Unconscious Bias Requires Concentration, Consistent Effort from Providers
Racial disparities in the delivery of hospice and palliative care have been well documented,1,2 as have efforts to overcome them3,4, including AAHPM’s Diversity & Inclusion Committee (see sidebar on page 20). But the problems underlying care inequities may go deeper than many AAHPM professionals appreciate.
Diane Finnerty, assistant provost for faculty at the University of Iowa, gave an eye-opening presentation on the impact of unconscious bias at the recent Annual Assembly in Chicago in March. Also called implicit, hidden, or cognitive bias, unconscious bias reflects attitudes that the individual may not even be aware of but that influence the care professionals provide.
Finnerty, who pursues issues of gender equality and antiracism in her academic and community work, reviewed mounting evidence for the existence of this phenomenon, and then challenged the packed room to clarify their motivations for addressing it. “The research literature provides evidence of the existence of unconscious bias and also evidence-based practices to intervene,” she said. The unconscious bias research base is a rich and helpful tool that can be used to break through our collective denial, she said. “The question is not: do unconscious biases exist in all of us—because clearly they do. The question is: What are we going to do about it?” she asked.
Unconscious bias is defined in terms of attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. They may be manifested in microaggressions, defined as brief and commonplace daily verbal, behavioral, or environmental indignities in the form of interruptions, marginalizations, and misidentifications that together communicate hostile, derogatory, or negative slights—racial or otherwise.
Unconscious bias is more prevalent than people realize, Finnerty said. “The research shows that behavior is better predicted by one’s unconscious biases than by acknowledged ones,” she said. And trying to repress or deny these unconscious biases only serves to activate them more strongly—especially when people are tired, rushed, multitasking, cognitively overburdened, or in need of closure, which could be a description of our healthcare system.
Implicit Bias Leads to Unequal Treatment
The Joint Commission’s recent Quick Safety monthly newsletter “Implicit Bias in Health Care”5 finds that unconscious bias leads to differential treatment of patients by race, gender, age, language, income, and insurance status. Other areas impacted by implicit bias include sexual orientation, weight, immigration status, and religion—or lack thereof. In hospice and palliative care there are biases over academic versus clinical work settings, for-profit versus nonprofit hospices, professional categories, and career trajectories.
Bias in clinical decision making can result in overuse or underuse problems that directly lead to patient harm. The literature has documented access barriers,6 but even people who gain access to care are not treated equally. How are they informed of their treatment options? What are the differential treatment decisions most correlated with race? How many cognitive errors in medical treatment are based on inadequate information by providers? As examples, Hispanic patients are seven times less likely to receive opioid analgesics in the emergency department than non-Hispanic patients with similar injuries. African-American patients receive fewer cardiovascular interventions such as “clot-busting” drugs7 and fewer renal transplants than matched white patients.
David B. Hunt, president and CEO of Minneapolisbased consulting and training firm Critical Measures (www.criticalmeasures.net), is one of the nation’s leading experts on cultural competence in healthcare. He urges professionals to do some intellectual work around unconscious bias to increase their bias literacy, which is the ability to recognize our own biases as individuals and then take action to set new expectations for ourselves and our organizations. “When there is an increase in bias literacy, you have greater opportunities to intervene when you see bias,” Hunt said.
It is also important to recognize the circumstances in which biases can occur most often. “Stratify patient satisfaction, patient complaints, and other adverse incidents by race, ethnicity, language, and other factors. Rigorously collect patient demographic data, and tie that to outcomes,” he said. Today only 23% of hospitals are doing that, Dr. Hunt says, but patient satisfaction scores are increasingly important to health systems. “All of the patient surveys have questions that relate to courtesy, which to my mind is a proxy for the respect that is given to patients. When we stratify patient satisfaction data for our hospital system clients, it is clear that patients of color are treated differently from the moment they enter the hospital,” he said.
“Our whole notion of unconscious bias has changed radically over 2 decades. We used to think of human bias as conscious and intentional. Today we understand that our biases are unconscious and largely unintentional.” One thing that has radically changed our understanding of human bias is the creation of the Implicit Association Test (IAT; https://implicit.harvard.edu/implicit/takeatest.html) sponsored by Project Implicit at Harvard. “This is a leading test for measuring unconscious bias in the United States and all around the world,” he said.
More than 4.5 million IAT tests completed on the website have clearly shown that implicit bias is pervasive and predictive of behavior. Hunt encourages Academy members to take some of the tests offered online on the IAT website and see what insights they might obtain. “Biases by themselves are not dangerous; they’re simply preferences. The real question is whether these unconscious biases influence physicians’ behaviors—resulting in patients being treated differently. I think the clear answer to that question is yes,” he said.
