Avoiding implicit bias in rheumatologic care: The role of empathy
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This month’s cover story analyzes a serious problem, namely the underrepresentation of patients from marginalized communities in lupus clinical trials.
Our panelists — Allen P. Anandarajah, MBBS, MS; Joy Buie, PhD, MSCR, RN; Candace Feldman, MD, MPH, ScD; Shivani Garg, MD, MS; and Rose McKeon Olson, MD; whom we thank — critically appraise this issue from multiple perspectives, including the clinical ramifications of data generated from trials with racial imbalances, as well as many of the complex contributing factors to this ongoing serious problem. Our panelists remind us that there are multiple factors that result in the lack of patients from underrepresented communities across clinical trials — and not limited to lupus alone — many of which stem from an array of complex, systemic societal issues. These include deep socioeconomic barriers impacting multigenerational poverty, as well as gaps in health literacy stemming from inadequate educational resources and opportunities.
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Even though these are but a few of the obstacles that must be overcome to achieve greater diversity in research, most of us view these as societal problems that have existed for generations without easy or quick solutions, issues that we as individual practitioners are largely helpless to fix on our own. I personally can appreciate this sentiment. However, I want to examine this in a more personal manner by asking, “What can we as practitioners do in our daily practice to begin to knock down such barriers, to enhance both the care and caring of those who in some way differ from us regardless of who we are?”
One of the obstacles to quality care, whether it be in the clinic or in research, and elegantly discussed in the roundtable, is implicit bias. For convenience, I will define implicit bias as our unconscious collection of stereotypes and attitudes that we harbor toward certain groups of people. These stereotypes or attitudes may be based on their skin color, their ethnic heritage, their gender, their sexual preferences, their education and on and on and on and on. When reflecting on our own implicit biases, most of us tend to minimize our personal culpability and the impact of our behaviors. I for one have fallen in that category and have become more aware of my shortcomings in recent years as I have sat in on medical school lectures as a preceptor, which — after I got over my initial denial — has been and continues to be a humbling and rewarding process of self-reflection.
In my opinion, our own capacity for implicit bias is something we all should think about and consciously work to minimize in our own lives, and especially in the care of our patients. I am not debating the boundaries of “woke culture” here, but rather the way we unconsciously think and sometimes behave when we are in the presence of those who, in one or more ways, are merely different from ourselves. To do this requires candor and humility and is not often comfortable to explore.
As many of the readers of Healio Rheumatology know, I have written on empathy in health care many times, and again I suggest that empathy can be part of the solution to minimize or eliminate implicit bias from our own practice, if not our own lives. If empathy is our ability to stand, but not live, in the shoes of another, I can safely say it is easier to be empathic to those more similar than different from us. As I like tell my students, “It’s easy to be nice to nice people.” Rheumatologic care should not only be about evidence-based and high-quality data, but should also be personal. Getting to know people — ie, our patients — as I believe most rheumatology practitioners generally do over time, is a great start. This requires asking extra questions when we have the time. Exploring our patients’ concerns as well as their complaints is mission critical to me every day in my practice.
Picking up on clues as to what our patients’ moods are — sad, angry, happy, etc. — and of course maintaining physical — not just online — connections with the patient, are skills that constantly need to be refreshed. I don’t want to portray these skills as a quick fix for parsing implicit bias, but cultivating these practice behaviors can strengthen the skills that tell patients we will not only take care of their rheumatic disorders, but we actually care about them. This is my take. What’s yours? Please share your thoughts with me at calabrl@ccf.org or at rheumatology@healio.com.
- For more information:
- Leonard H. Calabrese, DO, is the Chief Medical Editor, Healio Rheumatology, and Professor of Medicine, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, and RJ Fasenmyer Chair of Clinical Immunology at the Cleveland Clinic.
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