Subconscious Racism and Healthcare: Understanding Our Implicit Bias

050325-N-6504N-021Ideal healthcare consists of physicians that treat patients equally, irrespective of race, ethnicity, or color of skin. Efforts to eradicate bias and racism have been implemented in our modern society through several laws and social movements. For the most part, people expect that bias and racism will not play a role in the operating room, but this is not always the case. Novel studies from many prestigious institutions found that there may be an implicit, or subconscious, root of racism and bias. This bias affects the quality and equality of healthcare. The only way to improve this measure is to make the implicit explicit and allow physicians to prevent their subconscious bias from interfering with the quality of their care.

In 1998, researchers at Harvard University developed a novel test to measure implicit bias to study whether or not people have a subliminal affinity towards particular races. The Implicit Association Test (IAT) presents four racial groups: Blacks, Whites, Hispanics, and Asians, and asks direct questions concerning race. Then comes the interesting part. The test divides words into two groups: positive words and negative words. It arbitrarily assigns the negative word group with a particular race and the positive word group with all other races. The words and racial groups are then assigned to a selected key on a keyboard. The test-takers see a series of faces, one at a time, with a word from either the positive or negative word group. Takers are asked to use the assigned keys to recognize if the person and the word are correctly matched based on the assignment. Then the other racial groups are assigned to the negative word group.  The IAT measures the speed at which test-takers associate the negative words with the chosen racial group as well as how many errors are made with each race. The test concludes with a few additional survey questions about preconceptions of the four various racial groups and ultimately calculates a score using the answers to the survey questions, the speed of association, and the errors made when pairing words to racial groups [1].

This research not only presents major findings regarding racism in general, but also plays a role in the quest for equal, unbiased healthcare for all. One application of the IAT provided increasing evidence that the subconscious bias of physicians can influence the quality of healthcare for various racial groups. A study conducted at Harvard Medical School used results of three IATs of various physicians, a brief questionnaire, and an online clinical account of a patient in the emergency room with coronary artery disease to see if doctors had any sort of subconscious bias towards a particular group. The results measuring implicit, or subconscious, bias revealed that physicians “showed stronger associations of negative attributes to blacks than whites.” [1] This result contrasted with their explicit, or conscious, biases, which revealed that race would not influence their decision to give thrombolysis, an arbitrarily chosen treatment. The implicit biases, however, showed strong associations with their decisions in prescribing thrombolysis. Physicians with notable anti-black biases were less likely to treat patients with thrombolysis. Physicians expressing implicit bias also thought that black patients were generally less cooperative, which influenced their decisions for treatment. These results were not associated with their explicit opinions and demonstrates that their actions were subliminal [2].

This study was the first of several to provide evidence of unconscious racial bias among physicians, its dissociation from conscious or explicit bias, and its predictive validity. The results suggest that physicians’ unconscious biases could contribute to racial and ethnic disparities in the use of medical procedures, like thrombolysis.

Another study at Stanford University found that unconscious bias played a role in surgical safety for patients. The unconscious bias, according to the study, is defined as a part of normal cognitive processing where people’s subliminal associations dictate their responses to certain tasks, scenarios, and medical encounters [3].  Therefore, the physicians are unaware that they are making decisions based on stereotypes and prejudices [3]. The study found that racially discordant relationships between physicians and patients result in more passivity among patients and less information sharing by the physicians [3]. More research found that physicians used different verbal styles and body languages depending on the race of the patient. Physicians were more verbally dominant and less patient-centered if a patient were black as opposed to white.

If these issues plaguing equal healthcare for all are subconscious, how is this issue able to be effectively addressed? It seems as if the only solution is a mental re-wiring of common notions of race. Since this long-term solution is difficult and almost unfeasible, researchers found that simply being aware of the unconscious bias can significantly help physicians provide more equal care to people of all races. The Harvard study regarding implicit bias and its predictions of thrombolysis decisions showed that physicians that were conscious of the study’s purpose were significantly more likely to diagnose white and black patients equally [3]. Understanding the issue and making the implicit explicit could therefore allow equal care to become more of a reality for all patients.

Potential solutions may also arise through an increased emphasis on the education of social issues such as stereotyping and prejudice. The study at Stanford University suggests that implicit bias should be considered as occurring in normal cognition and should be treated like other possibilities of human error that can occur in the operating room.

The physician must additionally be able to embrace the patient’s sociocultural context with empathy. Being able to understand the patient is a tool that allows the physician to make decisions by putting himself or herself in the patient’s shoes [3]. Thus, acknowledging the possibility of error through implicit bias and being capable of empathizing with the patient will allow physicians to mitigate their subconscious discrimination.

While at first, the findings of implicit racial biases seem disappointing, there are ways to address this issue and improve the quality of care for our nation’s diverse patients. The goal should not be to eliminate the bias that is evidently inherent in a physician’s, rather any person’s, psyche but to find ways to make the unconscious conscious. Doing so will allow physicians to treat their patients fairly, regardless of race, ethnicity, or color of skin.

References

1. ProjectImplicit. 2011. “Project Implicit Social Attitudes.” Last modified 2011. Accessed July 30, 2013. https://implicit.harvard.edu/implicit/Study.

2. Green, Alexander, Dana Carney, Daniel Pallin, Ngo Long, Kristal Raymond, Lisa Iezzoni, and Banaji Mahzarin. 2007. “Implicit Bias Amongst Physicians and its Prediction of Thrombolysis Decisions for Black and White Patients.” J Gen Intern Med: 1231-1238. Accessed July 30, 2013.  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2219763/.

3. Santry, Sheena, and Sherry Wren. 2012. “Role of Unconscious Bias in Surgical Safety Outcomes.”Surgical Clinics of North America. no. 1: 137-15. Accessed July 30, 2013. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3417145.

Adiba Matin is a third year student at the University of Chicago majoring in Biology with an interest in public health. Follow The Triple Helix Online on Twitter and join us on Facebook.

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