___________________________________________________________________ Implicit Bias in Health Care
Another study assessed 40 primary care physicians and 269 patients [72]. The IAT was administered to both groups, and their interactions were recorded and observed for verbal domi- nance (defined as the time of physician participation relative to patient participation). When physicians scored higher on mea- sures of implicit bias, there was 9% more verbal dominance on the part of the physicians in the visits with Black patients and 11% greater in interactions with White patients. Physicians with higher implicit bias scores and lower verbal dominance also received lower scores on patient ratings on interpersonal care, particularly from Black patients [72]. In focus groups with racially and ethnically diverse patients who sought medical care for themselves or their children in New York City, participants reported perceptions of discrimi- nation in health care [73]. They reported that healthcare pro- fessionals often made them feel less than human, with varying amounts of respect and courtesy. Some observed differences in treatment compared with White patients. One Black woman reported [73]: When the doctor came in [after a surgery], she pro- ceeded to show me how I had to get up because I’m being released that day “whether I like it or not”… She yanked the first snap on the left leg…So I’m thinking, ‘I’m human!’ And she was courteous to the White lady [in the next bed], and I’ve got just as much age as her. I qualify on the level and scale of human being as her, but I didn’t feel that from the doctor. Another participant was a Latino physician who presented to the emergency department. He described the following [73]: They put me sort of in the corner [in the emergency department] and I can’t talk very well because I can’t breathe so well. The nurse comes over to me and actually says, “Tu tiene tu Medicaid?” I whispered out, “I’m a doctor…and I have insurance.” I said it in perfect English. Literally, the color on her face went completely white…Within two minutes there was an orthopedic team around me…I kept wonder- ing about what if I hadn’t been a doctor, you know? Pretty eye opening and very sad. These reports are illustrative of many minority patients’ expe- riences with implicit and explicit racial/ethnic biases. Not surprisingly, these biases adversely affect patients’ views of their clinical interactions with providers and ultimately contribute to their mistrust of the healthcare system.
DEVELOPMENTAL MODEL TO RECOGNIZING AND REDUCING IMPLICIT BIAS
There are no easy answers to raising awareness and reducing health providers’ implicit bias. Each provider may be in a differ- ent developmental stage in terms of awareness, understanding, acceptance, and application of implicit bias to their practice. A developmental model for intercultural sensitivity training has been established to help identify where individuals may be in this developmental journey [74; 75]. It is important to recognize that the process of becoming more self-aware is fluid; reaching one stage does not necessarily mean that it is “conquered” or that there will not be additional work to do in that stage. As a dynamic process, it is possible to move back and forth as stress and uncertainty triggers implicit biases [74]. This developmental model includes six stages: • Denial: In this stage, the individual has no awareness of the existence of cultural differences between oneself and members of other cultural groups and subgroups. Individuals in this stage have no awareness of implicit bias and cannot distinguish between explicit and implicit biases. • Defense: In this stage, the person may accept that implicit biases exist but does not acknowledge that implicit biases exist within themselves. • Minimization: An individual in this stage acknowledges that implicit biases may exist in their colleagues and possibly themselves. However, he or she is uncertain of their consequences and adverse effects. Furthermore, the person believes he or she is able to treat patients in an objective manner. • Acceptance: In the acceptance stage, the individual recognizes and acknowledges the role of implicit biases and how implicit biases influence interactions with patients. • Adaptation: Those in the adaptation stage self-reflect and acknowledge that they have unrecognized implicit biases. Not only is there an acknowledgement of the existence of implicit bias, these people begin to actively work to reduce the potential impact of implicit biases on interactions with patients. • Integration: At this stage, the health professional works to incorporate change in their day-to-day practice in order to mitigate the effects of their implicit biases on various levels—from the patient level to the organiza- tion level.
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