Implicit Biases in Healthcare and Medical Education

“The uncomfortable truth is that we live in a society in which stereotypes about groups of people are ubiquitous, and it follows that almost everyone has some implicit bias.”
- Don Goldmann, the Chief Scientific Officer Emeritus and
Senior Fellow at the Institute for Healthcare Improvement
 

Recently, I completed my senior thesis. While writing and revising were taxing, finding a topic that was both impactful and manageable given the timeframe and resources was the most difficult, but most essential part. In choosing a topic, I reflected on past experiences and situations. I was looking to make a difference, so I had to dig deep and get personal! Different memories stuck out to me and many involved when I had experienced or witnessed bias. This included being told by my academic advisor that students with my (Hispanic) “surname” tended not to do well in the natural sciences or being told by a doctor to “study with the Asian kids” when she found out I was pre-med. While these biases were awkward to hear, especially coming from well-respected women of color, I thought about the biases that are impactful and life-altering. I reflect on my experience shadowing a couple summers ago where I often heard other pre-health students in my program express their biases against patients, including refugees and transgender individuals. It occurred to me that these were the future doctors of the United States, a country already riddled with racial health disparities. Thus, I began researching cultural competency in American medical colleges, hoping this curriculum could intervene and help patients from having negative experiences.

After interviewing a handful of New York City deans, directors and doctors, I soon realized cultural and structural competency was no longer at the forefront of medical school curricula. While it is important to understand the cultural beliefs, traditions, and socio-economic structures at play in a patient’s everyday life that affect their health and medical experience, it is often the biases of doctors that negatively affect the care they offer to their patients. My thesis centered around implicit bias training and schools’ recent transition in training their students and faculty to be aware of their biases, in order to offer the best treatment to patients and ensure positive experiences for their students and faculty of color.

I discovered that while many medical students and doctors hold explicit biases, meaning they know that they hold racist or sexist beliefs, everyone holds implicit or unconscious biases. As the name insinuates, people are unaware of these biases. Despite being “hidden”, they inform our thoughts and actions and are shaped by society and culture, greatly influencing our associations. For example, an implicit bias could be assuming that a Black woman entering your hospital room wearing scrubs is your nurse instead of your doctor because society has both socially and systemically influenced your belief that doctors are Caucasian men and not Black women. Biases are often racial but can also involve socio-economics, gender, sexuality, religion, geography, etc.

Implicit biases can be dangerous as they create health disparities and startling statistics. For instance, the CDC reports that Black, American Indian, and Alaska Native women are two to three times more likely to die from pregnancy-related causes than Caucasian women, increasing with age (CDC). Despite Serena Williams’ wealth and status, as a Black woman, she was still affected by the implicit biases of her nurses and doctors when they initially wrote off her plea for help concerning several small blood clots in her lungs after her delivery (Vogue). Moreover, these biases affect women of color regardless of their socio-economic status as many students and medical professionals still believe women of color have thicker skin or higher pain tolerance (Hoffman et al 2016). To combat this, California Governor, Gavin Newsom, approved a new law in October of 2019 that mandates all hospitals and clinics in the state to implement implicit bias training for all health care providers working in perinatal services (Huffington Post). California State Senator Holly J. Mitchell pushed this law into action saying, “Black women deserve better. Bias, implicit or explicit, should no longer impact a woman’s ability to deliver a full-term baby or to survive childbirth” (Essence). She believes implicit bias training is the answer and challenges Black women to ask obstetricians if they have received such training before selecting one to deliver their baby.

This is definitely a step in the right direction. For my thesis, I interviewed a doctor at a renowned NYC medical school who explained that when he was studying at this medical school in the 1970s, “they would tell [students], ‘With Latina patients, don’t take what they’re complaining about too seriously because they tend to be dramatic.” Unfortunately, this aligns with my grandmother’s experience in the ‘70s when she was a recent immigrant from Mexico. The medical staff at the hospital laughed and turned her away when she told them she, a woman in her forties, was pregnant and needed immediate medical attention. When she came back bleeding a week later, they told her she was miscarrying.

Bias doesn’t just affect patients but often students and faculty at medical schools. When speaking with a doctor at another NYC medical school, she explained to me how biases affected her students, her co-workers and herself, causing an exodus of faculty of color, including herself as a Black doctor, professor and director. She described how implicit biases are quite clear in clinical rotations since part of the exam is subjective, and recounted a time when a faculty member, observing a Latina medical student during rotations, wrote in their notes “This Latina is so articulate.” While this may sound like a compliment, it stems from an implicit bias that Latinx and Afro-Latinx students are not typically articulate and instead, the ability to speak fluently and/or coherently is an uncommon quality among the Latinx and Afro-Latinx population. Within the clinical rotations, discrimination of students by faculty can be a real issue, leading to grade disparities within medical schools based on race. If a faculty member has a bias against a student because of their background, then it is highly likely it will be reflected in their notes, and consequently, their acceptance into their desired residency.

Bias is not special to this country alone. It exists everywhere and creates health disparities among diverse and homogenous populations around the world. When the odds are already stacked against us as Latinx and Afro-Latinx entering healthcare, Latinx and Afro-Latinx in healthcare or as Latinx and Afro-Latinx patients, we must strive to unlearn our own biases and call out others’ for their biases. It can literally be the difference between life or death.

Harvard has developed Implicit Bias testing for different topics. Click here to take a test and learn which biases and preferences you have.

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