The Role of Implicit Bias in Diagnostic Inequities
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In this program:
What is the role of implicit bias in diagnostic inequities? Medical laboratory scientist Dr. Kyle Riding discusses implicit bias, social learning, and solutions to improve health outcomes.
Transcript
Interviewer:
What role does implicit bias or stereotypes play in contributing to diagnostic inequities in your opinion?
Dr. Kyle Riding:
So that is a wonderful question, and I want to start by talking about the fact that with implicit bias, if we're going to talk implicit bias, we need to de-stigmatize it so folks accept that it's there, and we need to show ourselves grace. Obviously, knowing you have an implicit bias and carrying that forward, no, no, no, no, no, we don't do that here, okay? But we are social creatures. We're individuals existing within a society, and we learn from each other. And so sometimes social learning is a really powerful thing and a really positive thing, all right? We learn different social cues and different knowledge through that social learning. However, it can also lead to things like implicit bias that cause negative health outcomes, and we don't want to see that.
So the first step in addressing the implicit bias is recognizing our own, okay? It's showing ourselves the grace to sit back and say, "You know what? I'm not perfect. I too will carry implicit bias and can inadvertently harm patients if I don't work to address it." So, for example, I kind of want to tell a story on this one. I have a friend. She recently had extreme menstrual pain and quite a lot of bleeding relative to her norm, okay? She is approaching the age of perimenopause, but she's a medical professional so she knows this is not normal. She knows that the pain and the bleeding she was experiencing, this is not normal.
So she goes to her physician, and this physician is a male physician. And unfortunately, this male physician just made an incorrect assumption. He said, "Oh, this is normal. This is a normal part of perimenopause." And my friend, again, having that knowledge of being a medical professional said, "No, no, no, no, no." Your average consumer may not know that, folks, so as medical professionals, we need to reflect. We need to be the ones to say, "Oof, I should have caught that, I should have paid attention." So she went to a female provider and an underlying anatomical issue was identified and managed because of seeing that second provider.
So was that first physician a bad person? Were they incompetent? I'm going to say, you can't determine that by this one case. Maybe they are, maybe they're not. This is one case where they had an implicit bias. And we as healthcare professionals need to take it upon ourselves, he should have taken it upon himself, to challenge himself in that moment and question if that bias was there or not. So tackling implicit bias is hard, because it's rooted in that social learning and it's implicit, as the name says, so it's not a conscious lack of caring. It's not a conscious lack of competence.
However, one technique that I heard one time that I really, I really loved; I thought this was a really cool technique. And again, this may not be applicable in all care sections, but if you are trying to understand your own implicit bias, when you're seeing patients and you're looking over a case, change or remove some of the demographic information in your head. In your head, just instead of saying, "This is a 45-year-old female," say, "This is a 22-year-old female." Okay? Would your care plan change? Would your approach to diagnostic follow-up testing change? And if the answer is yes, there may be a very good biological reason. Cool, go with it. That difference in age, there are some things that change over time and as we age, and that's reasonable.
However, if your answer changes, and you don't have a biological basis, you have found one of your implicit biases that you need to examine and say, "Okay, I know it's here, I accept that it's here, but now I need to tackle it." Okay? So that's where the showing yourself grace comes in, that's where the understanding you're not a horrible person, that it's there, but you need to address it. Because if you don't, you're not fulfilling your oath that you do no harm.
Interviewer:
And although this is really great advice for providers, this is information for everyone, for patients to take into consideration when they're with a provider as well. So do you think social determinants of health such as income, education, insurance coverage, all of these things, you think they can contribute to inequities and accessing or even receiving timely diagnostic tests?
Dr. Kyle Riding:
I'm just going to dive in and say, I don't think it, I know it. And there are a lot of evidences to support that. Social determinants of health like the ones you listed, play a major role in health inequities. When you look at our society in the United States as a whole, our life expectancy has been mostly going up where a more healthy society than we've ever been. However, in a lot of those health gains...and we're seeing a lot of health losses in individuals without the means to access them. So let's talk about socio-economic status here. Folks who have a lower income are less likely to have jobs that give them health insurance, less likely to have access to care providers because care providers may not be able to thrive in a practice setting where there isn't a clientele base that..unfortunately, healthcare is a business. And if there's not a base of insured individuals, they may not be able to make ends meet, and they're less likely to have patients with lower income, may not even have means to get to the healthcare appointments. They maybe don't have a vehicle or reliable transport, and they may live in an area that doesn't have good public transport. So they're going to have a lack of access to not only physicians who can prescribe lab tests or diagnostic tests and medicine, they're not even going to have access to a phlebotomy draw station to have the lab tests done in some instances.
So the other piece is education. And education is another major predictor. There have been dozens, if not hundreds of studies relating education to access to healthcare and positive health outcomes. This relationship is more complex, but typically relies on the fact that education will usually get you a higher paying job, that gives you access to health insurance, access to reliable transportation, access to medical offices and hospitals, and less exposure to risk factors for chronic diseases. And that education, your education could have nothing to do with healthcare whatsoever, but through that process of becoming more educated and attaining credentials in any field, you develop critical thinking skills that can be applied to your own health behaviors, and so you tend not to smoke, you may not drink as much, and those health behaviors influence.
So in terms of action items as medical professionals, something that we need to do, it's critical that we use our voices as learned professionals in medical space, talk to policymakers, build health systems that take into account social determinants of health with meaningful and impactful outcomes that can occur. And at our own healthcare facilities, in our own backyard, we are responsible for examining patient outcomes and identifying health disparities amongst those that we care for, and making sure that we leverage our facilities’ power to improve the health and wellness of those communities that we serve regardless of income, regardless of education. Because that's what we got into medicine to do, let's leverage those professional settings that we belong to to make that happen. Healthcare is a business, there's money in business, let's make sure some of that money goes to the folks that really need it so we can work on these disparities.
Interviewer:
And I also want to add to what you were saying with education. So having a greater income and education can also kind of link towards patients having better self-advocacy skills. I've noticed those patients with lower socioeconomic statuses are usually more likely to kind of not speak up for themselves when they're in the face of a provider or someone that's of a higher status in their opinion. So it's interesting to see that not only do these lower SES statuses of patients and less insurance coverage has more obvious contribution to their access to care, but also in a sense for the patient themselves, how they think of themselves and how they communicate and connect with the provider that's of a higher socioeconomic status than they are, that also really relates to the communication that they even have with their providers altogether. So it all really ties together, unfortunately.
Dr. Kyle Riding:
When you were saying that, I actually think of my parents. My parents, actually, they graduated high school, and that's as far as they went. They have me as one of their children, my sister is a lawyer that's general counsel for a senator. And so they've two kids that have succeeded in the educational landscape. My mom tells me all the time, she feels when she goes into her doctor's office, "What do I know? Who am I?"
Interviewer:
Right, exactly.
Dr. Kyle Riding:
And I tell her, I'm like...
Interviewer:
You're the patient. [chuckle]
Dr. Kyle Riding:
“You're the patient. You're part of this team. You know your body better than anyone. That physician may have gone through a ton of education, and they are very smart people, and they're wonderful trying to help you. But you are the smartest person about your body.” So one more actionable item, stop telling patients they're crazy for knowing their own body, even if you think it. Because, of course, we do have some patients that sometimes may not want to be...
Interviewer:
Hypochondriatic, but still...
Dr. Kyle Riding:
Yeah. Well, they may just not want...they may not like the answer. They may not like the reality of what's going on. Medicine in its modern form has its limits on what we can identify and detect, but don't tell them they're crazy. Don't tell them they're wrong. Just find a different way to deliver that message and work through their anxieties with them.
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