The topic of unconscious bias has risen to the forefront of conversations in academic medicine. At Digestive Disease Week® (DDW) 2019, the AGA Diversity Committee sponsored a symposium for our members to join the discussion.
With a focus on patient care, we pose the question: Does race impact the health of the communities we serve? This question intersects with our national history and identity. Taken separately, race and health care can be controversial topics. Intersecting the two is confusing and complex, and these conversations are difficult. Nonetheless we must engage in this dialogue for our patients’ sake. Meaningful change can be achieved, and we hope that after reading this, you will share our optimism. With intentionality, we can bridge health care gaps, relieve suffering and save lives.
As an illustrative scenario: A non-smoking 64-year-old African American male in excellent health, with no family history of colorectal cancer (CRC) switches to Veterans Administration (VA) care due to an insurance change. His new primary care physician noted he was never screened for colon cancer. The patient confirmed that a colonoscopy or a stool test was never previously recommended. He undergoes colonoscopy, and resection of a 6 cm rectal polyp which reveals intramucosal carcinoma, with negative margins. The patient enters a surveillance colonoscopy program and maintains excellent health.
“Meaningful change can be achieved, and we hope that after reading this, you will share our optimism. With intentionality, we can bridge health care gaps, relieve suffering, and save lives.”
This real-life scenario reflects the underutilization of screening exams in minority groups in the U.S., a critical factor in CRC racial disparities. The stakes could not be higher for our African American patients, with the highest CRC mortality rate in America, 20 percent higher than non-Hispanic whites from 2009–2013. How can this happen? Does bias in our health care models adversely impact our black patients in particular?
What is unconscious bias?
Biases can be unconscious (implicit) or conscious (explicit). Explicit biases are ones we are aware of. Unconscious bias instead is an association that develops without awareness, intention or control, informing our actions unintentionally (and we all have them). In our case, the prior providers were not likely purposefully denying our patient life-saving preventative care based on race, but may have had unconscious assumptions based on race, such as the patient’s willingness to enter a screening program, that led to the lack of a screening recommendation.
Bias can also exist at the systems-level. Studies show blacks are disproportionality hurt where screening is not operationalized through an automated program. In addition, minorities cluster for care in low-performing hospitals that fail to adhere to evidence-based care delivery. Health care systems like the VA and Kaiser Permanente are leading by example to systematically bridge disparity gaps and provide equitable care for all patients.
How does bias reflect back on the physician from patients?
Internalized and inherited experiences of racial bias can subsequently manifest as unconscious bias which plays out in interactions with physicians and medical scientists. The impact is realized in interactions with the medical community, including how patients seek out and share information with medical practitioner, which are critical pieces to ensuring positive health outcomes from CRC screening and prevention strategies. Patient-to-provider bias may also target physicians’ age, gender, race, ethnicity, accent, religion or LGBTQ status. Thus, it is important to understand that in all interactions, bias can exist bidirectionally. More importantly, it is necessary to gain insight into the experiences inherent in the expression of bias which can only bolster the medical care relationship.
How can you learn more about your bias and what steps can you take to increase self-awareness in your practice?
The first step is to accept that we all have bias. It does not make us bad people, it makes us human. What matters most is what we do with that knowledge. By slowing down and consciously considering our biases, we can mitigate their impact. Take the Implicit Association Tests to identify which biases are more relevant for you (https://implicit.harvard.edu/implicit/aboutus.html) and see the additional resources below for more reflection.
Race-based health care disparities in colon cancer screening is a solvable problem. Our medical societies are critically important to getting the word out, and AGA has committed time and resources to closing disparity gaps. Unconscious bias is but one component of the problem that can be addressed through self-awareness, historical understanding, and community engagement. Through national committee work and government advocacy, AGA is also addressing these topics by leveraging the strength of its membership to positively impact health care policy. We as individuals and gastroenterologists can also do our part, one patient at a time.
Disclosures: Dr. Munroe, Dr. Lamousé-Smith and Dr. Quezada have no conflicts to disclose.
- Unconscious Bias in Academic Medicine: Overcoming the Prejudices We Don’t Know We Have (Association of American Medical Colleges): https://news.aamc.org/diversity/article/unconscious-bias/
- How Training Doctors in Implicit Bias Could Save the Lives of Black Mothers (NBC News): https://www.nbcnews.com/news/us-news/how-training-doctors-implicit-bias-could-save-lives-black-mothers-n873036
- Doctors Can Fight Implicit Bias Against African American Patients (Bloomberg News): https://www.bloomberg.com/opinion/articles/2018-08-28/doctors-can-fight-implicit-bias-against-african-american-patients