#7 - Implicit Bias
Implicit Bias can affect everything we do over our daily lives. It's especially important to recognize it in healthcare. Today we discuss what is implicit bias, how it manifests in our everyday lives, testing for it, and how we can protect our thoughts against it.
Definition
An underlying psychological process that often goes unseen and is used to categorize objects, people, places into certain routine definitions and assumption of actions.
Examples
For instance if I say "kindergarten teacher" then you may automatically think of a woman teaching children. You likely don't think of a man teaching children. Or if I say a smart mathematical person you may think of an Asian person on a computer or calculator.
In the medical field this can have bad consequences. If a radiologist or ER doctor is looking at the x-ray of an African American male who has cystic fibrosis they may not think of cystic fibrosis as a diagnosis, because cystic fibrosis typically occurs in white males. However if another doctor comes along and does not know the patent they may correctly read the x-ray and say it is cystic fibrosis.
How to fix it?
In this podcast I cover some of the ways to fix this problem.
Happy Listening!
Transcript
(00:00.802)
Welcome back. Today we're going to talk about implicit bias. And implicit bias is these internalized stereotypes that unconsciously affect our own perceptions, how we act in life, as well as our decisions. So if you imagine a kindergarten teacher
your brain will likely conjure up a woman who is teaching young children. It will not likely conjure up a man who is teaching young children. Simply because of your exposure across time and the effects from social interactions and marketing, they unconsciously drive you to choose certain things.
(01:23.09)
implicit biases are present in our brain to help us conserve energy and make quick decisions. Sometimes these implicit biases can be bad. For instance, in the elderly, you are more likely to ignore them, not talk to them, and they become socially isolated. So this means that they can develop depression, which
leads to suicide. So they have a higher rate of suicide as they get older. And this is a form of negative implicit bias. You do not want to talk to them because your brain says, well, they may not know much because they're old and they live in the past. And so therefore I will not gain anything from talking to them. In the healthcare industry, this implicit bias can have big implications.
So let's say a doctor is reviewing a chest X-ray and he knows that the patient is black. Well, they may not assume that the patient has cystic fibrosis because cystic fibrosis is higher in white males. So their brain will remove the picture of the X-ray that is supposed to look like cystic fibrosis and replace it with something else.
Now another physician comes along who does not know the patient and looks at the x-ray and says, oh, well that's actually cystic fibrosis. And so not knowing the patient demographics may open the brain to wider possibilities and help them achieve the correct diagnosis.
from my own experience, I was treating a patient that had sickle cell anemia. And this patient was African-American, dark skinned. And with sickle cell anemia, you can have extreme pain in your limbs because you're not getting oxygen to that limb. So what happens, you have a sickle cell crisis and oxygen is kind of not delivered
(03:42.562)
the red blood cell is deformed. And this results in excruciating pain. So my patient showed up in the ER and I was like, well, why, I wonder why he's in the ER? I just, you know, kind of looked in the chart that day when I was in clinic and I saw that he was having a sickle cell crisis. So I just walked down to the ER and talked to him for a bit and he was not getting any pain medications.
And I was like, oh, they probably looked at him and said this patient is a drug seeker because he's young and how can he be in this much pain from sickle cell anemia? So I had to do some education for the ER department and kind of show them what it feels like. And what it actually feels like is if you take a blood pressure cuff and you put it around your arm and blow it up and leave it there.
you will quickly find out that your arm goes numb and can't get oxygen and it starts to feel like a sickle cell anemia attack.
So luckily I was able to get him some pain medication as well as treatment for his sickle cell anemia attack and he was treated much better.
Unfortunately, the young population is not the only one to be stigmatized. Other groups include advanced age, like the elderly that I talked before, non-white race, HIV positive, people with disabilities or substance use disorders, including alcohol use disorder, people who have low socioeconomic status, mental illness, non-English speaking.
(05:38.338)
That's another one. Non-heterosexual and obese patients. Going back to people of advanced age, or the elderly, when I used to go and treat them in their homes, they would often want to talk a lot. And at first I was like, are they just trying to get attention? You know, why are they wanting to talk to me a lot? I did not recognize the fact that basically they are lonely.
And unfortunately, physicians overall are less willing to treat older adults, especially with suicidal ideation, but in fact, older adults have a much higher rate of completing suicide than younger adults. And it's very interesting that nurses will even provide less education
to older adults. Sometimes I think we can assume that older adults have more time on this earth and maybe they have dealt with things that we are talking about, but in fact, healthcare is extremely complex and you may not run into any part of it until you are much older. And in fact, you do run into more of it as you get older because your body starts to break down.
The CDC has actually declared racism as a serious public health threat. They did this back in 2021. Pediatric or children who are non-white face significant racial biases from healthcare professionals. And we also know that...
these biases are increased when the physician is under pressure and ambiguity, such as a clinic that sees 30 or so patients in the insurance-based model will have a lot more racial bias than, let's say, a direct primary care practice would like mine, where I can take an hour with my patients and I've scheduled them out to decrease my stress.
(08:01.718)
so that I can make a lot better, well-informed decisions for them. One way to reduce this racial bias is to actually expand your network and form friendships with people of different healthcare professions, that they may have different backgrounds than being white. So one of the things that I like to do, even outside of the healthcare profession,
is have friendships with people that are from different countries. And this includes people from Latin America, as well as Africa and multiple other countries where I can see that this significantly helps my implicit bias. So if I see something on the news, which is actually trying to strengthen that bias,
by saying that, oh, look at this black community. They, you know, there's lots of fighting going down here. There's lots of drugs in this community. Well, it's not because they're black, it's likely because there isn't a lot of money going into that area. So they have significantly less decision capability. And I'll look towards my friends that I actually grew up with.
