The Role of Unconscious Bias in the Exam Room
Phyllis B. Bouvier, MD for the Diversity Committee In 1999, Congress requested that the Institute of Medicine assess the extent and source of racial and ethnic disparities and suggest interventional strategies. In 2002, the report, “Unequal Treatment,” confirmed that “racial and ethnic disparities in healthcare are not entirely explained by differences in access, clinical appropriateness, or patient preferences. Disparities exist in the broader historical and contemporary context of social and economic inequality, prejudice, and systemic bias.” Prejudice is an unjustified negative attitude and discriminatory behavior based on a person’s group membership. Stereotypes are social categories people use in acquiring, processing, and recalling information about those we do not know as individuals. Stereotypes can be cognitive shortcuts, often used when we are short on time. Yet, even when stereotypes are evidence-based, they are likely to lead to disparities when the provider does not take into account the individual’s unique identifiers. Both stereotypes and prejudice are likely to produce negative outcomes. Unconscious (implicit) biases are thoughts that are outside of a person’s conscious awareness. They are habits of the mind, learned over time through repeated personal experience and cultural socialization. These beliefs are highly resistant to conscious change. An individual’s implicit evaluations may differ from their explicit beliefs (those beliefs that are verbalized). In this situation, a person might hide private thoughts and attitudes from others. Or, a person may not be conscious of the existence of those thoughts and attitudes. Research indicates that a discordance between a provider’s verbal and non-verbal responses leads to the assumption by the patient that the non-verbal response is indicative of the provider’s true attitude. Current disparity research is focusing less on the technical aspect of care (for instance which test or medication was ordered), and more on the interpersonal aspect of care (for example, expression of bias and cultural competence). There is a strong relationship between provider interpersonal behavior and patient satisfaction, adherence, utilization, and outcomes. Multiple cultural influences shape a patient’s view toward healthcare, as well as the patient’s past experiences with healthcare providers. Our cultural perspective automatically and unconsciously influences the way we perceive others and behave toward them and in turn this influences the way we interpret their behaviors. Similarly, the patient brings his own set of expectations, beliefs, and behaviors to the encounter. It is important to find out your own attitude, awareness, and sensitivity to cultural differences. According to research, there is evidence that racial and ethnic minority groups are more likely to perceive bias and lack of cultural competence when seeking treatment in the healthcare system than Caucasian patients, even when controlling for demographic factors, health literacy, self-rated health status, and source of care. The provider may demonstrate the potential for unconscious bias in the questions asked during determination of the appropriateness of treatment. For instance, the provider may believe that the patient’s behavioral characteristics make him more or less appropriate for a particular treatment, service, or procedure. They may unconsciously confirm this belief/bias through the questions they ask or don’t ask. Project Implicit was developed in 1998 as a virtual laboratory examining the issue of implicit bias with its use of the Implicit Association Test (https://implicit.harvard.edu/). This test can be used to measure those unconscious beliefs that exist outside our awareness and control, and which may be divergent from our conscious beliefs. Findings of this research include: 1. Implicit biases are pervasive. 2. People are unaware of their implicit biases. 3. Implicit biases predict behavior, and those who test higher in implicit bias have been shown to display greater discrimination. 4. People differ in levels of implicit bias, since bias can be affected by your particular group membership, dominance of your group in society, and experiences. Implicit attitudes tend to be resistant to deliberate change, but cognitive biases may not have the same constraints and may be amenable to change. What can you do to rid yourself of an undesirable bias? Experts recommend first creating social conditions that allow new learning experiences. Then, be vigilant since the bias may enter when least expected into your judgments and actions. Consciously create an action plan to compensate for the bias. Focus on patients in terms of their unique qualities rather than as belonging to a certain population. Build a partnership with the patient by acknowledging and understanding his or her cultural diversity, by showing respect for the patient’s health beliefs and practices, and by valuing cross-cultural communication. This type of patient centered care has the goal of eliminating disparities and can lead to what Melanie Tervalon describes as “cultural humility”: a lifelong commitment to self-evaluation and critique, to redressing the power imbalances in the physician-patient dynamic, and to developing mutually beneficial and non-paternalistic partnerships with communities on behalf of individuals and defined populations. References 1. Avey H. Health Care Providers’ Training, Perceptions, and Practices Regarding Stress and Health outcomes. Journal of the National Medical Association. 