COVID-19 Racial Disparities in Healthcare: Implicit Bias
July 7, 2020
“It’s Time To Address The Role Of Implicit Bias Within Health Care Delivery"
A January 15, 2020, article in the Health Affairs Blog provides a perfect segue as our conversation turns to Implicit Bias , its impact on health outcomes, and its role in perpetuating racial disparities.
Below are key excerpts. You may read the entire article by clicking on its title above.
"After many decades of study and exposition in the medical and sociological literature, policy makers and health care providers have finally turned their attention to social determinants of health (SDoH) and their effects on health outcomes. This is a welcome development. It brings needed focus on social and economic factors that play a vital role in how people live, both within and outside the health care system."
"In addition to the long overdue focus on SDoH, there is another uncomfortable truth about the scope of bias within the health care system—about the uneven access, poor quality, and at times nonexistent care experienced by racial minorities. This truth was documented by the National Academy of Medicine in a groundbreaking 2002 report, which made clear that medical care can exacerbate the impact of social factors outside the health care system that lead to poor health, contributing to even worse outcomes and experiences by minority patients. Yet, since this report, we have not realized major improvements that address disparities or improve health equity at scale."
"We are concerned that whether the discussion is framed around health disparities, health equity, or SDoH, there is a supposition that social issues exist outside of health care or are hoisted onto the health care delivery system. Often missing from today’s discourse is the fact that individuals and communities interacting with the health care system are subjected to disparate treatment at the hands of clinicians. The popular press has made this point, with particular focus on disparities in maternal and child health that have led to persistent and devastating outcomes for black women and babies. Journalists have dealt head-on with the impact of bias, racism, and discrimination in and out of the health care system, noting for example that black women in the highest education, income, and wealth groups have worse outcomes than white women on the lowest end of the socioeconomic strata."
"Medicine and health care act as if we have no role in producing or promulgating health disparities but instead are simply responding to them. There may be a certain comfort for medicine in this approach. SDoH are “external” to the health environment and reflect broader social factors that largely shield the health care delivery system from direct accountability. Much of the discussion on SDoH addresses individual socioeconomic issues that are amenable to policy solutions: transportation options to ease access to medical care, housing supports to address homelessness, or prescriptions for food (akin to medical prescriptions). And, indeed, these interventions address key factors that lead to poor health outcomes, even in the face of adequate medical interventions. Implicit bias, by contrast, is "internally" driven and must be addressed by the delivery system. Acknowledging that interactions within the health care system can drive poor outcomes is no easy task and far less amenable to point solutions."
“It’s Time To Address The Role Of Implicit Bias Within Health Care Delivery, " Health Affairs Blog, January 15, 2020.
Dayna Bowen Matthew, lawyer and leader in public health who focuses on racial disparities in health care, joined the University of Virginia Law School faculty in 2017. She is the author of the book “Just Medicine: A Cure for Racial Inequality in American Health Care.” (3:05)
" Our continued failure to fashion an effective response that purges the effects of implicit bias from American health care, Matthew argues, is unjust and morally untenable. In this book, she unites medical, neuroscience, psychology, and sociology research on implicit bias and health disparities with her own expertise in civil rights and constitutional law. In a time when the health of the entire nation is at risk, it is essential to confront the issues keeping the health care system from providing equal treatment to all." ...NYU Press, publisher
Two noted physicians talk about the effect of racism — both conscious and unconscious — on quality of care for people of color.
David R. Williams, MD, MPH, Professor of Public Health at the Harvard T.H. Chan School of Public Health, has been researching health inequities in the United States for two decades. In an 8-part series on health equity, he sits down with Don Berwick, MD, President Emeritus and Senior Fellow at IHI and former administrator of the Centers for Medicare and Medicaid Services, to talk about health equity and why it’s important. Part 3, Does Racism Play a Part in Health Inequities? (6:40) and Part 4, How Can Providers Reduce Unconscious Bias? (4:33) help us to further understand the role of implicit bias in the deliver of healthcare.
For more about bias, go to Black Voices and view Dr. Damon Tweedy's interview on the PBS News Hour and Stanford professor Jennifer Eberhardt's June 4, 2020, TED Talk.
Hidden in Plain Sight — Reconsidering the Use of Race Correction in Clinical Algorithms
June 17, 2020
Darshali A. Vyas, M.D., Leo G. Eisenstein, M.D., and David S. Jones, M.D., Ph.D.
Personal Stories: How bias looks and feels from the point of view of both a patient and an insightful physician.
"Racist Like Me -- A Call to Self-Reflection and Action for White Physicians" Deborah Cohan, M.D., M.P.H.
New England Journal of Medicine, Feb 28, 2019
Medical Education: The problem or the solution?
MIssingBullsEye-NEJM.pdf"How Medical Education Is Missing the Bull's-eye," LaShyra Nolen, B.S. New England Journal of Medicine, June 25, 2020.
Ghosts collective subconscious.pdf"Ghosts of Our Collective Subconscious -- What Blackface in a Yearbook Photo Means for Medical Education," Dereck W. Paul, Jr., M.S. New England Journal of Medicine, August 1, 2019.
Additional Context and Related Material
Interested in Checking Your Own Implicit Associations?
"Project Implicit is a non-profit organization and international collaboration between researchers who are interested in implicit social cognition - thoughts and feelings outside of conscious awareness and control. The goal of the organization is to educate the public about hidden biases and to provide a “virtual laboratory” for collecting data on the Internet."
"The Implicit Association Test (IAT) measures attitudes and beliefs that people may be unwilling or unable to report. The IAT may be especially interesting if it shows that you have an implicit attitude that you did not know about. For example, you may believe that women and men should be equally associated with science, but your automatic associations could show that you (like many others) associate men with science more than you associate women with science."
The degree that this test can predict behavior is unclear; it is important to recognize its limitations and criticisms that have been raised. Notwithstanding its limitations, however, none of its critics refute the existence of unconscious bias and that it can influence life experiences.
Take the test if you like. Its purpose for this group is merely to offer the Project Implicit's feedback as an opportunity for self-reflection.
Scroll to the bottom of the document on the right to proceed with the test. Select RACE from the list of tests you are offered.
Additional Material Added After the Meeting
After our session, Ruth Kandell shared links to an informative Lown Institute Hospitals Index that ranks hospitals not only on how they serve their patients but also how they serve their community. Find general information about the index below, with Boston rankings listed on the left.
