The weeks that followed George Floyd’s death on 25 May, 2020 in Minneapolis, Minnesota have seen a global outcry against racism. A broader assessment of systemic racism is taking place within every sector of society, including medicine. Although the medical profession strives for equal treatment of all patients, disparities in healthcare persist. Though we might not like to admit it, our healthcare systems are still infiltrated with acts of prejudices based on race, ethnicity, gender and much more.

Doctors have been molded throughout medical school and all their training to be non-prejudiced during patient encounters. It’s not only asked but demanded of us. This leads to many physicians believing that they possess no biases. Stereotypes may not be consciously endorsed by physicians, but their mere existence influences how information about an individual is processed. This leads to unintended biases in clinical decision-making, so called “implicit bias”.

All of society is susceptible to these biases, including physicians. At some point in our lives, we are all guilty of making quick associations and generalizations.

An implicit/unconscious bias is the unconscious attribution of particular qualities to a member of a certain social group. Implicit bias is an aspect of implicit social cognition: the phenomenon that perceptions, attitudes, and stereotypes operate without conscious intention.

Implicit bias occurs because of the brain’s natural tendency to look for patterns and associations to try to simplify the world. This ability makes human decision-making more efficient. Because the brain is constantly bombarded with more information than it could conceivably process, mental shortcuts make it faster and easier for the brain to sort through all of this information.

For physicians, the uncertainty and time pressure surrounding the diagnostic process may promote reliance on stereotypes for quick medical decision-making.

Implicit stereotypes are largely influenced by experience. They are based on learned associations between some trait and a social group and may not be limited to race. It’s important to understand that implicit bias is not the same as racism. Overt racism involves conscious prejudice against members of a particular group. It can be influenced by both explicit and implicit bias.

Other forms of discrimination influenced by implicit bias include ageism, sexism, homophobia and ableism. These attitudes are often not only triggered by direct personal experience but the result of a complex series of events. Cultural conditioning, media portrayals, education, family members, authority figures, peers and social history can all contribute to the implicit associations that people form about the members of other social groups.

Implicit biases operate on an unconscious level and might not look as destructive as our declared beliefs and prejudices. However, the role of implicit biases in health care delivery cannot be understated. Implicit bias affects the dynamic of physician-patient relationships. It contributes, accentuates or exacerbates health care disparities by shaping physician behaviors, clinical decision-making and treatment outcomes. This leads to differences in medicine along the lines of race, ethnicity, gender or other characteristics.

Some instances of implicit bias affecting patient care include:

  1. Black and Hispanic people are less likely to receive pain medication than white people even when they both receive equal pain scores.
  2. Physicians high in implicit bias were more likely to dominate conversations with black patients and their patients in turn admitted having less confidence and difficulty opening up to their physicians.
  3. Physicians are less likely to treat suicidal ideation in elderly patients, despite the fact that 85 years and older have the second highest record of completed suicide than any other age group worldwide.
  4. Women are less likely to be diagnosed Chronic Obstructive Pulmonary Disease (COPD) than men having similar history and physical examination findings. 

Though we strive to ensure equality and inclusivity in medical schools and clinical settings, we recognize that medical education and trainings at large have been historically and are presently perpetrated by acts of injustice. Despite the fact that physicians’ implicit biases seem commonplace, we aren’t taught how to deal with these biases. The medical curriculum doesn’t contain much on how to navigate through these situations.

Acknowledgement of your implicit bias is key.

One of the benefits of being aware of your implicit biases is that you can assume a more active role in overcoming them. Even though these biases operate on an unconscious level, it is possible to challenge them and adopt new attitudes.

Implicit biases are malleable.

The implicit associations that we have formed can be gradually unlearned. This can be done through a variety of debiasing techniques at a personal and organizational level.

Individuation

Individuation is when you focus on specific details of a certain member of a group to avoid over-generalizing. Intentionally seeking increased focus on individual patient information, apart from their social groups, can help us from making generalizations and associations.

Taking other’s perspectives

Deliberately practicing perspective taking, considering contrast viewpoints and recognizing multiple perspectives can reduce implicit biases.

Increasing Opportunities for Contact

Spending time with individuals you have a bias against helps you have a better understanding of your differences. Actively seek out opportunities to engage in interactions with members of marginalized groups.

Accountability

Being aware of their own biases provides an opportunity for people to reconstruct their flaws. They can then take measures to overcome their own biases.

Counter Stereotyping

Exposing individuals to counter stereotypical experiences can have a positive impact on unconscious bias. Intentional efforts to include faculty from underrepresented groups can help reduce the unconscious associations of these responsibilities as unattainable.

Cultural Humility

Cultural humility emphasizes that individuals must acknowledge the experiential lens through which they view the world. This includes understanding that their view is not nearly as extensive, open, or dynamic as they might perceive. By integrating cultural humility into healthcare training procedures, schools and organizations can strive to eliminate healthcare professionals’ implicit biases.

Workforce diversity

Health care institutions must commit to a culture shift by promoting inclusivity and diversity in their workforce. This involves the recruitment and retainment of a critical mass of underrepresented individuals. The importance of different perspectives and backgrounds must be emphasized.

When I chose to pursue medicine, I was thrilled to commit to something that can’t been practiced in vacuum.

When we care for our patients, we tend to take care of them as whole beings with all that makes up who they are. Their background, their color, their race, their psychological state and much more is all a part of them.

But the true test will always be through action, in practice. This requires a conscious intention to check our privileges and take action. As full-fledged practicing doctors, as doctors in training and as medical students we need to vow to work on dismantling our prejudices and discriminatory practices against people of color or caste and more. We need to tear down our own biases first, then the biases of others.

We need to continually introspect, and challenge our own biases. Medical schools, hospitals and all clinical settings should become places of diversity, inclusivity and healing. This process will not be quick or easy, yet now is a good time to start making a change.

Read more about anti-racism here.

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Category: Anti-Racism    Health
Tagged with: implicit bias

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  • Avatar
    Nirmal

    Excellent write up.
    Is it some thing nearly equal to not giving enough importance?

    • Avatar
      Dr. Preeti Shakya

      Thank you Sir! I wouldn’t say this is something people consciously try to be ignorant of as it runs entirely in the unconscious but one can definitely assume a more active role in overcoming them if we start acknowledging them and their affect on health care delivery.

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