By Emily Margosian, assistant editor

“Of all forms of inequality, injustice in health care is the most shocking and inhuman,” remarked Martin Luther King, Jr., at the National Convention of the Medical Committee for Human Rights in 1966. More than 50 years later, the impact of implicit bias on patient care has become part of an ongoing national discussion about the pernicious effects of negative stereotyping in a diversifying United States. However, in contrast to deliberate racism, sexism, ageism, or other forms of discrimination, implicit bias is both unconscious and automatic. “These biases are deeply ingrained in our inner psyche, and it causes us to relate to people in different ways,” explains Amit Pandya, MD, past chair of the AAD’s Diversity Task Force. While physicians may view themselves as more impervious to bias than most due to the altruistic nature of their profession, research suggests that not only is bias in health care widespread, it is also having a significant impact on patient care. Dermatology World consults with physician experts both within and outside the specialty to discuss:

• Common sources of physician bias

• Care disparities created by unconscious bias

• Solutions for reducing bias within dermatology

How does bias manifest in patient care?

The effects of implicit bias can take many forms during the average physician-patient encounter, often favoring one’s own social group. “If you’re a man, for example, you may be less comfortable interacting with women; if you’re white, you might have a bias that favors white patients as opposed to those who are black, Hispanic, or Asian,” says Dr. Pandya. “I make a point to always stop myself when I’m making a diagnosis or treatment plan and ask: Would I do this for any patient, regardless of what type of person is in front of me?”

Due to the unconscious nature of implicit bias, physicians may be inclined to alter treatment recommendations or prescription habits based on what they perceive as a patient’s ability to comply. However, this perception may actually be derived from incorrect stereotypes about that patient’s age, gender, race, or socioeconomic group. “Implicit biases explain a potential dissociation between what a person explicitly believes and wants to do (e.g. treat everyone equally) and the hidden influence of negative implicit associations on her thoughts and action (e.g. perceiving a black patient is less competent and thus deciding not to prescribe the patient a medication),” explains a 2017 BMC Medical Ethics article (doi: 10.1186/s12910-017-0179-8).

Beyond differences in clinical decision-making, incorrect perceptions about patients can result in strained physician-patient communication, and ultimately result in disparities in quality of care. “From a health care standpoint, studies have shown over and over again that we treat patients differently based on the color of their skin, their weight, or their sexuality,” says René Salazar, MD, assistant dean for diversity and professor of internal medicine at Dell Medical School at the University of Texas at Austin. “We’ve spent more than two decades now pouring lots of money into health disparities research, but where we haven’t really moved the needle nearly as much as we should is motivating physicians to be more aware of this.”

While physicians are more likely to self-identify biases against patients with perceived low intelligence or those who are overweight (see sidebar for more on dermatology’s top biases), overall, race and socioeconomic status emerge as main predictors of worse health outcomes in the United States.

Race

“As far as implicit bias in health care, we all know that it exists and that it does negatively affect the care patients get,” says Valerie Callender, MD, medical director of Callender Dermatology and Cosmetic Center, and current member of the AAD Board of Directors. “Often the literature describes disparities in care between African-American and Caucasian patients, in which African-American patients receive poorer care as a result of stereotypes that they are either poor, can’t afford the medication, or can’t understand instructions.”

Additionally, a physician’s body language or non-verbal cues during an appointment with a patient of a different race may cause a communication breakdown that ultimately results in poor treatment outcomes. “For black patients, there is often a feeling of disrespect, or that they aren’t heard,” says Dr. Salazar. “If we’re interacting in a way that’s a little bit standoffish — I’m crossing my arms, or the way I’m interacting is less engaging — it can have a huge impact on the patient-physician relationship. How likely will it be that you’ll come back and see me? Or that you’re going to follow-through with the treatment I’ve prescribed you?”

Unconscious racial bias has also had a well-documented impact on physician prescription habits, particularly in regard to analgesics. A 2007 study found that physicians were twice as likely to underestimate pain in black patients compared to all other ethnicities combined (J Natl Med Assoc. 2007;99(5):532-538), and another more recent study investigating emergency room opioid prescriptions identified being of a non-white race as the number one predictor of provider mistrust (doi: 10.1371/journal.pone.0159224).

Assuming providers are acting unconsciously, where do these racial biases stem from? Subtle, everyday reinforcement from media, friends, family, and cultural and political institutions may be to blame. “We may consciously reject negative images and ideas associated with disadvantaged groups (and may belong to these groups ourselves), but we have all been immersed in cultures where these groups are constantly depicted in stereotyped and pejorative ways,” notes the BMC Medical Ethics piece (doi: 10.1186/s12910-017-0179-8). Dr. Salazar agrees that unconscious bias is often reinforced by an environmental feedback loop that physicians are not unaffected by. “I’ve been in rooms where you hear these messages on TV — black men depicted as thugs for wearing a hoodie, whereas a white boy who rapes a woman is in a suit and tie. It’s powerful how these images reinforce our stereotypes,” he says.

