How Doctors Can Confront Implicit Bias and Systemic Racism

Race and ethnicity play an important role in health outcomes, and that has become much more apparent in the midst of the coronavirus (COVID-19) pandemic. According to the Centers for Disease Control and Prevention (CDC), Black Americans, Hispanics and Latinos, and Native Americans are among the groups with the highest rates of hospitalizations and death due to the virus.

Systemic racism in all of its forms is at the heart of this disturbing reality. Communities of color struggle with a number of socioeconomic factors that contribute to poorer health outcomes, including on-average lower incomes and rates of health insurance coverage which can affect access to the health care system. But communities of color also face bias within the health care system and can receive lower quality of care as a result. Research shows that Black Americans are more likely to receive lower quality care for health services such as cancer and H.I.V. treatment, prenatal care, and preventive care. They are also less likely to receive cardiovascular disease treatment.¹ This lower quality of care is pervasive even when the insurance status, income, age, and severity of the health issue is comparable to white patients.²

For those living with lupus — a disease that disproportionately impacts women of color — this can be a profoundly damaging reality of their day-to-day interaction with the health care system. The lower quality of care they are provided with can lead to longer time from symptom development to diagnosis, misdiagnosis, ineffective or damaging treatment, and heightened stress that can exacerbate symptoms of lupus — all of which can have potentially deadly outcomes.

It is absolutely necessary for health care professionals to become aware and actively work on uprooting the systemic racism within the health care system and their own implicit bias that negatively impacts their patients' outcomes. Below are some ways you can commit to that work.

Uncover and dismantle your implicit bias

Research shows that medical students and residents hold false beliefs about the difference between Black people and white people's bodies — a recent study published in the Proceedings of the National Academies of Science revealed that 40% of first and second-year medical students believe that Black people's skin is thicker than white people's skin. Study participants who held false beliefs about Black people's bodies rated their Black patients' pain as lower and made less accurate treatment recommendations.³

In the context of a lupus diagnosis, a Black patient may complain of experiencing extreme fatigue but because of implicit racial bias, their doctor may not take it as seriously as they would a white patient. That can result in the Black patient's life-saving diagnosis to be delayed often until more serious symptoms arise.

All of your patients, regardless of race and ethnicity, have an intuition and understanding of their own body that should be honored by the health care professionals treating them. It is important to know that bias exists both in individuals and systems and to think about the ways this may affect your patients.

Acknowledge your patients' potential financial barriers

For most people in America, particularly those with chronic health conditions like lupus, health insurance is necessary in order to ensure they are able to pay for both primary and specialized care. Many Americans receive their health insurance through their job, but Black Americans experience higher levels of unemployment or employment at jobs that do not include health care within their benefit packages than white Americans.⁴ This crisis has heightened during the COVID-19 pandemic that has left millions of Americans unemployed, many of whom relied on their jobs for insurance for both themselves and their families.

Although you are limited in how you can assist with this reality, simply acknowledging in a respectful way that a treatment option may be difficult for your patient to agree to based on its financial burden can help your patient feel like you understand their experience. Direct them toward resources, such as organizations that can help them access low-cost and free medical care or organizations that can offer assistance with prescription medication costs. There are also organizations that can provide assistance with transportation to medical care, housing and utility assistance, and financial planning.

Provide diverse resources

The resources you use in your office to help explain important concepts to your patients should be diverse in language, cultural competency (meaning the resources speak to cultural norms that may be a factor in your patients' lives), and imagery. Patients should feel represented in those resources — this allows them to feel more connected with the information and more likely to take it seriously as it relates to their own lives.

Accommodate patients' language barriers

For many patients, English is not their first language and that often makes access to effective health care more difficult. It is important to remember that patients have a legal right to an interpreter and language barriers should not prevent them from receiving the best care possible. The practical realities faced by health care providers in daily practice can make this challenging, but doctors should plan ahead to accommodate their patients' varying languages as best they can.⁵

Do your best to hire a diverse staff that represents the diversity of your patients so that there is someone who can potentially translate for patients when they come into the office. Use medical interpreters when necessary and write down or type up all the important information and instructions so your patients can translate it at home. Although asking family members to translate medical information or during appointments is sometimes necessary, it should be avoided whenever possible. The family member may not understand the information they are translating or the patient may not feel comfortable speaking to the doctor about health issues through a family member.

Use plain language

Plain language is the use of everyday language to break down complicated medical jargon and make health education more accessible to the general public. Not only should your in-office resources be in plain language, but your communication with your patients' should be in plain language. You can ensure your patients understand all the necessary information you are providing them with by:

Talking slowly and clearly, looking for cues of confusion in your patients' body language. If you note any confusion, stop and ask what they need help understanding.
Focus on what patients need to know and what they need to do.
Writing down and defining any medical language you use to describe their condition so they can refer to it later.
Repeating information if necessary.
Use the Teach Back Method to ensure agreement and understanding. For example by saying, “I want to make sure that I have explained everything clearly. Can you tell me in your own words what our plan is and what you need to do?”
Taking notes and reading it back with them to make sure they understand the information as you have written it out.

The Agency for Healthcare Research and Quality offers a health literacy toolkit that can help you communicate more effectively with all of your patients.

Increase your cultural competency

There is a large historical context that has created mistrust for the health care system among communities of color, with Black Americans in particular bearing the weight of this history.⁶⁷⁸⁹¹⁰ This has resulted in less participation in preventive care, a longer time from symptom development to diagnosis which leads to less effective treatment, lower rates of vaccination, and less participation in clinical trials among Black Americans. All of these factors contribute to the poorer health outcomes and higher rates of death due to chronic illness among Black Americans.

It will take a long time for the health care community to rebuild trust within the Black community and other communities of color, but this trust is vital in order to strengthen the health outcomes of marginalized groups. Cultural competency from doctors and their staff is at the core of this rebuilding process. You can increase your cultural competency by:

Actively seeking knowledge and education about varying groups' experiences to understand their sentiments and fears surrounding the medical community.
Having frank, candid conversations that allow your patients, particularly those who are marginalized by the health care system, to express their concerns toward you, their treatment options, and the health care system as a whole without you being dismissive and defensive.
Acknowledging and validating your patients' concerns, while also providing them with the best information possible to help them feel more comfortable with your recommendations for treatment.
Being warm and friendly in order to facilitate a space where all of these conversations are possible.
Creating a running list of the concerns you hear about frequently from varying groups so you can do your own research to best address them when they arise with another patient.
Educating your staff on cultural competency and the ways they can use it in their everyday interactions with patients.