Implicit Racial Bias in Healthcare: Addressing the History of Structural Injustice

Illustrated by Haley Pak

When Jason Dahlke, an emergency paramedic in Portland, Oreg., was called into an emergency call for a black man around 60 years complaining of extreme pain in his hands and feet, Dahlke “followed the standard procedure and gave the patient a blood glucose test” in which the test showed low blood sugar levels. Although he gave the patient glucose, Dahlke did not give any pain medicine to the patient. When asked if he would have administered the pain medicine if the patient were to have been white, he replied he would not have been sure if he would have. Although Dahlke says “race doesn’t affect the treatment they give,” he also says he and his co-workers are starting to think more about implicit bias when treating patients (1).

Years of prejudice against the African American population affects modern healthcare systems that puts African American patients at a disadvantage. Though prejudice may not be as explicit and blatant as it was during the Jim Crow era, the repercussions of such pernicious bias against the African American Union Army veterans contribute to the racial mortality gap and health disparities to this day. In a study by Dr. Shari Eli, a professor of Economics at the University of Toronto, physician bias against African Americans in the late 19th and early 20th century impacted mortality and income outcomes for Civil War veterans. In order for veterans to receive higher pension, they had to provide physician approved proof of disability (2). The study found that although black and white veterans were equally likely to report pain, physicians were twice as likely to doubt pain for black veterans and more than three times to accuse black veterans as “exaggerating” their illness” (2). Therefore, black veterans were not able to receive as much pension as their white counterparts because of the physicians’ biased assessment that may have disallowed the black veterans from qualifying for higher pensions. The study noted that an additional dollar in monthly pensions income led to an additional 0.3 years of life (2). Society constantly depicts certain disadvantaged or underprivileged populations in a stereotypical and pejorative way that is projected onto cultural understandings of the world. Such cultural understandings may be the root of the problem regarding implicit bias in the healthcare setting.

Despite the rapid advancement in medicine, the same pervasive bias that neglects African American patients’ illnesses still exists today. According to a review of a study examining pain management in American emergency rooms, physicians tended to prescribe African American patients less pain medication compared to white patients. According to data from 14 previously published studies of pain management in American emergency rooms, when practitioners assessed patients with bone fractures or acute pain from traumatic injuries, “black people were 41% less likely to get pain medication than white people.” Physician implicit bias may not only affect acute pain, but also chronic noncancer pain. According to a study examining the impact of patient factors on the underestimation of pain perception of chronic noncancer pain, physicians were “twice as likely to underestimate pain in black patients compared to all ethnicities combined.” Furthermore, not only were physicians more likely to underestimate pain for black patients, they overestimated pain in 18.9% of white patients compared to 9.5% in black patients (4). The differences in pain perception by race between patient and physician can have prominent consequences. This statistic provides a need for better, more standardized ways of pain assessment. Physicians’ implicit biases may interfere with healing processes and decrease care that is provided for African American patients. A physician’s lack of care towards pain management may further the distrust in the healthcare institution that has failed to treat them properly because of implicit bias.

Another facet of bias in healthcare manifests through an algorithm from Optum, UnitedHealth Group Inc.’s health services branch that determines which patients require the most intensive medical needs. The algorithm “which has been applied to more than 200 million people each year” considerably underestimates medical needs of black patients. More specifically, the algorithm makes circumstances particularly disadvantageous for African Americans because of the pre-existing data that informs the program that “less money is spent on black patients with the same level of need as white patients.” Research conducted by Ziad Obermeyer, who studies machine learning and health-care management at the University of California, Berkeley, shows that according to the algorithm, “care provided to black people cost an average of $1,800 less per year than the care given to a white person with the same number of chronic health problems.” This means that the algorithm will conclude that black patients are less sick because they have been historically provided less care and thus have a lower risk score. Therefore, through this platform, inherited racism further instigates structural racism and stereotyping in healthcare. The algorithm follows a feedback loop that feeds more injustice into a system that already makes it disadvantageous for African Americans and other minority groups.

The implications for what unbiased healthcare could look like is shocking. 17.7% of the patients the algorithm assigned extra care to were black, but “the proportion would be 46.5% if the algorithm were unbiased.” The article mentions that in order to fix medical bias in this algorithm, another variable should be added so that the calculation does not rely so heavily on the healthcare costs (6). But many developers working on the algorithm are faced with a barrier: How does such an algorithm – that is quantitative measurement – account for the history of pernicious racism that has oppressed African Americans throughout history? 