Unconscious Biases in Palliative Care
“If something is unconscious, then obviously people are not aware of it,” said Ronit Elk, PhD, research associate professor in the College of Nursing at the University of South Carolina, and a member of the Academy’s Diversity & Inclusion Committee. “I was thrilled to see so many people come to the session we presented on this topic at the recent Annual Assembly. I would have said that people who work in the palliative care field are more open to consider these things. Each of us comes to this thinking: ‘I’m really open. I’ve done a lot of work on myself.’” But more work needs to be done, Dr. Elk says. Before they do anything else, professionals should take a look at what’s going on in their programs.
“I don’t know that we’ll ever completely obviate our unconscious biases, but we can mitigate a lot by communicating our openness in order to reduce the discomfort of our patients,” said Sean O’Mahony, MB BCh BAO, associate professor of hospice and palliative medicine at Rush University Medical Center. Openness means communicating that you are welcoming of people from all cultural backgrounds and avoiding generalities and stereotypes about groups other than yourself, he says.
It is also important to have some cultural humility, being careful not to put other people into boxes. “There are so many different cultures and ethnic groups—and individuals’ personal takes on them— that you can’t possibly be expert in all of them. That’s why you need to bring an inherent level of curiosity to your patients, just being aware of how limited your own experience is. And remember these families have many more strengths and values that contribute to how they cope with illness,” Dr. O’Mahony said.
What Is the Academy Doing?
In 2013 the American Academy of Hospice and Palliative Medicine empaneled the Diversity & Inclusion (D & I) Committee, which has developed a Diversity Statement for the organization, along with a framing vision, multiyear strategy, and plan, with the ultimate goal of increased outreach, education, and engagement of a broader spectrum of members, resulting in improved and expanded care to patients and families who are too often underserved.
The D & I Committee has sponsored presentations at the Annual Assembly, including the session on unconscious bias highlighted in this article. It also has developed articles on the subject in the Journal of Palliative Medicine and held World Cafes for members to share their perspectives.
“In general, when trying to teach these concepts (to medical students), we encourage providers to take time to listen, not to overspeak with our own agenda,” he adds. “We try to communicate that medical expertise doesn’t trump the values of patient and family. The care we provide has to be humancentered, which means we have to pay attention. We have as much to learn as to teach, and when you find yourself feeling uncomfortable with a particular group, you can use that as an opportunity to learn.”
Another form of unconscious bias specific to hospice and palliative medicine is prejudice against specialists who are perceived to overtreat their patients, said Timothy Quill, MD FACP FAAHPM, professor of medicine at the University of Rochester. “Your team can help you understand why some patients want more aggressive treatment than you think they should—and why our assumptions about palliative care potentially protecting patients from overtreatment are not for everybody,” he said. “This kind of tightrope walk is where palliative care has a built-in advantage—running it by our team. Everybody on the team has biases, but we’re more likely to have a broader range of perspectives as a team. Especially if we can start to share stories and examples of bias in our work.”
People often choose palliative medicine as a career because of experiences they’ve had of the medical system overtreating a patient. “So we come to these questions with a pretty good-sized chip on our shoulders,” Dr. Quill said. “Early on when I was a palliative care attending, there was an African-American patient for whom the care team desperately wanted the palliative care consultant to get the family to sign a DNR (do not resuscitate) order. I went in there every day until the patient’s wife finally said: ‘Stop coming here!’ I was brutalizing the wife and not listening to her in my efforts to ‘protect’ her. I learned a hard but important lesson about my own bias from that patient.”
Overt bias and discrimination clearly exist in health care and are problematic, but unconscious bias is also prevalent and probably affects more members of HPM teams, said Bruce Scott, MD HMDC FACP, of Wright State University. “Multiple studies have shown differences in the treatment of pain for different populations. As clinicians, we already have a tendency toward underestimating symptom burdens. When the patient is in a group which is labeled as ‘other’, there is a strong risk that this underestimation will be greater,” he said.
Gay, lesbian, and transgender patients have also likely experienced multiple episodes of healthcare discrimination in their lives,8 Dr. Scott said. “In a hospice interdisciplinary team setting, when I was covering for another physician’s team, we discussed a new admission of a transgender woman (male to female). The nurse presenting the patient used her (nonpreferred) birth name and terms like ‘he/she’ or ‘shemale’ when referring to the patient. This was a caring nurse who would have been appalled to think that he was acting in a discriminatory way,” Dr. Scott relates.
