Physicians need to acknowledge implicit bias

By | January 29, 2020

“Oh, you’re here to take me to my test.”  I have heard this too many times to count, and I have come to perfect my response. “No, I am not patient transport, your social worker, or your nurse. I am your doctor.” After a moment of confusion, I usually see a facial expression signaling that the patient is reframing his or her initial thoughts. Maybe I am misidentified because I am young, or black, or female. No matter the reason, I get annoyed instantly every time this happens.  Do patients have some preconceived notion about who I am? I always conclude my internal dialogue wondering, “Will they trust me?”

In sharing these experiences, I feel that women, especially minority women, deal with this more than other physicians. Although this issue may seem insignificant to some, continually having to define your role drains morale and can erode confidence. In spite of my white coat and MD,  patients mistake me for everything BUT a doctor. I have joked that, even if I tattooed MD on my forehead, there would still be misperceptions about my position. All kidding aside, the repeated misunderstanding about women being physicians speaks to the strength of implicit bias in medicine.

Implicit bias stems from our past experiences and stereotypes. It is an unconscious process that allows our brains to make automatic associations based on initial yet superficial qualities. Basically, implicit bias is one way our brain sifts through the information constantly bombarding us.  Patients may be more at risk of relying on automatic, unconscious associations when they are stressed or sick. Yet, I have often wondered, do these interactions affect patient care?

So if you find yourself annoyed by repeatedly stating, “I am your doctor,” here are a few things to consider:

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Implicit bias is strong

Physicians’ implicit bias toward patients is commonly discussed. Yet we aren’t taught how to deal with being on the receiving end of bias. Nonetheless, the “hidden curriculum” during medical school and residency has provided models of how to navigate these situations. What I have found most helpful is to quickly establish common humanity with patients. By sharing small aspects of my story, I can help people disassociate from their previous biases.  Giving patients the opportunity to reconstruct their thoughts about who I am, and hopefully, establish a trusting and therapeutic relationship.

Confronting bias is important

I would be debt-free if I had $ 10 every time a nurse asked for orders from my six-foot plus, usually white, male medical students in their short white coats. We all have biases about the type of person we look to for help.

During my second year of residency, I worked with an amazing female fellow in the ICU who helped me find my voice in high-stakes situations. She encouraged me to correct people when they were looking to the wrong members of the team for orders or guidance. She taught me something important at that moment — you have to confront bias head-on.

Acknowledgment is key

As I mentioned above, confronting bias provides an opportunity for people to reconstruct their initial associations. This confrontation can be tricky, though, when a patient is involved. What is the appropriate way to “check” your patient? I think most of us already do this in a proper manner: We politely correct patients (no matter how many times it takes). Is it hard to repeatedly define your role? Absolutely! Yet this is why I think acknowledgement of the bias against you as a physician is very important.

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Physicians need to acknowledge to their team that they are being bombarded by waves of implicit bias.  Because I just can’t believe that this doesn’t affect us. When this happens to me, I conscientiously tell my team about the interaction. I do this not to make people feel uncomfortable, but to make sure I am scrutinizing my own bias so as not to affect patient care.

Implicit bias is everywhere

We are all guilty of making quick associations, especially in high-stakes situations. It is important to make patients feel comfortable, but there isn’t anything wrong with clarifying and re-clarifying your role. Most importantly, we should all try our best to support each other during these situations. Be open to the fact that some colleagues might need to air their frustrations as a way to manage their own bias toward patients. Acknowledging our human flaws and supporting each other really is what’s best for our patients and for us.

Cassandra Fritz is an internal medicine chief resident who blogs at Insights on Residency Training, a part of NEJM Journal Watch.

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