Implicit Bias and Racial Disparities of Care: Recognizing and Addressing the Role of Implicit Bias in Vulnerable Patient Care

Given current events I think many physicians—me included—are going through critical self assessments of our approach to vulnerable patient care.  

We interact with new people daily and have to quickly make decisions about their care that can have lasting implications. Yes, we are supposed to be helping them, but what assumptions—our implicit bias—do we carry into the medical encounter that may have undermined their care.  What diagnosis did we forget to consider, test we did not think to order, or medication should we have prescribed?

And while we’re taught about implicit bias in medical school to mitigate this risk, research and the COVID-19 pandemic continue to flag it as an ongoing issue so—clearly—we are not doing enough.

The Insidiousness of Biases 

Despite more education—and perhaps because of it—healthcare professionals are at risk of these unintended biases. A 20171 study on physicians showed that—even when delivering patient care—by and large healthcare professionals exhibit the same levels of implicit bias as the wider population. Perhaps understanding how these biases work can help providers actively address it, improving patient care for minority and other vulnerable populations.

Implicit biases stem from neurological processes, where the brain—processing billions of stimuli each day—makes quick “snap” decisions based on patterns observed in events, groups or individuals. While pattern processing is integral to language2—and likely makes us better on the medical rounds and/or our boards that are seen as proxy for being a good doctor—this pattern processing can become treacherous when it leads to the development and growth of implicit and unfair biases toward others that undermine our ability to treat patients objectively. 

Because of the high volume of stimuli the brain is exposed to each day, we are not able to consciously interpret everything we see, and we (often ignorantly) rely on real or imagined past patterns to manage this stimuli.3 For physicians, often on point for the majority of critical medical decisions, these biases become especially dangerous because they can insidiously impact the care we provide.

The Impact of Bias. 

Unchecked, our implicit biases can remain latent and seemingly asymptomatic until we’re confronted with the overwhelming evidence of their impact. As a first step in managing them, we have to recognize that these biases have far reaching consequences for those we treat. 

For just one example, when it comes to pain assessment and treatment, multiple studies have shown that non-white patients are at a higher risk for receiving no, or inadequate, pain assessment and control than their white counterparts.4 

For example, in cancer care, 31 percent of African-American and 28 percent of Hispanic patients receive insufficient pain management.  Unsurprisingly then, it was found physicians underestimated the degree of pain for over half their Hispanic  and African-American patients.  This wasn’t just an issue of race, either, as physicians are more likely to underestimate pain severity for female patients as well.5 

Statistics surrounding maternal mortality also highlight the discrepancies in care that minorities face, with women of ethnic and racial minorities experiencing 28 percent more cases of maternal morbidity when compared to white women—and women of indigenous or black descent being twice as likely to die as a result of a pregnancy-related condition.  This is of course not all due to implicit bias—there are explicit, systemic issues that drive these disparities as well—but when you can see the decrease in the quality of care even in these patients’individual care encounters, it’s clear implicit bias has a role.

As physicians—and therefore often leaders in our clinics, hospitals, and organizations, we must take personal responsibility for reducing our biases by exposing ourselves to, and immersing ourselves in, diversity. We can advocate for diversity in hiring, invite minority-lead organizations to present to and partner with us as appropriate, and educate ourselves about minority leaders—especially those individuals who contradict the biases we have.  And we must personalize this—as a white cis hetero male raised in the South, the onus is on me to improve my care, not to expect others to do it for me.

And the first steps in improvement may not even be that hard!  Even a change as small as intentionally shaking up a social circle or Friday-night restaurant to increase our interaction with those different from us may reduce our own implicit biases,6 7 with one laboratory study showing that participants who were even just exposed to images and information about minorities showed a significant reduction in implicit bias.8

Addressing Bias at the Organizational Level

Fortunately, those studies and others indicate that implicit bias can be mitigated, and even just increasing awareness of our biases is a good first step in preventing them from undermining the care we provide.

Even more encouraging is that while advanced training around implicit bias certainly won’t hurt, there is much we can do now to address bias—without excessive cost, third-party training, or elaborate programs. 

As organizations, we can strive to create an environment where care teams focus on the patients as individuals. Studies show that a significant negative association exists between the time spent interacting with a patient and the levels of implicit bias the provider exhibits.9 In other words, if we want to lower the impact of implicit biases in our organizations, we must adjust workflows to increase the time each provider spends with a patient, or at least ensure their time with the patient involves interacting with the patient, not just being near them!

