Fighting the subconscious biases that lead to health care disparities

Physicians work to identify and respond to their own biases.

Growing up in rural Alabama at a time of segregated waiting rooms and physicians who refused to touch black patients, Ron Wyatt, MD, MHA, ACP Member, saw health care disparities firsthand. “And frankly, I had never met a black physician,” he said.

Dr. Wyatt recalled a close family member—a poor, mostly illiterate man in his 60s—who died in the hospital of a ruptured appendix without being seen by a physician. Although black patients may be treated better now, he said, disparities in care insidiously persist.

Photo by Thinkstock
Photo by Thinkstock

“It's not a matter of technology; we have the best technology in the world. It's not medication; we've got the best medicines in the world. It's not access; I can leave here right now and go to any hospital in Chicago and walk in and be seen,” said Dr. Wyatt, medical director of The Joint Commission's Office of the Chief Medical Officer in Oakbrook Terrace, Ill. “It's institutionalized inequities that, I believe, are driven by biased decision making—by prejudice that some folks aren't even aware of.”

How bias works

When hospitalists have mere seconds to process a patient's situation, powerful impressions, assumptions, and ideas flow through their brains unnoticed. While helpful for making swift decisions without much effort, these quick-draw notions, called implicit biases, can also lead to unequal patient treatment.

The brain's explicit cognitive system contributes to conscious and effortful thoughts, which may well be unbiased and egalitarian. Meanwhile, the implicit system produces an automatic response that typically goes undetected, according to Michelle van Ryn, PhD, professor of health services research at Mayo Clinic in Rochester, Minn.

“Most of what we do comes from it, because it's very rapid, and it evolved to help us survive a very complex world…. Our culture and the images we see around us get stored in that system as information about a category or group category,” she said. Although some refer to this system as an unconscious one, that's not entirely true. “Sometimes, people can become aware of it. It's not like we are choosing it, but we can detect it,” Dr. van Ryn said.

About 75% to 80% of white Americans have negative biases toward black Americans, she reported. “It's been shown over and over in multiple samples—physicians, everybody…. When you start counting out the images that you get exposed to and how many of them portray blacks positively and how many have at least 1 subtle negative thing, it's not surprising,” Dr. van Ryn said.

A 2013 study synthesized research documenting the existence of implicit bias and found that it is not restricted to black patients. For instance, Hispanic patients in 1 study were 7 times less likely to receive opioids in the ED than non-Hispanic patients with similar injuries. “We know that in the population, if we test a person's bias towards people of color or any other kind of minority group, people tend to favor white people,” said study author Elizabeth N. Chapman, MD, a geriatrician at the University of Wisconsin Hospital in Madison. “They tend to favor the majority group in general, and that holds true for physicians also…. Even if you are of the minority category yourself, you may have that preference—it's not as strong, but even kids as young as 3 years old have a tendency to prefer white faces to black faces, regardless of their color themselves.”

The first step to overcoming these implicit associations is for physicians to realize they might have some bias, she said. “I think it's hard for physicians to admit it because, even though we know this implicit bias is part of being human, we don't always feel like we're regular humans. We work these long hours and we push ourselves to these limits…so sometimes I think it's hard to admit there's a problem,” Dr. Chapman said.

What about access?

Gaps in health care access are often offered as an explanation for racial health disparities, but Dr. Wyatt said even black professionals like himself, a practicing internist for 25 years, face unequal treatment in hospitals. For instance, after developing a 103.3° fever after traveling to Zambia last summer, Dr. Wyatt sought care from an established hospital, where “from the minute I walked in, I was disrespected,” he said.

The triage nurse walked in front of Dr. Wyatt—not beside him—when taking him to the ED physician, he recounted. “I'm walking along thinking, ‘What if I fell down?’” he said. “The physician, to this day, I don't know his name. He didn't wash his hands. He barely looked me in the face. He prescribed me an antibiotic that I never took because he didn't come back in to explain to me why, and when he did come back in, he stood with 1 foot in and 1 foot out the room that I was in, and he literally talked to the wall,” Dr. Wyatt said.

Encounters like this, whatever their cause, could lead to worse outcomes for patients. “In some cases, it is absolutely conscious bias,” Dr. Wyatt said. “In a lot of cases, it's subconscious bias. The problem is the outcome of those decisions, how the patient feels, and how the family is treated…. Something happens in that patient encounter that leads to these persistent disparities.”

