Battling Bias: Racial bias and its effects on patient care

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Editor’s note: This is Part 4 of “Battling Bias,” an ongoing series on the role of healthcare executives, administrators, providers and staff in confronting issues of race in their professional lives and their communities.

Less than 100 milliseconds, or about one-tenth of a second — that’s how long it takes our brains to categorize people by race.1

When it comes to offering the best care to all patients, taking an active approach to recognizing implicit biases, working to mitigate them and developing cultural competencies is important for physicians and other patient-facing staff.

Many healthcare providers exhibit no types of racial bias in routine, day-to-day interactions with patients; yet there are numerous studies that point to gaps in care outcomes differentiated by patients’ racial background.2 In some cases, biases can be “triggered” when providers are busy, distracted, tired or under pressure — conditions that are increasingly the norm for many specialties and care settings.3

This bias without intention — “aversive racism”4 — is one of many examples of areas where we can recognize and begin to confront our ways of thinking and reacting to improve our personal and professional lives.

And with a growing body of evidence of racial disparities in the response to COVID-19 across the United States, existing issues of racial bias have potential to further compound one of the most serious public health concerns in decades.

Recognizing biases and the imperative for change

Jessica Ellis-Wilson, CMPE, founder of Practical Management, notes that “the reality is we are all inherently biased” in some fashion based upon the inner workings of our brains. “Humans innately fear ‘the other’ — that’s something that is very deep in our brains,” noting the role of the amygdala in sending out signals to the rest of the body “that present as fear when we are presented with someone that we cannot classify as like us.”5

Such signals may have been useful in early humans for survival, but in modern times, “we have evolved to the extent that [those signals are] not as helpful of a cognitive response,” Ellis-Wilson said.6

The science behind biases influencing care outcomes

Research has found evidence of implicit bias around numerous factors, such as gender, age, sexual orientation, religion and disability, though most research is focused on race. (Read Joy Stephenson-Laws’ MGMA Connection article for a brief overview.)

The Institute of Medicine’s landmark Unequal Treatment report found statistically significant health disparities based on race and ethnicity still existed, even when factors such as insurance status, income and severity of illness were normalized. It found higher mortality rates from cancer, heart disease, heart disease and diabetes among Black and other patients of color.7 “These disparities can be directly linked to the implicit bias, which can exist even in people who are part of the affected group,” Ellis-Wilson noted.

Bias results in behavior that is preferential toward or against specific groups. “They influence treatment decisions, they influence our daily interactions and they can truly adversely impact the patient-doctor relationship,” Ellis-Wilson said.

There also are studies that show the promise in promoting recognition of and active work against biases. A December 2015 review of more than a dozen healthcare studies found that physicians who were rated as empathetic or compassionate by their peers had fewer stereotypic attitudes and less implicit bias than physicians who are ranked low in empathy.8

Where to begin: Steps to confronting bias

To combat implicit bias, you must first identify it in yourself, Ellis-Wilson said. She recommended American sociologist Milton J. Bennett, PhD, and his Developmental Model of Intercultural Sensitivity (DMIS) as a means to understand the stages of ethnocentrism you may have — in other words, how much you place your own culture as central to your view of the world. It goes from “denial” to “integration” in terms of understanding where your implicit or unconscious biases are.

“The goal is being able to recognize it and act on it and recognize where that behavior and those biases fit in terms of culture. … Once we start to identify where our biases lie, we can challenge them.”

Ensuring buy-in

Organizational efforts to confront implicit bias can be difficult, as there’s not always a cost savings involved. But for medical practices, Ellis-Wilson suggests there is alignment with the ethical imperative to do no harm to patients. “And implicit bias does harm,” she noted. “It entrenches negative stereotypes in ourselves,” hurting those against whom those stereotypes are held.

Once buy-in is obtained, there is also the work of winning over individuals who exhibit a degree of aversive racism or those who want to suggest that they “don’t see color” or don’t have a need to consider their biases. That type of thinking “invalidates people’s lived experiences, and it removes the accountability from ourselves in confronting bias,” Ellis-Wilson added. “That's a place of incredible privilege to be able to say, ‘I don't want to have to think about it,’ and the reality is that we do — we all have to think about it,” Ellis-Wilson said. “This is a journey of 1,000 steps, and we all have to start somewhere.”