Unfortunately, the fast-paced conditions sustained by most doctors—beset10 with constant distractions, high stresses, and short appointments—leave them increasingly more susceptible to unintentional biases. By increasing patient time even marginally—to learn the patient’s name, occupation, and about a few personal details such as family members, pets, or hobbies—care teams can have the time needed to step past existing biases and see the patient for who he/she/ze is. 

Additionally, making patient care a collaborative effort diversifies the voices speaking for each patient, creating a system of “checks and balances” and ensuring that no single individual’s bias gets in the way of the patient’s well-being.  Given the amount of caregivers a patient will touch in their passage through a clinic or an Emergency Department (the front desk, a medical assistant, a nurse, etc.) there is ample opportunity to gain more insight into that patient, as long as we are listening to them (and to each other).

Removing the Shame from Healing

Leaving med school, many of us took to heart “to do no harm,” and with that in mind, facing the implicit biases we have and the impact they cause can be especially demoralizing. 

Understanding the pervasiveness of the issue can help motivate us beyond paralyzing guilt to actionable change—with empathy and understanding for ourselves and others. I liked what Danielle Jones, manager of the AAFP’s Center for Diversity and Health Equality, shared: 

“No one is immune to this, even those of us with the most egalitarian goals of fairness and equality. When you frame it from that perspective, I think it makes people a lot less defensive and more open to having a conversation around ‘what are my biases, and what can I do to address them?’” 

There is no one-easy-way to eradicate the racism we’re seeing nationwide, but as healthcare professionals we can do our part. We can strive to see the biases we have, move past our guilt, open up conversations about them and keep each other accountable in doing and being better, together.

Related Reading: The path to pandemic preparedness has already been forged by Medicaid

Ben Zaniello, MD, MPH is an infectious disease physician and the chief medical officer of Collective Medical.

 

1FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare professionals: a systematic review. BMC medical ethics, 18(1), 19. https://doi.org/10.1186/s12910-017-0179-8
2Mattson M. P. (2014). Superior pattern processing is the essence of the evolved human brain. Frontiers in neuroscience, 8, 265. https://doi.org/10.3389/fnins.2014.00265
3Staats, C., Capatosto, K., Wright, R., & Contractor, D. (2015). State of the Science: Implicit Bias Review 2015. http://kirwaninstitute.osu.edu/wp-content/uploads/2015/05/2015-kirwan-implicit-bias.pdf
4van Ryn, M., & Fu, S. S. (2003). Paved with good intentions: do public health and human service providers contribute to racial/ethnic disparities in health?.American journal of public health, 93(2), 248–255. https://doi.org/10.2105/ajph.93.2.248
5Anderson, K., Mendoza, T., Valero, V., Richman, S., Russell, C., Hurley, J., DeLeon, C., Washington, P., Palos, G., Payne, R., & Cleeland, C. (2000). Minority cancer patients and their providers. Cancer—Interdisciplinary International Journal of the American Cancer Society. https://acsjournals.onlinelibrary.wiley.com/doi/10.1002/(SICI)1097-0142(20000415)88:8%3C1929::AID-CNCR23%3E3.0.CO;2-2
6FitzGerald, C., Martin, A., Berner, D. et al. Interventions designed to reduce implicit prejudices and implicit stereotypes in real world contexts: a systematic review. BMC Psychol 7, 29 (2019). https://doi.org/10.1186/s40359-019-0299-7
7Dasgupta, N., Asgari, S. (2004). Seeing is believing: Exposure to counterstereotypic women leaders and its effect on the malleability of automatic gener stereotyping. Journal of Experimental Social Psychology. https://www.sciencedirect.com/science/article/abs/pii/S0022103104000253
8Dasgupta N, Greenwald AG. On the malleability of automatic attitudes: combating automatic prejudice with images of admired and disliked individuals. J Pers Soc Psychol. 2001;81(5):800‐814. doi:10.1037//0022-3514.81.5.800
9Penner, L., Dovidio, J., Gonzalez, R., Albrecht, T., Chapman, R., Foster, T., . . . Eggly, S. (2016, August 20). The Effects of Oncologist Implicit Racial Bias in Racially Discordant Oncology Interactions. Retrieved June 12, 2020, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5012663/
10E;, A. (2014, December 12). How Physician Electronic Health Record Screen Sharing Affects Patient and Doctor Non-Verbal Communication in Primary Care. Retrieved June 12, 2020, from https://pubmed.ncbi.nlm.nih.gov/25534022/

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