[Yellow Cohort] Module 2, 2018-19

[Nabil Al-Kourainy]

Please submit your Reflections/SOAPs for Module 2. Thank you.

[Nabil Al-Kourainy]

Physicians and Implicit Bias: Reflection

Subjective:
As physicians we see patients from all walks of life, ethnic backgrounds and socio-economic positions in our society. While one must strive to insure that each patient is treated solely as an individual, the reality is that all of us are human beings and have been preconditioned by society to approach patients, especially ethnic minorities with preconceived notions. As society preconditions us to do just that. Take for example how blacks are portrayed on television or movies. Blacks are usually associated with violence, drugs, usually engaging in criminal activities. This has been the case since the beginning of television. In fact, it was not until the Cosby Show, that blacks were featured on television as professionals, with Dr. Cosby an OBGYN and his wife Mrs. Cosby an attorney. Despite the successes of the Cosby show blacks continued to be featured mostly as criminals. This has in turn perpetuated stereotypes and the reality is that more blacks are incarcerated than whites. Minorities are also assumed to have poorer health literacy and pay less attention to their health than whites.

Objective:
Prior to beginning my practice of medicine, I recognized that I possessed some unintentional bias toward black individuals in particular. I questioned myself, and why I had these biases. Was I racist? I certainly did not harbor any ill will or feelings of hatred toward these individuals. Despite that, I recognized that I had pre-conceived opinions of black individuals even before ever seeing them. Why was this? As Devine described in Chapman et al, these biases are “automatic (implicit) and controlled (explicit) aspects of prejudice.” They are “unconscious” and “often differs from explicit beliefs”. I was encouraged to read from Chapman et al that “knowing about a stereotype distorts processing of information about individuals.” I learned that “research supports a relationship between patient care and physician bias in ways that…perpetuate health care disparities.” And, that “…negative perceptions could…reduce adherence, return for follow-up, or trust…” therefore perpetuating health care disparities. This knowledge encourages me because it means that I can do something about these pre-conceived notions when addressing these patients. The physician must fight these implicit biases, recognize that they are there and train through repetition himself/herself to approach each patient as an individual, rather than allowing stereotypes to affect the delivery of care.

Assessment:
While Chapman et al did an admirable job illuminating the existence and origins of implicit bias, I feel that the article was lacking in effective strategies to combat these biases, other than making the reader cognizant of them, and asking the reader to essentially try to put himself/herself in the patient’s shoes. In contrast, the Devine article which Chapman et al referenced entitled “Long-term reduction in implicit race bias: A prejudice habit-breaking intervention (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3603687/#!po=34.7328) makes a valiant effort to arm the reader with strategies that he/she may employ to counteract these biases including stereotype replacement, counter-stereotypic imaging, individuation, perspective taking and increasing opportunities for contact. These strategies have the potential to counter-act some of the biases that many physicians have. Individuation for example focuses on educating oneself with specific information about an ethnic or socioeconomic group, with the goal being that with more knowledge of their story, one may empathize rather than judge.

Plan:
After reviewing the aforementioned articles, it is clear to me that I possess unconscious bias towards patients. I have been influenced by the media and entertainment industries to see the differences in people first, rather than our commonalities. As a physician to address these implicit biases, I make efforts to try to treat all patients the same at baseline. I can listen to their concerns, and obtain historical information, that to the best of my ability is free from judgement. Then, I can be a professional, and treat their medical ailments just as I would for any other patient. Making efforts to treat the patient and their condition, regardless of their socioeconomic status, ethnicity or previous history. By treating my patients with care and compassion, while I may not be able to eliminate the biases that I inherently possess, I can ensure that those biases are not manifested in my care of patients.

