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Unconscious bias in patient care

How underlying assumptions can affect patients and colleagues

October 2016

Published in the October 2016 issue of Today’s Hospitalist

MOST OF US pride ourselves on being able to recognize explicit bias when we see it, whether it is overt racism, homophobia, ageism or sexism. But the reality is that our unconscious biases—tied to many of those same issues and more, including people’s weight, socioeconomic status and physical disabilities—can make spotting bias difficult.

Speaking at this year’s Society of Hospital Medicine meeting, René Salazar, MD, professor of medical education and assistant dean for diversity at the University of Texas at Austin Dell Medical School, pointed this out: Unconscious, implicit bias is not only more prevalent but “just as problematic” as the conscious, explicit type.

That’s because, despite our best intentions, “we all hold unconscious beliefs about various social and ethnic groups,” Dr. Salazar said, “even though such beliefs are incompatible with our conscious values. It’s important to acknowledge that.”

“We all hold unconscious beliefs about various social and ethnic groups.” 

bias-salazar~ René Salazar, MD University of Texas at Austin Dell Medical School


It’s also important to work to identify and manage such blind spots. Otherwise, he added, unconscious biases can derail your workplace as well as your ability to deliver patient care.

Reinforcing biases
What exactly qualifies as unconscious bias? According to Dr. Salazar, unconscious bias refers to social stereotypes that individuals form outside their conscious awareness. “Bias stems from our tendency to organize social roles by categories,” he said, noting that forming biases is a normal aspect of human life driven by natural survival instincts. “Biases develop over time, and many factors contribute including where you grew up, your friends and family, and other patterns of experience you had when you were young.”

Bias is also constantly bolstered by the omnipresent media. By way of an example, Dr. Salazar showed two news photographs taken in New Orleans after Hurricane Katrina. The caption of one stated that the young black man shown in the photo was seen wading through chest-deep water after looting a grocery story.

The other caption, which referred to a photo of a young white man and woman, noted that they were wading through chest-deep water “after finding bread and soda from a local grocery store.”

“How these messages are presented in the media can have a profound effect,” Dr. Salazar pointed out. “Those messages can constantly reinforce unconscious bias in a negative way.”
Unconscious biases can become particularly problematic for physicians because they are perfectly set up to be vulnerable to them. For one, the culture of medicine does not highlight self-care or self-examination. In addition, stress—a constant in medical practice—is a great way to activate bias.

“At the end of the day after several admissions, you’re really running on reserves,” Dr. Salazar pointed out. “We’re often stressed, making high-stakes decisions and multitasking.”

And as clinicians, “We’re trained to think a certain way, which is all about pattern recognition,” he added. That can push physicians to be even more swayed by unconscious bias.

Unconscious bias on the job
Unconscious biases also fuel what Dr. Salazar called “microaggressions,” subtle experiences that aren’t necessarily overt, but can nonetheless set the tone for a work environment.

“Individually, microaggressions may not seem very powerful,” he said. “But over time, they may collectively contribute to a hostile work environment.” In a group of rounding medical students, for example, young women may repeatedly be asked to remove trays from patient rooms.

Unconscious biases can also have an enormous impact on hiring and job-performance evaluations.

In one 2000 study, Dr. Salazar pointed out, “blind” orchestra auditions—in which musicians played behind a screen to conceal their gender—led to a 50% increase in the number of women advancing beyond the preliminary rounds. Further, implementing a blind audition strategy led to a 25% increase in the hiring of women musicians.

Then there was a 2004 study titled, “Are Emily and Greg More Employable than Lakisha and Jamal?” In that study, researchers sent out four fictitious resumes in response to real help-wanted ads. The resumes all listed the same educational references and qualifications, but had different names.

The result: “Emily” and “Greg” garnered 50% more callbacks for interviews compared to “Lakisha” and “Jamal” across the entire spectrum of jobs advertised, from cashiers to executives. Researchers concluded that racial bias may have contributed to the findings.

As for gender bias, studies have found that women pay a motherhood penalty in terms of hiring and job evaluation, with women who have children being perceived as being less competent and receiving lower starting salaries. For men, on the other hand, having children “was almost the reverse,” Dr. Salazar said. “They were not penalized, and they sometimes benefited in their careers from being fathers.”

Research has also repeatedly zeroed in on the gender gap in women physicians’ compensation and advancement. A study in the November 2013 issue of Academic Medicine, for instance, found that early-career physician researchers who were women earned $31,000 less than their male counterparts. The authors wrote that the disparity could not be fully explained “by specialty, academic rank, work hours, or even spousal employment.”

State of the science
As for health disparities, Dr. Salazar said that more than two dozen studies dating back to 1995 have looked at the impact of unconscious bias on medical decision-making. Two-thirds of that research found evidence of either conscious or unconscious race bias.

