How to Check Your Implicit Bias At The Door
Implicit Bias: An Overview
Implicit bias is defined as the unconscious “attitudes or stereotypes that affect our understanding, actions, and decisions”. [1] It occurs without conscious awareness, is not readily apparent to oneself, and may be at odds with one’s stated beliefs. The Implicit Association Test (IAT) is one of the gold standards in measuring implicit bias. Tests of implicit bias can be taken for free through Project Implicit, a nonprofit organization and research group. [2] Overall, more than 70% of people who have taken the race attitude IAT have shown implicit preference for white Americans. One study found that physicians are no different: of more than 400,000 medical doctors that took the race attitude IAT, there was an overwhelming implicit preference for white Americans relative to black Americans. [3] Women physicians were shown to have less implicit bias than men physicians, but only black physicians showed no implicit race preference.
Foundational to cognitive bias theory is that human cognition can be divided into two categories. This dual-process theory was classically described in the book, “Thinking, Fast and Slow,” by Daniel Kahneman. [4] He describes two systems of thinking: System 1 is intuitive unconscious reasoning; it is based on heuristics or mental shortcuts. It is quick, emotional, and relatively effortless. It is also prone to bias and cognitive errors. In contrast, System 2 is slower and more deliberative. It is more logical, and is less prone to errors. Emergency Medicine (EM) physicians often rely on heuristics and System 1 thinking. [5] Gestalt plays into medical decision making as physicians rely on unconscious pattern recognition of the whole. Most of the time, this type of thinking works well and many of our accepted clinical decision rules incorporate clinician gestalt into the criteria. As a trade-off, EM physicians are more vulnerable to implicit bias. It is important we recognize this reliance on unconscious thinking and reasoning that can result in racist actions and decisions towards our patients and their care. Tips to mitigate implicit bias are outlined below.
Mitigating Implicit Bias:
1.) Be Aware
Studies have shown that just being aware that implicit bias exists can result in a change of behavior. [6,7] Hearing about other biases can be helpful in reflecting on one’s own actions. Whether it’s personal reflection on a case, or looking at data from one’s own department or national EM trends, acknowledging discrepancies in care can be a galvanizer for more thoughtful and just care in the future.
2.) Perspective-Taking
Perspective-taking is a conscious attempt to envision another person’s point of view. [8] Studies have shown that the simple mental exercise of putting yourself or your loved one in someone else’s shoes significantly reduces implicit bias. [7] One study asked nurses to look at a photo of either a white or black patient in pain. [9] First they were asked to use their best judgement to determine how much pain medication they needed. The white patients were given significantly more pain medication than the black patients. In contrast, when nurses were first instructed to imagine how the patient felt, the patients were given equal analgesia, regardless of race. This tool is deceptively simple for how powerful it is.
3.) Watch Your Language
We know that the words and language we use in the electronic medical record matter. The language we use can have a direct impact on the care we provide, and can often reveal our personal biases about a patient.
One example of the influence of stigmatizing language describes patients with sickle-cell disease. A 2011 survey at the American College of Emergency Physician’s Scientific Assembly completed by 655 EM providers from 49 states found that those who used the term “sickler” to refer to patients with sickle cell disease had more negative attitudes towards those patients, and were less likely to give adequate pain medication. [10] Stigmatizing language not only affects the care we individually provide, but also impacts the attitudes of future providers towards the patient.
The Department of Addiction Medicine at Massachusetts General Hospital looked at the phrasing of “a substance abuser” versus “having a substance use disorder” to describe patients. Providers reading the vignette that used the term substance abuser were more likely to recommend punitive rather than therapeutic measures. [11] The “abuser” was more likely to be blamed for their substance related difficulties and less likely to be assessed as having a problem that was the result of an innate dysfunction. Another vignette study of two chart notes compared stigmatizing versus neutral language to describe the same hypothetical patient, a 28 year-old man with sickle cell disease. The stigmatized example was a composite of real medical records from the same medical center. Stigmatized language was defined as language that cast doubt on the patient’s pain, portrayed the patient negatively, and implied the patient was irresponsible and uncooperative. Exposure to the stigmatizing language note was associated with more negative attitudes and less aggressive management of the patient’s pain. [12]
While we strive for objectivity, our documentation is often subjective. There are steps we can take to ensure professionalism, mitigate our own biases, and limit bias conveyed to future providers. These steps include:
Ensure you add only relevant details, and avoid irrelevant comments about behavior and conflicts with the healthcare team. For patients who are combative or uncooperative, use specific language if possible, documenting any reason the patient may provide for his/her behavior.
