Racial Bias in Medicine a Barrier to COVID Health Equity | Healthiest Communities Health News

The disproportionate impact of COVID-19 on American populations of color relative to white Americans should force us to examine how implicit bias contributes to health disparities. As of early January, 1 in 595 Indigenous Americans, 1 in 735 Black Americans and 1 in 1,000 Latino Americans had died from COVID-19, compared with 1 in 1,030 white Americans.

A recent study suggests that structural circumstances in Black and Latino communities – such as housing inequality, access to health care, limited employment opportunities and poverty – may explain disproportionately higher out-of-hospital deaths due to COVID-19 among these communities. Yet while these are valid and complex obstacles to health equity, one barrier that health care providers can affect directly is the role implicit bias has in medical decision-making.

Implicit bias refers to unconscious attitudes and stereotypes held toward other people. In the health care setting, when ideas about a patient are made because of unconscious associations rather than that person’s individuality, it can lead to poor care.

Over the course of the COVID-19 pandemic, multiple articles have been published on implicit bias and its role in the medical management of people of color. One piece detailed stories of Black patients being sent home from health care facilities with symptoms deemed not serious enough for testing, and then eventually dying at home from COVID-19. Their families carry an added burden of wondering whether racial bias may have played a role in their loss.

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Many potential factors can be offered as rationale for these and similar results, including limited access to cancer care, a higher rate of coexisting chronic illness in Black patients with heart disease, patient preference, cultural factors or perhaps a physician’s inability to perceive a patient’s pain. However, implicit bias also may be a factor.

A commonly used measure of implicit bias is an Implicit Association Test, in which test-takers can be asked to link images of Black and white faces with pleasant and unpleasant words. In one study, physicians were presented a vignette of a patient, randomly assigned as Black or white, with chest pain and an electrocardiogram indicating a heart attack. As participants’ IAT-measured, anti-Black implicit bias increased, the likelihood of Black patients being recommended for a therapy for coronary artery disease decreased, while the likelihood of that therapy being recommended for white patients increased. Another study found that physicians with an implicit pro-white bias were more willing to prescribe narcotic medication to white patients following surgery than to Black patients.

Implicit bias is ubiquitous and starts forming at an early age from repeated reinforcement of social stereotypes. Simply being aware of one’s unconscious bias is a way to limit its impact on influencing decisions and behavior. In the study that randomly assigned race to a patient with chest pain, an increase in pro-white implicit bias among physicians who were aware that the study examined racial bias was associated with a higher likelihood that therapy would be recommended for Black patients.

Beyond personal awareness, however, “explicit and consistent training and education and commitment to cultural competence is absolutely critical for the future of our health care workforce,” as Harvard professor Dr. Howard Koh told USA Today last year. That training should begin in medical school: Every medical student needs to be aware of their own implicit bias so, as they become a knowledgeable and skilled physician, they can make clinical decisions that best serve their patients. To help achieve this, the American Association of Medical Colleges – an organization that has outlined learning objectives and guidelines for medical student education – should explicitly include the reduction of bias in medicine as a goal for all of their 172 accredited medical institutions.

Some schools have implemented courses aimed at this objective, such as the University of Virginia‘s Social Issues in Medicine class for first-year students, which helps them “recognize and analyze the relationships between sociocultural environments and the occurrence, prevention and treatment of disease.” The University of California–San Francisco School of Medicine also offers first-year students a four-week Health and Society course that includes “an emphasis on health and healthcare disparities” and “content related to bias in medicine.” Describing and understanding “factors affecting health equity, including structural inequalities in access to and quality of health care,” are part of the school’s competency goals as students proceed toward graduation.

For physicians already in clinical practice, one way to ensure regular implicit bias training is to require it for state licensure. The state of Michigan serves as an example: In July, faced with the staggering statistic that COVID-19 was over four times more prevalent among Black residents than white residents, Gov. Gretchen Whitmer issued an executive directive aimed at establishing rules requiring health care professionals to take implicit bias training to obtain or renew a medical license in the state. California lawmakers in 2019 approved a similar measure regarding the inclusion of implicit bias training in continuing education for health care providers.

Meanwhile, the American Academy of Family Physicians offers a voluntary training option. Noting that “formal medical education and training” often does not include a curriculum on implicit bias in clinical practice, the AAFP unveiled a training guide as a resource for providers.

But with continued acknowledgment and incorporation of widespread efforts to address implicit bias as a subconscious barrier to health equity, its dangerous impact can be reduced.