Mask Off: Under the Guise of Implicit Bias by Aida Alazar

Understanding etymology is helpful in medicine. “Genu” and “corpus” are Latin for knee and body, respectively. “Hippos” is Greek for “horse” and “kampos” for “sea monster.” (Can you tell I am in a brain sciences block?)

Now, let us understand the meaning of one of medicine’s most provocative topics: implicit bias. “Implicit” signifies that bias is implied, but not expressed, and that bias is natural or essential to something perhaps more insidious. Secondly, bias is “with no qualification or question; absolute.” So how do we teach medical students about biases that affect patient care when they are in fact assumed and unquestionable?

Medical schools are beginning to stress the importance of understanding implicit bias, using tools such as the Implicit Association Test (IAT) to screen for implicit racial bias. Research shows that medical students leave their institutions after four years with more biases favoring white people and fewer favoring black people. Even in the emergency department, where we anticipate less discretion and an urgent objective to save, there is a persistent anti-black bias among doctors and nurses. When it comes to pain management, studies have long shown that black patients are under-treated for pain compared to white patients.

The doctors leading implicit bias research and teaching my class at the time presented their findings as an exercise for us with two vignettes. Take a patient that is brought into the ER with drowsiness and a drunken gait. You find that they have a high blood alcohol level, administer IV fluids and allow them to rest. This patient also reeks of alcohol and like they haven’t showered in days. Their clothes are torn and dirty, their face unkempt. A few hours of rest and bags of saline later, the patient is conscious and reports that they are in their normal state of health. You dismiss them that same night and open up the patient bed for your next emergency.

A week goes by and a new patient is brought to your ER with drowsiness and drunken gait. You administer the same treatment clinically as the first case, and wait a few hours for the patient to come to. You notice this patient is dressed in a suit and clean-shaven. When they wake up, you learn that the patient is an alumnus from your university, works the same finance job as your brother-in-law, and had one too many drinks at the bar last night. They also wanted to avoid a family brunch at their in-laws the next morning, so you offer this patient a room overnight and suggest monitoring until the next morning.

These two cases and outcomes really happened for one physician, who confessed that he had connected with the second patient, related to his story and sympathized with the guy. When he thought back to the first case, though, he knew that such an explicit difference in treatment cost more for the hospital with an unnecessary overnight and, more importantly, was driven by bias. This individual’s preferential treatment was undoubtedly influenced by more than appearance (i.e. partiality toward education and employment, weighing a breach in hospital policy, etc.). Still, deconstructing the biases affecting patient care is the intent of implicit bias pedagogy in medicine.

So how exactly can we “fix” this bias? One solution posed by his team is cultural competency training for staff — for example, if a patient does not speak English, train more translators to speak Spanish. But how do you become culturally competent about patients who present with the chief complaint of homelessness? Or when they speak a language other than Spanish or English? Or when their problem is not within the scope of a differential diagnosis? Will our profession allow for comprehensive training on the structural causes of homelessness and racism? The way medical students are being taught implicit bias today lacks the perspective of the historical contributions of institutionalized, sociopolitical marginalization on health.

I admire the efforts of physicians and other professionals researching implicit bias in practice and offering solutions. But I challenge all of us to reconsider what implicit bias is. The category of implicit racial bias is not as simple as associating white faces with rainbows and black faces with snakes, as screening for implicit racial bias with the IAT might suggest. Training physicians in cultural competency does not equip them to know the legacy of centuries of social and economic oppression that manifest as healthcare inequalities.

Research illustrates that medical students believe black patients experience less pain physiologically than white patients. What is missing from such studies of bias is an understanding of the causative agent. This is where the IAT falls short, as implicit biases do not ultimately determine actions (i.e. anti-black bias does not always indicate fewer analgesic prescriptions for black patients). Though tempting, implicit bias does not always explain the explicit differences in treatment. Rather, explicit differences in treatment historically contribute to our biases in both cognition and action. The legacy of plantation medicine, whereby white doctors in the antebellum South documented and dictated that black slaves had thicker skin and therefore a higher threshold for pain than whites, is the missing link explaining our shortcomings in research. Anecdotal evidence from tour guides on former plantations in the South and literature from physicians in the nineteenth century reveal the truth: socially upheld biases declaring explicit difference pervade two hundred years later, snaking into institutions and praxis under the guise of implicit bias.

Provider actions that perpetuate healthcare disparities and disfavor patients of color is neither new nor natural. Our understanding of implicit bias as “implied,” “assumed” and in the “nature or essence of something though not revealed, expressed, or developed,” is inadequate. Racial biases are highly questionable; so can we call them implicit? Evidence of unconscious biases should not stand isolated from their tangible roots. Rather than reifying socially upheld beliefs by naturalization, exposing students to articles and case studies of the policies and punishments that instated racism, homelessness and other forms of marginalization in America may actually guide providers toward social justice.

Restructuring of curriculum for medical students and even residency training should seek to uncover the ways in which biases develop. Efforts to address biases in healthcare are shifting away from cultural competency and toward structural competency and provider reflection. What would happen if we exposed students to a structurally competent curriculum that interrogated the role of race in institutions that create bias? Focusing our education toward structurally competent and historically-relevant lessons in healthcare can dismantle biased systems. I urge anyone considering how to address biases that are related to health disparities and social determinants to consider the institutionalized forms of explicit bias that slip in beneath white coats.

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