Bias in health care

Unconscious or implicit bias comes in many forms and is common in all people, regardless of upbringing, profession, ethnicity, or race. Doctors may think they are treating all their patients equally, but that may not be the case, and patient outcomes can suffer.

Medical Economics spoke with Maria Hernandez, Ph.D., president and CEO of Impact4Health, to discuss bias in health care and what physicians can do to make sure every patient is receiving equal treatment.

Medical Economics: What is implicit bias and how does it impact care?

Maria Hernandez: Implicit bias, sometimes called unconscious bias, are those mental assumptions or quick snap judgments that we make about others. They can be positive or negative, but they influence how we behave toward that person. And some of the literature out there suggests that in about the first seven seconds of meeting someone, you may make 11 different assumptions about that person. The first five assumptions about race, ethnicity, gender, even ability, are not so difficult to imagine. But some of those others are things like trustworthiness, things like your education level. Once those form, it's very difficult to retake that first impression, and come up with a different view that of that individual. So you can imagine, this is a really important issue for physicians to be aware of, and it can really impact the quality of care.

ME:Most doctors think they're treating everyone equally. What are some examples of how this isn't necessarily true, even if they're not aware of their bias?

MH: Equal treatment truly is doing the same thing for everyone, but when we're talking about equitable outcomes, it really means looking at what that person may need, specifically, and what their capabilities may be to adopt a treatment plan or follow a course of care. That really does vary across all socio-economic groups and different ethnicities, and so on. Let me give a really concrete example. I think that we know for example, Latinos have twice the rate of diabetes in our country as others. And some may point to a couple of factors that might be genetic. But the fact of the matter is that if you say to someone, you know, I want you to eat really fresh food, I want you to get out and exercise, I want you to take time to de-stress your life, that's really good advice. But not everyone is going to be able to carry that out in quite the same way. We know that if the person lives in a food desert, for example, it's hard to find fresh food. We know that if they live in a crowded environment, it's not so easy to get out and exercise. But even when we suggest those things, it's often important for a physician to consider what would this mean for this particular patient or this particular group of individuals. So some organizations, some health systems, are really taking that into account. And they're trying to make suggestions for that population in a way that's meaningful for them, and that they can actually adopt. That's just one tiny example of how we have to think about what is the context of that patient's circumstances as we try to navigate what's in their best interest.

ME: What can doctors do to make sure they're not allowing bias to affect their care decisions?

MH: I think for any physician, the first thing is awareness. Anytime you want to solve a problem, you need to know that you've got a problem. I think one of the tools that I've used in our presentations with physicians, the one that physicians are quite familiar with, is confirmation bias. So the first diagnosis is made and everything else is sort of seen through the lens of that diagnosis to confirm it. That's why we believe so much in second opinions. That's why we think so much so highly of having a specialist take a look at something to really clarify what is going on. If I say to the participants in our classroom you have cognitive biases that really do shape your behavior — what's the best thing to do to avert behaving or acting on those biases? It's the same thing you see in many other professions, and that's to slow down a bit before you begin the conversation with your patient, just recognize, ‘I'm about to encounter someone, they may be different from my background and may be different in their history than others that I see, what possibly could shape my engagement with that particular patient?’ That's number one. Number two, is when you begin to have that conversation is to really listen. There's some statistics out there that say a physician will interrupt a patient 18 seconds into the conversation. Just think about that. We know it's hard because everyone's so busy, there's a lot to do. But the fact that you interrupt or interject something, in and of itself isn't bad. It might be that you're clarifying, or you're asking a question. But just understand, once you've done that, for certain ethnic groups, that really sets you apart, like, ‘Oh, my gosh, I've got a doctor that's asking me a question. I'm nervous, I may not know the language, and the language may be a little bit of an issue.’ And so after that question, or after that interruption, just watch to see how quiet that patient becomes. If they're not speaking much after that, it may mean you've now got to invite more information. I often say it's fine if you need to interject, but make sure you get back to what the patient originally wanted to talk about. Make sure that you're following the thread of thought that was there, and understand that they have a life experience that might be very different from yours. It's important to really tune in. I also think empathy right now is the superpower for great physicians. The fact that you can maybe put yourself in their shoes, understand that they're really anxious about whatever presenting problem they may have, and just really tune into that so that you can be maybe a little bit more patient, a little bit more careful, about how that conversation goes during that first assessment.

ME: Is unconscious bias just a physician problem? Or does this permeate the entire care staff?

