Question 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. Self- reflection and awareness can be useful tools. Reflecting on the question “Would I react differently if the patient were White or heterosexual?” can be a useful strategy. The quality of communication is also related to word choice. The Linguistic Inquiry and Word Count software was used to analyze 117 videotaped racially discordant physician–patient encounters. Providers with higher levels of implicit racial bias (based on IAT scores) more frequently used first-person pronouns and anxiety-related words than did providers with lower implicit racial bias scores. 31 Communication is a major factor in a patient’s experience of trust in the clinical encounter. 32 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 of which contribute to healthcare disparities. 33,34,35 Even high-status Black 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. 36 Ms. Williams’s experience causes some to reflect on the 2019 Centers for Disease Control and Prevention (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. 37,38 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, and so on, provider behavior can be influenced by implicit bias.
ACCELERATING IMPLICIT BIAS 39
Given the rapid, unconscious associations that characterize implicit bias, factors that impede the slow, careful reflection of multiple factors can be fertile ground for implicit bias. Many providers may see these factors as basically describing Mitigating Implicit Bias 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 be with a patient) ● Complexity (e.g., multitasking or needing to consider multiple factors quickly) ● Physical constraints (e.g., working long hours) Several strategies 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 and 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. 40,41,42,43 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. Self-Awareness With knowledge of the development and process of implicit bias as a foundation, a pause-and-reflect approach can increase occasions when providers deliberately take a few moments to reflect on their thoughts and behaviors when interacting with a patient and/or making an important
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.
decision. Pausing allows for a few seconds to reflect on the kinds of associations that they may be making as the patient walks through the door based on the way they’re dressed, their gender, their race, or any other characteristic. Discovering personal tendencies or becoming aware of an area of personal bias can help in modifying communication, where necessary. Such self-awareness can prompt providers to focus on seeing a given patient as an individual (individuation) and trying to see things from the patient’s perspective (perspective taking). Organization Systems and Processes Implicit bias can play a key role in fostering and reinforcing systems of inequities in hiring and promotion. Race, gender, accent, weight, and so on are factors that not only impact implicit bias in patient care but can also influence hiring and promotion decisions. Mitigating unconscious bias in rewards and recognition, as well as in selection decisions, is of critical importance in work to increase the diversity of medical students, clinical providers, researchers, managers, and senior health care providers. Cues and Reminders Information about implicit bias as well as motivation to reflect on personal biases can begin to fade months or even weeks after the initial intervention. Strategies to stimulate recall or remind providers about the work to mitigate implicit bias can be useful. Key words or phrases on the treatment room computer screen or even a specially designed screen saver can be used as a reminder. A mobile phone background can contain a photo or a word that serves as a reminder every time the provider uses the phone. Changing the photo or word periodically can help to avoid habituation. The inside cover of a folder containing CVs can list key phrases to remind search committee members to avoid bias in the screening process.
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Book Code: PCIL1525
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