[Yellow Cohort] Module 2

[Leslie Kao]

Please submit SOAPs for Module 2:

[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, the current case against Mr. Cosby not withstanding, 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 sterotype distorts processing of information about individuals.” I learned that “research suppors a relationship beterrn 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. One are which I feel Chapman and Devine failed to recognize is that while implicit bias is real, there are other reasons why physicians possess bias toward certain groups, namely personal experience. For example, I recently encountered a 48 year old African American female whose chief complaint was chronic low back pain. Her previous physician had prescribed Norco and Valium which the patient said helped her sleep through the night. I explained to her about the lack of evidence for chronic pain and opiates and how there is an opiate epidemic in the US at present. She stated she had tried NSAIDs, had refused physical therapy due to lack of time, stated topicals didn’t work not did muscle relaxants. She was convinced that only opiates could alleviate her symptoms and there was no dissuading her. This experience is unfortunately not uncommon and despite the physician’s best efforts, the patient had preconceived notions about their condition which they won’t move away from. It is experiences like these that lead physicians to make assumptions, which my be true or may be false when encountering their next patient with similar complaints.

Plan:

What then. An an individual do to combat illicit bias? I can do a better job listening to my patients and trying to understand the backstory of how they have come to be in their current state of health. I can treat each patient as an individual rather than employing stereotypes based on affiliation with certain groups. I can work to mentally put myself as best as I’m able to do so in that patient’s shoes, empathize BG rather than judging. While I recognize that I possess implicit bias, some based on stereotype, and others based on personal experience, possession of this knowledge is powerful, and will allow me to actively oppose these biases as I continue to practice medicine.

[John Dawdy]

S:
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.

O:
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 two caught my attention specifically. The first being that Hispanic patients receiving 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. The second was in COPD diagnosis between men and women and the outcome that these patient that are at baseline more susceptible to this disease process are under diagnosed and under treated when other confounding variables are controlled for. These findings not only help inform of the necessity of an awareness of these biases but make me question my own care practices.

A:
With this article in mind I have been thinking about 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 Cardiology Consult service that I had met in hospital many times in the past. This patient presents to the hospital often non-compliant to his medical therapy and with general non-specific complaints. Most staff at the hospital know him and are used to his demanding and what are often felt to be exaggerated complaints. One such complaint is that he often presents with chest discomfort which is often attributed to his missed diagnosis and volume overloaded status. This episode he once again presented with this discomfort but he said that it was different from previous episodes. I had discussions with the ED and observation physicians that were annoyed that he was back and that our service wanted him to undergo ACS rule-out, they assumed it was the same old complaint. However, this admission the patient was found to be having STEMI, underwent cardiac cath and required stent placement. Thinking back on this patient I am glad that despite out preconceived notions of this patient that we continued to treat him, however I do wonder what sort of underlying biases would make physicians more willing to brush aside his complaints. Was it simply a “boy who cried wolf” scenario, or did his race, sexual orientation and socioeconomic status play a role in it.

P:
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.

[Marvin Kajy]

Subjective
This week’s article discussed how physicians may unknowingly perpetuate bias. They illustrated examples on how physicians may treat patients differently based on race or gender. As physicians, we are trusted with the ability to take care of all people regardless of a patient’s social and economic background. However, despite our best intention of providing equal treatment to all patients, we may unknowingly hold biases against our patients and that may impact our delivery of care. For example, when physician sees a patient who has COPD or cancer and is smoking, there may be this thought at the back of his/her mind that this is something they brought upon themselves.

Objective:
The article by Chapman at el tries to point out that physicians may have implicit biases. After reading this article, I developed a “self-check” for myself. Whenever I finish my assessment and plan for a patient I go back and ask myself “did I treat this patient with the best care possible that I can deliver him/her”. For example, during the past clinic week, I encountered a 60 yo African American patient with a PMHx of schizophrenia and 40-80 pack year smoking history. When I interviewed him, he said that he sometimes smokes as much as 4-5 packs of cigarettes per day to cope with anxiety and stress. He had a low dose CT scan done for lung cancer screening. CT scan was consistent with emphysematous changes. However, the patient was not on any COPD medications. I figured out an MRC score for him, started him on the appropriate COPD meds, give him the appropriate immunizations, gave him a referral for a 6-minute walk test and pulmonary function testing. On top of that I counseled him on quitting smoking. I went through an “internal check” to make sure I covered all the bases for the patient. This was in turn verified by the attending.

