Heightening Awareness of Implicit Bias and Its Impact on Patient Care During COVID-19

Implicit bias affects all of us, and it can affect how healthcare practitioners perceive and interact with others. This can ultimately influence the way we deliver care to our patients.

• What is implicit bias?
• Why is understanding implicit bias important?
• What factors put us at risk for implicit bias?
• Starting where the client is
• What can I do to address implicit bias?
• Resources and endnotes

What is implicit bias?

Implicit bias refers to the attitudes and stereotypes that affect our understanding, actions and decisions in an unconscious manner. The implicit associations we have in our unconscious can cause us to have feelings about others based on characteristics such as language, gender, appearance, race, ethnicity, age and class.1 These associations develop over the course of a lifetime beginning at an early age through exposure to direct and indirect messages about what we are supposed to think and feel.2 These associations can have a subtle effect on how we, as healthcare providers, perceive, interact with and deliver care to our patients.

Unfortunately, with the spread of the coronavirus, or COVID-19, there have been increased reports of bias, both explicit and implicit. Stereotypes and assumptions can perpetuate negative biases that can put others at risk for harm or isolation, or prevent people from accessing needed care. It is important to be mindful of:

• our language and how we label people
• stereotypical “jokes”
• the way we treat each other and the diverse communities we serve.

Diseases like COVID-19 can make anyone sick, regardless of race or ethnicity, and one way we can ensure that we are providing the highest quality of care for all people is by becoming more aware of our own biases and taking action to address them.

Why is understanding implicit bias important?

Two landmark reports by the Institute of Medicine, Crossing the Quality Chasm (2001) and Unequal Treatment (2002), highlighted pervasive racial and ethnic disparities in the US healthcare system.3,4 The reports found that even when they had the same insurance and socioeconomic status as non-minorities – and when comorbidities, stage of presentation and other confounders were controlled for – minorities often received lower quality healthcare.

Research shows that part of what causes disparities are the implicit biases of healthcare workers, which can unintentionally lead to providing lower quality care for patients. The literature shows that implicit bias based on race, gender, sexual orientation, weight, insurance and other group identification can affect providers':

• quality of clinical encounter
• diagnostic decision making
• symptom management
• treatment recommendations
• referrals to specialty care
• interpersonal behaviors, such as communication, empathy and trust5

Reports indicate that the coronavirus does not discriminate; however, people who are disproportionately affected by health disparities and poor social determinants of health – such as low access to healthcare, poverty, housing and food insecurity – with consequent higher comorbidities, have a significantly higher risk of being affected by COVID-19 with worse health outcomes.

What factors put us at risk for implicit bias?

Research shows that various factors can put us as risk for implicit bias. These include the following:

• emotional states such as anger, anxiety, fear and disgust
• lack of concrete guidelines for decision making
• being distracted or pressured
• long hours
• working in a fast-paced work environment
• dealing with crises
• being backlogged
• lack of feedback.6

The COVID-19 pandemic unfortunately puts us at risk for experiencing several factors that contribute to implicit bias. Therefore, it is important that we are aware of the unintended biases that can affect our work with patients and how to address them.

Starting where the client is

"People fail to get along because they fear each other; they fear each other because they don't know each other; they don't know each other because they have not communicated with each other."

– Martin Luther King Jr.

The doctor-patient encounter is often mediated by cultural norms and beliefs, stereotypes, stigma and implicit bias. Both patients and providers can bring factors such as stress, mistrust, time pressures and poor communication to the doctor-patient encounter that can lead to biased treatment decisions, poor adherence and, ultimately, negative outcomes.

Implicit bias has been described by Banaji and Greenwald as our “blindspot.”7 Being aware of what we bring to our interactions with patients and being intentional about how we engage patients to build trusting relationships are key to avoiding those blindspots. We are the most important tool in our interactions with patients. It is important that we start where the client is and practice from a patient-centered care model. This often allows the clinician to see and consider the whole person versus negatively labeling the patient or making assumptions.

What can I do to address implicit bias?

Addressing implicit bias is not always easy; it is a process. However, as clinicians we are often seen as having the power and influence over decision making for patients, and there are steps we can take to learn how to identify and address unconscious thoughts that can unintentionally influence patient care.

1. Make a personal commitment to learn more about your implicit biases

• You can start by taking the Implicit Bias Test (IAT) to help identify any hidden biases.
• Take the time to reflect on your results. Remember, the IAT shows that:
  • Implicit biases are pervasive and everyone possesses them.
  • We generally tend to hold implicit biases that favor the groups we identify with.
  • Implicit biases are flexible. The implicit associations that we have formed can be gradually unlearned through a variety of "de-biasing" techniques.
• Using what you have learned, work on developing an understanding of the potential for unconscious bias in your work and make a commitment to be alert.