A 2005 study in Circulation found that in 2 acute coronary syndrome patient groups with similar presentation—except that 1 was black, the other white—cardiologists most often provided interventions such as cardiac catheterization to the white patient, whereas the black patient was more likely to receive medical management.

“Those are going to lead to different outcomes, potentially. And when the question is asked—why?—the typical response is we need more research,” Dr. Wyatt said. “We really don't. We need to start to address conscious and subconscious bias and how it plays into decision making that leads to either better outcomes or chronic disease and ultimately death.”

Check yourself

As a potential solution, 2 professors at the University of Wisconsin at Madison—Christine Kolehmainen, MD, MS, and Molly Carnes, MD, MS—developed “Breaking the Bias Habit,” a 3-hour interactive workshop for internists, family practice physicians, and internal medicine residents that discusses the impact of bias. The team received a grant to further develop the program, which will be offered this coming spring outside the university, said Dr. Kolehmainen, an internist and associate director of women's health at the William S. Middleton Madison Veterans Hospital. “You can break any habit,” she said. “So, with practice, we think we can break the implicit bias habit.”

Their strategies to reduce implicit bias are summarized in the acronym EPIC—engaging in perspective taking, practicing the right message, individuating, and challenging stereotypes. The first point involves contemplating a patient's perceptions, which can help promote empathy, Dr. Kolehmainen said.

“If you have a patient who is of a different race, a different gender, a different socioeconomic status, or religious category that you might find it difficult to empathize with or connect with, before you walk into that patient room, take 20 seconds to imagine what their daily life might be like,” she said.

Dr. van Ryn added, “Once the doctor uses something called cognitive empathy or perspective taking and starts thinking of this person as their partner in care, those things can override implicit bias.” A shortcut to this approach would be using words like “we” and “our” when speaking with patients, she said.

Trying to be “colorblind” and saying that you treat everyone the same actually invalidates people's experiences, so it's important to practice the right message, according to Dr. Kolehmainen. “What research shows is that if you just tell people that they have implicit bias and everyone has that, it actually does harm because it sort of normalizes it and makes it an acceptable behavior. … Rather than just saying that everyone has implicit bias, [saying] that everyone has these biases and most people are working to change them… can help people stay on target,” said Dr. Kolehmainen.

Physicians can also try to individuate—that is, work to figure out more about patients as individuals instead of relying on stereotypes from the social category they belong to, she said. For instance, instead of saying that a 66-year-old black male presents with chest pain, try coupling that capsule sentence with more information, such as smoking status or family history, to round out that patient's story, Dr. Kolehmainen said. “Race is important to include, and that's why we teach it. Because in and of itself, race plays a factor in risk for disease at times, so you want to include race,” she said. “But that's not where the sentence should stop.”

Finally, Dr. Kolehmainen recommends challenging stereotypes and broad generalizations about groups of people with facts, such as how substance abuse rates are the same between blacks and whites. And although it's easy to be overworked on the inpatient wards, “research shows that you're more likely to fall back on stereotypes and bias habits when you're tired, stressed, and hungry,” Dr. Kolehmainen said.

Feedback is also useful when trying to learn these skills, said Christy Kim Boscardin, PhD, associate professor in the department of medicine at the University of California, San Francisco. The implicit-association test has been validated and used in multiple different contexts and professions, she said. The timed test measures users' automatic associations between concepts, such as people of various races, and certain adjectives or stereotypes. Project Implicit hosts a free version of this test online at “There's a consensus that it's actually a good tool for self-reflection and providing feedback,” Dr. Boscardin said.

Next steps

The motivation on the part of the overall health care system to do formal training on physician bias is pretty low for several reasons, Dr. Chapman noted. “It's an important piece, but it's not something that we can show saves money. I'd love to be able to do that, but the data is so slim right now that we can't show that the hospital is going to have these wonderful cost savings or shorter length of stay or fewer readmissions.”

However, Mayo Clinic is starting to do its own type of self-assessment. At the request of hospital leadership, Dr. van Ryn's research team recently conducted a system-wide climate assessment, which asked employees questions about diversity inclusion and exclusion and assessed the steps they are taking to prevent unintended bias. Staffers also took an implicit-association test. “As far as I know, Google is the only [other] company that's done this,” she said, noting Mayo got an average 68% response rate among the 59,000 employees.

The hospital plans to use these data as a baseline for a longitudinal study, which will test different interventions with the aim of building on strengths, addressing any gaps, and ensuring an equitable and welcoming environment—for both employees and patients, Dr. van Ryn said.