Evaluate whether quotes are necessary for medical care. It’s important to remember that we are often seeing our patients at their very worst. Those quotes will follow them throughout their medical life. Be thoughtful about quotation use and the inclusion of patient statements. Context is important, but it should not undermine the patient’s credibility.
Use appropriate descriptions and highlight context. It is critically important to avoid casting doubt on patient reports and experience. Avoid language such as “abuse,” “refuses,” “insists,” and “complains.” When documenting noncompliance, acknowledge and document the challenges and treatment barriers, both psychosocial and structural, that the patient is facing (ex. housing insecurity, income inequality, mental health, incarceration, lack of transportation, etc.). It is essential to contextualize a patient’s experience, choices, and challenges to reduce stigma and bias.
4.) Individuation
Individuation is the conscious effort to learn more about an individual patient in order to rely less on group stereotypes and assumptions to fill gaps in information. Information about a patient as an individual person becomes the foundation upon which the provider makes medical decisions and treatment recommendations, rather than relying on more generalized and biased information such as race, gender, and socioeconomic status. [7]
5.) Follow the Guidelines
While there are numerous examples in which algorithmic medicine can be problematic, it has been shown that guideline-congruent care results in better outcomes. [13] Minority populations are less likely to receive guideline-congruent care. [14] The judicious use of guidelines and treatment protocols can help to ensure equity of care. For example, a triage protocol to obtain an EKG on arrival for any patient with chest pain can help to offset some of the known disparities in triage and initial management for minority populations with chest pain. [15,17] Decision-making tools can mitigate some of our implicit bias or negative perceptions of a patient and objectively help to guide treatment recommendations and ultimate ED dispositions.
Acknowledging and actively addressing implicit bias, especially pro-white implicit bias, is a small but important step in combating systemic racism and resultant health disparities in medicine. Continuous reflection and introspection of our own perceptions and processes is necessary to combat implicit bias. The onus must be on each and every healthcare provider to become educated, active, and involved in pursuing health equity and racial parity.
AUTHOR: Erica Lash, MD is a fourth year emergency medicine resident and chief resident at Brown University/Rhode Island Hospital.
FACULTY REVIEWER: Jessica L. Smith, MD is Residency Program Director and an Associate Professor of Emergency Medicine at Brown University.
REFERENCES:
Sabin J, Nosek BA, Greenwald A, Rivara FP. Physicians' implicit and explicit attitudes about race by MD race, ethnicity, and gender. J Health Care Poor Underserved. 2009;20(3):896-913. doi:10.1353/hpu.0.0185
Kahneman, Daniel. Thinking, Fast and Slow. New York: Farrar, Straus and Giroux, 2015.
Green AR, Carney DR, Pallin DJ, Ngo LH, Raymond KL, Iezzoni LI, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231–8. doi: 10.1007/s11606-007-0258-5
Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. J Gen Intern Med. 2013; 28(11): 1504–1510.
Galinsky AD, Moskowitz GB. Perspective-taking: decreasing stereotype expression, stereotype accessibility, and in-group favoritism. J Pers Soc Psychol. 2000;78(4):708–24. doi: 10.1037/0022-3514.78.4.708
Drwecki BB, Moore CF, Ward SE, Prkachin KM. Reducing racial disparities in pain treatment: the role of empathy and perspective-taking. Pain. 2011;152(5):1001–6. doi: 10.1016/j.pain.2010.12.005.
Glassberg J, Tanabe P, Richardson L, Debaun M. Among emergency physicians, use of the term "Sickler" is associated with negative attitudes toward people with sickle cell disease. Am J Hematol. 2013;88(6):532-533. doi:10.1002/ajh.23441
Kelly JF, Westerhoff CM. Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. Int J Drug Policy. 2010 May;21(3):202-7. doi: 10.1016/j.drugpo.2009.10.010. Epub 2009 Dec 14. PMID: 20005692.