[John Dawdy]

This week’s topic was bias within medical care. The article focuses on describing the difference between explicit and implicit biases that not only physicians but all people have. That despite conscious beliefs indicating one way of thinking that subconscious learned responses to patient characteristics such as race, age, weight, socioeconomic status can impact the way that we as physicians interact with our patients. That despite our best efforts physician decision making can be influenced by these biases and have the potential for impacting patient outcomes. The article focuses on using objective evidence in order to illustrate that despite their best interests and outward altruistic intentions that physicians are still susceptible to being influenced by these implicit biases. They outline a number of interesting studies, but one caught my attention specifically. That Hispanic patients receive significantly less analgesics in an emergency room compared to non-hispanic patients; the authors use the explanation that Hispanics have a stereotype of being less stoic than other groups and have their pain underestimated due to the thought that they are exaggerating their suffering. This example not only help inform of the necessity of an awareness of these biases but make me question my own care practices. With this article in mind I have been reflecting on my own implicit biases and how they might be impacting the care that I provide to patients. The week prior to clinic I had a patient while I was on MICU that presented after leaving from another hospital AMA with incomplete treatment of infective endocarditis because she felt that she was being treated as an addict and that her IV drug use led to her health care providers minimizing her complaints. The bias’ of her physicians contributed to her not completing her therapy and progression of her disease process to a higher level of severity, and made me reflect on other similar situations where I may have minimized or brushed aside patient concerns and whether my reasoning was justified or reflected similar bias. Reflecting on the topic of implicit bias is an excellent reminder for physicians to check their own practice methods. Do our learned beliefs, whether explicit or implicit impact the care of our patients? How can we minimize this to most effectively provide equitable care to all the patients that we see. These are important questions and I think that simply being aware of these biases is the first, but not final, step in providing the best care that we can. Future steps are not to simply be aware of these biases but to frequently stop and think about whether we are being influenced by them during our everyday practice. This is easier said than done in the fast-paced, pattern recognition heavy practice of medicine, but an important goal none-the-less.

[Jie Chi]

Subjective: This week’s topic is about physician bias. Why bias occur despite well-intentioned providers? When faced with the need to make complicated judgments quickly and with insufficient and imperfect information, we rely on assumptions sometimes, associated with a patient’s social categories to fill in the gaps with information that may be relevant to diagnosis and treatment. This could be unconscious, which results in bias and therefore disparities in treatment, even when we are attempting to be objective.
Obejective: biases, whether conscious or unconscious, the bias could be particularly toxic in medicine, as they could lead to inequitable care and worsen health disparities. This does not mean that physicians express overt sexism, racism, or others forms of bigotry but rather that these unconscious beliefs about others can influence the kinds of treatments that they offer. Thus, bedside rationing can violate one of the cardinal principles of fairness, that clinically similar situations be treated similarly. So doctors could offer one patient with unstable angina with cardiac catheterization and stents, while offering just medical therapy to an African-American patient.
Assessment and plan: Physician bias is neither the sole, nor necessarily the main, factor contributing to such disparities, however, clinicians’ unconscious biases can amplify the cultural and background disparity in real life. We should always consciously look inward and self-reflect rather than memorize data to remind us never assume that we have mastery of a patient’s culture. We need to endorse sharing of learning, as well as communication among all members of the care team, so we are able to help each other see where bias may have entered into a decision and how they can be avoided in the future.

[Shivani Agrawal]

Bias is an important issue in medicine. We had a good discussion in clinic about experiences and talking about the article. As I mentioned during our meeting, I was surprised on how several female celebrities were treated during their experiences with child birth. Our patients are subjected to disparities in their health. It can be very challenging for them to make and keep their doctor’s appointments. I know the pharmacy inside the hospital makes it easier for patients to obtain their medicines due to ease of location and lack of public transportation in our city. However, it feels “wrong” to make the patients use that specific chain and give their business to that company.

During the GME meeting, some residents have stated that it can be difficult for patients to fill pain medication prescriptions at outside pharmacies. The patients usually are able to get their medications from the on campus pharmacy but the hospital pharmacies are only open limited hours. The patients are being denied pain medication despite having the prescriptions (and likely the prescriber checked the MAPS before writing the medication). Our patients have busy lives and the inability to get their appropriate medication is frustrating. Our article talked about inadequate pain control and disparities in pain management. The discussion and article were good reminders to remain non-judgmental when treating patients.

[Marvin Kajy]

The goal of medicine is to provide equal treatment of all patients. This is something ingrained in every physician starting from his/her medical school career. However, just as there are disparities in socioeconomic status, there are disparities in health care. Cultural and racial stereotypes may not be consciously expressed, but they are there subconsciously. It is human nature to constantly assess and judge what is in front of them. Many scientists have been called this as part of a survival mechanism. Unfortunately, their existence influences how information about an individual is processed and leads to unintentional biases in decision-making, so called “implicit bias”. All of society is susceptible to these biases, including physicians. Research has shown that implicit bias may contribute to health care disparities by shaping physician behavior and in turn producing differences in medical treatment. This has been proven in studies showing physicians with unconscious biases were less likely to treat black patients showing signs of heart attack with thrombolytics in the setting of acute myocardial infarction.