2003; 95(9): 833-845. 2. Banaji M. The Social Unconscious. Blackwell handbook of Social Psychology: Intraindividual Processes. Ed. Tesser and Schwarz. 2002. Chapter 7:134-158. 3. Burgess D. Reducing Racial Bias Among Health Care Providers: Lessons from Social-Cognitive Psychology. Society of General Internal Medicine. 2007; 22:882-887. 4. Burgess D. Why Do Providers Contribute to Disparities and What Can Be Done About It? J Gen Intern Med. 2004; 19: 1154-1159. 5. Cohen G. Reducing the Racial Achievement Gap: A Social-Psychological Intervention. Science. 2006; 313:1307-1310. 6. Cooper L. Delving Below the Surface: Understanding How Race and Ethnicity Influence Relationships in Health Care. J Gen Intern Med. 2006; 21:S21-27. 7. Johnson RL. Racial and Ethnic differences in Patient Perceptions of Bias and Cultural Competence in Health Care. JGIM. 2004; 19: 101-110. 8. Kai J. Professional Uncertainty and Disempowerment Responding to Ethnic Diversity in Health Care: A Qualitative Study. PLoS Medicine. 2007; 4(11): 1766-1776. 9. Nosek B. Moderators of the Relationship Between Implicit and Explicit Evaluation. Journal of Experimental Psychology: General. 2005; 134(4): 565-584. 10. Project Implicit. http://projectimplicit.net/ 11. Tervalon, M. et al. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998; 9(2): 117-125. 12. Tucker Smith C., Nosek B. implicit Association Test. I.B.Weiner & W.E.Craighead (Eds.), Corsini’s Encyclopedia of Psychology, 4th edition (pp.803-804). Wiley. 13. Van Ryn M. Paved With Good Intentions: Do Public Health and Human Service Providers Contribute to Racial/Ethnic Disparities in Health? American Journal of Public Health. 2003; 93(2):248-255. 14. Washington D. Transforming Clinical Practice to Eliminate Racial-Ethnic Disparities in Healthcare. J Gen Intern Med. 2007; 23(5):685-91.
Phyllis B. Bouvier, MD
for the Diversity Committee
In 1999, Congress requested that the Institute of Medicine assess the extent and source of racial and ethnic disparities and suggest interventional strategies. In 2002, the report, “Unequal Treatment,” confirmed that “racial and ethnic disparities in healthcare are not entirely explained by differences in access, clinical appropriateness, or patient preferences. Disparities exist in the broader historical and contemporary context of social and economic inequality, prejudice, and systemic bias.”
Prejudice is an unjustified negative attitude and discriminatory behavior based on a person’s group membership. Stereotypes are social categories people use in acquiring, processing, and recalling information about those we do not know as individuals. Stereotypes can be cognitive shortcuts, often used when we are short on time. Yet, even when stereotypes are evidence-based, they are likely to lead to disparities when the provider does not take into account the individual’s unique identifiers. Both stereotypes and prejudice are likely to produce negative outcomes.
Unconscious (implicit) biases are thoughts that are outside of a person’s conscious awareness. They are habits of the mind, learned over time through repeated personal experience and cultural socialization. These beliefs are highly resistant to conscious change. An individual’s implicit evaluations may differ from their explicit beliefs (those beliefs that are verbalized). In this situation, a person might hide private thoughts and attitudes from others. Or, a person may not be conscious of the existence of those thoughts and attitudes. Research indicates that a discordance between a provider’s verbal and non-verbal responses leads to the assumption by the patient that the non-verbal response is indicative of the provider’s true attitude.
Current disparity research is focusing less on the technical aspect of care (for instance which test or medication was ordered), and more on the interpersonal aspect of care (for example, expression of bias and cultural competence). There is a strong relationship between provider interpersonal behavior and patient satisfaction, adherence, utilization, and outcomes.
Multiple cultural influences shape a patient’s view toward healthcare, as well as the patient’s past experiences with healthcare providers. Our cultural perspective automatically and unconsciously influences the way we perceive others and behave toward them and in turn this influences the way we interpret their behaviors. Similarly, the patient brings his own set of expectations, beliefs, and behaviors to the encounter. It is important to find out your own attitude, awareness, and sensitivity to cultural differences.
