Curing Implicit Bias

How thoughts and perceptions health care providers unconsciously harborcan affect health care for minorities — and what can be done about it

Voncile Brown-Miller will never forget the day in 2008 when her brother was hit by a car.

At the hospital, a plastic surgeon who was on call came to the emergency room to treat her brother’s head wound. The plastic surgeon was Asian. Brown-Miller’s brother is African-American.

“He didn’t clean him up. He didn’t give him anything for pain for that area,” says Brown-Miller, who works as a research assistant in the oncology department at Wayne State University. “I said, ‘Wait just a minute. I was gonna wait and see what you were gonna do, but this is not the right procedure for what you’re doing.’ He just looked at me very surprised that I should know that. And he said, ‘Well, um, he’s probably so drunk right now that he wouldn’t even know that I’ll be doing this.’ ”

Brown-Miller, who worked at the American Cancer Society at the time, told the surgeon she worked “ … on health disparities and this is something we address and I just need to let you know that this is what I’m seeing from you right now.’ He stopped and we had eye contact and I looked at him and I said, ‘I need you to do your best. You are a plastic surgeon. That means you can give him a stitch that won’t even show a scar. That’s what I want you to do.’

“ ‘Alright, you’re right, I don’t know. I’ve been having a bad day,’ ” the plastic surgeon responded.

He began to share his frustrations about living in Detroit with Brown-Miller and she encouraged him to give the city a chance.

“While we were talking, he cleaned my brother’s wound,” Brown-Miller says. “He cleaned it really well. He got a suture kit and the needle was not the one he needed so he went and got another. He said, ‘This is a finer needle. This won’t leave a scar at all.’ I told him again, ‘Thank you. Thank you for listening and thank you for doing what I think you can do.’ ”

A Complex, Persistent Issue

Even though it ended on a positive note, Brown-Miller and her brother’s experience illustrates a complex, yet persistent problem in health care. Research has shown implicit bias — the attitudes and stereotypes that affect how we perceive or interact with a person or a group of people on an unconscious level — may negatively impact the care a patient of color receives.

According to a recent review of 15 studies that explored the level of implicit bias among health care professionals, low to moderate levels of implicit racial/ethnic bias were found among the providers in all but one study, with most appearing to prefer white people while being biased against people of color.

The results revealed implicit bias was significantly related to patient-provider interactions, treatment decisions and compliance, and patient health outcomes. Interactions and outcomes were more affected than treatment.

The subtlety of implicit bias — the fact that by definition it’s unconscious and that it occurs without a person knowing — makes it a challenge to acknowledge and control. But it can affect health even before a patient of color comes to a doctor, shaping their health “in really profound ways,” says Dr. Abdul El-Sayed, the Detroit Health Department’s executive director and health officer and the son of Egyptian immigrants.

“Also implicit bias fundamentally changes the means of improving health,” El-Sayed says. “It shapes the way students are treated by their teachers in school, the ways in which people are selected for jobs, the ways they are treated at those jobs. These things help to frame the great income and wealth disparities by race in the United States — and these change access to good foods, walkable neighborhoods, and health care.”

Louis Penner, a research scientist with expertise on the origins of implicit bias and a professor in the department of oncology at Wayne State University who works with Brown-Miller, recently conducted research that studied the interactions between 18 non-black oncologists and 112 black patients in Detroit.

The doctors took an implicit racial bias test several weeks before treatment discussions. Afterward, the oncologists’ communication and amount of time interacting with the patients were rated, and after the meetings, patients answered questions about how the oncologists acted toward them. The patients were also asked about how well they remembered what was said during their discussion as well as trust and treatment perceptions.

Implicit racial biases are typically expressed in very subtle ways, perhaps in things (such as) not making as much eye contact or smiling less with a black patient; or in other ways that are less subtle but are still outside the awareness of the person who is biased; that is they are not aware they are doing them,” says Louis Penner, a research scientist with expertise in the origins of implicit bias.

The results showed implicit racial bias negatively affected the oncologists’ communication, patients’ reactions during their meetings, and patients’ perceptions of recommended treatment. The doctors also tended to spend less time with a black patient, and time spent can make all the difference in a patient’s experience.

A Patient’s Story

For Margaret Brown, who is African-American, finding a lump in her left breast was just the beginning of her medical nightmare. In 2006, the Southfield resident who works as the executive director of the Fair Housing Center of Metropolitan Detroit was diagnosed with stage II breast cancer and had a lumpectomy.

While she was healing from a second surgery and resulting infection, Brown was told she could have radiation as a follow-up treatment and forgo chemotherapy. But, she was advised to see an oncologist as a matter of process.

After a long wait at the office, when she met with the oncologist, who was white, the doctor dismissively told her she would need six rounds of chemo.

Stunned, Brown started to cry, but the doctor simply turned around and left the room, saying nothing about what kind of chemo she recommended.

After a botched procedure by a resident to place a port — a small device that’s implanted to serve as an artificial vein — and three chemo treatments, Brown felt a familiar lump in her breast. She told the oncologist, who didn’t react, and the surgeon, who dismissed it as scar tissue.

Brown continued with chemo and began radiation. After three radiation treatments, she still felt the lump. Fed up, she demanded to see the radiologist, who examined her and immediately ordered a biopsy, which revealed the lump was cancerous.

Brown sought a second opinion, and while she waited, a team at her local hospital re-examined her case and recommended she have a mastectomy.

