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Recently, an associate editor was dismissed from a major medical journal resulting
from a podcast where he stated that there can’t be racism in health care since physicians
are not racist. His assertion that racism (i.e. racial bias) is absent in healthcare
is incorrect.
This incident brought to mind a book I read called Thinking Fast and Slow by Daniel Kahnemann. The book is based on Kahnemann’s Nobel Prize winning work describing
the two types of human thought. System 1 thought (98% of thinking) is fast, instinctive,
and emotional. Examples of System 1 thought include answering the equation “2 + 2
= ?” or filling in the blank "war and . . . ” System 2 thought is slow, effortful,
infrequent, logical, calculating, and conscious. An example of System 2 thought includes
trying to compare two automobiles being considered for purchase based on price and
quality.
When we take our time to think of ourselves interacting with people who may be different
than us, we know--based on societal norms--that we should treat everyone the same
and avoid bias (racial, gender-based, sexual orientation based, body-type based, etc.).
However, often when we interact with people on a day-to-day basis, our System 1 thinking
takes over. We may quickly create a plausible theory of what is driving someone’s
particular action or behavior by relying on our own associations and previous memories,
without accounting for the experiences, memories, and feelings of others. While our
System 2 thinking tells us we do not possess bias, our System 1 thinking may in fact
lead us to demonstrate unintended or “implicit” bias.
Why should we care about implicit bias in health care? Marginalized people, such as
people of color, are more likely to be seen in emergency situations as criminal and
violent. In medical settings, these groups are more likely viewed as noncompliant
with their medication. They may also be viewed as more likely to be medication-seeking
or to have ulterior motives other than trying to receive needed care (1).
With obesity, the stigma patients face can mean another health issue goes undiagnosed
and untreated. Unlike other health conditions, such as an autoimmune disorder or opioid
use disorder, obesity is a diagnosis that is visible that often result in others making
judgments. Health providers often assume patients who are morbidly obese cannot conform
to lifestyle modifications, that they haven’t looked at changing their diet, or that
they have yet to try an exercise program. So, the assumption is that they’re just
lazy (1).
These implicit biases have consequences for patients. Racial and ethnic minorities
and women are subject to less accurate diagnoses, curtailed treatment options, less
pain management, and worse clinical outcomes. The risks Black women face in childbirth came into the spotlight when tennis pro Serena
Williams nearly died after giving birth to her daughter. Williams said that a day after her emergency C-section, she felt short of breath.
Given her history of blood clots, she knew something was wrong. She struggled to convince
doctors, and when they finally checked her, it turned out she had several clots in
her lungs. Her insistence likely saved her life (2).
What can we do to address the issue of implicit bias? The first step is education.
I believe that most healthcare workers don’t purposefully treat patients differently
based on race, gender, sexual orientation, etc. However, I also know that our personal
experiences can dictate our responses to patients that may be interpreted as biases.
By acknowledging the issue of implicit bias in healthcare, we can begin to identify
solutions to providing everyone with the most appropriate care, in the most appropriate
setting, and at the most appropriate time.
Notes:
1. Taken from https://www.ajmc.com/view/implicit-biases-have-an-explicit-impact-on-healthcare-outcomes
2. Taken from https://www.nbcnews.com/news/us-news/how-training-doctors-implicit-bias-could-save-lives-black-mothers-n873036
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