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Everyday solutions to reduce implicit bias in health care

NEW ORLEANS — Unconscious biases remain pervasive in everyday interactions between health care providers and patients and lead to worse outcomes for racial and gender minority populations, but several concrete actions can reduce or neutralize such tendencies, Quinn Capers IV, MD, FACC, FSCAI, said during a keynote at the CHEST Annual Meeting.

“You are all good people; I am a good person,” Capers, associate dean for admissions at Ohio State University College of Medicine, said here. “But it is likely that, at some point, I have discriminated against others. It is so important that we treat people fairly, but in our field — medicine — it is critically important. Health care disparities still embarrass our nation’s health care system. We can easily override our implicit biases.”

Implicit bias, Capers said, is defined as a positive or negative mental attitude toward a person, thing or group that a person holds at an unconscious level. That is contrasted with explicit bias, he said, which is defined as a positive or negative mental attitude toward a person, thing or group that a person is aware of and is under conscious control.

Implicit white race preference, Capers said, is not the same as racism.

“They are quite different, with the difference having everything to do with intention, awareness and control,” Capers said.

The same, he said, goes for preference based on sex. Capers showed the audience at CHEST 2019 two advertisements for a Delta Airlines app that tracks baggage and flights. The ad featuring a man noted that the app can help a person change their flight to fit a change in meeting schedule. The ad featuring a woman noted that a person can use the app to “keep an eye on your favorite shoes.”

“This is a stimulus,” Capers said. “You might not be paying attention to this, but it tells a story that builds a narrative in your unconscious brain. What it tells you is men are worried about their meetings, and women are worried about their wardrobe.”

That internal narrative, Capers said, can make its way into everyday interactions with patients. Research shows that physicians have the same implicit white preference as people in other professions — a rate of about 70%.

Negative health outcomes

In a study published in August 2016 in the Journal of Clinical Oncology, 18 non-black oncologists completed an implicit racial bias measure several weeks before video-recorded treatment discussions with new black patients (n = 112). Observers rated oncologist communication and recorded interaction length of time and the amount of time oncologists and patients spoke. After the interactions, patients answered questions about oncologists’ patient-centeredness and treatment perceptions.

The researchers found that the oncologists who scored higher for implicit racial bias had shorter interactions with black patients, whereas patients and observers rated these oncologists’ communications as less patient-centered, Capers said. Additionally, oncologist implicit bias indirectly predicted less patient confidence in recommended treatments as well as greater perceived difficulty completing them.

“If you are interacting with a patient from a group against which you are unconsciously, negatively biased and you ‘over-talk’ them, you smile less, you provide less eye contact, what is the worst that could happen?” Capers said.

In another study, physicians watched a film featuring one of several actors, all reading an identical script in the same tone of voice about having chest pains. After watching one actor, the physicians were asked if they would refer the patient for a heart catheterization procedure to check for a blocked artery.

The white male patients, Capers said, were the most likely to be referred, followed by white women, black men and then black women.

“Now how many of you think that these physicians are bad people?” Capers said. “Of course not. They are humanitarians like you are. But good people can discriminate because unconscious biases can hijack our good intentions.”

Overriding biases

There are several research-driven solutions clinicians can utilize to reduce or neutralize implicit bias during interactions with patients or, on the college admissions or hiring level, interviewees, Capers said.

Common identity formation — During interaction with a patient or interviewee, probe to find a common identity, Capers said. Ask the person questions about interests and activities that you share in common, such as family size, community, a common hobby or sport. “It turns out if you are in a group, you automatically have a bond with others in that group,” Capers said. “Simply finding that out can reduce your implicit bias in a one-on-one interaction.”

Perspective taking — “Really try to get inside their head and their life and walk a mile in their shoes,” Capers said. “I have to think, what did this person have to do to get to me today? Maybe they had to make arrangements at work 2 weeks in advance. Maybe they had to find child care. Then they get here and have to figure out where to park their car. It’s all pretty stressful. If I contemplate that, I develop empathy for them, and that is the key.”

Consider the opposite — When data seem to point to one conclusion, briefly look for data supporting the opposite conclusion before making a final decision, Capers said.

Counter-stereotypical exemplars — Spend time with or focus on individuals you admire from groups against which you have a bias, Capers said. “Force yourself to spend time with someone of a different race, gender, sexual orientation. ... If you’re a Democrat, go to dinner with some Republicans,” Capers said. “If you force yourself to do that, you will undoubtedly see traits you admire.”

“This is doable,” Capers said. “We ought to consider this just as important as the prescriptions that we write and as the procedures that we recommend. We have a lot of power in our interactions with our patients. You are fair consciously, but it turns out our unconscious minds may be leading us astray. But, we can overcome it. It takes work, and attention, but I know you think it is worth it, as I do.” – by Regina Schaffer

References:

Capers Q. But I’m not racist, sexist, homophobic, etc! Implicit bias and discrimination in health care. Presented at: CHEST Annual Meeting; Oct. 19-23, 2019; New Orleans.

Penner LA, et al. J Clin Oncol. 2016;doi:10.1200/JCO.2015.66.3658.

Disclosure: Capers reports no relevant financial disclosures.