A Path to Equitable Patient Care
When the healer's hand unknowingly carries the weight of bias, the very essence of medicine is at stake.
Healthcare is a realm where science and compassion ought to be the norm. However, healthcare providers are not immune to the subtle, yet impactful presence of bias. This blogpost will illuminate the hidden facets of implicit bias in medical care and explore potential paths to a more just and equitable patient experience.
The purpose of this blog is to raise awareness, share data, and support providers in finding the right resources to continue the inner work of identifying and dismantling implicit bias. Doing this confronting and sometimes uncomfortable work is hugely rewarding for your patients, team, community, and for your own humanity.
“Of all forms of inequity, injustice in health care is the most shocking and inhuman.”
The National Institutes of Health define implicit biases as, “...unconscious mental processes that lead to associations and reactions that are automatic and without intention; actors have no awareness of the associations with a stimulus maintain that social status is relational and people unconsciously hold more negative attitudes or feelings about membership of an outgroup (people with whom they do not share identities) than about membership of an ingroup (people with whom they share identities).”
The American Psychological Association describes implicit bias as such, “...people may hold negative unconscious or automatic feelings and beliefs about others that can differ from their conscious attitudes.”
Implicit bias develops early in life from repeated reinforcement of social stereotypes. Implicit pro-white bias occurs among children as young as 3-5 years of age.
Between 1998 and 2006, more than 4.5 million Implicit Association Tests were completed, and the results showed the following:
Implicit bias is pervasive
People are often unaware of their implicit biases
Implicit biases predict behavior
People differ in levels of implicit bias
The impact of implicit bias in healthcare is glaring. Non-white patients receive fewer interventions, Black women face higher mortality rates after breast cancer diagnosis, and patients of color are less likely to be prescribed pain medications. This bias even extends to more invasive treatments, such as Black men being less likely to receive chemotherapy and radiation for prostate cancer and more likely to undergo testicle removal.
Patients of color are often unfairly blamed for being passive about their healthcare. Additionally, patients who perceive bias from their providers have more difficulty remembering what their physicians told them, have less confidence in their treatment plans, and believe it would be more difficult to follow recommended treatments.
It’s important to note that while many implicit bias studies in healthcare have been conducted with Black patients and non-black providers, other researchers are studying implicit bias in relation to other ethnic groups, people with obesity, sexual and gender minorities, people with mental health and substance use disorders, older adults, and people with various health conditions.
To combat implicit bias, healthcare providers must adopt skills and strategies to break their thought patterns and habits. These include perspective-taking, emotional regulation, and partnership-building. Empathy, in particular, plays a crucial role in patient satisfaction, self-efficacy, and overall health outcomes. When providers view themselves as part of a larger group, it becomes easier to empathize with others, thereby reducing bias.
At the organizational level, healthcare facilities can play a significant role in addressing implicit bias. To create an equitable environment, organizations should evaluate the racial climate, investigate and address discrimination reports, and establish monitoring systems to track disparities in care. Promoting racial diversity at all levels of the organization hierarchy can help reduce bias, and organizations should implement training to equip clinicians with the knowledge and skills to prevent racial biases from affecting patient care.
Additionally, healthcare organizations can implement work policies and clinical procedures that protect clinicians from high cognitive load and promote positive emotions. When clinicians’ cognitive capacity is low or overtaxed, memory is biased toward information that is consistent with stereotypes. High cognitive load can be created by productivity pressures, time pressure, high noise levels, inadequate staffing, poor feedback, inadequate supervision, inadequate training, high communication load, and overcrowding.
Healthcare providers must also take proactive steps to combat implicit bias. This includes gaining an understanding of the various cultures their patients come from, avoiding stereotyping, recognizing the impact of unconscious bias, and following National Standards for Culturally and Linguistically Appropriate Services*. Techniques like "teach-back" and practicing evidence-based medicine can also help reduce bias in patient care.
Studies have shown that implicit bias is deeply ingrained in the healthcare system, causing devastating health inequities. The only intervention found to reduce implicit bias involved a prejudice-habit-breaking approach, which was effective for undergraduate students.
The learning and training environments for healthcare professionals are crucial in addressing implicit bias. Formal diversity training in medical school has little or no effect on students’ levels of implicit bias over time. Implementing and psychological methods to address psychological problems of bias have proven effective over the longer term.
Transformative Learning Theory (TLT) can help disrupt existing paradigms by challenging assumptions and promoting critical reflection. Increasing interaction with underrepresented groups, faculty, and patients, along with the perceived quality of that contact, can reduce bias and encourage healthcare professionals to actively address their biases.
Prejudice habit-breaking intervention, based on theory developed by Patricia G. Devine, PhD, and William T.L. Cox, PhD, of the University of Wisconsin–Madison adopts the premise that bias, whether implicit or explicit, is a habit that can be overcome with motivation, awareness and effort, includes experiential, educational and training components. Michelle van Ryn’s company, Diversity Science - helps organizations apply the best findings and interventions on implicit bias to creative inclusive cultures.
Other suggestions include seeing the patient as an individual rather than a stereotyped member of a group and Individualizing patients to encourage medical students to question stereotypes about a patient's ethnic group. This can help patients become more engaged with their treatment and fostering patients' sense of being “on the same team” as their provider. Ultimately, it’s about how to improve your skills as a doctor or nurse. It requires commitment and practice.
Implicit bias remains a persistent challenge in healthcare, perpetuating disparities in patient care. To create a more equitable healthcare system, raising awareness about implicit bias is vital. Healthcare organizations and providers must actively work to address these biases through training, awareness, and policy changes. By doing so, we can take significant steps towards ensuring that every patient receives the equitable care they deserve.
If you are a practice owner looking for support to lower your stress levels and fall (back) in love with your practice, schedule a strategy call to see how we can help you take back your time, grow your practice and elevate your leadership.
Sources:
Tackling Implicit Bias in Healthcare NEJM 2022
https://www.nejm.org/doi/full/10.1056/NEJMp2201180
Eliminating explicit and implicit biases in health care: evidence and research needs
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9172268/
Quick Safety 23: Implicit Bias in Healthcare
How does implicit bias affect patients’ healthcare? APA
https://www.apa.org/monitor/2019/03/ce-corner
Implicit Bias and Racial Disparities in healthcare ABA
With implicit bias hurting patients, some states train doctors
https://stateline.org/2022/04/21/with-implicit-bias-hurting-patients-some-states-train-doctors/
Additional Resources:
Anti-Oppression Leadership Academy https://nadifantastic.com/
Black Women’s Maternal Health
https://nationalpartnership.org/report/black-womens-maternal-health/
Mandated Implicit Bias Training for Health Professionals—A Step Toward Equity in Health Care
https://jamanetwork.com/journals/jama-health-forum/fullarticle/2795358
National Institutes of Health Implicit Bias Training
Teach-Back Method
https://www.ahrq.gov/patient-safety/reports/engage/interventions/teachback.html