Assessment:
Medicine is a scientific field. From the beginning of our medical career we are taught to group medical conditions and associate them with certain individuals. For example, people from the Middle East tend to have dyslipidemias, Northern Europeans have a high prevalence of cystic fibrosis, African Americans are at increased risk of sarcoidosis and systemic lupus erythematosus, alcoholics can have a multitude of electrolyte derangements and IV drug users are at increased risk for infections. These population “associations” are not simply human generated. They are backed by scientific evidence. I argue that a certain degree/level of bias in anyone’s clinical practice is needed and even inherently necessary to practice medicine. This allows you to better take care of your patients and it may even allow you to catch a disease in its early stages before it reaches its full effect and causing harm to the patient. However, we can’t have our bias affect the care of the patient

Plan:
When we graduated medical school, we took the Hippocratic Oath which is a moral code for ethical conduct and practice in medicine. Physicians are humans and we are prone to hold biases about a patient the minute we walk into the room and greet the patient. However, I think that the main point of the article by Chapman et al is to be aware of these biases and not have it affect my medical decision making. This article allowed be to develop an internal “self-check” as I described earlier. In addition, we all must go back to the good old history and physical exam. We must spend the extra time with the patient and really try to figure out their past and present before we label patients with certain diagnoses or start ordering labs. This will undoubtedly make us better physicians and allows us to deliver optimal medical care.

[Kalyna Jakibchuk]

S: I think implicit biases are a great topic to discuss. The most important thing about implicit bias, in fact, is to talk about it. The challenge is that they are difficult to identify within and so that can make it more difficult to talk about. By bringing awareness, however, I think people are challenged to try to identify their own biases.

O: This week after reading the article, I tried to think about my own biases and biases that are present in our medical community. A number of biases came to mind. One was for a gentleman in his 40s that thought he had gout and actually it seems even the physicians he has seen over time have had differing opinions about what type of arthritis he has. In discussing his health, it came to light that he likes using various herbal remedies, and takes advice of his friend (that he specifically mentions is vegan) on what medications are ok to take. He stopped taking various medications because he said one caused him to have oily skin, the other caused his knee to swell up. He mentioned that in taking a vitamin for his eyes that his far sightedness would improve only on days when he would take the medication. Now, in reference to his gout, he had received a dose of colchicine which he said resolved his gout. Knowing the patient takes herbal supplements and takes advice from his friend (that the patient mentioned was vegan) made me question his understanding of his illnesses and his perception of whether a medication (like colchicine) truly helped or if it was a placebo effect. Although, based on his clinical picture I do not highly suspect gout, being aware of my bias and also taking into account the uncertainty of other physicians who have also seen him I will be watching him closely not to discount gout but to keep it in the differential if a flare were to occur in the future.

A: I have previously studied this topic of implicit biases and have been aware that we are unaware of biases, as funny as that sounds. I appreciated taking the time to reflect on my own biases again and to discuss with other residents what biases they see in our community.

P: I will continue to reflect on this in my career. However, I do think that objective ways to assess and avoid biases are necessary like the studies they have done to bring awareness and guidelines for certain diseases. I have personal guidelines I refer to for various diseases which I think can help, although patients often stray outside of a pre-defined coarse of disease.