Keys to success

Ellis-Wilson offers these suggestions in working on recognizing implicit bias in your workplace:

• Remember that it cannot be fixed overnight. “It's a 20-year journey to change bias,” she cautioned. “Repeated positive exposure to that which we are biased against can eventually change that culture. But just saying, ‘I am not going to hold this bias anymore,’ is not going to be helpful.”
• Exercise stereotype awareness, not suppression. Negative stereotypes are natural societal phenomenon, and it's better to recognize them and use strategies to counteract them rather than try to actively suppress them “because it doesn't work,” she said.
• Cultivate relationships with diverse groups of people. Make a concerted effort to expose yourself to other experiences and perspectives that differ from your own, via media, books, music and more. “Narratives center others, it can be fiction or nonfiction,” she added. Repeated positive exposure to other groups can increase empathy and increase individuation. That allows us to start to see the similarities between us rather than just the differences.
• This isn’t about political correctness. “It's about treating people with respect, and it's about providing the best possible care for our patients and the best possible protections for our staff so that no one in our staff, our teams, our providers, our patients, ever feel unwelcome in our spaces,” Ellis-Wilson added.
• There’s no shame in acknowledging what you don’t know. “As healthcare leaders, we have to create environments that decrease triggers and increase awareness of implicit bias and promote ongoing learning,” Ellis-Wilson said. “When we look at providers, we teach empathy in medical school and medical training. But across the board, most people don't get any kind of empathy instruction. And people are less empathetic with people that they perceive as dissimilar.”
• Keep track of your daily surprises. Moments that cause surprise for you often involve information that runs counter to a stereotype you might hold. “It will give you great insight into your own biases,” Ellis-Wilson said.

Embracing the discomfort

During a recent presentation, “Stop Killing our Patients: Pandemic, Protest and the Outcry for Justice,”11 Kirk Johnson, PhD, ordained clergy, United Church of Christ; and adjunct professor, College of Arts & Sciences, Seton Hall University, underscored the need for humility and honesty in confronting biases, as well as some discomfort. “Every single person has their own biases. … If you're white, you have to be uncomfortable in order for change to occur. And don't take it personal: It's not one person's fault that we inherited this mess called systematic racism.”

Race, Johnson noted, is a social construction, and negative stereotypes about any racial group have been “constructed over centuries,” which will require actively confronting those ideas. “As a doctor, as a healthcare professional, as a human being, we have to weed those ideas … about people who are deemed as ‘the other,’ and really look at patients, look at people for people, as human beings,” Johnson noted. “It's going to take all of us to collectively decipher and alleviate all of the different biases that are deeply rooted within our society, including our medical system, as well.”

This work should begin personally as a reflection on yourself, Johnson added. “Be courageous, don't be scared, don't feel guilty,” Johnson said. “Work with those particular feelings and emotions that you have within yourself in order for those particular emotions and feelings and assumptions or stereotypes that won't be actually reflected towards your patients, those individuals who are part of communities of color.”

Additional resources

• Georgetown University’s National Center for Cultural Competence (NCCC) has a module on conscious and unconscious biases in healthcare.
• The Institute for Healthcare Improvement’s Achieving Health Equity white paper (2016) includes guidance for measuring health equity, a case study of integrating work to improve health equity and a self-assessment tool to gauge focus on and efforts to improve health equity.
• The Department of Health & Human Services’ Office of Minority Health has national standards for culturally and linguistically appropriate services in healthcare.
• The University of California San Francisco’s Office of Diversity and Outreach has multiple resources on the state of science on unconscious bias.

Editor’s note: Other installments of the “Battling Bias” series include:

• Part 1: How intuition and unintentional biases can shape how decisions are made
• Part 2: Building diversity in recruiting and hiring
• Part 3: Sustaining inclusivity through organizational culture

Notes:

1. Kristof N. “Our Racist, Sexist Selves.” The New York Times. April 6, 2008. Available from: https://www.nytimes.com/2008/04/06/opinion/06kristof.html.
2. Stephenson-Laws J. “Diagnosing bias: Racial animus continues to negatively affect community health.” MGMA Connection. January 2019. Available from: mgma.com/diagnosing-bias.
3. Ibid.
4. Dovidio J, Gaertner S, Pearson A. “Aversive Racism and Contemporary Bias.” In C. Sibley & F. Barlow (eds.), The Cambridge Handbook of the Psychology of Prejudice (Cambridge Handbooks in Psychology, 267-294. Cambridge: Cambridge University Press. doi:10.1017/9781316161579.012.
5. Ellis-Wilson J. “Confronting Implicit Bias.” Webinar. June 17, 2020. Available from: https://www.nhmgma.com/event-3869414.
6. Ibid.
7. Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Smedley BD, Stith AY, Nelson AR, editors. Washington (DC): National Academies Press (US); 2003. PMID: 25032386.
8. Hall WJ, et al. “Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review.” American Journal of Public Health, 105, no. 12, Dec. 1, 2015: e60-e76. https://doi.org/10.2105/AJPH.2015.302903.
9. Seton Hall University. “Stop Killing our Patients: Pandemic, Protest and the Outcry for Justice.” June 19, 2020. Available from: bit.ly/3hATHPu.