“By discussing the stresses that transgender people encounter on a daily basis, including misgendering, I was able to correct this language in a less confrontational manner. By using the patient’s preferred name and gender description myself and emphasizing that this would be a way to reduce stress on the patient and refrain from contributing more to symptom burden, it was relatively easy to get buy-in. If nobody had pointed this out, the nurse (and likely others on the team) would not have realized the extra burden they were creating for the patient.” What Is the Academy Doing? In 2013 the American Academy of Hospice and Palliative Medicine empaneled the Diversity & Inclusion (D & I) Committee, which has developed a Diversity Statement for the organization, along with a framing vision, multiyear strategy, and plan, with the ultimate goal of increased outreach, education, and engagement of a broader spectrum of members, resulting in improved and expanded care to patients and families who are too often underserved. The D & I Committee has sponsored presentations at the Annual Assembly, including the session on unconscious bias highlighted in this article. It also has developed articles on the subject in the Journal of Palliative Medicine and held World Cafes for members to share their perspectives.
What Can You Do About Unconscious Bias?
What can Academy members do about this problem that they may not even have been aware of? Dr. Elk encourages palliative care professionals to learn more about their own biases, such as by taking the IAT. “Now that you know, you can’t take it back,” she says. “Find ways to work on yourself and get acquainted with the culture and background of the persons you are biased against, so you can begin to see them as valuable human beings and recognize what they need from you—rather than the other way around.” A recent issue of the Journal of Palliative Medicine, co-edited by Dr. Elk and focused on palliative care for African Americans, challenged those in the field to be aware of their own, often unconscious, biases, and recognize their role in ensuring that the needs of African-American patients are met.9
A recent article in the ACP Hospitalist10 offers the acronym EPIC to describe basic steps health professionals can take to remedy unconscious bias in themselves, their colleagues, and their health systems:
- Engaging in perspective taking, which is the cognitive component of empathy—walking a mile in another's shoes, thinking of them as a partner in their care
- Practicing the right message
- Individuating one's understanding of patients as persons, not just members of groups
- Challenging stereotypes—employing debiasing techniques and stereotype negation: just say no when presented with stereotypical traits.
Professionals also can investigate reports of subtle or overt discrimination and unfair treatment in their programs, identifying and working to transform formal and informal norms that ignore and/or support racism. Give team members equity-specific targeted feedback. All the things that leading palliative care providers are doing to overcome healthcare disparities and promote racial and other diversity at all levels of their organizations are important, but remember that some biases may be unconscious to well-meaning palliative professionals.
“I can’t emphasize enough how important it is to return to one’s motivations for engaging in this work,” Finnerty said. “Knowing disparities exist is one thing—but committing to the painstaking work to overcome them is something else.” She notes that implicit bias scholar Patricia Devine compares bias to a habitual behavior. “Her research shows that like efforts to break any other bad habit, we need to commit intention, attention and time,” Finnerty said.
“It is also important to emphasize that unconscious bias can be present even in the practices of compassionate, committed professionals like those who choose the hospice/palliative care field,” she added. “It is up to each of us to ask what role we play in perpetuating disparate outcomes and what we are willing to do to change. There isn’t a simple playbook for improving health outcomes, but the unconscious bias literature offers useful tools for improving interactions with patients and colleagues, and for rethinking engrained organizational habits like employment practices. The door is open—we just need to walk through it.”
- Sharma RK, Cameron KA, Chmiel JS, et al. Racial/ethnic differences in inpatient palliative care consultation for patients with advanced cancer. J Clin Oncol. 2015; 33(32):3802-8.
- Reese DJ, Beckwith SK. Organizational barriers to cultural competence in hospice. Am J Hosp Palliat Care. 2015; 32(7):685-94.
- Reese DJ, Buila S, Cox S, Davis J, Olsen M, Jurkowski E. University-community-hospice partnership to address organizational barriers to cultural competence [published online Sep 23 2015]. Am J Hosp Palliat Care. 2015.
- Johnson KS, Payne R, Kuchibhatla MN. What are hospice providers in the Carolinas doing to reach African Americans in their service area? J Palliat Med. 2016; 19(2):183-9.
- The Joint Commission. Quick Safety 23: Implicit bias in health care. Quick Safety. 2016; 23.
- Institute of Medicine. Unequal treatment: Confronting racial and ethnic disparities in health care. http://www. nationalacademies.org/hmd/Reports/2002/Unequal- Treatment-Confronting-Racial-and-Ethnic-Disparities-in- Health-Care.aspx#sthash.4c6P4UVv.dpuf. Published March 20, 2002.
- Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007; 22(9):1231–1238.
- Lambda Legal. When health care isn’t caring. New York, NY: Lambda Legal; 2010. http://www.lambdalegal.org/ publications/when-health-care-isnt-caring.
- Special Issue: Palliative and End-of-Life Care for African Americans. J Palliat Med. 2016; 19(2):123.
- Durkin M. Fighting the subconscious biases that lead to health care disparities. ACP Hospitalist. 2016; 17-19.
Go to the table of contents for more articles.