How biased are you … really? Most of us like to consider ourselves fair and impartial. We have our favorite things, people, and places, but we consider ourselves fair-minded and savvy enough to know if we’re being unfair … right?
Medicine has a long and controversial history with bias. It is no secret that minority groups — Native Americans, Black Americans, the mentally ill, and the poor — were exploited for scientific advancement as a result of negative biases against them. These practices formed much of the foundation on which the institution of medicine is built, and, still today, evidence of these antiquated beliefs can still be found in our textbooks and practices. For instance, in lab reports you can still find a separate Glomerular Filtration Rate for Black Americans. Most nephrologists know it’s invalid, and was based on a doctor’s erroneous assumption that Black people had denser muscle tissue than white people — but it’s still there. Unfortunately, that particular belief has trickled down and is believed to be the primary reason for the uneven distribution of narcotics and higher levels of care for Black Americans in ERs today.
Bias, of course, is not limited in its impact to the aforementioned minority groups, nor is it wielded only by white clinicians. It affects all of us.
For instance, not too long ago, I walked into a patient room and the first thing I noticed was the many tattoos that festooned my patient’s arms. Some of the images were violent and sexist, some were also symbols commonly used by racist groups. The patient himself was sitting with his arms folded, an insolent look on his face. It would have been easy for me to adopt a negative opinion about him. After all, I don’t know anyone like him, I don’t have friends with tattoos, and it would have been easy to dismiss the man as intolerant and therefore not worthy of my respect or consideration. On the other hand, reacting in kind would likely have reinforced biases he may have held about me, and I would have learned nothing from the interaction.
So instead, I chose a different approach: I took a deep breath and greeted him as I would have any of my other patients. He started out terse and monosyllabic in his replies, reluctantly answering only after I’d asked a health question more than once. When I spoke to him, I noticed he wouldn’t look at me.
While I was counting his pulse, I noticed a tattoo of a straight flush on one of his arms. “Nice ink,” I said. For the first time, he looked at me and not through me.
“Yeah,” he said, “I got that in ‘Nam, back in 1970.”
I told him that I too was a veteran, but of the Air Force.
“Fly-boys.” He snorted derisively.
I asked him if he was Army, Navy, or Marine, and he proudly stated he was a Marine for life. “Is there any other kind?” I replied. And finally, he smiled at me. As the exam continued, we chatted amicably about poker, good and bad tattoos, and our respective branches of the military. By leaving my biases at the door, I was able to find something in common with my patient. The act of consciously avoiding assumptions and pre-judgments allowed me to see him as more like me than different. It was a moment of growth for me — and it may have been a moment of growth for him, too. We were able to find a place to meet each other as people, with mutual respect.
In my experience, there are several mindfulness practices that can prevent bias from creeping into our personal and patient interactions.
1) Leave bias at the door before entering a patient room.
An unconscious bias is no longer unconscious if you’re thinking about it. If you find yourself rushing to judgment about a patient’s appearance, weight, clothing cultural iconography, or language, take a moment to clear your head and reset.
2) Educate yourself about other cultures and people.
Let what you learned inform your opinions, so you no longer rely on reflexes, which are usually based on what you have heard or have “always known” about people with whom you are less familiar.
3) Critically examine your opinions about different races or cultures.
Are your opinions grounded in personal experience? What we may think of as “common sense” may actually be bias. That is, it might be someone else’s explicit bias that has trickled down into your subconscious, forming an implicit bias. Do your previously held beliefs “hold water” when compared to your personal experiences? Forming your own opinions and being open to change is imperative to minimizing bias.
4) Expand your personal experience to form new opinions.
Those who spend most of their time among people that are like themselves, with little other influence, are at greater risk of developing strong opinions that are negative and not based in fact. It’s easy to see your own experiences and opinions as “normal,” and to expect others to feel the same — and if you see yourself as “normal,” you are much more likely to see anything different as abnormal or inferior. This is a slippery slope that plants the seeds of bias and prejudice. Ask yourself about the diversity of your experience. Are you well-rounded socially, or are you just assuming that you are? How much time do you spend among people who are culturally or racially different from you?
5) Push your own limits regarding unfamiliar people.
Start small. Find a store or restaurant that you have not visited before, or learn a new language. Respectfully examining other cultures and people will help to mitigate implicit bias. Cultivating an appreciation for other cultures and people will enrich your experience, as well as the experience of others. I am working on learning Spanish, the language many of my patients speak, and they are more than happy to help me during their visits because it strengthens our rapport and improves their care experience.
By consciously working to minimize bias in our practices and personal lives, we can improve our patients’ experiences and provide better and more holistic health care. Insulating ourselves risks complacency and binds us in a feedback loop that hinders personal growth and harms disenfranchised patient populations. If we are to purge bias in the halls of medicine, it starts with you and me, one patient at a time. And then we can save our biases for our sports teams, where they belong (GO SEAHAWKS!).
Do you push your own limits or consciously venture outside your comfort zone? How? Share your strategies for diversifying your personal experiences in the comments.
Arlene Dorrough has been a practicing PA for more than 15 years. She is currently working in occupational medicine and urgent care. She is also working as a Medical Examiner for the DOT. Arlene is a 2021–2022 Doximity Op-Med Fellow.
Illustration by Diana Connolly