Background:

In recent years, public health incidents such as the ongoing coronavirus pandemic (Covid-19) and the more recent monkeypox outbreak have highlighted the significance of recognizing and addressing systemic inequalities in healthcare. This includes the presence of implicit bias among medical professionals, which puts marginalized groups at a disadvantage in regards to seeking medical treatment. While impartiality towards patients is a core principle of health care ethics, it is evident that there is a discrepancy between this standard and the extent to which medical professionals adhere to it. In a study investigating implicit stereotypes in medical decisions, Moskowitz, Stone, and Childs (2012) found that when primed with a black face, doctors reacted more quickly for stereotypical diseases such as drug abuse, HIV, hypertension, obesity, sarcoidosis, sickle cell anemia, and stroke.

This indicates that similar to the wider population, healthcare professionals are also susceptible to unconscious biases, which can influence clinical judgment and behavior. These biases can have adverse effects on the quality of patient care because a doctor may apply a racial stereotype to a patient without thoroughly examining the individual's medical history. (FitzGerald and Hurst 2017)

As a result, BIPOC patients may experience delays in diagnosis and treatment, which can damage the relationship between patients and healthcare providers. This makes patients less likely to adhere to medical advice, resulting in increased healthcare costs, lack of improvement, and worsening health conditions. To fulfill the goal of delivering impartial patient care, medical professionals must examine the role of individuals and organizations in propagating implicit bias.

Sources of Bias:

In order to develop bias reduction strategies, we must identify the sources of implicit bias in medical education. Joseph et al. (2021) states that in medical education settings, bias can originate from four groups: peer-to-peer interactions, educators, clinical placements, and learning environments. These factors can influence how medical professionals interact with patients and peers within educational and clinical settings. Not only does implicit bias harm patients, but it also hinders career advancement opportunities for students and professionals from racial and ethnic minority groups.

Students, educators, and professionals all exhibit unconscious biases that are maintained or exacerbated during their education and career training. This can result in negative attitudes and behaviors towards patients, medical students, and other professionals from underrepresented groups. One literature review found that “healthcare educators’ personal biases have been shown to be enacted in various ways including lecture materials, clinical assessments, recommendation letters, and award systems.” (Joseph et al. 2021, 6) This demonstrates that an educator’s personal biases can interfere with student learning.

Similarly, van Ryn et al. (2015) found that medical students exhibit higher levels of implicit bias after hearing negative comments about black patients from residents and senior staff during their clinical placements. This indicates that medical students, educators, and professionals all play a role in propagating physician bias, therefore it is crucial for individuals and organizations to actively seek ways to challenge biases and stereotypes in health care. Additionally, the misrepresentation of race within preclinical curricula can also lead to misconceptions about racial differences and reinforce negative stereotypes.

Presenting racial and ethnic differences in disease burden without contextualization causes students to place an undue importance on biological differences while overlooking the various social and structural determinants of health. For example, Amutah et al. (2021, 874) states that “students are primed to view sickle cell disease as affecting only Black people, rather than as common in populations at risk for malaria.” As a result, a physician may overlook this condition as a diagnosis for nonblack patients such as Mediterranean individuals, leading to delays in diagnosis and treatment. Furthermore, inaccurate interpretations of race may lead to the use of race-based clinical guidelines, which are inaccurate and possibly harmful.

A good example of this is the upwards adjustment made when estimating glomerular filtration rate (GFR) of Black patients, which raises the threshold of concern only for them. According to Amutah et al. (2021, 875), “A patient with one Black parent and one White parent and whose creatinine level is 2.8 mg per deciliter would have an estimated GFR of 18 ml per minute per 1.73 m2 if identified as White and 21 ml per minute per 1.73 m2 if identified as Black. As a White patient, she would qualify to be added to the waiting list for a kidney transplant, but as a Black patient she would not...” This illustrates how race-based clinical guidelines can delay treatment for some individuals, further contributing to disparities in health care. Because of this, it is also important to consider the role of medical schools in perpetuating physician bias.

