How I Learned to Treat My Bias

The Washington Post Sunday - - Outlook -

At our hospi­tal in Ten­nessee not long ago, I saw my pic­ture on the hall­way mes­sage board along­side those of other doc­tors in a dis­play thank­ing us for our ser­vice. My Asian-In­dian com­plex­ion set me apart — it’s some­thing that I am rarely con­scious about in ev­ery­day life. It got me think­ing: When I walk into the room, do my pa­tients see me as a for­eigner?

Then I won­dered: When I walk into a room, how do I see my pa­tients?

For the next few days I ob­served my­self when­ever I en­tered a hospi­tal room to see a new pa­tient. To my sur­prise, I re­al­ized that in the ini­tial glance I viewed pa­tients as an “el­derly black man” or a “His­panic worker” — and all the bag­gage that comes with their race, gen­der and eth­nic­ity. My prej­u­dices had kicked in.

Un­for­tu­nately, the en­tire health sys­tem sees pa­tients by race, gen­der and eth­nic­ity, and it has a pro­found ef­fect on how care is de­liv­ered.

The In­sti­tute of Medicine in its 2002 re­port “Un­equal Treat­ment” cited some provoca­tive sta­tis­tics. Black pa­tients, for ex­am­ple, tend to re­ceive lower-qual­ity care for can­cer, heart dis­ease, HIV, di­a­betes and other ill­nesses. Black men are 40 per­cent more likely to die of can­cer than white men. Th­ese dif­fer­ences of­ten per­sist even af­ter ac­count­ing for age, sever­ity of ill­ness and de­lays in seek­ing treat­ment among dif­fer­ent groups.

How can this hap­pen in Amer­ica in 2007? It’s sim­ple. So­cial psy­chol­ogy shows that stereo­typ­ing is a uni­ver­sal hu­man men­tal func­tion. We use so­cial groups (race, sex and eth­nic­ity) to un­der­stand peo­ple — to gather or re­call in­for­ma­tion about peo­ple from our minds. The men­tal pro­cess­ing goes some­thing like this: When I en­ter the room in which a pa­tient is wait­ing for me, I do four things.

First, in the sec­onds be­fore our ini­tial greet­ing, I au­to­mat­i­cally and of­ten un­con­sciously ac­ti­vate my stereo­type. Thus, I as­sume a young His­panic man is likely to be an unin­sured con­struc­tion worker.

Sec­ond, even though I be­lieve that I do not judge peo­ple based on stereo­types, the data show it is very likely that I do. When I see an el­derly black wo­man I am more likely to ask her about church as a sup­port struc­ture than I am to ask a white man the same ques­tion be­cause I as­sume she is church­go­ing.

Third, af­ter the en­counter, my stereo­typ­ing af­fects how I re­call and process in­for­ma­tion. A white man com­plain­ing of pain re­ceives more at­ten­tion than a His­panic wo­man with the same com­plaint be­cause I stereo­type white men as be­ing more stoic.

(Re­mem­ber that stereo­typ­ing is dif­fer­ent from med­i­cal pro­fil­ing based on dis­ease epi­demi­ol­ogy. A young black wo­man with ane­mia is more likely to have sickle cell dis­ease than an el­derly white man is, based on bi­ol­ogy and racial back­ground.)

Fourth, my stereo­types prob­a­bly guide my ex­pec­ta­tions and han­dling of the pa­tient, re­sult­ing in a self-ful­fill­ing prophecy. An el­derly black man is un­likely to un­der­stand the de­tails of a di­ag­no­sis, I as­sume, so I spend less time ex­plain­ing his dis­ease and its con­se­quences. Ul­ti­mately, such a pa­tient is less in­formed about his ill­ness.

The most glar­ing re­sult of black-white in­equal­ity in health care was found in a 2005 study is­sued by for­mer sur­geon gen­eral David Satcher. He es­ti­mated that clos­ing the black-white mor­tal­ity gap would elim­i­nate more than 83,000 deaths per year among African Amer­i­cans.

It is painful to write th­ese things. As health-care work­ers we try to be un­bi­ased in our de­liv­ery of care.

Once I be­came aware of how I thought when I en­coun­tered pa­tients, I was able to start chang­ing. Though I ini­tially saw a pa­tient as an el­derly black wo­man, my forced re­flec­tion helped re­duce the stereo­type. As our con­ver­sa­tion de­vel­oped, the stereo­type melted away. I be­gan to see my pa­tient rather than his or her so­cial group.

I hope that pa­tients have done the same for me. I hope that they did not see me only as a brown for­eigner but rec­og­nized me as a doc­tor keen to be a part­ner in their health care.

As a so­ci­ety we can over­come prej­u­dices in health care by fac­ing our ten­dency to stereo­type. Medi­care and its con­trac­tors — qual­ity im­prove­ment or­ga­ni­za­tions — are train­ing doc­tors in a “cul­tural com­pe­tency” pro­gram in which they re­ceive free ed­u­ca­tional cred­its and be­come aware of bi­ases in care de­liv­ery and cul­tural per­cep­tion of ill­ness. (I am tak­ing the course.)

As for pa­tients, I have an­other sug­ges­tion. The next time you see a worker at a fast-food restau­rant, ask your­self: What stereo­types did your mind au­to­mat­i­cally ac­ti­vate?

Aware­ness is the first step to change. The writer is an in­fec­tious dis­ease physi­cian in Mem­phis and a med­i­cal di­rec­tor of Medi­care’s qual­ity im­prove­ment or­ga­ni­za­tions in Ten­nessee and Ge­or­gia.

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