What Is the Impact of Unconscious Bias on Laboratory Diagnostics and Health Outcomes?
Expert Dr. Marilyn Bibbs Freeman from Virginia Department of General Services Division of Consolidated Laboratory Services (DCLS) discusses unconscious bias, some impacted patient groups, and solutions toward improved health outcomes.
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In this program:
Can unconscious bias impact laboratory diagnostics and health outcomes? Expert Dr. Marilyn Bibbs Freeman from Virginia Department of General Services Division of Consolidated Laboratory Services (DCLS) discusses unconscious bias, some impacted patient groups, and solutions toward improved health outcomes.
Transcript
Interviewer:
So, Dr. Freeman, can you discuss any specific research studies that have explored the impact of unconscious bias on laboratory diagnostics or patient outcomes? And what were the key findings of these studies? What steps can be recommended to address such biases?
Dr. Marilyn Bibbs Freeman:
Recently, I read a journal article by Jasmine Marcelin and her fellow research associates. It was a peer-reviewed journal article from the Journal of Infectious Diseases. And she's really looking at the impact of the lack of diversity in healthcare professionals. And how by increasing diversity, we can help mitigate unintentional cognitive biases that are derived from the cultural stereotypes and eventually become the root cause of the inequities that we are seeing in health settings. These inequities the authors say, can be visible in medical school admissions, clinical interactions of a doctor with the patient hiring and promotion of laboratory professionals and personnel, how different professionals across specializations interact with one another. Because, if you go to your general practitioner and you suddenly have high blood pressure, but maybe you also now have a heart condition too, your general practitioner is going to need to work very closely with your cardiologist.
How do they interact? And do they do it well? Because their interaction really determines how your health outcome may look. The authors go on to talk about the importance of diversity in research. If I was in a setting where everyone in the room was majority class, but I'm asking them to make decisions and do research for something that affects my community, what is the likelihood that everyone in that room is well-versed enough to understand what the needs of my community may be? But they're the ones driving the research. So there needs to be some type of interconnectedness between the people doing the research and the people that are going to be the receivers of the services that the research supports. And so we need diversity, we need engagement, we need allyship, we need advocacy across professions as well as across research and decision-makers to make those things, even in treatment decisions.
So I'd love to use my mother as an example. Please don't tell her if you see her, but she's at an age where she needs to have me or someone we love accompany her to the physician, and she has high blood pressure. And so we go to the doctor's office and her blood pressure's not controlled, though she's on I believe two medications. Doctor looks at her blood pressure, looks at her chart from a year ago and says, okay, we're just gonna give you another pill. And she was like, “Okay, thank you.” And so I said, “Let's pause for a second.” And I began to ask the physician questions. I said, “Are you going to ask her about her diet? Oh, well, well, Ms. X, what are you eating for breakfast? What are you be eating for lunch?”
Obviously, she ran down a list of non-heart healthy foods I said, “Are we going to talk to her about exercise?” “Oh, yes. Let me ask her about exercise.” I had to be there to be my mother's...
Interviewer:
…advocate.
Dr. Marilyn Bibbs Freeman:
Advocate so that she didn't just get another pill and I wonder how often that happens. And so, having people that are diverse and knowledgeable of our communities becomes very, very essential. A lot of times, the way we've stereotyped diseases has hampered research and using HIV is another tangible example. In the ‘80s, it was a disease supposedly of white gay males that stereotype prevented research into communities of color, women, children, and other important populations. Had we recognized that sooner, could we have had a leg up on treating HIV and battling that particular crisis. So the authors of this particular journal article recommend a few things, and they put it into three buckets.
Things that organizations can do, things that the individual can do, or things that both the individual and the organization can do together. And from the organizational standpoint, they believe that leadership needs a commitment to cultural change and understanding. They also believe that agencies and companies need to have meaningful DEIA training, not just something that checks a box, but something that can be utilized, understood, and applied for the individual. They really promote self-reflection. That's hard. Self-assessment is hard. Some of us can't do it well, some of us do it well and don't want to hear the outcome. There are so many different reasons that make self-reflection very difficult. But change can be a really good thing. And I think it's worth a try if we are going to improve the health outcomes of patients and the people that we're serving. Individuals can also question and actively counter stereotypes.
If I hear someone now say that HIV is a disease of gay white males, I know better, and I now know how to have an intelligent conversation and say, no, that is not the case. We saw the same thing with the recent monkeypox outbreak. Oh, let's focus on homosexual activity. No, everyone can get monkeypox. Let's focus on the communities as a whole. Individuals and organizations can learn to be better mentors and sponsors of underrepresented or marginalized communities. We can work to exhibit cultural humility and curiosity, and then also we can intentionally diversify our experiences and what they meant by that. Because I had to do a little more reading and it's one of my favorite journal articles but what she really meant by that is, how can I learn about you to make the best decisions for you, if I haven't even tried to know you?
Interviewer:
Exactly.
Dr. Marilyn Bibbs Freeman:
Exactly. So put yourselves in those spaces, learn people have great curiosity and respect, and then use information that you're learning to make a change in equitable or that will help support equitable health outcomes.
Interviewer:
Right. I'm going to copy what you did and talk about my mom too. Because hopefully she doesn't see this either. But she has, I guess, one of the more common diseases in America. Diabetes that's a very expensive disease to have if you have to take insulin but when I was a kid, I used to go with her to her doctor visits. And when I would go with her, and these are things I didn't notice until like I got older and started working in healthcare. But when I would go with her, they would have a very brief visit. They would go through her labs briefly, not really explain a whole lot of it. I didn't totally understand at the time either. And I'm pretty sure she didn't either and then they say, okay, well your A1C is a little bit highTer. Okay, your hemoglobin's fine.
This is fine. This is fine. Your, your glucose, though it still seems like you're not really controlling it. I'm going to up your insulin, I'm going to up your insulin aspart (NovoLog) or up something. And she was just like, okay. And that'll be it. And then we would go home, we'd go to one of the pharmacies, get the medication on the way home, usually pretty expensive. And then that would be the end of it until the next checkup in a few months. And it wasn't until like I got older that I realized, “Mom, why didn't you ask him why your A1C was so high? Why didn't you tell him, ‘Hey, my ankles had been swelling more at night.’ Why didn't you tell them that? Oh, well you actually don't get that much sleep because you work two jobs.” Like, these are things that were never really discussed.
And they probably could have been very helpful from an educational standpoint, prevention, prevention to help her in terms of not having to add another insulin. She's on three different insulins right now, but at the time, I think she was on just two. But it was just...it can be very frustrating, especially when you're a child, and you don't have the knowledge to be able to advocate for someone who's not advocating for themselves. So, having an advocate in those spaces can be very important. And having an unconscious bias is very important too. And acknowledging it is very important as well.
Dr. Marilyn Bibbs Freeman:
Absolutely. You bring up actually another topic, or not another topic, but kind of an offshoot of the same conversation, which is health literacy. In the past, when we're talking about health literacy, it's always been talked about as if it was the other person's responsibility. It's the patient's responsibility to understand what is happening to them. And we're seeing a shift. Now, you can actually refer to the Healthy People 2030 document where it's saying, health literacy is not just the responsibility of the patients, it is also the responsibility of the medical provider. And so you need to provide information in a way that is digestible and understandable for the communities that you're providing services to. Otherwise, how do you get their buy-in to be compliant with.
Interviewer:
Exactly.
Dr. Marilyn Bibbs Freeman:
Treatment. So yeah.
Interviewer:
And sometimes compliance or a lack of compliance is confused with just the lack of education. So...
Dr. Marilyn Bibbs Freeman:
Absolutely.
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