In order to combat workplace implicit bias, many institutions have implemented the Implicit Association Test (IAT) to measure unconscious attitudes or beliefs about current social stereotypes. It spurred organizations like Project Implicit that was founded in 1998 “to educate the public about hidden biases and to provide a ‘virtual laboratory’ for collecting data on the internet” (7). It is true that seemingly small implicit biases have an enormous effect on behavior and decisions. However, the IAT acknowledges the importance of recognizing implicit bias and does not provide any further information on strategies to reduce implicit bias.

One approach in reducing medical bias involves education of medical students. The current medical training environment often neglects the initiative for providers “to examine their role in the complex issues of unequal care and unconscious bias.” Vidya Viswanathan, a medical student at Perelman School of Medicine at the University of Pennsylvania, suggests that medical schools should start supplementing their curriculum with implicit bias rounds where medical students, residents, and attendings should discuss cases “in which bias may have altered the care of a patient.” Like other complications that may have compromised a patient’s survival, implicit bias should also be formerly considered and discussed within practitioners to reduce unequal treatment based on race or ethnicity.

In an observational study that tracked the implicit bias of 3,547 medical students across 49 U.S. medical schools, curriculum relating to “health disparities and minority health, racial climate” and increased interracial contact during school reduced implicit bias of the students. Students were prompted to complete the Black-White Implicit Association Test and questionnaire during their first and last semester of medical schools. The study found students that regularly heard “negative comments from attending physicians or residents about African American patients” had a significant increase in the predictors of increased racial bias. Physicians may learn to perpetuate negative racial stereotypes while in medical school. In order to most effectively combat the issues of implicit bias in future physicians, medical schools can foster an environment in which students can practice self-evaluation and educators can facilitate discussions about the effects of unconscious bias.

However, there is a caveat to drastic interventions for implicit bias. Research shows that “intentionally trying to suppress bias may actually make it ‘rebound’ at a later time,” making it difficult to determine to what extent the intervention should be implemented. After the Institute of Medicine (IOM) discovered the presence of health care disparities due to bias, raising awareness about unconscious bias was their one and only solution (11). But simply raising awareness may not be enough to reverse the decades of injustice. Initiatives to increase awareness among healthcare providers may not have worked as planned. The study states that raising awareness about unconscious bias could encourage physicians and health care providers to become more observant in how they treat patients. However, mandatory diversity training programs at over 800 companies proved to be essentially counterproductive and “did not have a significant effect on prejudice levels.”

Although it may seem overly simplistic, it is nonetheless important that physicians also have the volition to reduce such implicit bias. Healthcare institutions should make sure that physicians are actively doing everything they can in their power to reduce the effects of implicit bias. In a social psychological analysis to reduce racial healthcare disparities by Dr. Louis Penner, a population science professor at Wayne State University School of Medicine, states that physicians “can reduce disparities by individuating patients and using patient-centered communication.” Patient-centered communication relies on establishing a relationship of trust and clear communication between the physician and patient. These factors may not only lead to a better quality of clinical interactions, but also better health outcomes (12). Another plausible addition to the solution for large healthcare systems is treatment standardization. Through standardized treatment, hospitals can gather information about treatments and outcomes so that it can reveal racial treatment disparities and “reduce unwarranted racial differences in treatment decisions.” Assessing such disparities can further the development of evidence-based interventions that may reduce disparities in treatment. 

The legacy of the prejudice that oppressed African Americans during slavery and the Jim Crow era exists in today’s health disparities and implicit bias within the healthcare system. The foundation of health disparities lie in negative stereotypes perpetuated by structural injustice. In order to most effectively provide equitable care, policymakers should create programs that educate medical practitioners about health disparities that arise because of implicit bias and rectify programs that perpetuate negative racial stereotypes. Educational intervention on health disparities due to structural injustice should begin early in medical practice and should facilitate meaningful dialogue about how it promotes medical bias. Without addressing the on-going history of social and economic inequality, progress towards eliminating implicit bias cannot be made.

Edited by: Sophia Xiao
Illustrated by: Haley Pak

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