2. Practice from a stance of dignity and respect

• Seek to learn about diverse cultural and health beliefs.
• Cultivating awareness and sensitivity can be more effective in acknowledging differences in diversity.8
• Make an effort to be inclusive – everyone is valued and all contributions are welcome.
  • E.g., respect gender identity of patients by using their self-identified names and pronouns in your interactions with patients.
• Do not support jokes that disrespect any group of people.
• View people as individuals instead of as part of a larger group.
• Practice patient-centered care – build partnerships with patients and their support person(s).
• View yourself as part of a larger group to increase empathy and trust.

3. Be conscious of your decision making process and check for bias

• Use established guidelines, assessments, check lists or process flows for doing your work, as appropriate.
• Avoid making assumptions/judgments based on first glance or “eyeballing” patients.
• Document the reasoning behind your decisions.
• Use shared decision-making tools to allow for enhanced communication, education and patient input related to the care plan.

4. Identify sources of stress and factors that contribute to pressure in the environment

• Work to minimize stressful situations that can cause you to rely on automatic thinking and lead to biased decisions.
• Practice mindfulness: Take a few moments between cases, meetings, etc., to clear your mind and refocus on the next task. (See Resources)

5. Develop a spirit of curiosity

• Get to know your patients beyond their diagnosis:
  • Assess for social determinants of health.
    • Ask patients about their social history to better support and understand the challenges they face.
    • Not assessing social history or challenges can lead to an inappropriate care plan.
      • E.g., patient not being able to afford prescribed medication.
    • Practice selective inquiry based on clinical considerations.
    • Look for “clinical red flags.”
      • E.g., child abuse/elder abuse/domestic violence.
• Use the Teach Back Method and Ask Me 3 techniques to enhance communication and improve outcomes between the provider and client.9,10 (See Resources)
• Utilize motivational interviewing techniques when assessing patients to focus on having an open dialogue to explore a patient’s readiness for change, rather than traditional advice-giving. This helps to identify barriers to change and decrease resistance. (See Resources)

Resources and endnotes

Resources

Jillian Rose, PhD, MPH, LCSW – Understanding Implicit Bias and Its Impact on Clinical Practice, Decision-Making and Achieving Optimal Health Outcomes.

C. Ronald MacKenzie, MD – Impact of Mindful Practice by Physicians and Patients, HSS Playbook.

Juliette Kleinman, LCSW, ACSW – Assessing and Addressing Health Literacy: A Critical Skill for the Healthcare Team to Improve Patient Outcomes.

Nancy Violette, PhD, LCSW, LCADC, ICCS – Motivational Interviewing: Creating Collaborative Conversations with Patients and Their Families to Enhance Healthcare Outcomes. Presentation at HSS, March 4, 2014.

Endnotes

1. Staas, C., Capatosto, K., Wright, R. A., & Jackson, V. M. (2016). State of the Science: Implicit Bias Review. Kirwan Institute for the Study of Race and Ethnicity. http://kirwaninstitute.osu.edu/implicit-bias-training/resources/2016-implicit-bias-review.pdf

2. The Joint Commission, Division of Healthcare Improvement. (2016). Implicit Bias in healthcare. Quick Safety. Issue 23.

3. Institute of Medicine, Committee on Quality of healthcare in America. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington. DC: National Academy Press.

4. Institute of Medicine. (2002). Unequal Treatment: Confronting Racial and Ethnic Disparities in healthcare Washington, DC: National Academy Press.

5. FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare professionals: a systematic review.BMC medical ethics,18(1), 19.

6. Casey, P. M., Warren, R. K., & Elek, J. K. (2012).Helping courts address implicit bias: Resources for education. National Center for State Courts.

7. Banaji, M. R., & Greenwald, A. G. (2013). Blindspot: Hidden Biases of Good People. New York: Delacorte Press.

8. Apfelbaum, E. P., Sommers, S. R., & Norton, M. I. (2008). Seeing race and seeming racist? Evaluating strategic colorblindness in social interaction. Journal of personality and social psychology, 95(4), 918.

9. Welcome to the Always Use Teach-back! training toolkit. (n.d.). Retrieved from http://www.teachbacktraining.org/

10. Ask Me 3: Good Questions for Your Good Health. Institute for Healthcare Improvement. Retrieved from http://www.ihi.org/resources/Pages/Tools/Ask-Me-3-Good-Questions-for-Your-Good-Health.aspx

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