Cultural competency training has become a priority over the last few decades as research has revealed health disparities linked to race, gender, ethnicity and disability. Harvard Medical School has integrated social determinants of health as part of their curriculum. Physician bias is not the only factor or the main factor contributing to such disparities, but clinicians’ unconscious biases can amplify them.

Relating to a personal level, physicians can harbor biases like any other human beings. Such biases—whether conscious or unconscious can be especially dangerous in medicine, as they could lead to inequitable care and worsen health disparities. My approach to counter implicit bias is to identify the implicit value judgments and acknowledge that they are there, but not to act on them. Recognize that every person is a unique individual who has our own individual experiences and education. This can be the glasses through which we see the world. As we mature, we are growing through new experiences and were adjusting the lens through which we see the world. Experience is context, and context is the lens through which we view the world. We cannot help having biases; it is a part of who we are.

[Deya Obaidat]

To treat patient and do no harm are the principles that we live by in the medicine community and this has been the case for thousands of years, and while providing the best care possible for every patient that we see is our goal whether it is in the clinic or the inpatient setting, it seems like we do have some bias toward thinking differently about certain group of people without even being aware about it which lead us to the our topic today about the implicit bias.

By the end of the day physicians are human beings and to each of us we do have our own believes, religious and political views and personal opinions about certain issues which might affect our thoughts and choices when we are dealing with a patient, without even knowing about or being aware of it, influence from the media seems to be playing the bigger part of it, we discussed earlier in the group how the media has been showing for years people from African American descent as criminals and drug abusers in our daily TV shows that we were watching, and despite us knowing for sure that it is not the case with every African American and we know that those people are only minority and do not resemble the whole African American community, we still do see some kind of bias toward prescribing less opioids to those patients despite them being in pain.

I do believe that being aware of implicit bias between physicians and the awareness of it makes a big difference in terms of treating the patients equally. Personalized medicine is a model that we have been talking about for years now, which is basically treating each patient as his own, not looking at race, sexual orientation, religion, gender …etc in a way that will affect your medical decisions toward that particular person because of any of it, and that your medical decision should depend on the patient condition while being aware of these different social determinant factors.

[Muhammad Usama]

This week’s topic is about physician bias and health disparities in our patient community. Many groups in our community are at disproportionate risk of being uninsured, lacking access to care, and experiencing worse health outcomes. For example, people of color and low-income individuals are more likely to be uninsured, face barriers to accessing care, and have higher rates of certain conditions compared to Whites and those at higher incomes. In addition to that, often minority groups also face implicit bias during the clinical encounters resulting in poor medical care. Black women are three to four times more likely than white women to die from pregnancy-related causes nationwide; in New York City, they are 12 times more likely to die. Certain health conditions that affect pregnancy outcomes are more prevalent in black women, such as obesity and hypertension. And black women are more likely to lack access to preventative care, highly rated hospitals and safe housing during pregnancy. But the problem is not limited to class: Having higher income and more education offers no protection for black women. i believe the disparity is at least partly caused by institutional racism in our society and health care system, conscious or unconscious. Over time, research shows, the stress of that racism has a physical effect on black women that shows up on a cellular level. The discussion this week led me to read more about it and contemplate about implicit biases in myself. The first step to solving a problem is “identifying” it as a problem. I believe continuing reassessing my biases will help me become a better physician and will reduce health care disparity in the population I serve.

[Lea monday]

I’ve tried to keep better track of my bias this week and really analyze myself to try to catch the unconscious implicit biases I have. I noticed I have a lot more then I realized. In particular, any obese patient with pain I immediately assume losing weight is the one true solution which isn’t fair for me to say. Also, I feel very defensive and almost suspicious of patients who are white men. I think with all the things going on with trump and the Kavanaugh trial and me being pregnant with a daughter, I’ve had enough of the patriarchy and the way privileged white men treat and talk about women. When I saw a white male patient this week and told him he had no proteiniria and he said “yeah I know I don’t have Ketones” I could feel my eyes rolling and myself becoming annoyed, assuming he was talking down and assuming he felt he knew more then me. That was really biased of me. He’s a nice guy and I shouldn’t have jumped to that conclusion.

