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Implicit Biases Have an Explicit Impact on Healthcare Outcomes

Laura Joszt
Implicit biases may be unconsciously formed, but they can have real impacts for patients in the healthcare system if physicians or other healthcare providers don’t take the time to recognize their own implicit biases.
Implicit biases may be unconsciously formed, but they can have real impacts for patients in the healthcare system if physicians or other healthcare providers don’t take the time to recognize their own implicit biases.

In 2016, Kelly M. Hoffman, PhD, associate researcher at Future Laboratories, coauthored a study1 on racial bias in pain perception and treatment that found black patients are undertreated for pain compared with white patients. The study examined false beliefs in 2 groups: laypeople without medical training and people with medical training.

While the individuals with medical training were less likely to endorse false beliefs—such as that black people have thicker skin or heal more quickly—Hoffman said it was still surprising how strong the endorsement of these beliefs were among people with medical training. Participants with medical training (medical students and residents) endorsed 11.55%, on average, of false beliefs compared with laypeople who endorsed 22.43% of the beliefs, on average.

These false beliefs are entrenched in the historical context of the United States, Hoffman explained.

“We know going back to slavery that physicians and slave owners perpetuated these types of ideas to help justify owning slaves and to help justify experimenting on black people’s bodies,” she said.

Yesenia M. Merino, MPH, a PhD candidate at the University of North Carolina at Chapel Hill, explained that in the health sciences, people don’t like to admit that observations can be subjective. In addition to considering the symptoms that present, providers need to also think about the context within which those symptoms present.

“We act as though our observations are objective truth and not influenced by our own context and our own biases and our own histories,” she said.

Implicit biases affect care all along the continuum, especially in mental health. Merino explained that not only are there assumptions about who has mental health issues, but also biases affect who is more likely to get a follow-up call from a provider or get an appointment.

Marginalized populations, such as the homeless or people of color, are more likely to been seen as criminal and violent in emergency situations and are more likely to be presumed to be noncompliant with their medication, but they’re also more likely to be presumed to be medication-seeking or having an ulterior motive other than trying to receive needed care.

In obesity, the stigma patients face can mean another health issue goes undiagnosed and untreated, explained Fatima Cody Stanford, MD, MPH, MPA, FAAP, FACP, FTOS, instructor of medicine and pediatrics at Harvard University.
Unlike some other health conditions, such as an autoimmune disorder or opioid use disorder, obesity is a diagnosis that is visible, and a lot of judgements are made. Stanford explained that health providers often assume patients with severe obesity cannot conform to lifestyle modifications, that they haven’t looked at changing their diet, or that they have yet to try an exercise program.

“So, the assumption is that they’re just lazy, and they haven’t done all of these things,” she said.

The reality is that obesity is caused by multiple issues, including genetics, the gut microbiome, and the environment. Unfortunately, obesity, the many factors that cause it, and how to treat it are not really taught in medical school, Stanford said. As a result, providers assume the patient did something wrong, and it is only once patients lose weight that providers really start to listen to the other issues a patient mentions.

For example, she said, if a patient says his or her hip is hurting, the physician assumes it is the weight. It is only after the patient loses 100 pounds and still complains about hip pain that the provider will look closer and find something like a cancer that went undiagnosed for a long time and could have been treated earlier.

“Obesity is so complex and requires so much investment on the part of the clinicians that it’s easier to just put the onus back on the patient,” Stanford explained.

In obesity care, bias may not only come through with how a provider or other health professional interacts with the patient, Stanford said. There are aspects of the healthcare experience outside of human interaction that can make a patient feel ill at ease, such as if the waiting room does not have seating to accommodate a person with severe obesity.

“They didn’t get any negative feedback from the front staff, they were received in a very positive fashion by the medical assistants, but just not having a place to sit down, to wait for the doctor or other professional that might be seeing them in that space gives them a sign that they’re not welcome there,” she said.

Patients with obesity pick up on things like if a doctor’s office doesn’t have a scale that can weigh them or a blood pressure cuff that can fit around their arm. These might be things that the health providers don’t think about, even if they think they are being welcoming to patients with obesity.

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