According to research, there is evidence that racial and ethnic minority groups are more likely to perceive bias and lack of cultural competence when seeking treatment in the healthcare system than Caucasian patients, even when controlling for demographic factors, health literacy, self-rated health status, and source of care. The provider may demonstrate the potential for unconscious bias in the questions asked during determination of the appropriateness of treatment. For instance, the provider may believe that the patient’s behavioral characteristics make him more or less appropriate for a particular treatment, service, or procedure. They may unconsciously confirm this belief/bias through the questions they ask or don’t ask.
Project Implicit was developed in 1998 as a virtual laboratory examining the issue of implicit bias with its use of the Implicit Association Test (https://implicit.harvard.edu/). This test can be used to measure those unconscious beliefs that exist outside our awareness and control, and which may be divergent from our conscious beliefs.
Findings of this research include:
1. | Implicit biases are pervasive. |
2. | People are unaware of their implicit biases. |
3. | Implicit biases predict behavior, and those who test higher in implicit bias have been shown to display greater discrimination. |
4. | People differ in levels of implicit bias, since bias can be affected by your particular group membership, dominance of your group in society, and experiences. |
Implicit attitudes tend to be resistant to deliberate change, but cognitive biases may not have the same constraints and may be amenable to change. What can you do to rid yourself of an undesirable bias? Experts recommend first creating social conditions that allow new learning experiences. Then, be vigilant since the bias may enter when least expected into your judgments and actions.
Consciously create an action plan to compensate for the bias. Focus on patients in terms of their unique qualities rather than as belonging to a certain population. Build a partnership with the patient by acknowledging and understanding his or her cultural diversity, by showing respect for the patient’s health beliefs and practices, and by valuing cross-cultural communication. This type of patient centered care has the goal of eliminating disparities and can lead to what Melanie Tervalon describes as “cultural humility”: a lifelong commitment to self-evaluation and critique, to redressing the power imbalances in the physician-patient dynamic, and to developing mutually beneficial and non-paternalistic partnerships with communities on behalf of individuals and defined populations.
References
1. | Avey H. Health Care Providers’ Training, Perceptions, and Practices Regarding Stress and Health outcomes. Journal of the National Medical Association. 2003; 95(9): 833-845. |
2. | Banaji M. The Social Unconscious. Blackwell handbook of Social Psychology: Intraindividual Processes. Ed. Tesser and Schwarz. 2002. Chapter 7:134-158. |
3. | Burgess D. Reducing Racial Bias Among Health Care Providers: Lessons from Social-Cognitive Psychology. Society of General Internal Medicine. 2007; 22:882-887. |
4. | Burgess D. Why Do Providers Contribute to Disparities and What Can Be Done About It? J Gen Intern Med. 2004; 19: 1154-1159. |
5. | Cohen G. Reducing the Racial Achievement Gap: A Social-Psychological Intervention. Science. 2006; 313:1307-1310. |
6. | Cooper L. Delving Below the Surface: Understanding How Race and Ethnicity Influence Relationships in Health Care. J Gen Intern Med. 2006; 21:S21-27. |
7. | Johnson RL. Racial and Ethnic differences in Patient Perceptions of Bias and Cultural Competence in Health Care. JGIM. 2004; 19: 101-110. |
8. | Kai J. Professional Uncertainty and Disempowerment Responding to Ethnic Diversity in Health Care: A Qualitative Study. PLoS Medicine. 2007; 4(11): 1766-1776. |
9. | Nosek B. Moderators of the Relationship Between Implicit and Explicit Evaluation. Journal of Experimental Psychology: General. 2005; 134(4): 565-584. |
10. | Project Implicit. http://projectimplicit.net/ |
11. | Tervalon, M. et al. Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. J Health Care Poor Underserved. 1998; 9(2): 117-125. |
12. | Tucker Smith C., Nosek B. implicit Association Test. I.B.Weiner & W.E.Craighead (Eds.), Corsini’s Encyclopedia of Psychology, 4th edition (pp.803-804). Wiley. |
13. | Van Ryn M. Paved With Good Intentions: Do Public Health and Human Service Providers Contribute to Racial/Ethnic Disparities in Health? American Journal of Public Health. 2003; 93(2):248-255. |
14. | Washington D. Transforming Clinical Practice to Eliminate Racial-Ethnic Disparities in Healthcare. J Gen Intern Med. 2007; 23(5):685-91. |