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Women have a higher rate of missed myocardial infarction. Black patients wait longer to receive care in the emergency department for chest pain. Transgender patients get asked questions about their orientation that have nothing to do with their clinical condition. A Latina woman does not get adequate pain medication because she is being “dramatic.” A female physician’s opinion is dismissed by her male colleagues. An older physician views residents as being “lazy” because they get to limit their work hours. Male physicians get paid more and achieve leadership positions more frequently than female physicians. You’ve heard this before and seen the research behind these disparities. None of this is intentional, yet somehow these things continue to happen and are a part of our daily lives. While the causes for these disparities are multifactorial, unconscious bias plays a big role.
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ACEP Now: Vol 36 – No 04 – April 2017Bias is a tendency or an inclination that results in judgment without question. In its most extreme, negative form, it is a prejudice against someone who is not like you that results in some harm to the “other.” It can also be positive. In reality, bias serves two purposes. It helps us to function on a daily basis, and most important, it serves to protect us from harm. Think about it. You are walking down the street at night in an unfamiliar area. Just ahead, you see the shadow of a figure walking toward you and see a glint of light off of a long pointy object in what looks like that figure’s hand. What do most of us instinctively do? We quickly move away from the figure. Why? Because most of us have developed a strong bias against strange and unknown figures holding presumably sharp objects that may cause us harm. While the figure may not be a true threat, our bias causes us to instantaneously perform certain protective actions. It is unlikely that we would approach the figure, do a careful and detailed assessment, review a long list of potential actions, and choose our option—we may not be alive if we did so.
Each of us is a unique individual who has our own individual experiences and education (both formal and informal). These can be described as our “book of rules.” Our “schema” organizes these rules. Together, these form the background, our “lens,” through which we view the world. We are constantly experiencing rules and reshaping our schema and background on a minute-by-minute basis. Background is context, and context is the lens through which we view the world. We cannot help having biases; it is a part of who we are.
No explicit preference for white or black patients or perceived cooperativeness was found. However, the IATs demonstrated implicit preference for white patients and implicit stereotypes of black patients as less cooperative with medical procedures and less cooperative in general.
In 1998, Anthony Greenwald, Debbie McGhee, and Jordan Schwarz created an implicit association test (IAT).1 This tool is the most recognized and commonly used test to measure unconscious bias and measures the strength of automatic associations between concepts (eg, black people, gay people) and evaluations (eg, good and bad). The IAT score is based on how long it takes a person, on average, to associate certain evaluative words with the concept being tested. Thus, if one quickly associates “good” words with “white” and “bad” words with “black,” there may be a preference of white over black. (A more detailed description can be found in the “Education” section at Implicit.Harvard.edu.) Currently, there are 13 tests on the Project Implicit website: Native American, Gender-Science, Asian American, Race (Black-White), Age, Disability, Weight, Presidents, Arab-Muslim, Skin-Tone, Sexuality, Weapons, and Gender-Career.2
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3 Responses to “How Does Bias Affect Physicians, Patients?”
April 15, 2017
Mark BuettnerThe IAT does not predict behavior of racial bias whatsoever. Is credible science not important anymore? The bias here is “Bandwagon Bias”. Perhaps we should pause before jumping on board.
It’s hard to disagree with the conclusion of Fiedler and his colleagues that it is only “fair and appropriate to treat the IAT with the same scrutiny and scientific rigour as other diagnostic procedures.” If that’s true, then between Project Implicit and cutting-edge diversity trainings, the IAT has misled potentially millions of people. Over and over and over and over, the IAT, a test whose results don’t really mean anything for an individual test-taker, has induced strong emotional responses from people who are told that it is measuring something deep and important in them. This is exactly what the norms of psychology are supposed to protect test subjects against.
May 19, 2017
Bernard L. Lopez, MD, MS, CPE, FACEP, FAAEMIn my article, I never said that the IAT predicts behavior of racial bias. Much research has been done on the IAT since it was first described. Thus, the test has undergone significant scientific scrutiny and raises questions on just exactly what it measures. One school of thought is that the IAT may simply be measuring the association of positive evaluations with the “in” or majority group and negative evaluations with the “out” or minority group and that it may not be a specific attribute effect but rather the manner in which humans behave. In my article, I describe a study that suggests that in-group/out-group membership, and not nationality, was the important factor.
Too often, people are told to take the test on their own. Therein lies the potential harm—they read the results and may assume that they are prejudiced against a group. The test may also be used by diversity educators who may suggest the existence of prejudice. In this regard, I agree with Dr. Buettner that the IAT is misleading. In my article, I gave the opinion that the IAT is a tool that can be used to stimulate thought about one’s unconscious biases but should NOT be used to measure one’s “prejudices.” Having a strong preference for a certain group does not mean that one is prejudiced against another. Knowledge of this preference is useful when dealing with someone from “the other” group as it allows you to consider how your bias may affect certain behaviors and decisions. The use of the IAT needs to be done in a controlled setting that stresses the fact that it does not measure prejudice and that it should simply stimulate thought about one’s unconscious biases.
I disagree with Dr. Buettner’s statement that the IAT is a test whose results don’t really mean anything for an individual test-taker. For the individual, the results suggest a preference. This preference, when used to stimulate thought (not measure prejudice) on potential biases, can be valuable in future interpersonal interactions.
Bernard L. Lopez, MD, MS, CPE, FACEP, FAAEM
June 2, 2017
Mark BuettnerPoint of Clarification: The opening sentence of my original response should read as follows: The IAT does not predict behavior OR racial bias whatsoever.
Mark F. Buettner DO, FACEP, FAAEM