By LaTonya B. Washington, MD

We are living in trying times.  COVID-19 and racial injustices have us facing two pandemics.  Throughout this time of social distancing and isolation, Americans have slowed down enough to recognize and feel the disparities that have long existed in our society.  COVID-19 didn’t create social disparities, but it certainly unmasked them revealing the disproportionate effects on persons of color.  The killings of George Floyd and Breonna Taylor were not the first instances of social injustice, but yet another example of the diminished value of Black lives in this country.  The commonality of bias plays a part in both of these pandemics.

Bias is simply defined as a prejudice in favor of or against one thing, person, or group compared with another.  Explicit biases are biases we are aware of on a conscious level while implicit bias refers to attitudes or stereotypes that affect our understanding, actions, and decision in an unconscious manner. Everyone contributes and is influenced by bias in the healthcare system including physicians, nurses, hospitals and health systems, managed care plans, and governmental entities. Based on this overwhelming reach, it is easy to see that bias can shorten and diminish the quality of life for persons of color and other disadvantaged people groups.

This history of bias against persons of color in the healthcare system in the United States traces back to the days of slavery.  Slaves of African descent were considered inferior and often unable to obtain medical care unless sought by their owners.  When medical care was provided, it was most often for the purpose of maintaining the integrity of the physical ability to work or for childbirth lending to furthering the workforce and property ownership since the children of slaves were considered property.  During the days of Jim Crow, hospitals and health systems were segregated with ill-equipped hospitals and wards for Black patients leading to increased morbidity and mortality as compared to Whites.  The history of unconsented medical experimentation contributes to implicit biases and distrust held by patients of racial and ethnic minority groups against the medical community.  The most well known is the Tuskegee Study of Untreated Syphilis in the Negro Male.   This study denied study subjects, all Black men of which two-thirds had known syphilis, treatment with penicillin despite it being identified as the treatment of choice in 1945 leading to the spread of disease, severe complications due to untreated syphilis, and death.  Another well-known instance of unconsenting subjects involves gynecological surgeries performed without anesthesia on enslaved Black women by the “father of modern gynecology”, Dr. J Marion Sims, who was widely celebrated for his contributions to medicine with endowed chairmanships and statues that were recently removed in 2018. 

Implicit bias stems from one’s personal knowledge of a people group influenced by one’s upbringing, exposures, media, and societal messaging.  These influences trigger stereotypes and biased perceptions and influence decisions and conduct.  Often persons of color are associated with criminality, animals, drug use/abuse, and hypersexuality.  These stereotypes influence decision-makers in public policy and health policy. 

These biases translate to healthcare delivery as well. For healthcare professionals, these unconscious beliefs lead to forming opinions prior to seeing or physically interacting with patients.  It can lead to leading providers diminishing symptoms, missing diagnoses, and potentially withholding complex medical information due to concern for the patient’s inability to understand the gravity of their medical condition.

Implicit biases aren’t just an issue in the delivery of care, many medical students and residents report instances of bias involving admittance to medical school and during training via comments from professors, attendings, ancillary staff, and other students or medical trainees.

Patients can be the perpetrators of and can be affected by these prejudices. Patients who perceive bias from their health care providers are unlikely to have healthy relationships with their physicians and nursing staff.  This may lead to the patient withholding pertinent information from the history leading to missed or delayed diagnoses and also to the patient being distrustful of the medical directives leading to nonadherence to the prescribed treatment plan. Patients often display racial and ethnic biases regarding the intellectual stature of training of the physician and whether the physician was trained in the US or abroad. Furthermore, some Black patients hold anti-Black physician biases due to the feelings that White physicians deliver better care influenced by the “White is right” principle.  As a recipient of both explicit and implicit bias from patients of various racial and ethnic groups, it’s important to identify and manage these actions appropriately such that they don’t impact the care provided to the patient.

Identifying bias is paramount to improving healthcare delivery for persons of color and other disadvantaged people groups.  The Implicit Association Test (IAT) is the tool of choice for neuroscientists and social psychologists to measure unconscious attitudes.  Testing to evaluate implicit bias in race, ethnicity, skin tone, sexuality, gender, religion, age, and disability are available on Harvard’s Project Implicit website.  Research using IAT demonstrated startling results showing pro-White and anti-Black selections when determining who is prosecuted in the criminal justice system, who is selected for a jury, hiring and promotion decisions, and which misbehaving students are disciplined in schools. Implicit biases affect behaviors and can affect a physician’s conduct towards patients including therapies delivered and care offered. Published studies have shown that implicit bias affects the pain assessment and management in Black patients due to the belief that Black patients experience less pain.  Furthermore, a recently published study supports physician and patient racial concordance was associated with significant improvement in mortality for Black infants with increased benefits in centers with challenging births and those hospitals delivering more Black infants.  

Bias definitely affects many aspects of healthcare delivery.  It’s important that both patients and providers work to manage and eliminate stereotypes and barriers to ensure the interactions are meaningful and productive to deliver efficient and effective care with improved outcomes for disparate people groups. 


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