Research suggests that we are more likely to rely on our implicit associations when we are under time pressures, have a high cognitive load (i.e., we have a lot on our minds at once), and when situations are ambiguous (i.e., we lack complete information) [1, 2]. Given the high stress and fast-paced environments in which clinicians operate, health care professionals are particularly vulnerable to an increased reliance on instinctive responses to individuals and situations. As such, even the most well-intended clinician may fall victim to biased decision-making. Moreover, studies show that clinicians, like all people, are prong to harnessing implicit biases that may impact their decision-making [3-5]. Indeed, the effects of unconscious bias can be seen in the dynamics of doctor-patient interactions, and clinical decision-making.
Clinician-Patient Interactions:
A notable manifestation of bias in health care is seen in the verbal and non-verbal communication dynamics between clinicians and their patients. For example, research suggests that higher levels of pro-White (vs. pro-Black) implicit racial biases may lead to clinicians having fewer positive interactions with Black patients [6 – 9]. One study in particular found that for those with high levels of pro-White bias “physicians were 23% more verbally dominant and engaged in 33% less patient-centered communication with African American patients than with White patients” [7, p.2084]. Moreover, higher levels of pro-White implicit bias and verbal dominance — which refers to the talk-time ratio of clinician to patient — led Black patients to perceive less respect from their physician [10].
Notably, patients may perceive the verbal and non-verbal manifestations of implicit bias in their interactions with a clinician.
This finding is extremely important given the connection between patients’ perceptions of care and the likelihood of them following through with clinical treatment plans and medication prescription [10].
Treatment Decision-Making:
In addition to the manifestation of implicit bias in clinician-patient interactions, bias has also been shown to influence clinical decision-making. Most notable are the findings of a 2007 study by Green et al, linking implicit biases with treatment of acute coronary symptoms [11]. Specifically, the researchers found that found that the stronger the physicians’ pro-white biases, the more likely they were to treat White patients with life-saving thrombolysis as opposed to similarly situated Black patients [11]. Similar studies have found racial variations in treatment of chest pain [12], pain caused by kidney stones and back problems [13], and even pediatricians’ prescription of narcotics for surgery-related pain in infants [14].
Needless to say, mitigating bias in the patient care process is critical if clinicians are to uphold the egalitarian values they ascribe to.
Back to Why Implicit Bias Matters | Proceed to Clinical Education
References:
[1] Burgess, D.J., Are Providers More Likely to Contribute to Healthcare Disparities Under High Levels of Cognitive Load? How Features of the Healthcare Setting May Lead to Biases in Medical Decision Making. Medical Decision Making, 2010. 30(2): p. 246-257.
[2] Bertrand, M., D. Chugh, and S. Mullainathan, Implicit Discrimination. The American Economic Review, 2005. 95(2): p. 94-98.
[3] Stone, J. and G.B. Moskowitz, Non-Conscious Bias in Medical Decision Making: What Can Be Done to Reduce It? Medical Education, 2011. 45(8): p. 768-776.
[4] Sabin, J.A., et al., Physicians’ Implicit and Explicit Attitudes About Race by MD Race, Ethnicity, and Gender. Journal of Health Care for the Poor and Underserved, 2009. 20(3): p. 896-913.
[5] Haider, A.H., et al., Association of Unconscious Race and Social Class Bias With Vignette-Based Clinical Assessments by Medical Students. Journal of the American Medical Association, 2011. 306(9): p. 942-951.
[6] Penner, L.A., et al., Aversive Racism and Medical Interactions with Black Patients: A Field Study. Journal of Experimental Social Psychology, 2010. 46(2): p. 436-440.
[7] Johnson, R.L., et al., Patient Race/Ethnicity and Quality of Patient-Physician Communication During Medical Visits. American Journal of Public Health, 2004. 94(12): p. 2084-2090.
[8] Cooper, L.A., et al., The Associations of Clinicians’ Implicit Attitudes About Race with Medical Visit Communication and Patient Ratings of Interpersonal Care. American Journal of Public Health, 2012. 102(5): p. 979–987.
[9] Hagiwara, N., et al., Racial Attitudes, Physician-Patient Talk Time Ratio, and Adherence in Racially Discordant Medical Interactions. Social Science & Medicine, 2013. 87: p. 123-131.
[10] Blair, I.V., et al., Clinicians’ Implicit Ethnic/Racial Bias and Perceptions of Care Among Black and Latino Patients. Annals of Family Medicine, 2013. 11(1): p. 43-52.
[11] Green, A.R., et al., Implicit Bias among Physicians and its Prediction of Thrombolysis Decisions for Black and White Patients. Journal of General Internal Medicine, 2007. 22(9): p. 1231-1238.
[12] Schulman, K.A., et al., The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catherization. The New England Journal of Medicine, 1999. 340(8): p. 618-626.
[13] Weisse, C.S., et al., Do Gender and Race Affect Decisions About Pain Management? Journal of General Internal Medicine, 2001. 16(4): p. 211-217.
[14] Sabin, J.A. and A.G. Greenwald, The Influence of Implicit Bias on Treatment Recommendations for 4 Common Pediatric Conditions: Pain, Urinary Tract Infection, Attention Deficit Hyperactivity Disorder, and Asthma. American Journal of Public Health, 2012. 102(5): p. 988-995.