By Annemarie Provencher, RN, CPHRM, HNC
Coverys is committed to addressing social injustices to help effect positive change and create a more diverse and inclusive society. to help effect positive change and create a more diverse and inclusive society. We recognize that healthcare providers are committed to these same ideals and strive to provide access to high-quality, inclusive care for the communities they serve. In order to advance the conversation, however, it is important for everyone involved in the delivery of healthcare to examine their own personal biases and understand how bias impacts patient care. We hope the following article will help initiate or continue conversations about bias and contribute toward meaningful change.
“im•plic•it bi•as /im `plisit `bīas/: The attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. Activated involuntarily, without awareness or intentional control. Can be either positive or negative. Everyone is susceptible.”1
Healthcare providers are devoted to the well-being of others and strive to treat all patients equally, as respected individuals. Yet despite a clinician’s aspiration to provide equitable care, the Institute of Medicine (IoM) suggests that “bias, prejudice and stereotyping on the part of healthcare providers may contribute to differences in care.”2 All of us are susceptible to bias, including healthcare providers and their patients. While healthcare providers undoubtedly hold themselves to a higher standard, studies show they exhibit implicit bias at the same level as the general population.3 Patients may also bring their biases to the healthcare encounter. In the same way that implicit bias unconsciously shapes our attitudes, it can unwittingly influence our behaviors, communication skills, and clinical decision-making. Whether on the part of the healthcare provider or the patient, bias can negatively impact the provider-patient relationship and the quality of care.5
Specific patient groups receive a significantly lower standard of care and have higher rates of complications, morbidity, and mortality as a result of provider bias. Patients most at risk for facing some sort of implicit bias include those who are obese, mentally ill, non-English speaking, non-heterosexual or gender nonconforming, or those who have a history of drug addiction or have low intelligence. Bias has also been found to be attributed to patients at lesser frequencies based on gender, advanced age, nonwhite race, attractiveness, and income level.4
Bias in the healthcare encounter can manifest itself verbally and nonverbally. Examples of nonverbal bias cues may include reluctance to touch or be close to a particular person, nervous or tense facial features, poor eye contact, headshakes, eye rolling, and shortened encounters. Implicit bias can also reveal itself through verbal expression, such as an increased rate of speech, dominant vocal tone, or noninformative conversation. In particular, the provider’s overuse of closed-ended questions can make it difficult for some patients to process and comprehend information and can “shut down” information flow from the patient and ultimately limit the provider’s ability to gather the information necessary to make sound clinical decisions. Evidence of implicit bias can even be found in medical record documentation where it can quickly spread to other healthcare providers and negatively impact the quality of care delivered to the patient.5
While these microagressions may be subtle, patients notice them. In addition to engendering a feeling of stigmatization, they can increase a patient’s chronic psychological stress and allostatic load, which contributes to poor health outcomes. “Allostatic load,” a term coined in 1993 by McEwen and Stellar, is the “wear and tear on the body” that accumulates as an individual is exposed to repeated chronic stress. The body responds to stressors through the allostasis process, which releases chemical messengers such as cortisol, noradrenalin, and epinephrine to help adapt to the stressor. Over time, the allostatic overload that results when these acute responses are overused or inefficiently mediated can accelerate the progression or development of atherosclerosis, cardiovascular disease, stroke, abdominal obesity, immunosuppression, and mood and anxiety disorders.6
Implicit provider bias is often observed in connection with physician attitudes toward obese patients and can negatively impact the medical encounter in several ways. Expressions of implicit bias during the healthcare encounter, such as a wince or “tsk” when taking the patient’s weight, may cause patients to feel disrespected, inadequate, shamed, or unwelcome. These negative experiences can adversely impact compliance and cause patients to delay seeking future needed care. Providers who treat obese patients may spend less time with them during the patient encounter and may allocate less time during that encounter to educating these patients about their health. Providers may also “over attribute” symptoms to obesity and fail to refer the patient for diagnostic testing or to consider treatment options beyond advising the patient to lose weight, which may result in misdiagnosis.7 In the end, these bias-related impacts can result in fewer referrals to specialists, poorer pain management, and greater delays in treatment.
