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Reducing the Impact of Implicit Bias on Patient-Physician In

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Matt Hughes

on 27 April 2015

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Transcript of Reducing the Impact of Implicit Bias on Patient-Physician In

Reducing the Impact of Implicit Bias on Patient-Physician Interactions
Thesis
There is a Documented Association between Implicit Bias and Poorer Health Outcomes
Decreasing the impact of implicit bias at the provider level
Stereotypes
A way for people to make sense of high levels of information using decreased mental processing. They can be more or less accurate and are completely natural to have.
Biases are technically different from stereotypes, but the two terms are related and are used almost interchangeably in the literature.
Implicit Bias
When a stereotype is used repeatedly, a psychological system is created in which the goals and act of stereotyping become invisible to the person relying on the stereotype.
Explicit Bias
When a person holds a stereotype but is aware of it
Implicit Bias Really Happens
All physicians except African American MDs show higher implicit than explicit bias.
Female physicians on average have less implicit bias than male physicians.
If a physician has high implicit bias, he or she is less likely to treat Black patients presenting with an acute coronary syndrome.
Increased implicit biases predict poorer visit communication and poor rating for patient perceptions of care, especially among Black patients.
Higher physician IAT scores correlate with perception by Black patients of:
decreased respect for patient
decreased confidence in physician
decrease in patient-centered dialogue
Aversive racism causes the worst patient reactions
Aversive racism describes a person who has low explicit but high implicit biases
Aversive racism outcomes are worse even compared to people with high explicit and high implicit biases
Group settings such as multicultural education classes or conferences can be useful in reducing racial bias
Such settings should aim to:
Increase understanding of and reduce guilt associated with bias
A normal human phenomenon that isn't always bad
Enhance internal motivation, such as egalitarian goals
This can be done through guided reflection about the benefits of justice and fairness.
Include small-group discussions with a provocative reflection trigger to enhance engagement of participants
People tend to check out in small group discussions of difficult topics. Including a story or statement that evokes an emotional response helps to engage participants.
Educate about stereotype threat
The fear of confirming as a self-characteristic a negative stereotype about a group to which one belongs
reducingstereotypethreat.org
Independent education is also effective in reducing implicit bias
Develop egalitarian goals and associate minority groups with those goals
Help providers to better articulate their egalitarian goals.
Conclusion
While implicit biases on the part of physicians are deep-seated and difficult to address, they are wreaking havoc on minority patients and must be eliminated. This can be done through specific interventions based in sound scientific research
There is a documented association between implicit bias of physicians and poorer health outcomes for minority patients.
However, the effects of implicit bias at the health provider level can be reduced by specific interventions in group settings and on an individual basis.
Implicit Associations Test
The most widely-used method of assessing implicit biases is the Implicit Associations Test (IAT), which measures the reaction time when asking a participant to categorize a picture (such as that of the face of a Black or white person) into different categories (such as good or bad).
Panel headings refer to sections of the IAT
Discordance between actions associated with implicit and explicit biases is interpreted by patients as deceitfulness
The patient perceives implicit bias through non-verbal signals such as body posture and eye contact, or through tone of voice
Particularly detrimental to interracial interactions in which there is already a level of mistrust
Physicians with high ingroup favoritism are more mentally drained as a result of interracial encounters, no matter their race. This can cause physicians to be less likely to access explicitly-held egalitarian beliefs, which can cause implicit biases to dictate the behavior of the physician.
Even if a doctor has the conscious belief that all people are equal, when he or she is tired, subconscious (implicit) beliefs take control.
A doctor is more likely to become drained if he or she has high implicit bias in favor of their own race
Multiculturalism rather than color-blindness
A color-blind approach to inter-ethnic relations generates greater automatic racial bias compared to a multicultural approach
color-blindness: believing that race does not affect our interactions with others
multiculturalism: believing that there are racial differences, but we should celebrate the variety of experiences
Train physicians to recognize minority patients as opportunities to pursue their goals of helping others.
This will inhibit activation of negative stereotypes and encourage collection of more detailed, individualized information about the patient.

Use guided exercises in which the physician is instructed to associate minorities with positive attributes.
This counteracts negative stereotypes that may be held by the physician by making positive traits more accessible
Find common identity with the patient
Train physicians to ask questions about the patient’s social identities, interests, and activities that might be shared by the physician.
This helps to develop same-group sympathies, which inhibits stereotypes associated with the unshared identity.
Find counter-stereotypical information about the patient
This is difficult due to time restrictions but can be done through a detailed initial interview
Once again, this helps to break down any previously held negative stereotypes
Take the perspective of the minority patient
This can be done through guided exercises encouraging role-playing as minority patients by physicians.
Effective in increasing empathy in all situations, not only interracial physician-patient interactions
Betancourt, J. (2003). Defining Cultural Competence: A Practical Framework For Addressing Racial/Ethnic Disparities In Health And Health Care. Public Health Reports, 118(4), 293-302.
Blair, I., Steiner, J., & Havranek, E. (2011). Unconscious (Implicit) Bias and Health Disparities: Where Do We Go from Here? The Permanente Journal, 15(2), 71-78.
Burgess, D., Ryn, M., Dovidio, J., & Saha, S. (2007). Reducing Racial Bias Among Health Care Providers: Lessons From Social-Cognitive Psychology. Journal of General Internal Medicine,2007(22), 882-887.
Cooper, L., Roter, D., Carson, K., Beach, M., Sabin, J., Greenwald, A., & Inui, T. (2012). The Associations of Clinicians’ Implicit Attitudes About Race With Medical Visit Communication and Patient Ratings of Interpersonal Care. American Journal of Public Health, 102(5), 979-987.
Green, A., Carney, D., Pallin, D., Ngo, L., Raymond, K., Iezzoni, L., & Banaji, M. (2007). Implicit Bias among Physicians and its Prediction of Thrombolysis Decisions for Black and White Patients. Journal of General Internal Medicine, 1231-1238.
Haider, A., Sexton, J., Sriram, N., Cooper, L., Efron, D., Swoboda, S., . . . Cornwell, E. (2011). Association of Unconscious Race and Social Class Bias With Vignette-Based Clinical Assessments by Medical Students. JAMA: The Journal of the American Medical Association,306(9), 942-951.
Moskowitz, G. (2010). On The Control Over Stereotype Activation And Stereotype Inhibition.Social and Personality Psychology Compass, 4(2), 140-158.
Moskowitz, G., & Ignarri, C. (2009). Implicit Volition And Stereotype Control. European Review of Social Psychology, 20, 97-145.
Penner, L., Dovidio, J., West, T., Gaertner, S., Albrecht, T., Dailey, R., & Markova, T. (2010). Aversive racism and medical interactions with Black patients: A field study. Journal of Experimental Social Psychology, 46(2), 436-440.
Richeson, J., & Nussbaum, R. (2004). The Impact Of Multiculturalism Versus Color-blindness On Racial Bias. Journal of Experimental Social Psychology, 40, 417-423.
Richeson, J., Trawalter, S., & Shelton, J. (2005). African Americans' Implicit Racial Attitudes and the Depletion of Executive Function after Interracial Interactions. Social Cognition,23(4), 336-352.
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Sabin, J., Nosek, B., Greenwald, A., & Rivara, F. (2009). Physicians’ Implicit And Explicit Attitudes About Race By MD Race, Ethnicity, And Gender. Journal of Health Care for the Poor and Underserved, 20(3), 896-913.
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