Question

How can stereotypes lead to bias in a health care setting?

How do individual and cultural factors affect personality development?

Answer 1

There is compelling evidence that increasing diversity in the healthcare workforce improves healthcare delivery, especially to underrepresented segments of the population Although we are familiar with the term “underrepresented minority” he Association of American Medical Colleges, has coined a similar term, which can be interchangeable: “Underrepresented in medicine means those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population” [3]. However, this definition does not include other nonracial or ethnic groups that may be underrepresented in medicine, such a bisexual, transgender, or questioning/queer individuals or persons with disabilities. US census data estimate that the prevalence of African American and Hispanic individuals in the US population is 13% and 18%, respectively while the prevalence of Americans identifying as LGBT was estimated by Gallup in 2017 to be about 4.5% . Yet African American and Hispanic physicians account for a mere 6% and 5%, respectively, of medical school graduates, and account for 3% and 4%, respectively, of full-time medical school faculty As for LGBTQ medical graduates, the Association of American Medical Colleges does not report their prevalence . Persons with disabilities are estimated to be 8.7% of the general population,while the prevalence of physicians with disabilities has been estimated to be a mere 2.7% .Furthermore, although women currently outnumber men in first-year medical school classes , gender disparities still exist at higher ranks in women’s medical careers .

Unconscious or implicit bias describes associations or attitudes that reflexively alter our perceptions, thereby affecting behavior, interactions, and decision-making. The Institute of Medicine (now the National Academy of Medicine) notes that bias, stereotyping, and prejudice may play an important role in persisting healthcare disparities and that addressing these issues should include recruiting more medical professionals from underrepresented communities Bias may unconsciously influence the way information about an individual is processed, leading to unintended disparities that have real consequences in medical school admissions, patient care, faculty hiring, promotion, and opportunities for growth Compared with heterosexual peers, LGBT populations experience dispar)ities in physical and mental health outcomes Stigma and bias (both conscious and unconscious) projected by medical professionals toward the LGBTQ population play a major role in perpetuating these disparities Interventions on how to mitigate this bias that draw roots from race/ethnicity or gender bias literature can also be applied to bias toward gender/sexual minorities and other underrepresented groups in medicine

The specialty of infectious diseases is not free from disparities. Of >11 000 members of the Infectious Diseases Society of America (IDSA), 41% identify as women, 4% identify as African American, 8% identify as Hispanic, and <1% identify as Native American or Pacific Islander (personal communication, Chris Busky, IDSA chief executive officer, 2019). However, IDSA data on members who identify as LGBTQ and members with disabilities are not available.

The IDSA annual compensation survey reports that women earn a lower income than men [18], and a review of the full report demonstrates similar disparities among URM physicians, compared with their white peers While it may not be feasible to assign a direct causal relationship between unconscious bias and disparities within the infectious diseases specialty, it is reasonable and ethical to attempt to address any potential relationship between the two. In this article, we define unconscious bias and describe its effect on healthcare professionals. We also provide strategies to identify and mitigate unconscious bias at an organizational and individual level, which can be applied in both academic and nonacademic settings.

UNCONSCIOUS BIAS—THE ROLE IT PLAYS AND HOW TO MEASURE IT

overt racism, misogyny, and transphobia/homophobia continue to influence current events. However, in the decades since the healthcare community has moved toward becoming more egalitarian, overt discrimination in medicine based on gender, race, ethnicity, or other factors have become less conspicuous. Nevertheless, unconscious bias still influences all human interactions . The ability to rapidly categorize every person or thing we encounter is thought to be an evolutionary development to ensure survival; early ancestors needed to decide quickly whether a person, animal, or situation they encountered was likely to be friendly or dangerous . Centuries later, these innate tendencies to categorize everything we encounter is a shortcut that our brains still use.

Stereotypes also inadvertently play a significant role in medical education .Presentation of patients and clinical vignettes often begin with a patient’s age, presumed gender, and presumed racial identity. Automatic associations and mnemonics help medical students remember that, on examination, a black child with bone pain may have sickle-cell disease or a white child with recurrent respiratory infections may have cystic fibrosis. These learning associations may be based on true prevalence rates but may not apply to individual patients. Using stereotypes in this fashion may lead to premature closure and missed diagnoses, when clinicians fail to see their patients as more than their perceived demographic characteristics. In the beginning of the human immunodeficiency virus (HIV) epidemic, the high prevalence of HIV among gmen led to initial beliefs that the disease could not be transmitted beyond the y community. This association hampered the recognition of the disease in women, children, heterosexual men, and blood donor recipients. Furthermore, the fact that white y men were overrepresented in early reported prevalence data likely led to lack of recognition of the epidemic in communities of color, a fact that is crucial to the demographic characteristics of today’s epidemic. Today, there is still no clear solution to learning about the epidemiology of diseases without these imprecise associations, which can impact the rapidity of accurate diagnosis and therapy.

IMPACT OF BIAS ON HEALTHCARE DELIVERY

Unconscious bias describes associations or attitudes that unknowingly alter one’s perceptions and therefore often go unrecognized by the individual, whereas conscious bias is an explicit form of bias that is based on one’s discriminatory beliefs and values and can be targeted in nature. While neither form of bias belongs in the healthcare profession, conscious bias actively goes against the very ethos of medical professionals to serve all human beings regardless of identity. Conscious bias has manifested itself in severe forms of abuse within the medical profession. One notable historical example being the Tuskegee syphilis study, in which black men were targeted to determine the effects of untreated, latent syphilis. The Tuskegee study demonstrated how conscious bias, in this case manifested in the form of racism, led to the unethical treatment of black men that continues to have long-lasting effects on health equity and justice in today’s society . Given the intentional nature of conscious bias, a different set of tools and a greater length of time are likely required to change one’s attitudes and actions. Tackling unconscious bias involves willingness to alter one’s behaviors regardless of intent, when the impact of one’s biases are uncovered and addressed

There is still debate, however, about the degree to which unconscious bias affects clinician decision-making. In one systematic review on the impact of unconscious bias on healthcare delivery, there was strong evidence demonstrating the prevalence of unconscious bias (encompassing ethnicity, gender, socioeconomic status, age, weight, persons living with HIV, disability, and persons who inject drugs) affecting clinical judgment and the behavior of physicians and nurses toward patients . However, another systematic review found only moderate-quality evidence that unconscious racial bias affects clinical decision-making . A detailed discussion of the impact of unconscious bias on healthcare delivery is out of the scope of this article, which is focused on the impact of unconscious bias as it relates to healthcare professionals themselves. Nevertheless, strategies to mitigate the effects of unconscious bias can be applied to healthcare delivery and patient interactions.