At that point, a friend encouraged Brown to see Dr. Randa Loutfi at Henry Ford Hospital. Loutfi was the opposite of Brown’s first oncologist. “She said, ‘Mrs. Brown, I’m sorry to tell you this but I agree you need a mastectomy. You have triple negative breast cancer and the drugs you were given work on hormone-based cancer,” Brown recalls. Loutfi told Brown that in addition to a mastectomy, she’d need to endure another six rounds of chemo with the correct medications.

But, Brown says, there was a big difference: Loutfi took the time to sit down and explain the treatment she recommended, as well as its side effects.

Today Brown is in remission and is thankful she was able to discover the second tumor. “Otherwise, I might not have sought a second opinion and may have never known that I had been treated with the wrong medication,” she says. “I can only speculate as to the reasons why I did not get the thorough attention my case deserved.”

While Brown hesitates to say bias was a factor in the care she received from her first oncologist, her lingering questions about what did happen highlight the added burden patients of color often carry during medical treatment.

“I think some assumptions were made about whether I could afford the right drugs. I think there were some assumptions made about what kind of insurance I had,” Brown says.

El-Sayed says this kind of stress can have a wide-ranging impact on health for patients of color and society as a whole.

“Things like the clutch of a purse as a black man walks by, or the assumption that a mother of color cannot parent her children effectively if they are crying in public, or the sideways glances at a woman in a hijab — all of these increase the stress levels of people of color in perceptible ways,” El-Sayed says. “That stress in turn produces a stress response that can be really corrosive with time. That’s one of the more important reasons why people of color often have higher rates of hypertension, obesity, and cardiovascular disease.”

Margaret Brown was diagnosed with stage II breast cancer in 2006 and had a lumpectomy. It was just the beginning of her medical nightmare. After meeting with an oncologist — who took time to explain treatment — and several rounds of chemo, she is in remission today and finds support and comfort in the Gilda’s Club Women of Color group.

Teachable Moments

“All of us bring biases,” says Dr. Nelia Afonso, an internist who is assistant dean for community integration and outreach and professor of biomedical sciences at Oakland University William Beaumont School of Medicine.

Afonso took the Implicit Awareness Test and was surprised to learn that she, too, had an unconscious bias — about age.

“(When it comes to aging) you think about 60 and older and I’m close to that (57 years old),” she says.

A part of Project Implicit, which is a collaborative effort between researchers at Harvard University, University of Virginia, and University of Washington, the IAT is one of the most commonly used methods to measure bias. The computerized test examines unconscious thoughts and feelings and measures response time to concepts and people. According to Project Implicit, an implicit preference result doesn’t necessarily mean someone is prejudiced, and could contradict what someone consciously thinks.

Furthermore, how implicit bias affects people’s judgments is not understood and could be influenced by other factors. But it’s a starting point for further exploration that can clarify how implicit bias affects perceptions and actions.

“I think just being aware of how you sometimes dismiss things because you bring your bias … (you need) to think of it differently (and see the patient) as a person who has their own values,” says Afonso, who is also OUWB’s course director of the Art and Practice of Medicine.

One way to do this is through patient-centered communication, a trainable skill that doctors can learn.

At OUWB, “in the very first semester they learn how to listen to patients and see things from the patients’ perspective,” Afonso says. “We stress a lot on the patient story, the patient’s narrative. And I think that once you do that you’re humanizing the person and not stereotyping. Whether they’re a different ethnicity or different race once you think of the person as a human being you are more able to put yourselves in the shoes of another.”

In medical school, “there was some emphasis on cultural competencies and learning about bias, but a lot of it was extra after school hours and electives,” says Dr. Asha Shajahan, a physician working for the Department of Family Medicine at Beaumont Health in Troy and Grosse Pointe who does a lot of health advocacy work in the community. “You could master all of the basic sciences, but if you don’t have the ability to connect with patients or understand patients it’s kind of useless.”

Hospital systems are also trying to offer staff physicians more education on having better conversations. Henry Ford Health System is piloting a program called C.L.E.A.R. (Connect, Listen, Empathize, Align, Respect) Conversations, which was started by physicians in critical care who saw a need to communicate better with their patients. The program, using improvisational actors who role-play specific scenarios, focuses on strategies and skills so the patient is not just seen as a disease or demographic.

Maria Kokas, director of learning systems and resources at Henry Ford Hospital, says the program is being modified to recognize the community’s diverse population. They’re also piloting another program to specifically address bias and physician awareness for better understanding of the patient.

“What really embeds is practice,” Kokas says. “Practice requires a safe space situation with very real situations. … A big focus is to make sure all physicians have the skills to raise awareness in the arena of bias and stereotyping, raising awareness in themselves and how they can improve their skills.”

Brown-Miller, the research assistant who works with research scientist Penner at Wayne State University, says the key is for physicians to see each patient as an individual rather than representative of an entire population.

“At what point do you catch yourself and say I haven’t dug deep enough? At what point do you have a real conversation with someone?” she says. “It helps to peel some of those layers back. When do you realize you have more things in common than not? Are you a father? Are you a mom? How many children do you have? What are your kids doing? That connects people in a special way. And, when you have those conversations, it makes us all more human.”

The efforts being made today at schools and in hospitals are a positive step forward.

“I think eventually we will begin to see outcomes what we’re trying to institute at this point in medical school and residency programs,” Afonso says. “Even hospital health systems are much more aware than they were 10-15 years ago.”