Implicit biases are more likely to surface when providers are experiencing stress or burnout—common occurrences in the healthcare setting. When providers are stressed, fatigued, or operating with a high cognitive load, they are less effective at processing new information and more likely to rely on implicit associations.8 Physician burnout, which has been defined as a “loss of enthusiasm for work, feeling of cynicism and a low sense of personal accomplishment,” can also be associated with bias. A 2016 Medscape survey revealed that 55% of physicians who were experiencing burnout also reported holding biases.9 Regardless of whether biases are triggered by stress, fatigue, cognitive load, or burnout, the result is the same—medical decision-making and physician interpersonal behavior are negatively impacted.
Implicit biases are hard wired. They develop over time based on life experiences and exposure to news, social media, and the opinions of friends and family. Bias can unknowingly and unintentionally influence physician judgment and patient relations. Consider the following strategies to counter bias and minimize its impact on patient care:
- Develop self-awareness. Increase awareness of your own biases by conducting a self-analysis, using tools such as:
- Provide training. Provide cultural competency education and training for all physicians and staff, including support staff (e.g., receptionists, medical technicians). A good place to start is National Culturally and Linguistically Appropriate Services (CLAS) Standards.
- Encourage case discussion. Consider implementing implicit bias/health equity rounds by developing an interdisciplinary platform to discuss cases in which bias may have altered patient care. Implicit bias rounds can complement existing morbidity and mortality (M & M) rounds or exist as a standalone initiative offering a safe forum for discussion.
- Implement interventions. Implement mindfulness-based interventions, such as exercises that focus on paying attention to process details of clinical care, increasing adherence to practicing evidence-based medicine, being present in the moment, and actively renewing a nonjudgmental approach. Studies suggest that mindfulness practice may enhance provider-patient relationships, medical decision-making, quality, patient safety, and provider well-being, as well as alleviate burnout.10
- Practice empathy. Embrace patient centeredness and individuality. Practice techniques that foster empathy by increasing self-awareness, enhancing listening skills, and encouraging respect and tolerance for the patient as an individual rather than as part of a racial or social group.
- Implement culturally competent communication techniques. Elicit patient information through culturally competent and comprehensive interviewing skills. Use communication techniques such as asking open-ended questions and linguistics devices known as “continuers” to draw out the patient’s concern.
- Respond to bias triggers. Recognize and mitigate or avoid situations that might amplify bias, such as fatigue, stress, cognitive overload, or provider burnout.
Implicit bias can negatively impact the physician-patient relationship, affect whether patients return for care or comply with treatment recommendations, and unintentionally influence care outcomes. Implementing strategies to counter implicit bias can promote the establishment of successful physician-patient relationships and support quality care, and also may help decrease medical malpractice risks.
No legal or medical advice intended. This post includes general risk management guidelines. Such materials are for informational purposes only and may not reflect the most current legal or medical developments. These informational materials are not intended, and must not be taken, as legal or medical advice on any particular set of facts or circumstances.
1. Staats C, Capatosto K, Tenney L, Mamo S. State of the science: implicit bias review 2017 edition. The Ohio State University Kirwan Institute for the Study of Race and Ethnicity. http://kirwaninstitute.osu.edu/wp-content/uploads/2017/11/2017-SOTS-final-draft-02.pdf
2. Institute of Medicine. Unequal treatment: what healthcare providers need to know about racial and ethnic disparities in healthcare. Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. March 2002.
3. FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Medical Ethics. 2017;18:19.
4. Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health. 2015;105(12):e60-e76.
5. Goddu AP, O’Conor K, Lanzkron S. Do words Matter? Stigmatizing language and transmission of bias in the healthcare record. J Gen Intern Med. 2018;33 (5):685-691.
6. McEwen BS. Protective and damaging effects of stress mediators. N Engl J Med. 1998;338;171-179.
7. Phelan SM, Burgess DJ, Yeazel MW, et al. Impact of weight bias and stigma on quality of care and outcomes for patients with obesity. Obes Rev. 2015;16(4):319-328.
8. Burgess DJ. Are providers more likely to contribute to healthcare disparities under high levels of cognitive load? How features of the healthcare setting may lead to biases in medical decision making. Med Decis Mak. 2010;30(2):246-257.
9. Peckman C. Lifestyle report 2017: Race and ethnicity, bias and burnout. Medscape. January 11, 2017. https://www.medscape.com/features/slideshow/lifestyle/2017/overview. Accessed April 10, 2019.
10. Fortney L, Luchterhand C, Zakletskaia L, et.al. Abbreviated mindfulness intervention for job satisfaction, quality of life, and compassion in primary care clinicians: a pilot study. Ann Fam Med. 2013;11(5): 412-420.