[shanker kundumadam]

S : This weeks article discussed about implicit bias in medical practice. This affects all strata of people working in healthcare including the nurses, MAs, physicians, med students and so on. Race, gender, economic status are all contributory to implicit bias. The cultural background of the health care personnel also influence the implicit bias

O : I saw a patient early this week. This gentleman moment i walked into the door was acting very indifferent. He was not interested in any conversation with me initially. He pulled his chair to the other end of the room and sat there far from me. Even before i started the conversation i had a notion in my mind that this will be a “Tough patient ” who is gonna give me trouble today. When asked about his Past med history he was just giving careless answers. 15 mins into conversation i realized things were getting better and he was being more attentive and giving clear answers. I casually asked him about the list of his medications when in reality based on my first impression of him i was not expecting that he would be able to give me much information about his medications. To my surprise this gentleman knew every medication he was taking he knew the dosing he knew the side effects. As conversation progressed he turned out to be a very jovial person , so much fun to talk to. Once he got out of the room i just thought to myself how silly it was of me to have had a prejudice like that before knowing him well. Since then and also reading the article i realized we all have a “implicit bias created by first impression , not determined by race or gender but sometimes merely by how the patient greeted you when you walked into the room. That moment onwards i determined that i would never categorize patient as ” Nice” or ” Not easy ” based on first impression

A :
I believe since this above encounter i have been consciously trying to avoid that bias and i am slowly making progress

P:
I plan to continue acknowledging my own implicit biases many of which i dont even know yet. I will be vigilant to understand them and make active efforts to get rid of them

[Shivani]

S: Stereotypes and biases affect our day to day. Despite our best efforts, it may be influencing our medical care without us realizing.
O: This clinic week, I discussed the article with one of my patients. She/he works in security at a local venue and talked about how he/she felt discriminated against when there was a situation that required quick response. The patient told me about how she/he thinks the situation would have been handled differently if she/he was not African American.
In addition, a faculty shared how African American women with breast cancer often get mastectomies (when perhaps radiation/ lumpectomy would have been sufficient) due to cost. I looked up this topic and learned there is also inequity in reconstruction after the procedure when compared to other racial groups.
A: After reading the article and our small group discussion, I will continue to work hard to prevent any previous bias to affect my patient care. The patient appreciated me sharing the point of our article with her/him. Also, I learned about the differences in breast cancer treatment between races.
P: I will continue to offer patient centered care. I will continue to work hard to do the best for my patients. I will use the techniques shared in the article and small group to improve my care.

[Lea Monday]

Subjective
All people including physicians likely have implicit and unintentional bias. The article illustrated examples of this.
There were many examples using race, sex, socioeconomic status and other examples.

Objective
The existance of this bias did not surprise me, however, the factual percentages in the article were quite surprising. For example the way age matched men vs women with dyspnea were diagnosed differently with COPD. The article did a good job giving examples. The article did not give much useful information on how to challenge this issue, which I suppose isn’t that surprising given there are no easy answers and these are things that are incredibly complicated and major issues in our country.

Assessment:
I discussed this article with my husband and used the week interactions to evaluate my own biases. I have a hard time not being biased toward patients who have no idea what is wrong with them and no idea what medications they are taking, or what doctors they are seeing. I have been actually trying to change my mind set recognize the numerous issues at play like low health literacy and a general sense of being overwhelmed rather than writing this behavior off as a lack of ownership or responsibility.

Plan:
I really like the plan one person mentioned at the group talk. After each patient I need to ask myself, would my plan change at all if this person was a different sex, race, age, with/without mental illness, not abusing drugs/etoh, etc. If the answer is yes, then I need to go back and re-assess my plan.

[Deya Obaidat]

S: I feel like physicians always try to be as efficient as they can with every single patient that they have and while they are trying to do that they sometimes look at different patients differently, as they might prefer patients over the other and have some misjudgments about the patient’s situations as they might actually treat two different patients with the same condition differently and I do feel that such a difference in the treatment is NOT intentional most of the time, but it is related to many factors and a large portion of it would be related to the patient himself as it could depend on his race, sex or age sometimes which has nothing to do with any studies or evidence based medicine.

O: a lot of studies talked about the implicit bias that shows the preference to give thrombolytics to white rather than black males when they present with symptoms of chest pain , and it also showed that making the physician aware of such a bias will make the bias less likely to affect them during practice.

