The global Covid-19 pandemic came with financial, emotional, and physical health implications for just about everyone worldwide. Along with those burdens, a significant strain was placed on resources, people, and systems. Issues that were lingering just beneath the surface bubbled up, inequities became highlighted, and urgent outcries and demands for swift solutions became harder to ignore. For some disadvantaged groups, however, Covid-19 served as a catalyst for welcome and much-needed changes. In fact, some groups saw an improvement in circumstances unlike anything they’ve experienced. Why? Two words: Unconscious bias.
Protection from discrimination doesn’t include unconscious bias
According to a study by the U.S. Department of Labor, disabled individuals in early 2020 were experiencing their highest labor market participation rates since 2008. What was the reason for this spike? During Covid-19, when most jobs became remote, it may have been that people with disabilities felt protected by the extra layer of technology. Potential employers didn’t have the opportunity to develop any notions about them when something as unremarkable as arriving at the interview could cause bias to kick in.
Many people with a disability won’t disclose it when applying for a job for fear of being eliminated early from consideration. Even after obtaining a job, some people may not ask for accommodations to avoid possible discrimination or being bullied by co-workers or managers. While the Americans with Disabilities Act protects workers with a disability, it does not protect them from unconscious bias.
Healthcare workers aren’t free of unconscious bias
There’s recently been an increase in awareness of the implications of unconscious bias in healthcare settings. Despite a high ethical standard, unconscious bias also influences the behaviors and treatment choices of doctors and other clinicians. How can the “healers” be biased? Because they’re people. If you’re breathing, you’re biased. It’s natural, we’re all programmed with preferences and biases from the time we are born.
Discriminatory behavior in health care, as elsewhere, is very difficult to identify and prove. Its insidious nature makes it nearly impossible to pin-point. And it is even more difficult to address when the person doing it may not be aware of their actions stemming from their personal biases. It’s also an uncomfortable topic that causes tension.
Some of the psychology behind it
We make decisions based on our biases every day without realizing it – unconsciously. It likely starts when we are babies. One study found that when babies are placed in a room full of stuffed animals, the babies decide the unchosen animals aren’t liked. In other words, when babies choose a stuffed animal, they then decide the animals they didn’t choose aren’t as good as the one chosen.
This labeling happens unconsciously, simply as a way to justify our choices. We decide we like what we choose. And then our brain searches for the rationale to justify our decision. According to the study among babies, we label what we didn’t choose as “bad” and what we chose as good. Then we build familiarity with our subconscious choices, and our choices become implicit. This phenomenon occurs at all ages.
Implicit bias in action
Biased medical treatment of people based on their race and ethnicity has been documented for decades. Black and brown Americans are, for example, systematically undertreated for pain in comparison to white Americans. And here on this blog, Libby Wetter has given examples of racism and unconscious bias in reproductive care.
One striking study of medical students and residents found that half held false beliefs about biological differences between white and black skin. The perpetuation of such implicit and ingrained falsehoods in the medical community–such as black people’s skin being thicker than white people’s skin–is not only false but dangerous. And according to Yalda Jabbapour and John Westfall, also writing here at this blog, even the language used in medicine arguably perpetuates these unconscious biases (e.g., black box warnings).
In December 2020, a black woman with Covid-19 died after complaining of racist treatment by the hospital where she was receiving care. She was a physician. Even with her credentials and expertise, she reported the treating physician did not believe her intensity of pain. She noted they treated her like a drug addict and her doctor dismissed her when she complained of severe pain. The white male doctor treating her in the suburbs of Indianapolis reportedly refused to give her pain medications to help her cope with pneumonia from Covid-19.
Solving the problem of unconscious bias in health care
Universities are beginning to mitigate such issues in patient care at the teaching level. Johns Hopkins University School of Medicine, for example, took steps to change their curriculum to address unconscious bias and understand structural racism as it applies to patient treatment and interactions with colleagues.
With the recent insurgence of racial protests, hospitals and other patient care organizations have responded by implementing diversity and inclusion training, which sometimes includes the subject of unconscious bias. Many organizations are adding executive roles, such as a Chief Diversity Officer, to create accountability for addressing biases in treatment. This is a great start but unfortunately it’s not enough.
Currently, there are very few studies about the effectiveness of such training and other interventions in reducing levels of unconscious bias. A systematic review of such interventions from 2019 suggested future studies should focus specifically on a few key areas. First, they should investigate the effect of interventions on both implicit stereotypes and implicit prejudices. Second, studies should examine the effects of institutional and organizational changes on implicit biases. Third, and arguably most importantly, studies should monitor the long-term effects of interventions.
Health care providers can take action individually
There are a few steps health care practitioners can take to help eliminate unconscious bias in health care. An article from Cardiology Magazine published by the American College of Cardiology lists some helpful steps:
- Find a common interest. Ask patients questions about interests and activities that you have in common. Ask about their family, community, and hobbies or sports.
- Take the other person’s perspective. Try to understand a patient’s life and walk a mile in their shoes.
- Consider the opposite. When data seem to point to one conclusion, look for data supporting the opposite conclusion before making a decision.
- Counter stereotypes. Spend time with people you admire outside your own group to help you better understand differences.
Looking ahead
What can health care organizations do to further address bias? In addition to the ideas above, hospitals and other patient care organizations could enlist the help of researchers. Social scientists who do research-based cultural audits could assist in the discovery of problems with unconscious bias that need to be addressed. They might also identify organizational structures that contribute to the feelings of inequity.
Teaching about unconscious bias early in medical school programs, and encouraging faculty to have difficult conversations about the topic might be the most effective approach. It’s a great way to introduce the subject as it applies to medicine. And catching problems before students begin their medical careers may help lead to better outcomes. If we grow our awareness early, maybe unfortunate situations like the black physician who passed away prematurely in 2020 would happen less often.
