The racial disparity in the judgment of pain has been studied as an example of implicit bias in healthcare. In research by Mende-Siedlecki and colleagues, White providers demonstrated more stringent thresholds in perceiving pain on African American faces versus White faces, and those with more stringent thresholds for African American patients prescribed fewer non-narcotic pain relievers. 29 This was not true for Asian faces, suggesting that other-face dynamics were not at play. This research did not investigate whether gaps in empathy or perspective taking skills might be a partial explanation for the disparity. PLEASE COMPLETE CASE STUDY EXERCISE 2. Implicit bias has also been shown to impact the quality of the clinical encounter, particularly communication. In an early study, primary care physicians took the IAT and had their clinical encounters recorded. 30 Provider race bias on the IAT was associated with lower quality communication with African American patients, such as more provider verbal dominance, lower patient positive affect, poorer patient ratings of interpersonal care, lower perceptions of respect from clinicians, and lower likelihood of recommending the clinician. The quality of communication is also related to word choice. One hundred and seventeen videotaped racially discordant physician-patient encounters were analyzed using the Linguistic Inquiry and Word Count software. Providers with higher levels of implicit racial bias (based on IAT scores) more frequently used first-person pronouns and anxiety-related words than providers with lower implicit racial bias scores. 32 Communication is also a major factor in a patient’s experience of trust in the clinical encounter. 33
There is abundant evidence that even when controlling for variables such as insurance, socioeconomic status, geography, and even socioeconomic status, implicit bias is an important influence on patient satisfaction and referral for treatment, both contributors to healthcare disparities. 34,35,36 , Even high-status African American patients can experience disparate treatment. When giving birth, tennis star Serena Williams suffered a pulmonary embolism, although thankful for the care she received, she noted that her status likely contributed to her getting a level of care not afforded to all women. 37 Ms. Williams’ experience causes some to reflect on the 2019 CDC report that indicated a racial disparity in pregnancy-related deaths. Implicit bias can not only influence the assessment of pain but can also influence provider decision making in high-discretion situations. 38,39 For example, of the two or three tests that might be available for a particular condition, there is sometimes discretion on the part of the provider in terms of which test is given or how soon a test is recommended. While consciously endorsing values of equity, fairness, high quality care, etc., provider behavior can be influenced by implicit bias.
Given the rapid, unconscious associations that characterize implicit bias, factors that impede the slow, careful refection of multiple factors can be fertile ground for implicit bias. Many providers may see these factors as basically describing their day-to-day work. But recognizing these factors can provide an opportunity to try to make small modifications, where possible, to mitigate the influence of implicit bias.
Mitigating Implicit Bias
There are several strategies that have shown promise in mitigating or reducing the occurrence of implicit bias. Given the brain’s innate rapid processing of large amounts of data every second and the acceleration factors mentioned above, there is no strategy that can completely eliminate unconscious associations or bias. Further, approaches to mitigating or reducing implicit bias are most effective when more than one strategy is utilized. Strategies to consider include the following: 41,42,43,44 Increasing Knowledge It is useful for workshops and presentations to describe how implicit bias develops and its relationship to societal stereotypes (race, gender, sexual orientation, disability, etc.). Presentation of research findings can help providers understand how implicit bias can negatively impact various aspects of the clinical encounter and contribute to healthcare disparities. As a component of workshops, case studies can help providers apply knowledge to realistic, complex situations. Refresher experiences are also useful.
Accelerating Implicit Bias 40
Quick Implicit Bias Facts Several factors can accelerate implicit bias or make it more likely to be a significant influence. • Time constraints (e.g., limited time to see a patient) • Complexity (e.g., multitasking or needing to consider multiple factors quickly) • Physical constraints (e.g., working long hours)
Instructions: Spend 10 minutes reviewing the case below and considering the questions and commentary that follows. Case Study Exercise 2 John is a White nurse caring for an African American pregnant woman in an obstetrics unit in a hospital. The patient is a lesbian and had an in vitro fertilization. Her partner is White and asks to speak to you, the physician, in private and not in the patient’s room. The partner mentions that she recently saw a news story about how African American women are treated unfairly in comparison to White women. You’re sure that her partner will be given the same level of care as other patients, and you give this reassurance consciously in a deliberate manner. However, you know that, in addition to this conscious process, there are potential areas of implicit bias that might occur, both in decision making and in communication.
1. How might the racial difference between the nurse, John, and the patient influence provider-patient communication?
Commentary on Question 1: Given the history of racism in America, racial discordance between provider and patient may negatively impact trust in the clinical encounter. African American patients may have experienced racial insensitivities, bias, or discrimination in the past and may be vigilant for signs of caring and trust from the provider. In addition to racial implicit bias, there can be implicit bias based on other characteristics, such as sexual orientation.
2. How might implicit bias show up in this case?
Commentary on Question 2: Given that there might be a difference between conscious attempts to be fair and equitable and implicit bias, care needs to be taken to ensure that word choice and nonverbal communication (eye contact, smiling, etc.) do not reflect unintentional bias. Further, nonverbal bias includes not touching and standing further away from the patient. 31 Self-reflection and awareness can be useful tools. Reflecting on the question, Would I react differently if the patient was White or heterosexual? can be a useful strategy.
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