Reprinted from the summer 2021 issue of The Ohio Family Physician
By: Jillian Atherton, EdD, LPCC-S, Director of Behavioral Medicine at Mercy Health Anderson Hospital Family & Community Medicine Residency Program; and Wade Rankin, DO, CAQSM, Program Director at Mercy Health Anderson Hospital Family & Community Medicine Residency Program
A new patient is on your busy clinic schedule, awaiting your entrance to the exam room. You walk in and notice a 52-year-old Latino male, presenting as moderately disheveled in appearance, visibly worn by the day, and wearing casual clothes. He greets you, and while engaging in ‘small talk’ and describing recent back pain, speaks perfect English. Immediately impressed and desiring to build rapport with your new patient, you compliment his ability to speak perfect English; however, he winces, smiles a strained smile, and seems ‘on-guard.’ Something feels compromised. The issue in this scenario includes the assumption that Latino individuals do not speak English as their first language. This is a common form of racial/ethnic bias, simultaneously considered a ‘microaggression,’ and goes unrealized by the physician in this scenario vignette. As well intentioned as this physician seems to be, it is very possible to express explicit and genuine liking of a certain racial/ethnic group, while concurrently having an unconscious or implicit bias against that same group.
So, what is implicit bias? Any thoughts and feelings you have that exist beyond your conscious awareness are implicit (or unconscious) attitudes, rendering it a challenge for even those with exceptional self-awareness to recognize and control. Implicit attitudes are a byproduct of the human brain’s natural tendency to seek patterns and associations, from a very young age, to make sense of and form predictions in a complicated world. When these implicit attitudes form unconscious judgements and determinations, they become biased, and can be positive, negative, and/or neutral. While each implicit attitude has the potential to unconsciously result in personal bias(es), negative implicit attitudes, especially those regarding people of color, contribute to a desperate need for conversation and action about racial/ethnic biases that continue to hallmark widespread issues of past and present generations.
Specific to the field of medicine, medical and healthcare disciplines commonly demonstrate the role and scope implicit bias contributes to disparities in health and healthcare systems. A meta-analysis, including reviews of 15 implicit bias research studies, showcased evidence of implicit racial/ethnic bias among health care professionals where implicit bias was demonstrated in terms of positive attitudes toward whites and negative attitudes toward people of color.1 Implicit bias scores, spanning various groups of people of color, were found to be relatively similar, alike to those measured in the general population. Further, implicit bias was significantly and specifically related to interactions between patient and physician, treatment decisions and adherence, and patient health outcomes. These findings highlight the need for the healthcare profession to address the role of implicit bias as it relates to disparities in healthcare.2
Implicit bias and disparity form an unfortunate connection in medicine. Racial/ethnic minority populations in the United States most frequently encounter the following disparities in health care: access, quality, and outcomes.3
“Compared with white people, people of color face more barriers to accessing care, which includes preventive services, acute treatment, and chronic disease management. People of color are also generally less satisfied with their interactions with healthcare providers. The National Healthcare Disparities Report4 showed that white patients received better quality of care than Black American, Hispanic, American Indian, and Asian patients. Dominant communication styles, fewer demonstrated positive emotions, infrequent requests for input about treatment decisions, and less patient-centered care seem to characterize patient–provider interactions involving people of color.5,1
Other patient characteristics evaluated in the healthcare setting lend themselves to implicit bias from the provider, including gender, age, sexual orientation, national origin, and disability; however, most research on implicit bias in health care tends to focus on race. Studies that have focused on implicit bias across a variety of identity characteristics find evidence of implicit bias on sexual orientation, age, ethnicity, gender, disability, and religion.6
Implicit bias research reviews suggest implicit bias may be triggered while engaged in stressful work environments.1 Medical professionals commonly serve as peer mentors and preceptors to medical students, residents, and fellows, and have the potential to role model implicit bias, unknowingly. These demonstrations can present in numerous forms of cognitive implicit biases that are susceptible to maladaptive learning in medical environments by medical professionals.
Table 1 on page 32 is an adapted representation of several types of implicit bias and cognitive processes that commonly occur in a standard physician-patient encounter.7
Due to implicit bias being designated as an unconscious process, it is commonly assumed to exist as a stable feature of the mind, incapable of flexibility or change. Fortunately, research shows that implicit attitudes and biases are capable of long-term change.8 Specifically, sexual orientation implicit biases have demonstrated a faster rate of change in the general population than many other characteristics. Regardless, intentionality surrounding diversity and equity policies, or interventions, can launch conversations about implicit bias in a positive direction that aims for greater equity and mitigates health disparities.
Consider your 52-year-old Latino male patient from the earlier vignette. After meeting with and completing an examination, you learn he is a second generation owner of a local plant nursery you pass on your drive home each day. He shyly admits to taking on most of the ‘heavy lifting’ at the business so his elderly father, who also works with him, doesn’t get injured. He strained a muscle the day before while lifting a 50-pound bag of soil. As evidenced by the patient’s wince and strained smile after your English-speaking comment, the patient-physician relationship in this scenario swiftly shifted from a willing openness to quick closure due to race/ethnic bias. Our patients and healthcare system challenges and demands us to concert effort in recognizing and overcoming these biases.
References available on the Ohio Academy of Family Physicians website.