Reducing Implicit Bias in the Clinical Setting

Educational Objectives

The goal of this program is to improve the care of patients of diverse backgrounds. After hearing and assimilating this program, the clinician will better be able to:

1. Describe the neural networks that are involved in the activation of bias.
2. Implement personal and systemic practices to reduce the incidence of implicit bias.

Summary

Disparities in clinical practice: a study using data from the Medical Expenditure Panel Survey from 2006 to 2013 showed that black and Hispanic patients were, respectively, 30% and 40% less likely to have access to an outpatient neurologist and had more emergency department (ED) and inpatient admissions than non-Hispanic white patients

Bias: explicit bias is a conscious belief; implicit bias is subconscious; a bias may be in favor of or against a particular group or individual

Neuroanatomy of bias: complex neural circuitry is activated by perception-based input (eg, faces, clothing, demeanor) and knowledge-based input (eg, social status, occupation); perception-based input — involves the amygdala, dorsolateral prefrontal cortex (controls executive function), and dorsal anterior cingulate cortex; knowledge-based input — involves a broader network that includes the amygdala, ventral medial prefrontal cortex, and ventral striatum

Factors that affect activation of bias-related neural networks: characteristics of the perceiver; prior experiences with other individuals or groups (can diminish perception-based activation of the amygdala); internal motivation to appear unbiased (people who lack motivation to fight against their biases will have less activation of these neural networks); power differentials (individuals in high-power positions often display more implicit racial bias)

Manifestations of implicit bias: implicit bias often manifests during busy situations that require multitasking or unfamiliar experiences or encounters (when pattern recognition and automaticity are used frequently)

Factors that affect equitable access to care: many factors other than race and ethnicity are involved

English proficiency: a study that evaluated the effect of English proficiency on ED visits and readmission within 30 days showed that patients with limited English proficiency had a higher risk for return with chronic obstructive pulmonary disease and heart failure but not with pneumonia or hip fracture (less complex conditions); disparities involving ethnicity and limited English proficiency are often related to poor or minimal use of medical interpreters

Sexual orientation and gender identity: 2015 United States Transgender Survey — of >27,000 transgender individuals surveyed, 33% of those who had seen a primary care provider in the previous year reported ≥1 negative experience when accessing health care, 31% reported that none of their health care providers knew they were transgender, and 23% reported delaying or avoiding care out of fear of mistreatment or discrimination; relevance of sexual health and gender identity to neurologic care — transgender women taking gender-affirming hormones have an increased risk for stroke and of developing multiple sclerosis; hormones also can interact with antiepileptic drugs and may affect other hormone-responsive conditions

Interventions to reduce implicit bias

Identify one’s biases: identify any subconscious biases using an implicit association test (available online)

Challenge automaticity: in fast-paced situations, use data-driven rather than gut-based decision making; monitor outcomes to ensure decisions make sense and to identify whether different treatments are being offered to different groups

Challenge stereotypes: practice individuation with each patient to learn about the patient’s life, fears, expectations, and needs; diversify intergroup experiences to help understand different perspectives

Use inclusive language: ask patients their preferred name and ensure that name is recorded in their chart and electronic health record; use gender-neutral terminology until patients provide their preferred term; ask generally about family, spouses, or significant others and then use the specific term provided by patients

Use interpreters: confirm each patient’s preferred language for communication; always offer patients an interpreter in a way that does not make them feel uncomfortable in accepting the offer; best practices for using a medical interpreter include speaking slowly and clearly, allowing the interpreter to translate as one goes along, and using verbal and nonverbal communication to signal that there will be a long block of speaking; in teaching settings, always ask patients if they are comfortable with English being spoken to the trainees

Understand patient perceptions: learning how patients feel about their symptoms, how they function outside the clinic setting, and how their symptoms are affecting their life helps for building rapport, appropriate counseling, and ongoing management

Recognize nonverbal communication: this includes items visible in clinical spaces (eg, posters, television screens), intake forms (eg, gender and language options), interpersonal interactions (eg, nonthreatening physical positioning, open body language), and clothing (eg, the white coat is often viewed as a sign of power)

Confirm the patient’s understanding: when counseling patients, ask what they know about their condition and medications; correct misconceptions and gauge patients’ understanding by asking them to explain back what they have heard

Review written communication: documentation can communicate bias; in a study in which medical records were presented using either neutral language (eg, requires opiate medications) or stigmatizing language (eg, narcotic dependent), stigmatizing language resulted in trainee physicians showing less positive attitudes toward the patient and prescribing less aggressive pain management (despite being unblinded to group randomization)

Readings

Chen MY et al: Multiple brain networks contribute to the acquisition of bias in perceptual decision-making. Front Neurosci. 2015;9:63; Goddu AP et al: Do words matter? Stigmatizing language and the transmission of bias in the medical record [published correction appears in J Gen Intern Med. 2019 Jan;34(1):164]. J Gen Intern Med. 2018;33(5):685-691; FitzGerald C et al: Interventions designed to reduce implicit prejudices and implicit stereotypes in real world contexts: a systematic review. BMC Psychol. 2019;7(1):29. Published 2019 May 16. doi:10.1186/s40359-019-0299-7; Juckett G, Unger K: Appropriate use of medical interpreters. Am Fam Physician. 2014;90(7):476-480; Karliner LS et al: Do professional interpreters improve clinical care for patients with limited English proficiency? A systematic review of the literature. Health Serv Res. 2007;42(2):727-754; Rawal S et al: Association between limited English proficiency and revisits and readmissions after hospitalization for patients with acute and chronic conditions in Toronto, Ontario, Canada. JAMA. 2019;322(16):1605–1607.

Disclosures

Members of the faculty and planning committee reported nothing to disclose.

Acknowledgements

Dr. Rasool and Dr. Rosendale were recorded at the 53rd Annual Recent Advances in Neurology, held February 12-14, 2020, in San Francisco, CA, and presented by the University of California, San Francisco, School of Medicine. For information on future CME activities from this sponsor, please visit meded.ucsf.edu. The Audio Digest Foundation thanks the speakers and the University of California, San Francisco, School of Medicine, for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

NE111802

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

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