How to Identify, Understand, and Unlearn Implicit Bias in Patient Care

 

Taking steps to recognize and correct unconscious assumptions toward groups can promote health equity.

Fam Pract Manag. 2019 Jul-Aug;26(4):29-33.

Author disclosures: no relevant financial affiliations disclosed.

Jamie is a 38-year-old woman and the attending physician on a busy inpatient teaching service. On rounds, she notices several patients tending to look at the male medical student when asking a question and seeming to disregard her. Alex is a 55-year-old black man who has a history of diabetic polyneuropathy with significant neuropathic pain. His last A1C was 7.8. He reports worsening lower extremity pain and is frustrated that, despite his bringing this up repeatedly to different clinicians, no one has addressed it. Alex has been on gabapentin 100 mg before bed for 18 months without change, and his physicians haven't increased or changed his medication to help with pain relief.

Alisha is a 27-year-old Asian family medicine resident who overhears labor and delivery nurses and the attending complain that Indian women are resistant to cervical exams.

These scenarios reflect the unconscious assumptions that pervade our everyday lives, not only as practicing clinicians but also as private citizens. Some of Jamie's patients assume the male member of the team is the attending physician. Alex's physicians perceive him to be a “drug-seeking” patient and miss opportunities to improve his care. Alisha is exposed to stereotypes about a particular ethnic group.

Although assumptions like these may not be directly ill-intentioned, they can have serious consequences. In medical practice, these unconscious beliefs and stereotypes influence medical decision-making. In the classic Institute of Medicine report “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” the authors concluded that “bias, stereotyping, and clinical uncertainty on the part of health care providers may contribute to racial and ethnic disparities in health care” often despite providers' best intentions.1 For example, studies show that discrimination and bias at both the individual and institutional levels contribute to shocking disparities for African-American patients in terms of receiving certain procedures less often or experiencing much higher infant mortality rates when compared with non-Hispanic whites.2,3 As racial and ethnic diversity increases across our nation, it is imperative that we as physicians intentionally confront and find ways to mitigate our biases.

KEY POINTS

  • Implicit bias is the unconscious collection of stereotypes and attitudes that we develop toward certain groups of people, which can affect our patient relationships and care decisions.

  • You can overcome implicit bias by first discovering your blind spots and then actively working to dismiss stereotypes and attitudes that affect your interactions.

  • While individual action is helpful, organizations and institutions must also work to eliminate systemic problems.

DEFINING AND REDUCING IMPLICIT BIAS

For the last

ABOUT THE AUTHORS

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Dr. Edgoose is an associate professor in the Department of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health (UWSMPH) in Madison, Wis., where she directs the school's Diversity and Inclusion Advocates Program and her department's Office of Community Health....

Dr. Quiogue is an assistant clinical professor in the Department of Family Medicine, Kaiser Permanente School of Medicine Kern County Medical Center in Bakersfield, Calif. She serves on the school's Equity, Inclusion, and Diversity Subcommittee and is a former president of the California Academy of Family Physicians.

Dr. Sidhar is a third-year family medicine resident in the UWSMPH Department of Family Medicine and Community Health.

Author disclosures: no relevant financial affiliations disclosed.

References

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1. Smedley BD, Stith AY, Nelson AR, eds Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: Institute of Medicine, National Academy Press; 2003....

2. Hannan EL, van Ryn M, Burke J, et al. Access to coronary artery bypass surgery by race/ethnicity and gender among patients who are appropriate for surgery. Med Care. 1999;37(1):68–77.

3. Infant mortality and African Americans. U.S Department of Health and Human Services Office of Minority Health website. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=23. Updated Nov. 9, 2017. Accessed June 10, 2019.

4. Nosek BA, Smyth FL, Hansen JJ, et al. Pervasiveness and correlates of implicit attitudes and stereotypes. Eur Rev Soc Psychol. 2007;18(1):36–88.

5. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18(1):19.

6. Maina 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;199219–229.

7. Charlesworth TES, Banaji MR. Patterns of implicit and explicit attitudes: I. long-term change and stability from 2007 to 2016. Psychol Sci. 2019;30(2):174–192.

8. Sukhera J, Wodzinski M, Teunissen PW, Lingard L, Watling C. Striving while accepting: exploring the relationship between identity and implicit bias recognition and management. Acad Med. 2018;93(11S Association of American Medical Colleges Learn Serve Lead: Proceedings of the 57th Annual Research in Medical Education Sessions):S82–S88.

9. Burgess DJ, Beach MC, Saha S. Mindfulness practice: A promising approach to reducing the effects of clinician implicit bias on patients. Patient Educ Couns. 2017;100(2):372–376.

10. Lueke A, Gibson B. Mindfulness meditation reduces implicit age and race bias: the role of reduced automaticity of responding. Soc Psychol Personal Sci. 2015;6(3):284–291.

11. Devine PG, Forscher PS, Austin AJ, Cox WTL. Long-term reduction in implicit race bias: a prejudice habit-breaking intervention. J Exp Soc Psychol. 2012;48(6):1267–1278.

 
 

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