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Unconscious Bias: How Does It Affect Patient Care?


By Bernard L. Lopez, MD

Women have a higher rate of missed myocardial infarction (MI). Black patients wait longer to receive care in the emergency department for chest pain. Transgender patients get asked questions about their orientation that have nothing to do with their clinical condition. A Latino woman does not get adequate pain medication because she is being “dramatic.” A female physician’s opinion is dismissed by her male colleagues. An older physician views residents as being “lazy” because they get to limit their work hours. Male physicians get paid more and achieve leadership positions more so than females.

Bernard L. Lopez, MD, MS, CPE, FACEP, FAAEM, is the professor and vice chair of the Department of Emergency Medicine at Thomas Jefferson University Hospital, where he also serves as associate provost for diversity and inclusion and associate dean for diversity and community engagement for the Sidney Kimmel Medical College.

You’ve heard about these issues before and seen the research behind these disparities. None of this is intentional. We are in medicine to help people stay well and get better. We are fair and rational. Yet somehow, these disparities continue to happen and are a part of our daily lives. While the causes for these disparities are multifactorial, unconscious bias no doubt plays a big role.

Bias is a tendency or an inclination that results in judgment without question. In its most extreme, negative form, it is a prejudice against someone who is not like us that results in some harm to the “other.” It can also be positive. In reality, bias serves two purposes — it helps us to function on a daily basis and, most importantly, it serves to protect us from harm. 

Think about it — you are walking on the street at night in an unfamiliar area. Just ahead, you see the shadow of a figure walking toward you and see a glint of light off of a long, pointy object in what looks like that figure’s hand. What do most of us instinctively do? We quickly move away from the figure. Why? Because most of us have developed a strong bias against strange and unknown figures holding presumably sharp objects that may cause us harm. 

While the figure may not be a true threat, our bias causes us to instantaneously perform certain protective actions. It is unlikely that we would approach the figure, do a careful and detailed assessment, review a long list of potential actions, and choose our option — we may not be alive if we did so. The seemingly threatening stimulus travels to the brain stem and mid-brain and causes us to react. We focus on the task at hand to assure a quick response.

Each of us is a unique individual with our own individual experiences and education (both formal and informal) — these can be described as our “book of rules.” Our “schema” is our way of systematically organizing these rules. Together, these form the background — the lens — through which we view the world. We are constantly experiencing rules, reshaping our schema, and changing our backgrounds on a minute-by-minute basis throughout our lives. Background is context, and context is the lens through which we view the world.

These are our biases. Biases — we all have them. Race. Sexual orientation. Religion. Age. Hand dominance. Weight. Height. Accent. Appearance. And more. We cannot help having biases — it is a part of who we are.

The effect of unconscious bias is physiologic. A stimulus — a person, interaction, or circumstance — travels through our biased “lens” to the amygdala. A signal is sent to the brain stem and the limbic system, which then stimulates our hippocampus.

The cingulate gyrus causes our body to respond — you slam on the brakes with the threat of a collision, or you say or do something in response to a statement — all in the blink of an eye. Our cerebral cortex — the thinking portion of our brain — has not been involved as all of this happens in our unconsciousness. Given the millions of stimuli that we experience in the course of our day, we would not be able to function without these quick reactions.  

We cannot help but have biases. It is part of what makes us human. It is not an excuse — we must be aware of them and work with them. The lives of our patients are affected by bias, both conscious and unconscious. It is especially important that we consider our own biases as they will affect how we view and treat the most important people that we encounter — our patients.

Our biases play an unconscious role in how we interpret important clues in the history and physical exam of a patient. If your unconscious bias is such that you downplay certain aspects, this has the potential to negatively affect patient care — missed MI, reduced analgesic treatment, longer wait times, and so on. It also affects the lives of those we work with, affecting the patient care environment.

What Can We Do? 5 Ways to Address Unconscious Bias

  1. First, recognize and accept that you have bias. We all have them — Remember that they help us to function and serve to protect us, and that is a necessary part of who we are as humans.
  2. Reflect on your biases — Develop the capacity to shine the light on yourself. Research has demonstrated that a larger bias blind spot (the ability to "rationally" explain away our biases) is greater in those with higher cognitive ability (us), so recognize our tendency to do so. Realize that this is not easy to deal with (it requires more energy to use our cerebrum than our midbrain and brain stem) and comes with uncertainty.
  3. Explore the awkwardness and discomfort that comes along with examining your biases and how it affects your daily interactions.
  4. Engage with people that you consider "others" — Learn and gain experience from them.
  5. Finally, get feedback — Ask someone you trust, "How did I do?" This is how we learned our profession — We became educated, sought guidance and feedback, and practiced it over and over.

Bias is part of what makes us human, and it helps us to function. It is okay that we have them, but it is not an excuse. We must be aware of them and work with them. The lives of our patients depend on it.


Note: A version of this article appeared in the spring/summer 2017 issue of Pennsylvania Physician Magazine and was reprinted with permission.

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