[Salina Faidhalla]

This week topic is about physician bias and the impact of that on patient care. I believe that bias is apart of every human subconscious and physicians are humans so we are not immune to it and most of the times we are not aware of it.
reading the article highlighted how this bias cam affect and compromise patient care despite the physicians good intentions.
the IAT was used to measure the implicit bias in IM and EM residents and found significant pro-white bias which is honestly can be expected in the world we live in these days, but what shocked me is that some race bias was also found among pediatricians (to a lesser implicit bias compared to other physicians) but still being biased treating children made me imagine how bias can we be treating adults.
One of the situations Im thinking of right now is when we see some patients in the hospital and we receive the impression that this patient might have a drug seeking behavior and we will be subconsciously affected and we might under treat this patients pain and we might even convey this though to other co-workers which have a huge impact on this patient quality of care.
We should all have our own assessments and take patients complains and pain seriously regardless of race or ethnicity.
admitting that we can be biased can help us realize it and deal with it properly

[Syed Umer Mohsin]

Today’s topic reflected on a known bias in medical community, physician biased. Even though physicians try to be best advocate for the patients, it is very easy to be a victim of physician bias. Patient’s socioeconomic status, race and other social determinacies play a role in misguiding physicians. For instance, serving population in Detroit, it is easy to presume that patients are either uninsured and/or have poor health care access to heath. Even though this may be helpful in certain situations but it makes patients prone to not getting best treatment available. Newer medications in the market are tend to be more expensive and not covered by many insurance companies. When physicians are overwhelmed with patient load, they may not offer these medications to patients who are either homeless or un-insurance assuming that they may not get this medication. Physicians may not want to spend the time to find out if patient’s insurance covers these medications. Whereas, when dealing with an educated, Caucasian young male, we may presume that he has the best insurance and will cover such medications. Unintentional, we may be biased towards our patient and take away their right to best treatment available for them.

[Leslie Kao]

As I go through residency and as we continue to discuss SD topics, I realize I have so many unconscious and conscious biases from the ones I am extremely aware of eg, Vietnam vs Iraq2 vets, to ones that I am more uncomfortable admitting, eg, hygiene, gender, BMI, educational level, english fluency, etc. Even more than that though, I know I am affected by how affable a patient is and how open I perceive they are to my advice. It has been shown over and over that biases in medical care effect patient outcome, especially when we look at racial disparities when socio-economic/educational levels are accounted for.

[Hammad Ali]

Going through the article was extremely insightful for me personally. I realized that reading about these prejudices really brought to light the biases I have and how they affect my interaction with my patients. Going in to a room with the preconceived notion that this patient is going to be difficult to convince to be adherent to his medications, I find that in the back and forth discussion with the patient I get exasperated sooner and just give up. When I do not go in a room with this in my mind I tend to be more convincing, more patient and more likely to get through to my patient. This one tiny thing, thinking whether a patient will be adherent to medications, can have such a huge impact on my interaction with my patients and in the long run affect the health of my patient.
I think the article was a great way to give us residents insight in to our subconscious and being aware of this we can try to tackle it. Now we cannot claim ignorance.

[Eskara Pervez]

Last week I, along with my other team members had to take care of a transgender patient who eventually got diagnosed with HIV and Syphillis during her inpatient stay. We do not know how long she had had both of these illnesses. Neither did she. She expressed that she felt disrespected at the previous hospital she went to so she decided to leave from there before her proper workup was done. Why did she felt disrespected? Could the staff there let their implicit bias get the better of them? Where we also biased towards her given her sexual orientation and preference? To know the answer to this question we need better insight into ourselves.
Despite many recent advances in rights for sexual and gender minorities in the US, bias against lesbian, gay bisexual and transgender(LGBT) still exists.The current pace of change in public views on the equal rights and responsibilities of (LGBT) individuals in the United States is remarkable.1 It may be tempting, therefore, to assume that attitudes toward LGBT people have also changed dramatically and that LGBT people can now be “out,” or open about their identity, in nearly any setting. Academic health centers—with their focus on up-to-date research and improving patient satisfaction—seem poised to lead the way in changing the health care experience for LGBT patients.
But given evidence that implicit racial bias affects physician decision making, it is reasonable to assume that LGBT patients remain at risk of discrimination from even well-meaning providers.
The First step to address this problem is to accept its existence: that bias against LGBT individual exists.

