How Can Unconscious Bias Lead to Misdiagnosis?
More Programs and Publications Featuring Dr. Brandy Gunsolus
In this program:
How can misdiagnosis result from unconscious bias? Laboratory medicine scientists Dr. Brandy Gunsolus and Dr. Dana Powell Baker share their perspectives and personal experiences with bias.
Transcript
Dr. Dana Powell Baker:
And that actually touches on something that actually happened with me a number of years ago where I went to a physician complaining of feeling lightheaded, tired, sluggish, not sure exactly what was going on and their immediate diagnosis before any blood work, I think we only talked maybe two minutes was, "You must have diabetes." I was like, "What made you jump to that? We haven't done a glucose. We haven't done...you haven't even done a physical assessment on me yet." They're like, "No, what you have... "
Deandre White:
Did they even know your medical history at the time?
Dr. Dana Powell Baker:
No.
Deandre White:
Okay.
Dr. Dana Powell Baker:
No, this is a new visit, new patient visit.
Deandre White:
[chuckle] Okay.
Dr. Dana Powell Baker:
And they're like, "Well, based on your ethnicity and your weight, it must be diabetes." And so, she was even very direct in what she felt was going on with me. And so I was like, "Well, go ahead and take my glucose right now. I'm going to tell you it's normal, and I do not have diabetes." I'm like, "And if you want to take it a step further, let's do it.” And so, of course, everything came back, normal range, that would otherwise be increased or elevated and patients diagnosed with diabetes. I did not, still don't have diabetes. But see, but because of that fixation and the way she jumped, she didn't assess me for anything else. And so, I actually had to follow up with a separate physician.
Deandre White:
You make it harder to solve the problem.
Dr. Dana Powell Baker:
Yeah, I didn't I didn't leave there with a resolution or a treatment plan, because she refused to talk about anything else and just said she knew that stuff would come back and spoke to only that diagnosis.
Deandre White:
Yeah. Then it...
Dr. Brandy Gonsulus:
I have...
Deandre White:
Oh, go ahead. Sorry.
Dr. Brandy Gonsulus:
I've actually had a very similar experience to that. A number of years ago, I had started getting these excruciating migraine headaches and I was having numbness and tingling in my hands and feet. And so, I was referred to a neurologist and the neurologist never looked at me in my eyes, just sat there and was typing on his laptop. And he told me that the reason that I was having all of these issues was because of my weight and that gastric bypass would fix all of those issues for me. And I'm like, "I've been overweight my entire life. This just started.” And it turned out, didn't go to him again, obviously, [laughter] went to another neurologist and I had an autoimmune condition that was causing all of the problems. But I mean, he took one look at me and it was, "Oh, gastric bypass will fix your issues."
Dr. Dana Powell Baker:
That's another example of unconscious bias.
Deandre White:
Not only that it'll fix your issues, but you're heading towards a very expensive and complex procedure that you don't even need.
Dr. Brandy Gonsulus:
Right.
Deandre White:
That can cause more issues. Oh, you were saying something, Dr. Baker, I'm sorry.
Dr. Dana Powell Baker:
No, you're fine. I was just saying that's just another example of an unconscious bias that can creep in. And unfortunately, as you asked us earlier, strategies that can be implemented. I think, of course, continuing education is very important. I'm glad that for most of us that do hold a board certification or some form of medical license, we are required to have continuing education. But I think that's immensely important to have that not just from a kind of national meeting or conference dance, but also within each respective institution. We should be responsible for that continued training and competency for our for those individuals who are in practice within that institution. And I think that's something in terms of professional development that should be modeled and championed and supported because that's going to impact your patient ultimately. And so, if you want to preserve and maintain that quality of care that is comprehensive and holistic, we need to be invested in professional development, ongoing professional development rather, for our practitioners.
Deandre White:
Yes, and not every patient is Dr. Dana Baker or Dr. Brandy Gunsolus that can actually stand up for themselves and be their own advocate for their health and say, "No, I do not have diabetes. No, I do not need a gastric bypass." But not every patient is in that position and will immediately follow whatever instructions are given to them. So, it's just very important for providers to take that holistic route and look at the whole patient and look at the whole chart as they're supposed to actually do appropriate testing prior to making these assumptions. So what research priorities should be established to further investigate the intersection of lab values and ethnicity, including studies of genetic determinants, environmental exposures, health care access and health disparities?
