We know you always have your patients’ best interests at heart. But have you thought about the possibility that unconscious biases against certain genders, ethnicities, or cultures may be impacting your care?
A bias is the negative evaluation of one group and its members relative to another. Implicit or unconscious bias does not require an individual to be aware of their actions or beliefs.
It has been well documented in literature and studies that implicit bias in healthcare can directly lead to healthcare disparities. This concern continues to be a topic of nationwide attention, and has been a target goal in the Department of Health and Human Services Healthy People 2000 and 2010 initiatives.1,2 In Healthy People 2020 it was highlighted as a major continuing challenge.2 The National Institute of Health has prioritized eliminating healthcare disparities in its top five initiatives and has encouraged healthcare practitioners to consider how biases, stereotypes, and discrimination may contribute to such disparities.3
Almost 20 years ago, inequities in healthcare came to light in the Institute of Medicine (IOM)’s “Unequal Treatment” report written by a panel of physicians, public health experts, and behavioral scientists. The panel reported that racial and ethnic minorities received inferior healthcare more often than non-minorities, even when access to healthcare barriers such as insurance and income did not exist.3 Some of these affected groups include:
Minority ethnic populations
Immigrants
The poor
Low health-literacy individuals
Sexual minorities
Children
Women
The elderly
The mentally ill
The overweight
The disabled
Implicit bias has influenced trends in healthcare3 which include:4
Non-white patients receive fewer cardiovascular interventions
Black women are more likely to die after being diagnosed with breast cancer
Patients of color are more likely to be blamed for being passive with their healthcare
Heterosexual healthcare professionals have a moderate to strong preference for treating heterosexual people over gay and lesbian patients5
Fat shaming, which has proven ineffective for driving motivation, adversely impacts the patient experience6
Examine Your Own Biases
An important step in combating implicit bias is self-examination. Can you confidently say you have never made an assumption about a patient based on his/her/their appearance or other basic traits? We all have at one point or another quickly and automatically labeled people based on social or other demographic characteristics. Unfortunately, these actions are also the basis for stereotypes, prejudice, and ultimately, discrimination.
There are many tools available for use to examine your own possible biases. The Implicit Association Test (IAT) measures attitudes and beliefs that people may be unwilling to report. The IAT measures relationships between different concepts (e.g., gender/ethnicity) and your subconscious assessment (e.g., good/bad). Various IATs are available, including those for gender, ethnicity, sexuality, and more. Although the IAT is subject to controversy due to the lack of reproducibility and the question of what it measures, it can shed a light on what we may be closing our eyes to.7
Implicit bias is pervasive even if people differ in levels of such bias. People are often unaware of their implicit bias and that it predicts behavior.
As biases become recognized, healthcare providers can look for resources, strategies, and skills to minimize and prevent such unconscious and unintentional attitudes and stereotypes from negatively influencing the course of treatment and evaluations of certain groups. Whether it is a patient or a physician who brings prejudice into the healthcare setting, it can strain the doctor-patient relationship, even if the treatment is not impacted.8
Strategies to better care for patients of diverse backgrounds:
Focus on the characteristics of each patient, rather than their group identity
Aim to interact and discuss issues with colleagues and patients with diverse backgrounds and experiences
Approach patients with empathy and focus on their perspective (put yourself in their shoes)
How can I combat biases and stereotyping?
Be aware and point it out. Catch yourself when making negative preconceptions and openly talk about it
Be an example. Be a role model and respect people regardless of what stereotypes may exist
Speak up. Engage people around you to reflect and engage in open conversations
Be Educated
The California legislature recognized the link between implicit bias and strong racial disparities in maternal mortality and morbidity. Since 2021, California requires its hospitals to educate their perinatal care staff about implicit bias.9 Implicit bias training is also required for new nursing graduates.10 Effective January 1, 2022, implicit bias is required to be included in Continuing Medical Education Activities and programs.11
Monica Ludwick is a Senior Risk Management and Patient Safety Specialist for CAP. Questions or comments related to this article should be directed to MLudwick@CAPphysicians.com
References:
1Blair IV, Steiner JF, Havranek EP. Unconscious (Implicit) Bias and health disparities: Where do we go from here? Perm J. 2011; 15(2):71-78.
2https://health.gov/our-work/national-health-initiatives/healthy-people/…
3FitzGerald C, Hurst S. Implicit bias in healthcare professionals: A systematic review. BMC Med Ethics. 2017;18:19.
4Implicit bias in healthcare. Quick Safety. The Joint Commission. April 2016; 23.
5Sabin J, Riskind RG, Nosek BA. Health Care Providers’ implicit and explicit attitudes towards lesbian Women and gay men. American Journal of Public Health. 2015;105(9), 1831-1841.
6"Sizeism is a Health Hazard" Joan C. Chrisler, Ph.D. Angela Barney, M.A. Connecticut College, New London, CT. Poster presented at the 29th APS Annual Convention, 2017.
7Maina IW, Belton TD, Ginzberg S, Singh A, Johnson TJ. A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Soc Sci Med. 2018 Feb;199:219-229. Epub 2017 May 4.
8Gainsburg I, Derricks V, Shields C, Fiscella K, Epstein R, Yu V, Griggs J. Patient activation reduces effects of implicit bias on doctor-patient interactions. Proc Natl Acad Sci U S A. 2022 Aug 9;119(32): Epub 2022 Aug 1.
9https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=20…
10https://leginfo.legislature.ca.gov/faces/billNavClient.xhtml?bill_id=20… nursing
11https://leginfo.legislature.ca.gov/faces/billCompareClient.xhtml?bill_i…