[Sahrish Ilyas]

Physicians are just as susceptible to biases as all other members of societies. Implicit biases have a profound effect on healthcare delivery and can contribute to health care disparities. It is important first and foremost to acknowledge that we all are susceptible to these biases and it becomes imperative to think of bias reducing strategies in order to eliminate or narrow the healthcare disparities that exist as a result. I personally believe that of utmost importance is improving cultural competence wherein equal health care is provided to individuals of all races, ethnicities, cultural backgrounds etc. As discussed in our conversation earlier this week, one way this can be easier is to broaden our own social circles and incorporate more individuals of different ethnicities, races and cultural backgrounds as well as literacy. Another strategy could be increased # of minority healthcare providers. Overall it is evident that cultural competence is a key component of healthcare and we should continue to improve it in order to improve healthcare delivery and reduce disparities.

[Dana Kabbani]

Physician biases exist, and I have never been more aware of this than this past week. For the reflection this week, I will talk about an experience that my husband and I recently had. We recently had dinner with another couple, young physicians as well, who told us “black patients are always going to be noncompliant with treatment because they are not educated enough to care for themselves.” My husband is black. We engaged in a discussion where we explained social biases, social determinants, essentially how the system has failed the black community. I am not sure if we changed their opinion, but it saddened me to painfully realize the biases that many young doctors have. The reality is that we must take time to educate patients, maybe a little bit longer, show our patients compassion, and make a connection with them. And I know my colleagues in this program do. We all work together on a daily basis to try to tackle these biases and provide the best care possible to our patients.

[Aliza Rizwan]

Reading through the article seems like going through day to day life of a healthcare professional, where negative evaluation of a person on the basis of irrelevant characteristics such as race, gender, even status leads to implicit bias outside conscious awareness. Yes, as a physician we think we are at a paragon where we as a physician cannot make these choices but unfortunately in the real world we somehow somewhere end up in that pool as well.
Evidence have shown that the healthcare professionals exhibit the same level of implicit bias as the wider population. But in our case as a healthcare professional exhibiting these biases can likely lead to influence our diagnosis and treatment decisions and level of care in some circumstances.
For example, a young black male and victim of a drive by shooting by a stranger who after having a surgery for a complex shoulder fracture, was discharged with oral pain regimen with inadequate treatment of his pain just on the basis of having the stigma for “drug seeking” based on his race, gender and background. Leaving the patient in pain with lack of standard of care, and we naturally wondered why.
In order to combat implicit bias, we should consciously think of the patient’s perspective and focus on specific and unique details about an individual, instead of his or her social category, diminishing stereotyping and promote empathy.

[Mahvish Khalid]

This week’s discussion on implicit bias had a huge impact on me. While we are all aware of the conscious bias and make sure it does not cloud our judgement, implicit bias can still prevent us from making optimal decisions. This can have serious consequences on the quality of care we provide to the patients who are discriminated inadvertently.
It is extremely important for us to acknowledge and reflect on our implicit biases. Only then, we can take measures to overcome these challenges. One approach we can take is to consciously try not to generalize people but to solely treat them as individuals. Another way is to educate ourselves on perspectives that differ from our own.

[James Bathe]

Implicit bias is a constant thread in our society and often one of the main underpinnings of inequity in our actions. We form preconceived ideas due to our environment and how we are raised and this in turn colors our actions and behaviors. Implicit bias can cause one to develop distrust of someone due to their race and say, clutch their purse a bit tighter. However, it can be much worse when someone doesn’t rent a house to someone because that person is “one of them.” In particular, as health care providers, we have to be aware of these biases as we can end up harming patients in the name of good. For instance, many providers underestimate the amount of pain a black patient is experiencing. This can lead to under prescribing analgesics when indicated and leads to patient suffering. On the flip side, many older, white patients can often get pain medication beyond what they need due to these biases. I think having a program to point this is out is vital to combating bias, but we need to focus on the individual with the bias. Another bias is thinking that we aren’t biased, when in reality, who else is? Other than self reflection such as these modules, how best can we address our own biases?

[wsumed]

The Life and Crimes of Don King: The Shame of Boxing in America – Jack Newfield – 9780974020105

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