Addressing Bias in Healthcare: Solutions for Racial and Ethnic Disparities
Many medical professionals have encountered explicit racial bias in healthcare and are committed to addressing it when they see it. However, implicit racial bias, which can linger below conscious awareness, is widespread, often unaccounted for, and just as dangerous, said physician leaders during a recent panel discussion hosted by TDC Group.
The expert panelists discussed strategies to combat racial and ethnic biases throughout our nation’s healthcare systems, outlining best practices for making healthcare safer by making it more equitable.
The panelists were Elizabeth A. Howell, MD, MPP, Harrison McCrea Dickson President’s Distinguished Professor and Chair of the Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania; Lakshmi Krishnan, MD, PhD, Internist and Cultural Historian of medicine at Georgetown University, where she is the Founding Director of the Medical Humanities Initiative; and Ronald Wyatt, MD, MHA, Senior Fellow at the Institute for Healthcare Improvement and Private Healthcare Consultant.
Rooting Out Explicit Racial Bias
“Racism is an independent risk factor for death of Black people in the United States,” said Dr. Wyatt, and explicit racial bias is still damaging care for BIPOC patients, Dr. Krishnan explained. Dr. Krishnan defined explicit bias as prejudice or discrimination on a conscious level, giving examples such as “openly racist or pejorative comments on ward rounds.”
Beyond individual interactions, explicit racial bias can also lurk in the corners of medical protocols. For example, Dr. Wyatt said, “Even today, I saw a news report that the FDA was now working towards what to do about how pulse oximeters are used in care of Black and brown patients,” because pulse oximeters may overstate blood oxygen levels in patients of color, a patient safety risk. Along these lines, Dr. Wyatt asked panelists to consider “so-called race correction in medicine” and to discuss “the role that race correction has played historically and continues to play in health and healthcare to this day” in their specialties.
In obstetrics, some legacy systems of race correction are now being dismantled, says Dr. Howell. She referenced a race-based protocol that “had different definitions for anemia in pregnancy for Black versus White women.” This “set up Black women to be much more likely to have lower hemoglobin when they come in for delivery,” which increased the odds that they would need a blood transfusion. This outdated protocol from the American College of Obstetricians and Gynecologists, based on findings from the nineteenth century, was recently retired as part of a collaborative commitment by dozens of organizations to reduce racism in healthcare. Initial findings indicate positive outcomes where institutions have adopted more equitable prescribing of iron during pregnancy, and clinicians at Dr. Howell’s Penn Medicine encourage other institutions to follow suit.
Increasing Awareness of Implicit Racial Bias
More subtle and more pervasive than explicit racial bias, Dr. Krishnan says, is implicit racial bias, “which we all carry. And it's a form of cognitive bias. It causes us to group things inaccurately and confirm stereotypes, even if we believe that we are being fair.” Implicit bias is often soaked up from surrounding cultural influences, and it often lingers below conscious awareness. This unconscious bias, though unintended, can be just as harmful to the recipient as conscious, explicit bias. Examples of implicit bias include “downgrading patient-reported symptoms, spending less time speaking with and gathering information from patients for whom English is a second language, or making linguistic assumptions,” Dr. Krishnan says.
Attacking the problem of implicit bias begins with admitting that, despite intentions to do better, “We are not immune from this,” Dr. Krishnan says, confirming that “healthcare workers, unfortunately, exhibit the same levels of implicit bias as the wider population. And it has real impacts on care.” Fortunately, research shows that awareness of implicit bias as a hidden cognitive error is the first step in overcoming it.
Standardizing Care Processes
With implicit bias invisible to many well-intentioned medical professionals, system-level interventions are needed. “One way to address clinician bias,” Dr. Krishnan says, “is standardized workflows and decision support that prompt clinicians to consider specific presentations.”
For example, care bundles cluster crucial evidence-based best practices for specific situations. One care bundle has been used to prevent central line–associated bloodstream infections. Another successful example is found in maternal healthcare, where Dr. Howell referenced “how important it is to have the hemorrhage bundle as part of ensuring that we're standardizing care on labor and delivery units.”
Providing Peer Support
Conversations with colleagues about the process of diagnosis can also protect against implicit bias, which, again, can impede the thinking even of medical professionals who are actively attempting to avoid bias. “When physicians receive treatment recommendations collaboratively through an information exchange and a peer network versus our standard process of solo, independent reflection, diagnostic accuracy and equity improve markedly,” Dr. Krishnan says.
The Society of Hospital Medicine recognizes reflection as one of the “5 Rs of Cultural Humility,” and collaborative conversation with peers may extend and enrich a clinician’s reflection, thus aiding in addressing cognitive biases.
Educating Clinicians Throughout Their Careers
Clinician education about bias should evolve “beyond cultural competency or one-off intercessions for trainees,” Dr. Krishnan says. Instead, “all of this needs to be baked into the health professions curricula.” Some leaders, like those at Penn Medicine, are initiating top-down improvements at their institutions. Meanwhile, ground-up interventions by early career medical professionals can also have an impact on medical school education. Students at Boston University School of Medicine, for instance, recently combed through materials from multiple medical schools to present a proposal for improvement at their own institution.
Such adaptations of medical school curricula are right in line with Dr. Krishnan’s thinking: “I'm an educator, so I'm always thinking about: How are we teaching premedical students? How are we teaching medical students? Because these are our future practitioners and leaders.”
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