MH: It's a human problem. I think it's important for us to know that we all have unconscious bias. It's a lifelong effort to make sure that you're not acting on that bias. But yes, certainly your nurse practitioners, the LPNs, staff, anyone who comes in contact with the patient before you might even set you up for that bias to take place. Imagine that you are about to see a patient and someone has already entered information in the chart—something as simple as, wow, they're really complaining a lot about pain. And we know already that African Americans and Latinos actually receive less pain medication when they're presenting with any number of issues. And that's sometimes a benefit, because obviously not getting addicted to pain medications is a good thing. But you can imagine if you're in great distress, and no one believes you, or people assume that you're basically seeking pain medications for other reasons, that's not a good patient experience. And so anyone in the care team can have unconscious bias, and can express it in a way, maybe very subtly, but it can shape the course of care.

ME: Are medical schools doing anything to address the problem with unconscious bias with physicians?

MH: I do believe that there are now more medical schools that are including this as part of what's called ‘cross cultural care’ or ‘culturally competent’ care. It’s being aware of different ethnicities, different regions of the country, where health is defined in unique ways and seen through a different lens. And it's important for a physician to understand that. I think what's unfortunate though is it's not getting reinforced nearly enough once they begin to be a resident or go into practice. I'm happy to say that our firm is working with quite a few systems where they are actually beginning to implement training around unconscious bias or implicit bias. They're also working on cross cultural or culturally competent care as part of patient-centered care. I think that those systems are few and not yet to the norm. But I'm happy to see that I think the pandemic has made physicians extraordinarily aware that unconscious bias does exist. And then there's the other factor, the systemic bias, the bias that is kind of baked into the organization. And that means that I think the awareness is growing, and people are beginning to realize, if we're going to try and provide quality of care, we have to look at health equity, we have to look at factors that influence health equity, and unconscious bias is one of those.

ME: Is there any pattern to who is most likely to be influenced by implicit bias? For example, those from a middle-class background, those from rural areas, only white doctors—is there any pattern at all this?

MH: The pattern that I think does exist is if you have not had a lot of exposure to diversity in your training, and then you're put into an environment where there is extraordinary diversity. So imagine someone who does their medical school education in an environment where there's not a lot of diversity, and all of a sudden is working in an urban setting, Los Angeles, Oakland, New York, I think there's tremendous cultural shock that that person is going to be going through if they've never been exposed to it, and not talked about it, and not had their own sort of personal journey around this. Yeah, that's the person most likely to have unconscious bias that comes into the mix of how they're working with their different patients. But again, I just want to emphasize every single person on the planet has been influenced by a number of messages and events and circumstances that shape their beliefs about other people. Sometimes the word colorism comes up in as we talk about this in in diverse cultures. In the Latino community, if you're very light skinned, if you have blue eyes, sometimes Latinos will say, ‘Oh, this is such a beautiful person.’ There are those biases about those individuals, and that exists in African American communities and in other cultures across the globe. So it's a human condition, and I think the acceptance of that is step number one. We all have unconscious bias. So what are the things that we can do to make sure we're not acting on that?

ME: Is there a way to measure how bias is affecting care so that progress toward eliminating it can actually be tracked?

MH: I think with the pandemic, one of the things that could happen now is we're looking at the importance of collecting data about health outcomes. Looking at it through the lens of race, ethnicity, language preference, and now we're also adding sexual orientation and gender identity. There are hospitals that are really making an effort to look at health outcomes based on the real demographics, so that they can track whether or not those differences exist. Some of the early sort of warning signs, of course, are around maternal health, and around pain management and around heart disease and around diabetes. I think if you look at the historical data out there, we've known about health inequities, health differences among ethnic groups for quite some time. But with the pandemic, we now know, even more so that this is a problem in our health systems. Some hospitals are trying to create a health equity index. That means they look at certain outcomes, say, hospital infections or readmissions to the hospital or things like maternal health and cancer screenings, those things that we know we have to measure, I think are important opportunities for us to look at. How do these different populations fare? And again, those have been collected for quite some time. I'd say there's probably some controversy about collecting this data and actually knowing that these inequities exist. Health care tends to be kind of a competitive environment. Everybody wants to know that our safety scores are better than this, and we've received the best recommendations around the quality of care So you can imagine some hesitancy exists about looking at this data. But I think that's being in denial. I think we need to be willing to look at this, much like we look at safety issues. I think most hospitals now try to look at their safety record, not with the idea of being punitive to anyone reporting a safety violation, but to look at it as a learning opportunity and to do a root cause analysis of why it's happened. Well, if we're doing that about safety, I think we need to do that about health equity.