Health disparities exist and persist because of a complex interplay between structural factors and individual patient care decisions made by clinicians. However, it is often easier to identify the structural factors that perpetuate health disparities than to look internally at the unconscious factors inside us that perpetuate them. Structural factors including health insurance status, limited access to high quality healthy foods (“food deserts”), and the psychological distress from repeatedly experiencing racial discrimination all contribute to health disparities (Ndugga, 2021).
However, individual provider behavior, shaped by internal unconscious factors, plays an important role in the perpetuation of health disparities. Health professionals disregard reports of pain from people of color (Trawalter S, 2012), are less likely to refer black patients for thrombolysis treatment for myocardial infarction (Green, 2007), are less likely to prescribe black patients’ antidepressants for depression (Gonzalez HM, 2008), and more likely to misdiagnose them with schizophrenia than white patients (Schwartz RC, 2014). And yet, health professions are trained to be objective and “do no harm.” As a medical profession, we condemn explicit racism and want to see ourselves as egalitarian and nonprejudiced. In order to reduce the impact of implicit racial bias on our patients we must resist the impulse to withdraw into guilt and self-criticism, and instead engage in the challenging work of acquiring skills to mitigate their impact.
Implicit racial bias is defined as unconscious attitudes and stereotypes that can manifest in the criminal justice system, workplace, school setting, or in the healthcare system (Ruhl, 2020). These biases often result from trying to find patterns to navigate a complicated world and can cause individuals to unknowingly act in discriminatory ways.
Racial bias is ubiquitous and can be deadly. Implicit biases can be activated when individuals make split second decisions, like when an officer shot and killed 13-year-old Adam Toledo in Chicago. It can also impact medical care, such as the delay to recognize the severity of Dr. Susan Moore’s COVID infection in my home state of Indiana (Eligon, 2020).
Time pressures are just one factor that can increase the risk of bias in medical decision making (Croskerry, 2003). Health professionals commonly use pattern recognition and other fast thinking strategies in their clinical reasoning, enhanced and improved over time with experience and clinical feedback. But what if the feedback we receive unwittingly activates and reinforces unconscious stereotypes?
For example, Mrs. D a black woman with hypertension and kidney disease seeks care from a white health professional. The white provider may unwittingly allow less time for the patient to communicate her concerns (Penner, 2014) leading to dissatisfaction with her care. Her negative experience may influence her future behavior, such as missing the nephrology appointment or not following the provider’s advice. Or perhaps structural factors such as a high co-pay, or lack of transportation or childcare, prevent her from attending the nephrology appointment. Either can activate and reinforce the provider’s unconscious stereotypes of black patients being noncompliant or not caring about their health. The provider may be less likely to refer black patients to nephrology in the future.
This type of reinforcing feedback on implicit biases make them very challenging to defeat and counteract. And yet, it is also why it is so important to do this work! One important step is to address the structural factors involved in the perpetuation of health disparities. Some examples include:
- Training more doctors, nurses, and other health professionals from groups traditionally underrepresented in medicine with the goal of reducing health disparities through enhanced physician-patient communication(Kington R, 2001).
- Advocating for universal health care to reduce unequal access to healthcare based on socioeconomic or insurance status
- Addressing policies, systems, and environments that influence social determinants of health, such as access to transportation
- Recognizing and addressing race-based corrections in PFT or GFR calculations, that are based in a history of slavery and may contribute to disparities in lung and kidney disease
But how do we do our own internal work to address our own biases that unwittingly influence our decisions? The first step is to recognize that everyone has implicit biases, to critically reflect on your own biases, and learn about the effect of bias on health disparities. There is a growing body of literature on implicit bias recognition and management curricula in medical education (Gonzalez, 2021).
Another important step is to identify when our unconscious stereotypes are being triggered and to develop and alternative narrative. For example, when Mrs. D does not attend the nephrology appointment, this may trigger the provider’s unconscious stereotypes of black patients being noncompliant or not caring about their health. In order to counter this stereotype, the provider could try to identify the structural factors that contributed to the missed appointment. By identifying social and structural determinants of health, providers can potentially connect patients to resources to address unmet social needs.
Finally, recognizing the strength and humanity of our patients is also a powerful tool to counteract racial biases. Slowing down, the provider might learn that Mrs. D teaches middles school and cares for her aging mother with dementia. Getting to know the things that make our patients unique, or finding out about their family, can help to see them as individuals and reduce activation of racial stereotypes that fuel our implicit biases.
–Erin Goss, MD, AAHIVS, Community of Practice Member
Dr. Goss is an Assistant Professor in the Departments of Medicine and Family & Social Medicine at the Albert Einstein College of Medicine in Bronx, NY and a core faculty member for the Primary Care/Social Internal Medicine residency program at Montefiore Medical Center. She teaches a course on clinical reasoning and implicit bias
Bibliography
- Croskerry, P. (2003, August). The Importance of Cognitive Errors in Diagnosis and Strategies to Reduce Them. Academic Medicine, 78(8), 775-780.
- Eligon, J. (2020, December 23). Black Doctor Dies of Covid-19 After Complaining of Racist Treatment. Retrieved from NY Times: https://www.nytimes.com/2020/12/23/us/susan-moore-black-doctor-indiana.html
- Gonzalez HM, C. T. (2008, October). Antidepressant Use among Blacks and Whites in the United States. Psychiatr Serv., 59(10), 1131–1138.
- Gonzalez, C. L. (2021). Twelve tips for teaching implicit bias recognition and management. Medical Teacher.
- Green, A. R. (2007, Jun 27). Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. Journal of general internal medicine, 22(9), 1231-1238.
- Kington R, T. D. (2001). Increasing Racial and Ethnic Diversity Among Physicians: An Intervention to Address Health Disparities? In S. A. Smedley BD, The Right Thing to Do, The Smart Thing to Do: Enhancing Diversity in the Health Professions: Summary of the Symposium on Diversity in Health Professions in Honor of Herbert W.Nickens, M.D. Washington D.C.: National Academies Press.
- Ndugga, N. a. (2021, May 11). Disparities in Health and Health Care: 5 Key Questions and Answers. Retrieved from Kaiser Family Foundation: https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-key-question-and-answers/
- Penner, L. A. (2014, Oct). Reducing Racial Health Care Disparities: A Social Psychological Analysis. . Policy insights from the behavioral and brain sciences, 1(1), 204–212.
- Ruhl, C. (2020, July 1). Implicit or Unconscious Bias. Retrieved from Simply Psychology: https://www.simplypsychology.org/implicit-bias.html
- Schwartz RC, B. D. (2014, December 22). Racial disparities in psychotic disorder diagnosis: A review of empirical literature. World J Psychiatry, 4(4), 133–140.
- Trawalter S, H. K. (2012, Nov 14). Racial bias in perceptions of others’ pain. PLoS One, 7(11).