In the 19th century, it was widely believed that black slaves had a high pain tolerance and didn’t require medication for relief. Today we know better. Yet a study of almost one million youths over seven years, published last year in JAMA Pediatrics, corroborates other accumulating research that physicians undertreat African-Americans for pain relative to white patients based on best practices. The difference? The physicians in this study did not make treatment recommendations according to skin color. This is what unconscious bias looks like.
“Most unconscious bias is caused by well-intended people with blind spots,” said Howard Ross, author of Everyday Bias: Identifying and Navigating Unconscious Judgments. Ross, chief learning officer of Cook Ross, Inc., has been partnering with the AAMC to present workshops on unconscious bias for health professionals. Also known as implicit bias, these attitudes outside our awareness extend beyond race and ethnicity. People can have unconscious bias about sexual orientation, gender, weight, age, social class, or even height.
“Unconscious bias includes any assumption that is not accurate,” said Laura Castillo-Page, PhD, AAMC senior director for diversity policy and programs. “[Assumptions] can narrow the options a physician gives patients and this limits a patient’s opportunity to make a well-informed decision.” In 1997, for instance, an often-quoted study in the New England Journal of Medicine found that health care professionals were less likely to refer women and black patients for cardiac catheterizations, compared with white male patients.
The AAMC and The Ohio State University Kirwan Institute for the Study of Race and Ethnicity convened a forum in 2014 to examine how unconscious bias affects academic medicine and to identify strategies to mitigate the impact. Those discussions are the basis of an upcoming publication, Unconscious Bias in Academic Medicine: How the Prejudices We Don’t Know We Have Affect Medical Education, Medical Careers, and Patient Health.
“If we want to address disparity and quality of care, we have to tackle bias,” Castillo-Page said. It is not only physicians who need to be aware of it; a receptionist can be the gatekeeper in a medical setting, too, she noted. Similarly, patients have biases that affect care providers, such as when a female physician is mistaken for a nurse or a patient refuses treatment by a doctor from another country.
The AAMC-Kirwan publication will explore how unconscious bias affects academic medicine in all its domains: medical school admissions; undergraduate medical education; resident and faculty recruitment; faculty advancement, promotion, and tenure; faculty mentoring; and patient care. The final chapter covers best practices and recommended interventions.
Bias is “as natural as breathing”
To manage the overwhelming information we take in every day, our brains use shortcuts to simplify the process and enable us to make faster decisions. These shortcuts are born of automatic associations drawn from early life experiences, the media, and other societal influences. Put simply, “We like people who look like us,” Castillo-Page said.
The Implicit Association Test (IAT) was developed by psychologists Anthony Greenwald, PhD, and Mahzarin Banaji, PhD, authors of Blindspot: Hidden Biases of Good People, to measure the strength of these unconscious associations. This fast-paced test has shown that a majority of people prefer thin over fat, young over old, and light skin over dark skin. And a 2009 study confirmed that doctors’ implicit and explicit attitudes about race largely aligned with those of the general population.
“You can’t eliminate bias but you can ‘learn how to dance with it’ to minimize its effect.”
Howard Ross
Categorizing people without realizing it is “as natural as breathing” and allows us to navigate the world, Ross said. The one-day Everyday Bias Workshop he conducts through the AAMC makes people aware that they have biases and then shows them how to rewire themselves. You can’t eliminate bias but you can “learn how to dance with it” to minimize its effect, said Ross. “If you’re doing triage in the ER, there is no time to sit back and think—you just react. Students and physicians need to be trained on how to check their instincts.”
Close to 200 AAMC constituents have participated in the one-day learning lab on unconscious bias or the three-day workshop for staff seeking to create similar training programs at their institutions. Workshop participant LaMisha Hill, PhD, director of the Multicultural Resource Center at the University of California, San Francisco (UCSF), said it created a cohesive, safe environment to discuss a sensitive subject. “[The workshop] doesn’t resolve bias, but it can encourage greater empathy and compassion.”
Revising institutional policies and practices also can discourage bias. The AAMC-Kirwan report recommends that institutions ensure that teams and committees involved in high-stakes decision making are diverse in composition, for example. Or in the case of admissions and recruitment, committees might consider concealing names that can signal race, gender, or nationality.
Training students to keep biases in check
LaTanya Love, MD, said AAMC programming inspired her to develop workshops on unconscious bias for medical students and faculty at the University of Texas Health Science Center at Houston (UTHealth). “This is an area where a lot of schools can grow. [Unconscious bias training] is expensive in time only and can be done for minimal cost,” said Love, assistant dean for admissions and student affairs and diversity and inclusion at UTHealth Medical School.
One of the programs for UTHealth medical students introduced a teen in a wheelchair, who discussed her experiences of how some health care providers would talk to her differently than they would other teens. Panels of students discussing how being LGBT, Muslim, or living with a chronic health problem has affected their lives are part of the required curriculum as well.
Exposing students to people not like themselves helps them reprogram their thoughts, said Love, who is also associate professor of pediatrics and internal medicine at UTHealth. Faculty at the medical school also can attend workshops to help them identify any unconscious biases and adopt strategies to keep them in check. “If clinicians learn they have a bias toward a particular patient group, they have to make an effort to think about their actions before they walk into the [patient] room,” she said.
At the University of Massachusetts Medical School (UMMS), all students take the IAT as part of the required Determinants of Health curriculum in their first year. Elizabeth Tammaro, now a second-year student, was among many UMMS students who were surprised to find her test result revealed a slight preference to whites over darker-skinned people despite her strong egalitarian views. “We walk around with these errors in cognition that can lead to racist actions. It is so ingrained. I try to be more mindful in my thinking so I don’t have knee-jerk reactions.”
The goal is just that—to get students to think about bias before they become doctors, said Suzanne Cashman, ScD, professor of family medicine and community health at UMMS. “We include stereotyping and bias in the curriculum because we think it is a health determinant and definitely germane to medicine.” If clinicians have a bias that obese people are not going to work on their health, that affects their interactions, said Cashman, who also is director of community health in her department. “If overweight patients are made to feel uncomfortable, they don’t come back.”
UCSF made a strategic move to introduce unconscious bias training and to adopt practices that discourage bias, according to J. Renee Navarro, MD, vice chancellor for diversity and outreach. “There is racism and bias throughout our society. This is one of the most significant barriers to achieving health equity and inclusion.”
“We’re seeing some returns,” she continued. In addition to increasing awareness throughout the university, she said UCSF is becoming more effective in recruiting minorities, onboarding students, and retaining underrepresented faculty and staff. “Maybe we’re not quite at a tipping point, but people here are talking about [unconscious bias] and requesting training; it has caught on.”
Tammaro said the most valuable aspect of her unconscious bias training was the discussion it sparked. She and her peers left with many questions: “Where do we take this conversation next? What if we see unconscious bias? Can we walk up to our attending and say that?”
This is how change begins.
This article originally appeared in print in the January 2016 issue of the AAMC Reporter.