Dr. Brandy Gonsulus:
We could probably talk an hour just on this [laughter] topic itself. But to kind of shorten it down. One is to make sure that when we're doing research that we do have a diverse patient population that we're looking at, that we're looking at all potential variables. I remember that I was editing a chapter for a textbook and in this chapter of previous version of it, and it stated that African American children are always anemic compared to Caucasian counterparts.
Deandre White:
What does that even mean? [laughter]
Dr. Brandy Gonsulus:
And I was like, but this is just a blanket statement. It's not even taking into account socioeconomic status. It's not taking into account dietary status, access to healthcare. And we know that minorities overall have a much more difficult time getting access to healthcare and having access to nutrition and tend to have a lower overall socioeconomic status compared to the rest of the Caucasian population. And just to make a blanket statement, in a textbook, no less that this was due to ethnic variation. I was horrified. I'm like, no, no, no, no, no. Completely rewrote the whole thing, because you can't make statements like that if you haven't looked at all of the variables. And what we've seen in research is that the ethnicity is not the issue. It's everything else that factors into it. If those children had access to all of the food and the lunches, because they're...that the rest of the population does, if they had access to all the healthcare that the rest of the population does, that they have access to everything else, [laughter] would they be anemic? My assumption is, no, they wouldn't.
Dr. Brandy Gonsulus:
But I mean, or if they had chronic lead exposure, that can cause anemia because they're living in conditions where it still has lead paint. There's so many different...then that's environment exposure, there's so many different things that has been published previously that is just, it's wrong. And we're having to debunk all of these things, do more research to prove all of that's wrong, and then try to find the real issues that are going on at the same time.
Deandre White:
Right. Speaking of textbooks, my 9th grade biology textbook, I remember it said "Sickle cell disease in African Americans is prevalent in, I forgot the percentage, but it's like 15 percent of the population.” That's all it said, is this percentage of African Americans have sickle cell disease. And that was, I mean, unless it was a 9th grade textbook, but that's just starting from a younger age, just teaching you the wrong thing. And if you don't go to secondary school, if you don't go to college or if you don't get a further education of these things, you may always think that. So yes, textbooks need to be corrected. [chuckle] Do you have anything to add, Dr. Baker?
Dr. Brandy Gonsulus:
I'll just add that as we discussed, of course, inclusion of more underrepresented populations in research, that we also need to probably take a step back and even look at rebuilding trust with our underrepresented communities, because there is a lot of mistrust there when it comes to medicine and when, especially when it comes to laboratory testing and research. And we would be remiss that if we don't mention studies such as the Tuskegee experiment and other instances over history, that is not that long ago actually, if you do the math, it's pretty recent and relevant and a lot of memories and lived experiences or a lot of individuals who are connected or a part of these communities. So, I think it's really important to really share the why, why it matters that underrepresented populations are more included in research. What are the safety measures and parameters in place to ensure their well-being as a participant in those studies? And to really just acknowledge the history that is there. And in that acknowledgement, respecting that there may be some hesitation or there may be some negative feelings there regarding that.
But I think by really being able to demonstrate the value of their participation, how it will not only increase the wellbeing of themselves as individuals, but also the wellbeing of their communities. I think that with big volume, how is this advancing health equity? How is this helping to eliminate or diminish health disparities? How is this increasing access to resources that are essential to marginalized communities? And so, we need to talk about all those benefits and make sure that we are taking the time to address their concerns so that that way, and I say they, but that also includes me. I'm part of that underrepresented population. And so, making sure that there is that shared understanding and that shared mutual respect and trust so that we can increase that engagement, but also increase that education as well of what we're doing while we're doing it. What that overarching goal or end goal that we're really striving toward with this research. So those discussions are really important. And identifying those allies and community partners to help support that increased engagement in research will also be crucial to this work.
Dr. Brandy Gonsulus:
Absolutely.
Deandre White:
Oh yeah.
Dr. Brandy Gonsulus:
Couldn't agree more.
Deandre White:
And I work with clinical trial patients, so I will definitely say that education and trust is literally everything from the screening onward.
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