Moving Medicine Beyond the Individual Assessment for Implicit Bias
by Martín Escandón
During the orientation week prior to beginning medical school, all incoming students in my class were required to take an implicit association test (IAT). As part of the school’s cultural competence curriculum, students completed a computerized assessment of their reaction times associating portraits of individuals with varying skin color and positive or negative words. Taking longer to associate positive words with dark skinned individuals compared to light skinned individuals is thought to indicate subconscious preference for lighter skin tones. After taking the test, students participated in small group sessions to debrief about the assessment and then came together in a class-wide lecture to analyze the test results and why recognizing and understanding bias might be important for health care providers. Evidence indicates that the IAT is effective at increasing awareness about bias and it has been suggested as a way to minimize unequal treatment of patients based on perceived differences (Archambault, Rhee, Marion, & Crandall, 2008). We know that medical providers hold biases against individuals with darker skin tones and that these biases, intentional or not, result in worse health care and contribute to worse health outcomes (Sabin, Nosek, Greenwald, & Rivara, 2009; Smedley, Stith, Nelson, & Care, 2003). For example, we know that black adults are less likely to be admitted to cardiac intensive care units than white patients, Hispanic individuals are less likely to receive Deceased Donor Liver Transplantation, and black patients are less likely to receive adequate and timely pain medication in the Emergency Department than white patients (Mathur, Schaubel, Gong, Guidinger, & Merion, 2010; S., K.M., & a., 2012; Shippee, Ferraro, & Thorpe, 2011). To the credit of my medical school, they include the IAT at the beginning of training to start a conversation around the sensitive issues of race, ethnicity, racism and health.
In practice, the conversation never really happened. My school did not collect data on the results of students’ tests. No participant in my small group meeting volunteered their test result and no one acknowledged that they have biases. In the large group lecture, defensive medical students questioned the validity of the IAT itself and the lecturer was unable to discuss how bias can influence how medical decisions are made. In the three years after orientation, the curriculum never substantively revisited the issue of provider bias or racism.
When I took the IAT, it revealed I held a slight preference for darker skinned individuals; bias, after all, can run in any direction. Then and now, I understand that the important part of holding bias as a health professional is to recognize it and actively prevent this bias from influencing medical decisions or patient care. In the third year of medical school, completing rotations in the core medical specialties, I attempted to treat patients equitably and acknowledge my own biases. Unfortunately, the medical student occupies the lowest position on the treatment team, is entirely subordinate to the attending physician, and can at best indirectly influence treatment decisions. Even more problematic, despite treating very diverse patient populations at four county hospitals in California, only once did I work with an attending physician from a racial group that is underrepresented in medicine. Worse still, our teams routinely mistreated patients of color. Spanish speakers were often not offered interpretation services, wait times in clinics stretched to hours, misunderstandings were blamed on “cultural differences” and patients who questioned this treatment were labeled “difficult” and avoided on rounds. Shockingly, when I asked one surgeon why a 13-year-old girl had developed gallstones so early in life, she replied “She’s just Mexican.” People who were different from the treatment team were not afforded the same compassion and quality of care as other patients.
At the end of my third year I was exhausted from seeing black and brown patients being treated poorly. I decided to take the IAT again. My test revealed I now have a strong preference for lighter skin tones. Scientifically, this result is meaningless. I am sample size of one and my knowledge of the IAT introduces test-retest bias. Personally, however, I think my change is significant; after a year of being forced by people with light skin to participate in mistreating people with dark skin, how could I not be changed? I feel changed.
Lectures on implicit bias, the IAT, and the medical framework that focuses on individual behavior are not sufficient to correct the problems that institutional racism has created in our health care delivery system. Creating race consciousness and acknowledging how race can sway health care decisions is an important step on the path towards progress, but we must move further upstream. With a public health framework we focus on the social, political and economic structures that construct the institutional racism that influences how providers train and practice. Much as obliging individual medical students to confront their biases is an inefficient way to promote equity, to affect positive change in race-based health inequity, we must address the fundamental roots of these problems. In short, we must extend the struggle for health equity to the struggle for social equity.
Bibliography
Archambault, M. E., Rhee, J. a Van, Marion, G. S., & Crandall, S. J. (2008). Utilizing Implicit Association Testing to Promote Awareness of Biases Regarding Age and Disability. The Journal of Physician Assistant Education, 19(4), 20–26.
Mathur, A. K., Schaubel, D. E., Gong, Q., Guidinger, M. K., & Merion, R. M. (2010). Racial and ethnic disparities in access to liver transplantation. Liver Transplantation : Official Publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society, 16(9), 1033–1040. doi:10.1002/lt.22108
S., T., K.M., H., & a., W. (2012). Racial Bias in Perceptions of Others’ Pain. PLoS ONE, 7(11), 1–8. doi:10.1371/journal.pone.0048546
Sabin, J. A., Nosek, B. A., Greenwald, A. G., & Rivara, F. P. (2009). Physicians’ Implicit and Explicit Attitudes About Race by MD Race, Ethnicity, and Gender. Journal of Health Care for the Poor and Underserved, 20(3), 896–913. doi:10.1353/hpu.0.0185
Shippee, T. P., Ferraro, K. F., & Thorpe, R. J. (2011). Racial disparity in access to cardiac intensive care over 20 years. Ethnicity & Health, 16(2), 145–165. doi:10.1080/13557858.2010.544292
Smedley, B. D., Stith, A. Y., Nelson, A. R., & Care, C. on U. and E. R. and E. D. in H. C. (2003). Unequal Treatment: Confronting Racial and Ethnic DIsparities in Health Care.