In a study in the September 2007 issue of the Journal of General Internal Medicine, for instance, researchers used clinical vignettes and other tools to assess doctors’ perceptions of both fictitious black and white patients presenting with acute coronary syndrome. While the physicians in the study reported no explicit racial bias, findings revealed that more of them perceived African-American patients as being less cooperative in general, and less cooperative specifically with medical procedures. As doctors’ pro-white bias increased, their likelihood of treating white patients— but not black ones—with thrombolysis also rose.

Another study, this one published in the November 2015 issue of JAMA Pediatrics, found stark disparities in pain management in emergency departments in children diagnosed with appendicitis. Researchers found that black patients were far less likely to receive opioids than white ones (12% vs. 34%).

And in research published in the May 2011 issue of the International Journal of Obesity, researchers gauged the bias and care recommendations made by medical students for both obese and non-obese virtual patients. The authors found that the obese patients routinely received more negative stereotyping and were expected to have less anticipated adherence.

“Think about being the patient at the other end of that discussion,” said Dr. Salazar. “If you realize your provider has a negative perception of you, what’s the likelihood that you’re going to follow through with any recommendations he or she makes? It basically rips the alliance apart.”

Increasing personal awareness
What can doctors do? The first and most important step, said Dr. Salazar, is to become aware of your own unconscious biases.

An invaluable tool to help you do so is the implicit association test (IAT), which was introduced in 1998 and has now been used by more than 15 million participants. There are more than a dozen IATs that people can take online to gauge their perceptions of different ethnic groups, gender, sexual identity, disability, skin tone, weight, religion and many others.

The test, which measures the time it takes to match representatives of social groups to particular attributes, has been vigorously tested in terms of its reliability and validity. According to Dr. Salazar, the test can enhance people’s motivation to reduce the influence of bias by letting them privately recognize their unconscious biases.

Dr. Salazar offered his own experience as an example: A frequent taker of IATs, he has become aware of his unconscious bias against obese patients. That awareness came to mind recently when he was rounding as a ward attending in the ICU with a morbidly obese patient.

“I found myself not wanting to examine the patient, but I was able to catch myself before I did something consequential,” he said. “Because I could acknowledge that bias, I was able to pause and then treat the patient, doing everything I would do for any other. Think about the impact on those residents and students if I had failed to do an exam, and what message I would have been giving them.”

What to do
In his own practice, Dr. Salazar also tries to incorporate mindfulness in his daily routine as a strategy to reduce stress and anxiety. One technique he uses is taking a 30-second pause between seeing different patients “to clear my mind.”

Education is also key. Several medical schools across the U.S. include unconscious bias training in their curriculum. For more than a decade, for example, the University of California, San Francisco (where Dr. Salazar used to teach) has included sessions on unconscious bias in its curriculum for first-year medical students. Training includes having students take an IAT, then discuss their results in small groups.

That helps students more effectively break down their individual experiences. And in 2013, the UCSF office of diversity and outreach launched a campus-wide unconscious bias training program to increase awareness among faculty, staff, students and trainees.

Dell Medical School, which enrolled its inaugural class in July, is using a similar approach. Sessions on unconscious bias are planned for the first-year doctoring course and will also be included as part of the interprofessional education curriculum.

Further fixes include enhancing emotional regulation skills, in part through stress-reducing techniques, and communication training. Such training can improve physicians’ ability to build partnerships with patients by working to find common ground.

Dr. Salazar noted that institutions also have a big role to play. Dell Medical School, for instance, provides unconscious bias training to members of the school’s admissions committee. It also plans to hold training for its residency program admissions committees and core faculty.

“You may not be able to change these biases, but you can minimize their impact,” said Dr. Salazar. “You can take what you’ve learned and start to think about them differently.”

Phyllis Maguire is Executive Editor of Today’s Hospitalist.

How should you deal with racist patients?

_95869010.inddIN A PERSPECTIVE PIECE in the Feb. 25, 2016, New England Journal of Medicine, authors presented this dilemma: What should you do when a patient in the ED refuses to be treated by a physician due to that doctor’s ethnicity, gender or religion?

While “competent patients have the right to refuse medical care,” according to the piece, providers’ rights—particularly those granted under title VII of the Civil Rights Act, giving people the right to a workplace free from discrimination—also need to be part of the equation.

The article points out that nurses and nursing assistants have sued hospitals that forced providers to accede to requests for reassignment. However, doctors have not brought lawsuits, in part because many of them may not be hospital employees. Also, doctors tend to decide among themselves how to deal with such demands, even those fueled by bigotry.

According to the authors, a doctor’s response to such a request should take into account the patient’s condition and how stable he or she may be. If other physicians are available, it may be reasonable for doctors to decide themselves if the patient should be reassigned. Or physicians can choose to negotiate with the patient and/or family, or engage a nurse or resident to evaluate the patient—as long as patients know that isn’t the standard of care.

What also needs to be considered: the impact on the physician, for whom “expressions of patients’ racial preferences are painful and degrading indignities, which cumulatively contribute to moral distress and burnout,” the authors write. While they recommend that doctors should “subordinate their self-interest to a patient’s best interests,” they also advise hospitals to not accommodate such requests, even if individual physicians choose to do so.

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