Significant gaps in health outcomes by race, gender, and ethnicity persist. These health disparities are troubling to confront because they suggest some form of inequality in healthcare. For example, in the United States, compared with whites, black women have significantly higher rates of maternal mortality and black men have higher rates of prostate cancer mortality. The reasons for the disparity are multifactorial, but they can be broadly characterized by influences related to the patient, the healthcare system, and the larger society.
Examining the problem at the level of an individual patient illustrates how the various influences may interfere with high-quality care. For example, one patient may not receive preventive colon cancer screening because of his or her autonomous choice to decline the recommended procedure as part of an informed consent discussion. Another patient, however, might not receive this cancer screening because his healthcare provider was less likely to recommend it to some of his patients. Finally, larger social determinants of health, like low literacy or poverty, may interfere with another patient obtaining such appropriate care. In reality, these factors probably combine with one another in many patients. Regardless of the relative contribution of the patient, healthcare system, or society to health disparities, there is value in understanding specifically how the healthcare system and the physicians that practice within it may contribute (even inadvertently) to such disparities.
From an ethics perspective, physicians have obligations to promote high-quality care, reduce healthcare disparities, and to ensure they provide equal treatment to all of their patients. The AMA Code of Ethics specifies this responsibility in 1 of its 9 principles of medical ethics: A physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.
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One way that physicians may be contributing to the perpetuation of healthcare disparities is through implicit or unconscious bias. Implicit bias (IB) in healthcare is unconscious, unacknowledged thoughts and feelings that may interfere with fair, objective evaluations of different groups of people.1 This type of thinking is automatic, often culturally conditioned, and separate from rational thought processes. IB is distinguished from explicit bias or explicit prejudice in that IB is often contrary to one’s personal stated beliefs. For example, explicit bias is believing and taking a position that women are less competent than men in leadership positions. IB is an unconscious and unacknowledged attitude about women’s’ diminished competence in leadership positions but which is at odds with one’s explicit beliefs in gender equality. To the object of the bias, the explicit/implicit distinction is less important – bias or prejudice is always disrespectful regardless of whether the person is conscious of it or not. However, IB may be more amenable to change than explicit bias.
There is strong evidence for the presence of IB among healthcare professionals. Using the Implicit Association Test, which measures unconscious implicit preferences, physicians demonstrate IB in their thinking in numerous contexts. In these studies, primarily using hypothetical scenarios, white physicians demonstrate a pro-white bias in providing more guideline-concurrent care to white patients over other racial minorities.2,3 Similar implicit biases have been demonstrated towards obese patients compared to those with normal weight and towards women compared with men.4,5 How exactly IB leads to health disparities is less clearly established and is an active area of research. Researchers believe that if IB leads to biased physician recommendations or to less positive, trustful clinical interactions with patients (which could reduce patient adherence), these could both lead to worse health outcomes for the biased populations.6
What then should physicians do to address IB? Because all physicians are susceptible to unconscious associations (in some cases, even physicians who are members of the biased group7), the first and most critical step is to recognize that IB can interfere with good clinical judgment. Indeed, “simply knowing about a stereotype distorts processing of information about individuals.”1 Physician should accept that IB is an occupational hazard and not a moral failing or simply a way of assigning blame for health disparities. Second, slowing down the clinical reasoning process can allow for better appreciation of a patient’s perspective and individualizing patient care.8 This can be challenging in a fast-paced clinical environment, but also because “pattern recognition” is such a central part of clinical reasoning. Experienced clinicians are skilled because they recognize how certain clinical and epidemiologic patterns occur together and fit classic disease archetypes. When this automatic type of thinking relies on negative stereotypes, however, it puts clinicians at risk for IB.
Simply relying on physicians’ ethical and professional commitments to treat all patients equally is therefore not likely to stop IB. Like all other people, physicians are susceptible to negative stereotypes because they are also products of a culture and societal implicit messages that can sometimes trade on pejorative beliefs. These unconscious associations may be even harder to overcome in the setting of time pressures, fatigue, and information overload.
Despite the challenges, righting health disparities is the responsibility of all healthcare professionals. Even when the reasons for such disparities are multifactorial, healthcare professionals should minimize their contribution, whatever they might be. Seeking healthcare should not make some patients more vulnerable. That is something we should all get behind.
David J. Alfandre MD, MSPH, is a healthcare ethicist for the National Center for Ethics in Health Care (NCEHC) at the Department of Veterans Affairs (VA) and an Associate Professor in the Department of Medicine and the Department of Population Health at the NYU School of Medicine in New York. The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the NCEHC or the VA.
References
- Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. J Gen Intern Med. 2013;28:1504-1510.
- Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22:1231-1238.
- Weitzman S, Cooper L, Chambless L, et al. Gender, racial, and geographic differences in the performance of cardiac diagnostic and therapeutic procedures for hospitalized acute myocardial infarction in four states. Am J Cardiol. 1997;79:722-726.
- Borkhoff C, Hawker GA, Kreder HJ, et al. The effect of patients’ sex on physicians’ recommendations for total knee arthroplasty. CMAJ. 2008;178:681-687.
- Schwartz MB, Chambliss HO, Brownell KD, et al. Weight bias among health professionals specializing in obesity. Obes Res. 2003:11:1033-1039.
- Zestcott CA, Blair IV, Stone J. Examining the presence, consequences, and reduction of implicit bias in health care: a narrative review. Group Process Intergroup Relat. 2016;19: 528-542.
- Sabin J, Nosek BA, Greenwald A, Rivara FP. Physicians’ implicit and explicit attitudes about race by MD race, ethnicity, and gender. J Health Care Poor Underserved. 2009;20:896-913.
- Burgess DJ, FU SS, van Ryn M. Why do providers contribute to disparities and what can be done about it? J Gen Intern Med. 2004;19:1154-1159.
