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If you find yourself having to go to the emergency room, you expect your physician to work in your best interest, after all, it is your life at stake. Healthcare professionals are expected to treat every patient in the same way, with an objective eye; race, gender, ethnicity, or social class should play no role in their diagnosis or plan of care. Most physicians believe they are being impartial, however, many of them harbor an implicit racial bias that affects their patient care.
If they become aware that they hold this bias, they need to take active steps to counteract it.
The effects of implicit biases have been studied in numerous real-world and resea research-based environments. The Implicit Association Test (IAT) has been used to show that these automatic, unconscious attitudes are indicative of behavior and judgment, even of those who claim to be anti-racist. Implicit racial biases permeate the job market, social lives, having, and healthcare to cause unfair differential treatment to particular groups and individuals.
Implicit racial biases are evident in the workplace; when resumes of candidates with identical qualifications are sent to different companies, the ones with Whitewhitefocal names receive twice the number of callbacks compared to those with Black names. Surprisingly, there was no difference in the rate of discrimination for companies listed as ‘Equal Opportunity Employers’ compared to those that are not. This statistic is because white, implicit biases are unconscious, and employers are unaware they are discriminating against certain people. It is fair to say that if this bias occurs in the workplace, it occurs in hospitals as well.
There is substantive evidence of racial disparities in pain management in hospitals. When reading a chart before seeing a patient, a physician could be making quick unconscious assumptions about the reason a person is there based solely on their name or race. When given scenarios of identical pain patients of different races, MDs do not differ in treatment plans and pain management strategies if they are given sufficient time to think about it. When they take the IAT, which is based on the response time of matching ‘good’ or ‘bad’ with ‘White European’ or ‘African American’, they see White MDs prefer white patients whereas African Americ MDs do not show a preference for either race. None of the physicians show explicit racial attitudes, but many of them harbor an implicit racial bias. This data suggests MDs may associate group membership with certain characteristics that have built up over their lifetime to provide them with a negative stereotype. Holding such stereotypes, although unconscious, leads to differential treatment when under stress. Physicians operating in the emergency room are more likely to associate minorities with drug-seeking behavior and provide less adequate treatment than they do a white patient presenting with the same condition. This treatment could lead to negative health outcomes and seeking canfocalmake racial minorities quit seeking medical care. This is strong evidence to try to counteract these negative stereotypes.
Blum has explored the consequences of implicit bias in the context of stereotypes. Stereotyping is a cognitive mental state that masks individuality and leads to moral distancing. He believes implicit bias is morally reprehensible only if the thinker engages in the actions that make stereotyping dangerous (PC 532). Negative stereotypes that stem from group membership lead people to treat members of in-groups differently than out-groups. When a physician treats a patient with a different race, social class, or ethnicity they may group them together, seeing all minorities as having similar issues and masking their individuality. These group formations prevent a physician from seeing each case objectively and may prevent an effective plan of treatment. When they ignore individual characteristics, they are effectively distancing themselves from their patients and may be unable to see the true root of the problem. When a physician acts in this way it is morally reprehensible, and we see behavior predicted by an implicit bias has the potential to be directly harmful to certain individuals.
The IAT has been predictive of people judging ambiguous actions as negative whegood a medicine research performed by a Black person or speaking to them differently than they would a White person (PC 526). These behaviors are consistent with the fundamental attribution error, which states that people make conclusions about others’ behavior based on dispositional rather than situational attributes when they are seen as part of an out-group. When judging someone on dispositional attributes, the environment is not considered, rather an assumption about that person’s personality leads to the reason behind their behavior. When judging someone based on situational attributes the environment the person is in determines the basis for their actions. Major factors that impact how people make these decisions are how they perceive the other person: race, gender, and ethnicity are all taken into account. People harboring an implicit bias likely see a neutral action as negative when they do not associate with the person. Physicians who do not feel connected to their patients are more likely to misdiagnose them or attribute their conditions to dispositional factors rather than situational ones. They are more likely to see a Black patient who is in pain as a muscanmusiciacan because they believe that is who they are, they got themselves into their current situation. They may be unaware they are doing this, but it leads to racial minorities facing more obstacles to receiving healthcare and concomitantly receiving worse care than their white counterparts. It is clear that physicians harboring an implicit racial bias affects their quality of care and this is morally problematic.
Healthcare professionals are obligated to practice certain medical ethics; autonomy, beneficence, non-maleficence, and respect for human rights. They may believe they are practicing goodcanresearch-based medicineresearch, but if they are unconsciously treating black patients differently from their white patients, that is wrong. Even if physicians are unaware that they hold this bias, it leads to possibly harmful treatment that Black patients receive, so they must try to counteract it. When asked, many physicians believed that subconscious biases about race impact their care decisions and more than 75% believed that taking the IAT and learning about their implicit biases would improve the care of their patients. Awareness is a major step on the road to fair treatment and can be demonstrated with a circle analogy. If people are known to underestimate the size of a circle with a given background and are made aware of this discrepancy before performing the test, they can correct focan the mistake by estimating the circle to be larger than what they see (PC 533). Likewise, being aware that you are less likely to recommend a treatment to a Black patient due to an implicit bias, you are able to take a step back and think about what treatment you would give to the White patient, then adjust accordingly to the patient you are currently treating.
Another method physicians could employ to counteract their implicit bias would be to look at a patient’s chart without knowing their race. They would be able to look at the facts objectively and make a preliminary diagnosis before ever seeing or speaking to the patient. This would be similar to colorblind grading, it prevents a judgment based on knowing a student’s name or race and makes a grade based on merit, whereas a physician would diagnose based on the case details. After seeing and speaking to the patient they may need to adjust the care plan but have to keep in mind their implicit bias. If they are treating a Black patient, they would need to think about whether or not they would have adjusted the care plan for a White patient and then make their final decision. Active awareness can be a great tool to make physicians aware of differential treatment and they may be able to train their brains to change their behavior.
In addition to the direct approaches, the physician can take to overcome their implicit racial bias, the patient can also aid in improving their care. Stereotype threat affects both sides of the physician-patient interaction; a patient may become defensive if they believe their physician holds a belief about them and this may change how the physician acts toward the patient. This impairment in communication can be aided by self-affirmation from the patient. Self-affirmation is used to uphold one’s self-integrity, it has been used in school settings to diminish racial differences in face of a threat. Self-affirmation could prevent a defensive position taken by the patient and improve communication and trust with the physician. If the patient can trust their physician and their physician is actively trying to be objective and adjust for their implicit bias, the discrepancies in care outcomes that are subconsciously due to race can be improved and ultimately eliminated.
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