While long-term solutions for racial bias in health care are likely to be as complex as its cause, Dr. Pandya recommends dermatologists start by simply considering each patient in front of them as an individual. “You can’t make any assumptions about their likes, dislikes, dietary preferences, ability to speak English, ability to understand what you’re prescribing for them, or the products typically used in their culture — based on their ethnic background,” he says. “You can make some serious blunders, and that person may not come back and see you as a result.”

Socioeconomic class

While often linked to race and geographic location, a patient’s perceived socioeconomic class can also generate a range of biased reactions from the physicians they are seeking care from. “When I was at UCSF taking care of our Medi-Cal patients — which is the Medicaid equivalent in California — I would catch myself looking at the sticker, and as soon as I’d see Medi-Cal, my mind would start going a certain place, and I’d have to stop myself from going there,” says Dr. Salazar. “Absolutely socioeconomics, as well as language — and the assumptions made about them — can have a remarkable impact on how these biases play out in our interactions.”

Biased assumptions about what a patient’s insurance type dictates — inability to pay, non-compliance, or no-showing — can have implications beyond a visibly checked-out physician and a failed clinical encounter, with potential public health ramifications. A 2014 study found that an overwhelming 80% of patients with public insurance reported stigmatizing experiences in encounters with providers and the health care system, leaving them with unmet health needs and less likely to seek out care in the future (Milbank Q. 2014;92(2):289-318).

“A lot of times you may make assumptions based on someone’s speech, vocabulary, or appearance, and conclude that they’re very low on the socioeconomic scale and perhaps treat them a different way,” says Dr. Pandya. “I’ve personally volunteered at a free clinic for the past 16 years, and recommend that the average dermatologist who perhaps struggles with this may consider doing a mission trip or start volunteering at a free clinic one Saturday a month. That has helped me a lot in better understanding the people who are poor in our world.”

Recognizing and counteracting bias

Given the negative and well-documented effects of unconscious bias on patient care, what can dermatologists do to reduce its impact within the specialty? First steps include:

Notice your assumptions.

Start by becoming aware of what accents, specific items of clothing, or hairstyles are potentially triggering an unfavorable assumption about a particular person. Not sure what they are? Take a test. While there are several Implicit Association Tests (IATs) available online, Dr. Pandya recommends Harvard’s free Project Implicit questionnaire: https://implicit.harvard.edu/implicit/education.html. “After taking it, I found out that I have some bias against a racial group that I was unaware of,” he says. “I went on to read some books that discuss what it’s like to grow up as a person from that background. Once I had a better understanding of what it’s like to live in this country as a member of that group, it gave me greater insight that reduced my discomfort, and hopefully reduced my implicit bias.”

Dermatologists may want to consider staff bias training as well, suggests Seemal R. Desai, MD, president of the Skin of Color Society and a member of the AAD Board of Directors. “All employees — from the nursing staff to the front office — need to have at least some awareness of different patient backgrounds to make them feel as comfortable as possible,” said Dr. Desai. “I think it’s especially important in dermatology, because so much of what we do involves a great deal of the patient’s privacy, for either a medical or even cosmetic skin exam.”

Take steps to mitigate burnout.

Burnout among physicians is on the rise, and dermatology is no exception. In addition to negatively affecting physician health and well-being, research also suggests that physicians’ implicit bias can increase under conditions of stress. A 2016 study in Academic Emergency Medicine found evidence that cognitive stressors, such as increased patient load, can result in greater instances of implicit racial bias (2016;23(3):297-305).  

Feeling burned out?
Check out Dermatology World’s award-winning feature story “Feeling the burn” at staging.aad.org/dw/monthly/2017/september/feeling-the-burn to learn what you can do to avoid it — or recover.

Foster diversity.

“As the U.S. population becomes more diverse, so must our specialty,” said Henry Lim, MD, former president of the AAD and chair emeritus of the Henry Ford Hospital department of dermatology, in his November 2017 DW From the President column. Indeed, as dermatology’s patient population keeps pace with the nation’s changing demographics, cultural representation — and competency — among the physician workforce will be increasingly crucial, suggests Dr. Desai. “By 2020, more than 50% of the population will be skin of color, and we really need to have a workforce that reflects the patients we’re treating,” he says. “If you know you have a practice that cares for patients of different backgrounds, see if you have staff who can relate to that background. Is there an employee on your team who speaks Spanish? I myself speak Hindi and other Indian dialects, which is helpful for patients. If a patient is comfortable, that’s when we often get the best history and avoid having a communication issue that could ultimately affect a treatment outcome.”

While Dr. Callender agrees that looking to the future is an important step, she also advocates for the value of bias awareness and education for those currently in practice. “I think this could be tackled on the state level by requiring some form of bias training that includes cultural competency in order to get your state license renewed,” she suggests. “As a specialty, I think we should have CME devoted to this topic to make sure that we are treating all patients equally.”

Overall, “I think it’s important that you take the opportunity to make sure patients understand that you’re really there caring for them,” said Dr. Desai. “It can be as simple as teaching your dermatology colleagues to be more aware of bias. Hopefully, in the next few years we’ll start to see more and more dermatologists and fellows more knowledgeable about this issue.”