When delivering healthcare, doctors and other medical professionals are confronted with life and death situations. Big decisions must be made quickly. But, not all decisions are made consistently.

In addition to cultural racism — the overt, personal racism where an individual is aware of their actions — there is implicit bias. And this is just as much a problem in healthcare as it is in other parts of life. But what can be done about this?

Defining Bias

Implicit bias works on a subconscious level and manifests in the attitudes and behaviours of individuals who unknowingly behave differently when interacting with people of different racial backgrounds.

Even if someone sincerely believes that they are not personally racist, it is still entirely possible that they may be unconsciously driven by biases that perpetuate disparate outcomes.

“Most health care doesn't happen without some sort of communication,” explains Professor Howard S. Gordon from the University of Illinois in Chicago’s Institute for Health Research and Policy. “The doctor has to make a recommendation, the patient has to accept it, or ask questions and state whether they have any concerns.”

This communication, however, is not always so easy. “There may be differences in different cultural groups or racial groups where the doctor and patient have more trouble communicating,” Gordon said.

One striking example of the challenge caused by implicit bias was identified by Child Trends, which collected evidence that black women face higher rates of maternal mortality than white women.

They point to a 2015 study that revealed that half of a sample of white medical students hold the false belief that black skin is thicker than white skin, and thus can tolerate greater pain. The study also found that the people who do hold this belief rated the pain experienced by black patients lower, resulting in less accurate treatment recommendations.

However, unconscious bias is not just limited to treatment outcomes, it also impacts other parts of the healthcare process. For example, studies have discovered that racial bias affects interactions between patients and medical professionals: Surveyed black patients have found doctors more “dominant” and less collaborative during encounters, and have given lower scores on measures such as “warmth” and “friendliness”.

So how can unconscious bias be overcome? One organisation that has worked to tackle unconscious bias in its organisation is the UK’s Royal College of Surgeons, which cites the advice of Sondra Thiederman in outlining seven steps that can be taken by individuals, from "becoming mindful of your biases" to the final step, "fake it til you make it (what we say can become what we believe)".

In other words, the act of observing bias is the first step towards fighting it, as it makes you aware of your own biases in such a way that you will become conscious about avoiding them.

Changing systems

But are there policy interventions that can mitigate implicit bias? Back in 2015, the Obama Administration’s Office of Science and Technology Policy published a paper reviewing some of the most effective methods for society at large.

For healthcare, some of these same lessons can be taken. For example, doctors can be taught to “individuate” patients — to view patients as individuals rather than as part of a wider group. The same paper also recommends shifting to “patient-centred” communication, viewing treatment decisions as being made collaboratively with the patient, instead of something that is being dictated by the doctor.

Perhaps more important, though, are the structural and institutional efforts that can be made to tackle unconscious bias.

While the literature on this is less developed, one suggestion is that it is important for hospitals and institutions to collect data on healthcare and differential outcomes. The next article in this field guide explores one way a community in Australia has been handling such data. The more data institutions have, the more they are able to design and implement policies that reduce implicit bias on a very zoomed-in scale.

One other intervention that has been advocated by Nobel Prize winning surgeon Atul Gawande is more controversial. He has argued for more standardisation in treatment criteria and procedures. Part of his reasoning is that this, with the necessarily more aggressive oversight it would entail, would result in less unconscious bias as doctors would have fewer opportunities to exercise their own agency in decision making.

The challenge to this radical view is that it runs somewhat counter to the patient-centred and individualised model of healthcare that has become the standard in recent times.

Ultimately, implicit bias impacts us all and, unchecked, takes us further away from the goal of achieving health equity. The first step towards tackling these biases as policymakers is to acknowledge them. The next is to work out how to unpick the structures that give them potency. — James O'Malley

(Picture credit: Pixabay)