Say look their family was you know really nice and I ate at their house. I ate at his house we ran together we built tree houses together and later on in my life I danced salsa from Thursday evening to Sunday morning and Through that experience. I met all kinds of people from Latin America and around the world and so my brain understands it Oh
just because their skin is a different color doesn't mean that they have negative implications for my own survival. And I think that's what it really gets at is that your brain is trying to keep you alive by not associating with people who have bad habits. For persons with substance use disorder, alcohol use disorder, history of incarceration,
(10:28.25)
and sometimes exposure to police violence. One of the things that I often run into is that the staff of the hospital or the clinic basically do not have education on how to approach these people and discuss their history. And they will feel uncomfortable discussing it. So I did my residency in
Jackson, Michigan and It's a prison town. It's a very large prison town. So I would often run into these problems multiple times so I would see somebody who would drink the alcohol of a out of a alcohol hand dispenser and You know it was normal like that was like a Friday night and I would see people Who came in from the prison and they were put into our prison wing. It was a
double door enclosed high security wing. And so I'd walk up to the first door, it would open, I'd walk in, I'd put my phone in there, and a little cubby, the next door would open, and then it would close too, and I would walk to the patient's room with one very large guard, or maybe two very large guards, and I would basically just treat them with significant respect. And at that time, I wouldn't really delve into
their incarceration because it didn't really matter what was going on right there. What mattered was that they had this disease or this problem and I was gonna treat them for it. And some people may have a little bit of prejudice against that idea of not asking about that person's background, but.
Like I tell everyone, you don't always know, one, what you're doing, you're not in control of your faculties, and life can be extremely catastrophic. And it will come out of nowhere and put you in a situation where you need to make these hard decisions. For instance, eating or going to rob a gas station and get some money for some food.
(12:50.234)
Unfortunately, nearly one in three black men will be imprisoned in the US and this perpetuates all kinds of problems including the fact that The success of young black men depend on the number of adult black men in that neighborhood So the more of those adult black men in that neighborhood the more likely
those young adult black men will grow up to have financial success. So it's very important that we kind of look at our biases and be very careful when we're approaching these people who have already been stigmatized so that we don't keep repeating these behaviors that affect these populations.
and keep them in the actual status that we don't necessarily like to see in our brains.
(14:04.814)
So how do we fix this problem? Well, in the healthcare industry, one of the major problems like I alluded to before is that most healthcare providers, nurses and doctors are under significant stress. So this will increase our implicit bias because once again, our brain is trying to conserve energy and we are trying to help the patient very quickly.
So what needs to happen is we need to recognize it and then do a post follow-up examination of what happened. So in the healthcare industry, if you don't know, we actually have mortality and morbidity conferences where we discuss openly our mistakes in an area of hopefully non-judgmental advice and...
I think we could also include something like along the lines of implicit bias debriefing. Now we have to make these spaces stress free, meaning it's protected time like for our residents where they do not have to hold on to the phones and the attendings take care of it. We also have to stop putting so much pressure during the encounter.
So for instance, in a clinic that is insurance-based, they may see patients every 15, 20 minutes because those people who are above them are telling them to do this, to keep the clinic doors open because they have to hire more people to handle all of the insurance interference that occurs. So removing those requirements of insurance
will directly lead to decreased need for.
(16:11.694)
the compressed time to see patients. And we see this in direct primary care clinics where the patients report, wow, I was listened to, I was felt, I was, you know, heard as a human being. And you can see this in all of the fantastic Google reviews that are online. And of course I hear it in my clinic as well. They finally say, you know, or they say, finally, I have been treated like a real human being.
and not some type of cog in a wheel. So we also need to do some type of training, right? Even just like an hour of training in a time where it is given to the doctor to undergo this training and not taken out of their vacation or weekend time. So once again,
the managers of insurance-based clinics need to recognize that this is happening and resulting in significantly worse outcomes for their patients. And I personally recently underwent a couple of hours of training for implicit bias. And that's where I came up with this podcast. The training was extremely eye-opening. And although I've heard implicit bias in the past,
I'm actually really glad that I delved into this topic because it allows me to look at my own self, which I really like to do. Now, lastly, I think that we should also offer mindfulness training, which has also been stigmatized itself because it's often shoved into some hectic workday for the clinician and not.
been given the time that it deserves. And it's often used as a scapegoat as well. So mindfulness can actually contribute to seeing one's own thoughts and realizing that, oh, these thoughts don't align with what I actually want to accomplish, which is a really good diagnosis for my patient. As we get more training done in the workplace and allowing more time for it.
(18:37.23)
Hopefully we should see some type of butterfly effect where if we implement it in one small team, it will then come over to other teams because it's pretty interesting to do a little bit of self-reflection and then talking about it with somebody else allows them to see that this is going on and it's not just some commandment from the higher management.
(19:27.422)
If you want to look at your own self and see where you might have some implicit biases, you can actually take a test called an implicit association test. And I believe it's either Stanford or no, it's actually Harvard who have these tests available. So you can look at it and they're actually a gold standard in implicit bias research.
(19:56.046)
I hope that this podcast was insightful and you can take away some lessons from it and help to look at your own life and see where you might have some implicit bias. And I always encourage people to look into mindfulness training. It has significantly changed my life and I feel a lot better every day for it.