Policies and Recommendations:

Currently, several states including California, Maryland, Michigan, and Washington have adopted policies requiring healthcare workers to undergo implicit bias training, and others such as Indiana, Nebraska, New York, Oklahoma, South Carolina, Tennessee, and Vermont are advocating for it within their state legislatures (Ollove, 2022). However, decreasing bias through a single-faceted solution is difficult since bias is a complicated and multi-faceted problem. While implementing implicit bias training programs might be able to reduce bias on an individual level, it fails to address the structural and organizational flaws that contribute to disparities in the healthcare system. A strategy to counter implicit bias requires organizations to make meaningful changes at structural and institutional levels in addition to implicit bias training.

I. Commitment to Diversity and Inclusion:

It is important to note that strategies to combat implicit bias must go in tandem with strategies to increase diversity, inclusion, and equity. A diverse workforce will be more prepared to serve a diverse group of patients. Medical schools should demonstrate their commitment to inclusivity by developing strategies to reduce bias within student admissions and evaluations. One potential strategy would be having admissions committee members take the Implicit-association test (IAT) before reviewing applications or interview candidates, which would allow them to be more aware of their unconscious biases.

Another option would be to appoint women, minorities, and junior medical professionals to admissions communities, which would bring in different perspectives and backgrounds. Medical schools can also incorporate mentorship programs for racial and ethnic minority students, who may lack role models in their respective fields. These strategies can also be applied by other organizations to employee recruitment, training, promotion, and retention (Marcelin et al., 2019).

II. Curriculum Reforms:

Similarly, medical schools must develop a commitment to auditing current practices and processes to identify and eliminate biased language, ideology, and misrepresentations of race. This can be done by standardizing the language that is used to describe race and ethnicity. The National Academy of Medicine recommends “using a combined question to capture the social categories of race/ethnicity and using a set of granular categories (e.g., country of origin) to approximate ancestry” (Amutah et al., 2021, p. 873). In addition, the medical school curriculum must appropriately contextualize racial/ethnic differences in disease burden, as opposed to solely linking them to race or ethnicity. Finally, board examinations such as the USMLE should be reformed to avoid testing students on race-based clinical guidelines and racial heuristics.

III. Implicit Bias Training:

Health care professionals should be required to undergo implicit bias training as a part of their required continuing medical education (CME), because our understanding of cultural barriers is constantly growing and evolving. These programs should facilitate open discussions while allowing individuals to reflect on their personal biases. For example, an implicit bias training program could follow the structure of Balint groups (where medical professionals would meet regularly to discuss clinical cases) while implementing various single interventions such as experience, reflection, discussion, simulation. This will result in the participants having increased knowledge, understanding, and awareness of equity issues. It will also allow them to form positive connections with individuals from different backgrounds which can counter negative stereotypes and biases.

IV. Enforcing Accountability

Finally, organizations can implement transparent reporting systems for students, employees, and patients to report experiences of bias. A good example of this is the bias reporting tool created by UW Medicine, which allows "anyone who experiences or witnesses healthcare discrimination, microaggression or harassment to report it. In addition to evaluating and referring reports for follow-up, UW Medicine issues a report that describes the type of incident and the groups involved, such as patients, caregivers, staff, visitors and others - with the goal of targeting areas that need improvement." (Sharon Salyer 2022) By implementing a self-reporting system, organizations can hold individuals accountable for their behavior and evaluate the effectiveness of their initiatives.

Conclusion

Implicit biases are pervasive within healthcare and disproportionately affect marginalized groups. They may delay diagnosis and treatment in patients, making them less likely to adhere to medical advice or return for further treatment. Biases can also hinder career opportunities for minority students and medical professionals. Both individuals and organizations play a role in propagating implicit biases within educational and clinical settings. As a result, in order to counter implicit biases, we must make changes at structural and institutional levels along with implementing implicit bias training.

Works Cited

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Citation

MLA: Pham, Anna. “Addressing Racial Disparities in Healthcare.” Institute for Youth in Policy, Institute for Youth in Policy, 20 Sept. 2022, https://cite.yipinstitute.org/1yfwmMW.

APA: Pham, A. (2022, September 20). Addressing Racial Disparities in Healthcare. Institute for Youth in Policy. Retrieved from https://cite.yipinstitute.org/1yfwmMW

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Acknowledgement

The Institute for Youth in Policy would like to thank Marielle DeVos, Paul Kramer, Riya Kataria, Lilly Kurtz, and other contributors for developing and maintaining the Programming Department within the Institute. This capstone was awarded the "Oustanding Capstone" title in Fall 2022.