When a patient encounter turns into an interrogation: implicit bias in action

By Bi Awosika

Bi Awosika, MD FACP FHM

I ponder over a time when I was about to start another rotation on wards and received signout on the patients that I would be caring for during that week. One of the patients included an elderly gentleman with pneumonia whose family was greatly involved in his care.

My colleague had commented, “Nice patient and family; you will just love them!”

The following day I happily greeted the patient and the family at the bedside. I introduced myself as the new provider and, in turn, asked the other members in the room for introductions to gain a sense of the family dynamic.

As I delved further into the interview, the family at the bedside gently interrupted: “Oh, you are the new doctor…So you really became a doctor…what schools have you attended?” I replied that I have attended various schools across the country. My goal was to begin dialogue with the patient, for which he immediately spoke up and said: “That’s nice…what schools were they?” Another family member chimed in: “I think it’s important to know…” A brief silence fell as I scanned the room and smiled. After meeting a pattern of persistence of wanting to know, I finally divulged. “Wow, well…good for you…”

Good for you…

After leaving the room, I could vividly remember not quite being able to piece together my sentiments over the encounter.

The exchange that I usually enjoy of sharing each other’s background was cut short with the emphasis of where I trained being the only focus of the conversation.  I immediately felt that I may be overreacting over a family wanting to partake in small talk, but I could not get over the feeling of how it almost felt as if it was a mini interrogation.

What ensued was more questions of self-doubt and wonder. Am I truly making a big deal over it? Did my Caucasian male colleague get asked where he trained? Was it because I am a person of color and there may have been doubt of my abilities? Would each decision be scrutinized over just a tad more? What more would I need to prove?

Many years I spent working diligently, years of triumph and disappointment, to arrive at the point I am today, eagerly and selflessly ready to advocate for the patients I serve.

However, there are times where you encounter moments where you wonder if those special letters of ‘MD’ that you are privileged to have and hold dear, that defines your calling, may be solely based on how one perceives you and ultimately the biases that are held.

According to the Association of American Medical Colleges, implicit bias is defined as attitudes or stereotypes that are outside our awareness but nonetheless affect our understanding, our interactions and our decisions [3].

The impact of implicit bias and its implications in the realm of medicine transforms patient care on various levels. Consequently, there are biases towards healthcare providers, those that are towards the patients that are being served and, on a larger scale, biases that can affect the overall environment and construct of teams and institutions on a whole.

Further exploration touches upon the barriers of access and disparity in the medical system when biases affect the patients. When reflecting on race and sex, for example, men and Caucasians were more likely to be referred for cardiac catheterization than females and African Americans when it comes to the treatment of chest pain [1]. Additionally, differences of bias towards patients have also been measured in clinicians’ approach to pain management between various groups of patients or treatment offered in emergency care.

Implicit bias that has targeted certain groups has unfortunately also led to them developing a level of mistrust in the medical system. Establishing a strong patient-provider relationship from the beginning is crucial towards optimal patient care. As time moves forward, not recognizing that these biases exist will continue to propagate health disparities and dismiss the mistrust that arise in the medical system.

Biases not only affect decision making processes regarding clinical management and patient care overall, but also impacts the foundations of team-based framework to attain at our institutions. One example is the selection practices used for recruitment and training.  Within the Proceedings of Diversity and Inclusion forum [2], national experts participated in a discussion that explored the impact of implicit bias within recruitment practices. Particularly for resident recruitment, discussions that certain metrics such as solely relying on licensing exam scores may perpetuate the biases that can be seen in selection.

Names of applicants that sounded “foreign” to selection committees were seen as less favorable candidates. Activities that focused on serving the underrepresented communities were seen as “extracurricular” and considered lower in weight than if an applicant had participated in research and publications.

Other biases referred to the consideration of the prestige or reputation of a school, where previous applicants applied to a residency program who were seen as favorable candidates and how that bias can impact the current selection cycle. Ultimately, an applicant from that same school can earn a more preferential status regardless of whether he or she has strong qualifications or not. These represent only a sampling of biases that occur within the recruitment practices.

Despite more awareness recently, gender bias remains prevalent in medicine. Dr. Tamika Cross, an African-American physician who was a Chief resident in Texas and now practices in Ohio, attempted to offer medical expertise during an emergency on a U.S. flight and her efforts were deferred as she was questioned whether she was truly a physician [3]. It is imperative that the realization that implicit bias exists and has a powerful impact is not ultimately dismissed.

Prior to leaving the room, I reassured the patient and the family that although I am a new provider, that they can be certain that I would do my best to coordinate and advocate for optimal care. The patient and his family were at ease with these words that I have relayed many times, a statement I turn to during these types of encounters.

Whether we personally are the target or are witnessing our trainees undergo bias with our patients, there is the understanding that each member is equally important and capable of assisting in providing that care no matter the identity each possesses.

Considering recent events that highlight the need to resolve injustices and inequality, the persistent efforts to convey this message when we speak up and share in the moment during those encounters of bias are even more powerful.

Ultimately, as educators and leaders, we are challenged to ensure that implicit bias is not dismissed and that, through awareness, education, discourse and action, we together can strive to build towards a culture of diversity, inclusion and equity.

References:

[1] Webinar: Understanding Unconscious Bias in the Health Professions and How to Mitigate It. Diana Lautenberger. Director of Faculty and Staff Studies and Services. Association of American Medical Colleges. January 2019.

[2] Lewis, Darcy and Paulson, Emily, “Proceedings of the Diversity and Inclusion Innovation Forum: Unconscious Bias in Academic Medicine” (2017). Faculty Bookshelf. 132.

[3] Cooke, Molly, MD. Implicit Bias in Medicine. #WhatADoctorLooksLike. JAMA Intern Med. 2017;177(5):657-658. doi:10.1001/jamainternmed.2016.9643

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About the Author: Bi Awosika, MD FACP FHM is an Academic Hospitalist, Associate Professor of Clinical Medicine and Associate Program Director of the Internal Medicine Residency Program at the University of Cincinnati College of Medicine.

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