done.
A criticism of dispersing the portraits, however, is that they are an important reminder of our longstanding struggle with sex and racial bias in healthcare, and redistributing them may not be enough. On the other hand, removing them was also interpreted as an attempt to erase a reminder and celebration of accomplishments that we should not forget. To find the right balance, we should also look to efforts outside healthcare to help us find paths not yet considered.
The power of art
For example, the Harmon Foundation Collection consists of more than 40 portraits of prominent African-Americans. Ahead of its time, it premiered in 1944 with the explicit aim of countering racial stereotypes. More recently, the Smithsonian’s National Museum of African-American History held a day long symposium entitled “Mascots, Myths, Monuments, and Memory,” which delved into topics like racism in art and the politics of memory.5 In contrast, the artist Titus Kaphar has taken on centuries of racism in art by amending artwork to reveal the untold narratives of people of colour. His 2017 sculpture Impressions of Liberty was commissioned by Princeton University as part of a broader effort to acknowledge its connections to slavery. Art can also be used to make the invisible visible. In 2017, the Harvard TH Chan School of Public Health presented an installation of eight portraits of African-American and Native American pioneers in public health and medicine as “ghost portraits” printed in black and white on translucent fabric, which were hung next to colour portraits of the school’s founders and deans, all of whom had been white men. Subsequently, the exhibit was replaced by a portrait display of current staff and faculty, to reflect the changing community.
These are just a few examples of efforts that challenge us to consider how imagery and symbolism perpetuate harmful stereotypes in healthcare. Yet they also reveal how art can open the door to deeper—and sometimes unpleasant but necessary—conversations about racial and sex inequities. In the case of our institution, the decision to take down the portraits revealed painful and longstanding wounds in our community. This was exactly why opening the door was the right and courageous thing to do.
In the end, what matters most is that we at least consider the influence of imagery in healthcare. Portraiture as art acts as a mirror that reflects both our stated and unstated views on the world. Institutions owe it to themselves and their communities to examine the message they are sending.
At the time of writing Allen Kachalia was based at the Department of Medicine, Brigham and Women’s Hospital; Harvard Medical School.
Not commissioned, not peer reviewed.