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Tuesday Nov 08, 2016

Don't Let Implicit Bias Shape Physician Workforce -- or Patient Care

We medical students consume a lot of information on a daily basis. From memorizing blood supply and innervation patterns to practicing physical exam techniques, our minds are constantly consolidating large volumes of information.

On top of studying, we engage in social activities and cultivate relationships with friends and family. That's quite a bit to process, and like anyone else, our brains process stimuli both consciously and unconsciously. This means that we internalize subtle messages over time that we may or may not be aware of, and as a result, we develop unconscious preferences -- or biases -- that ultimately influence our judgment. We don't knowingly choose these preferences, but we can become aware of them and, in response, strive to balance our decision-making.

So, why is it important for me, a future physician, to understand the implications of unconscious bias?

It is essential to understand how this phenomenon may be affecting our future physician workforce, as well as our patients. The effects of unconscious, or implicit, bias are present well before medical school begins. As it turns out, many medical school applicants may be affected by the unconscious preferences of admissions committee members each year, especially during the interview process.

The Ohio State University College of Medicine decided to investigate to what extent implicit racial bias was present among its admissions committee members. Participants took a computer-based racial implicit association test, which identifies unconscious biases based on rapid associations of black and white faces with positive and negative words. The results, which were recently published in Academic Medicine, revealed significant levels of implicit white preference among all subgroups within the admissions committee -- men, women, students and faculty.

Beyond the generally accepted notion that racial bias is inherently problematic, we should appreciate why unconscious white preference is particularly significant in medical education. According to 2015-2016 data from the Association of American Medical Colleges (AAMC), about 6 percent of medical students identify as black, compared to 13 percent of the general U.S. population. Similarly, those who identify as Hispanic or Latino comprise about 5 percent of medical students, yet they make up nearly 18 percent of the greater population. American Indians and Alaska Natives are also notably underrepresented among medical students.

These medical student demographics will translate into physician demographics, and we have begun to recognize that diversity in the workforce actually impacts the quality of care that patients receive. A report from the AAMC on workforce diversity indicates that medical students from underrepresented racial and ethnic backgrounds are ultimately more likely to practice medicine in underserved communities and are more likely to choose a primary care specialty.

It has also been documented that patients who have a physician of the same race experience higher patient satisfaction, and treatment adherence may increase when physicians and their patients speak the same language. In light of persistent health disparities among racial minorities and the growing shortage of primary care physicians in the United States, these are noteworthy benefits that warrant a concerted effort to achieve greater diversity among those matriculating into medical school.

Medical students, physicians and other health care professionals are all susceptible to making decisions influenced by unconscious biases. The effects likely permeate all corners of health care, and several studies have highlighted how this phenomenon can lead to health disparities.

It has been well documented, for example, that racial disparities exist in the context of pain management, with black patients being less likely to receive opioid analgesics in an emergency care setting than white patients with the same recorded severity of pain. Other studies have demonstrated medical students and residents actually reporting lower pain severity for black versus white patients who were presenting with the same chief complaint or diagnosis.

Because of their unconscious nature, implicit biases are difficult to recognize, and consequently, it can be challenging to come to grips with them. It takes courage to talk about them, and to move forward, we must eliminate the stigma of recognizing and discussing our personal biases. It is important to remember that unconscious bias is not a reflection of character, but rather a manifestation of educational, familial and societal messages that we process during our lifespan. Only when we are aware of our unconscious biases can we make a concerted effort to make balanced, compassionate decisions.

So, how did participants in the Ohio State study respond after receiving their results? Many admissions committee members said they were mindful of their individual results when interviewing medical school applicants the following year, and one in five reported that knowledge of their result actually impacted their admissions decisions. Consequently, the following year's class was the school's most diverse ever.

As long as we commit to expressing compassion for ourselves and for our colleagues, reflection and adequate education on unconscious bias can be positive, transformative tools in medical education.

Explore your own implicit biases. The results may (or may not) surprise you.

Lauren Abdul-Majeed is the student member of the AAFP Board of Directors.

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