Recognizing and Combatting Bias in Medicine

Every moment, the human brain processes incredible amounts of information. This processing allows one to make decisions and take actions. Most of this goes on behind the scenes, a necessary efficiency that means we do not have to explicitly “think” about most activities. In medicine, this is especially necessary, and we often employ heuristics or mental shortcuts that ease the brain load and speed up the process of finding a satisfactory solution. How might these cognitive process impact our decisions and actions? Let’s take a closer look.

In this article, the author aims to present an introduction to the concept of bias in the world of health care, specifically implicit bias. Additionally, this discussion presents steps clinicians can take to learn more, along with examples of specific actions to improve behaviors and potentially improve relationships with patients and subsequent outcomes.

Bias means that a person prefers an idea and possibly does not give an equal chance to a different idea. Explicit bias requires that a person is aware of their prejudices and attitudes toward certain groups. Overt racism and racist comments are examples of explicit biases. Research suggests that explicit bias toward ethnic/racial groups has declined significantly over the past 50 years and is now considered unacceptable in general society.

In contrast, implicit (unconscious) bias appears more commonly and persistently. It occurs when stereotypes influence the brain’s automatic processing, and therefore those stereotypes impact your actions and judgments.

In health care, we need to think carefully about what bias means. Evidence identifies biases as negative factors in health care that distort evidenced-based decision-making.¹ To deliver impartial care, health care professionals should beware of making a negative evaluation linked to membership of a group or to a particular characteristic.² One cannot measure implicit bias with standard (self-reporting) survey questions. Instead, there are sophisticated instruments developed for this purpose, the most common of which is the Implicit Association Test (IAT).³ The IAT is a computer-based measure that relies on differences in response latency to reveal implicit bias. Project Implicit comprises a network of laboratories, technicians, and research scientists at Harvard University, the University of Washington, and the University of Virginia. The IAT measures attitudes and beliefs that people may be unwilling or unable to report and examines a wide variety of belief categories such as those relating to gender, ethnicity, body type, age, or disability. The IAT may prove especially interesting if it shows that you have an implicit attitude you did not know about.³

How Can Clinicians Take Action?

One of the goals of recognizing implicit bias in patient care is to address the underlying mechanisms that prompt the use of potentially stigmatizing negative patient descriptors. This includes preventing the introduction of biased language by providers, preventing the perpetuation of biased language by health care team members, and increasing awareness of the effects of providers’ language on the patient relationship.^1-4

Provider bias training can include many different key concepts and topics, one of which being competencies in non-stigmatizing language for interprofessional communication. Use of “people-first” language (for example, saying a patient has an “alcohol use disorder” instead of labeling the patient “alcoholic;” or saying someone is an “individual with diabetes” versus a “diabetic patient”) is becoming more common.⁵ Better education on race and racism may help equip providers with the understanding needed to identify, prevent the introduction of, and discontinue the use of, negative descriptors in the electronic health record (EHR) and in clinical practice. One can find suggested resources for further education at the US Department of Health and Human Services Office for Minority Health website and its Think Cultural Health Program.

How Does Bias in Health Care Relate to Biases in Society?

Impartial treatment of patients by health care professionals is an uncontroversial goal in health care. Despite this, the magnitude of reported bias in a health care setting or relationship varies, and studies suggest that clinicians have similar implicit biases to others in society.³ The presence of such implicit bias among clinicians further suggests that bias could play a role in health care disparities just as it plays a role elsewhere in society.

The implicit biases of the most significant concern to health care professionals are those impacting patients who are already vulnerable. Examples include minority ethnic populations, immigrants, poor people, individuals with low health literacy, sexual minorities, children, women, elderly people, mentally ill people, overweight people, and disabled people, but anyone may be rendered vulnerable given a certain context.⁴ Those vulnerable to the impact of implicit bias in health care are typically members of groups who are already disadvantaged on many levels.⁴

Final Thoughts

If health care professionals’ implicit biases contribute to health disparities, reducing those biases seems an obvious solution. Basic research supports that implicit bias is changeable.^2,3 Our own biases are often unintentional and not obvious from standard assessment. Recognizing these implicit biases is the first step in combatting them and changing behaviors in a way that has the potential to positively impact the care delivery process.  

Dr. Simon is the Executive Director of the New Mexico Podiatric Medical Association and a member of multiple committees for the American Public Health Association and American Podiatric Medical Association. She is a Fellow of the American College of Foot and Ankle Surgeons and practices in Albuquerque, NM.

References

1.    Aronson J, Burgess D, Phelan SM, Juarez L. Unhealthy interactions: the role of stereotype threat in health disparities. Am J Public Health. 2013;103(1):50-56.
2.    FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18;19.
3.    Blair IV, Steiner JF, Havranek EP. Unconscious (implicit) bias and health disparities: where do we go from here? Perm J. 2011;15(2):71-78.
4.    Martin AK, Tavaglione N, Hurst S. Resolving the conflict: Clarifying ’vulnerability’ in health care ethics. Kennedy Inst Ethics J. 2014;24:51–72
5.     Office of Disability Rights. People First Language. Available at: www.odr.gov/page/people-first-language. Accessed August 10, 2022.