Goddu AP, O'Conor KJ, Lanzkron S, Saheed MO, Saha S, Peek ME, Haywood C Jr, Beach MC. Do Words Matter? Stigmatizing Language and the Transmission of Bias in the Medical Record. J Gen Intern Med. 2018 May;33(5):685-691. doi: 10.1007/s11606-017-4289-2. Epub 2018 Jan 26. Erratum in: J Gen Intern Med. 2019 Jan;34(1):164. PMID: 29374357; PMCID: PMC5910343.
Vyas, Darshali A., Leo G. Eisenstein, and David S. Jones. “Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms.” New England Journal of Medicine 383, no. 9 (2020): 874–82. https://doi.org/10.1056/nejmms2004740.
Venkat A, Hoekstra J, Lindsell C, Prall D, Hollander JE, Pollack CV Jr, Diercks D, Kirk JD, Tiffany B, Peacock F, Storrow AB, Gibler WB. The impact of race on the acute management of chest pain. Acad Emerg Med. 2003 Nov;10(11):1199-208. doi: 10.1111/j.1553-2712.2003.tb00604.x. PMID: 14597496.
López L, Wilper AP, Cervantes MC, Betancourt JR, Green AR. Racial and sex differences in emergency department triage assessment and test ordering for chest pain, 1997-2006. Acad Emerg Med. 2010 Aug;17(8):801-8. doi: 10.1111/j.1553-2712.2010.00823.x. PMID: 20670316.
Pezzin LE, Keyl PM, Green GB. Disparities in the emergency department evaluation of chest pain patients. Acad Emerg Med. 2007 Feb;14(2):149-56. doi: 10.1197/j.aem.2006.08.020. PMID: 17267531.
ADDITIONAL RECOMMENDED READING:
Braun L. Race, ethnicity and lung function: A brief history. Can J Respir Ther. 2015;51(4):99-101.
Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. J Gen Intern Med. 2013; 28(11): 1504–1510.
Bulgin D, Tanabe P, Jenerette C. Stigma of Sickle Cell Disease: A Systematic Review. Issues Ment Health Nurs. 2018;39(8):675-686. doi:10.1080/01612840.2018.1443530
Hess, Leona. “How You Can Be the Change: Adopting Anti-Racist Approaches and Equity Lens.” YouTube. Icahn School of Medicine, May 21, 2018. https://www.youtube.com/watch?v=w-aUZZbGPmc.
Jones, C. P. “Levels of Racism: A Theoretic Framework and a Gardener’s Tale,” American Journal of Public Health 90 no. 8 (2000), 1212-1215. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1446334/
Jones, C. P. “Race, Racism, and the Practice of Epidemiology,” American Journal of Epidemiology, 154 no. 4 (2001), 299-304. https://academic.oup.com/aje/article/154/4/299/61900
Jones CP. Confronting institutionalized racism. Phylon. 2003; 50 (1–2): 7–22.
Kendi, Ibram X. How to Be an Antiracist. New York: Random House Large Print, 2020.
Matthew, Dayna Bowen. Just Medicine: A Cure for Racial Inequality in American Health Care. NYU Press, 2015. JSTOR, www.jstor.org/stable/j.ctt15zc6c8. Accessed 23 Oct. 2020.
McIntosh P. White privilege: unpacking the invisible knapsack. Peace and Freedom Magazine. 1989: 10–12.
Saini, Angela. Superior the Return of Race Science. London: 4th Estate, 2020.
Schnitzer, K., Merideth, F., Macias‐Konstantopoulos, W., Hayden, D., Shtasel, D., & Bird, S. (2020). Disparities in Care: The Role of Race on the Utilization of Physical Restraints in the Emergency Setting. Academic Emergency Medicine. doi:10.1111/acem.14092
Todd, K. H., Deaton, C., D’Adamo, A. P., & Goe, L. (2000). Ethnicity and analgesic practice. Annals of Emergency Medicine, 35(1), 11–16. doi:10.1016/s0196-0644(00)70099-0
https://pubmed.ncbi.nlm.nih.gov/8445817/
Washington, Harriet A. Medical Apartheid The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. Paw Prints, 2010.