By Javeed Sukhera, MD
After a recent consultation, my patient’s father, a fellow physician, asked me to re-evaluate my recommendations. While I had considered all appropriate practice guidelines and research on the topic, there was an almost obsessive inner monologue that somehow prompted me to reconsider. After all, here was a physician with a young child asking me to change my opinion; I might do the same in a similar situation. I began to wonder, how would I have responded to a parent who wasn’t a doctor—who perhaps had less education or hailed from a different socio-economic condition? Would I have been as likely to acquiesce to that parent’s wishes and reconsider my recommendation?
Much has been written about unconscious bias and its implications for health care organizations. At a recent plenary session at the Association of American Medical Colleges annual meeting, psychologist Mahzarin Banaji, PhD, spoke about her research, which is detailed in the book, Blindspot: Hidden Biases of Good People. While there is a wealth of data that reinforces the hypothesis that we are indeed biased individuals, there is more emerging research that examines the implications of our unintentional biases on medical decisions and adverse patient outcomes.
Fortunately, accreditation standards in medical education are recognizing the importance of educating future physicians about bias. The Liaison Committee for Medical Education standard ED-22 states, “Medical students in a medical education program must learn to recognize and appropriately address gender and cultural biases in themselves, in others, and in the process of health care delivery.” Canadian accrediting bodies are emphasizing the importance of “social accountability,” shifting the culture of medical education. Hopefully, health care accreditation systems will utilize their leverage to push for similar situations in care delivery organizations.
As a child and adolescent psychiatrist, I am particularly fascinated by the implications of unintentional bias on the medical care of psychiatrically ill patients. I see the unintended consequences of mental illness stigma almost daily, particularly in settings such as the emergency department. Well-meaning colleagues have considerable difficulty addressing psychosocial complexity, leading to a high frequency of psychiatric consults. Nursing staff often will spend far more time and attention on pediatric patients who need a dressing change then those who are in emotional distress. I observe the phenomenon in some of the warmest, most caring individuals I work with. They provide excellent care to most patients—unless the patient is attached to a history of psychiatric illness.
I clearly remember the first day of our psychiatric clerkship during my third year of medical school. After a tour of the local psychiatric hospital, a stand-alone facility built on the periphery of the city, I realized that I had never seen my classmates sanitize their hands as vigorously as they did at that moment. There was no infectious disease outbreak in the psychiatric hospital. Unfortunately, the perception among all of us, myself included, was that psychiatric patients were somehow unclean.
This observation appears to be consistent with data on medical student biases. During a pilot study I am conducting, 45.5 percent of third-year medical students rotating in psychiatry demonstrated an implicit bias that mentally ill patients were more dangerous than physically ill patients. Thirty percent of students felt that their results on the implicit association test were unexpected.
There is much research that demonstrates the negative effects of mental illness stigma; I wonder what literature on unconscious bias can bring to the topic. Perhaps the most salient impact relates to the “kick-back effect.” Studies show that merely protesting against stigma actually has the potential to increase rebound behaviors that increase bias. Although I observe mental illness stigma on an almost daily basis in my clinical work, merely calling it out would lead my colleagues to become more defensive and less open to change.
If we are to address the negative effects of stigma on patient care and outcomes, we cannot merely confront it. As Howard Ross, chief learning officer at Cook Ross and author of Everyday Bias suggests, confrontation sets up an “us versus them” dynamic that can perpetuate the problem. Rather than calling out others for their biases and ignoring our own, Ross challenges us to ask ourselves, “What’s my bias?” He advocates for a systematic approach to addressing bias that includes education about positive and negative effects of bias in health care, and advocates for engaging in conscious processing, exploring the uncertain, and addressing bias at all levels within an organization to shift culture toward inclusiveness and equity.
Javeed Sukhera, MD, is the Academic Director of Global Health Curriculum and Assistant Professor at the Schulich School of Medicine and Dentistry at Western University in Ontario, Canada. He can be reached at firstname.lastname@example.org.