A: there is always an element of implicit bias when it comes to dealing with patients from different ethnicities and sexes, although this kind of bias is difficult to get rid of and might take a long time to change what we have in our subconscious level, associate some races with some kind of behavior might affect our main goal of achieving the patient’s satisfaction overall

P: knowing that implicit bias exists will make me more aware of my decisions when it comes to certain ethnic groups or sexes, I will start to use more objective measures to diagnose and treat the patient which will include scoring systems and criteria measures rather than depending solely on my subjective evaluation of the situation

[James Bathe]

S: what is my perception/feeling of the topic/encounters.
• I’ve always felt that implicit bias was where most of the rubber meets the road when it comes to social disparities and attitudes. The most long term damage to a societal group is the continuous injuries brought on through biases in decisions. While someone yelling a slur is certainly hurtful and detrimental through its oft implied societal acceptance, the person passed over for a job or housing repeatedly will encounter more harms in the long run. These implicit biases weave through everyone in society, influencing outcomes of everything from basic social interactions to legislation. Of course, medicine is not immune to the ill effects of implicit bias. Doctors are people too and hold their own biases in every way. However, as providers of care, it is imperative that we minimize harm in every way possible and that includes addressing these biases.

O: a summary of interventions/skills I performed.
• Review of literature and online courses are incredibly helpful for addressing implicit bias. As the article for this week mentioned, being aware of biases helps reduce their ill impacts. However, awareness alone is not enough. Through exercises taken to actively take the patients perspective and standard practice guidelines, the effects of biases could be minimized.

A: my assessment of my performance/understanding/awareness
• It’s hard to really assess one’s own implicit biases. However, it is important to consider what is likely. Most physicians hold biases towards white straight males and this is especially strong in white males, making it very likely that I hold implicit bias. With that in mind, I do try to actively work with each patient as an individual and follow evidence based treatment guidelines.

P: My plan for improvement or new challenges.
• In the future, I plan to focus on good evidence based practice as well as actively trying to take on my patients’ perspectives. In addition, active participation in the social determinants program seems to be a good strategy to increase my efficacy in addressing my biases and their impacts on patient care.

[Jie Chi]

Physician bias within medical care

S: The article focuses on discussing the disparity of health disparities in the disadvantaged population due to socioeconomic status, sex, or race/ethnicity.. These disadvantaged groups experience, including disproportionate disease burden or behavioral risk factors, that are otherwise modifiable. Cultural stereotypes may not be consciously endorsed, but their mere existence influences how information about an individual is processed and leads to unintended biases in decision-making

O: I had a patient young IVD user with HIV, CD4 cell count 4, admitted for recurrent sepsis due to tricuspid endocarditis. Pt was treated for HIV infection at the last hospitalization and started on antiviral medication; however Pt was discharged and lost of follow up as he was homeless. He quickly back to the habit of IV injection and had a relapse of sepsis, finally end up in the hospital again. He met the criteria of surgical removal of the large vegetation of tricuspid valve; however, it was never done. It’s unfortunate that his multiple disadvantaging social statuses had a huge impact on his treatment, which was a perfect example of disparities in treatment decisions and implicit provider bias.

A: With growing evidence that implicit bias in physician decision-making makes a significant contribution to perpetuating health care disparities, it is critical to find ways to reduce its impact. Conceptualizing implicit bias as a “habit of mind” provides a useful framework for developing interventions.

P: By consciously realizing the possibility of bias, I will check up on myself every time I make a medical decision. I will try to provide opinion evidence that is fair, objective, non-partisan, and related only to matters within their area of expertise. I will also be cautious on commenting on the care of those in other types of practice.

[Marc Vander Vliet]

Subjective: Bias is a tricky subject as it is difficult to spot implicit bias. Personally, I think implicit bias is a bigger problem these days than explicit bias though the latter is sure to occur. It is helpful to be aware of the existence of implicit bias as it forces oneself to do some introspection to evaluate whether oneself is practicing implicit bias.

Objective: The article rightly points out the difficulty in identifying implicit bias as well as the challenges in mitigating the effects of implicit bias. Having a diverse physician workforce can help on systems level but we need better tools to identify implicit bias and correct for it on a personal level.

Assessment: None of us wants to admit that we are capable of contributing to bias but I think it can be helpful to realize that we are all susceptible to it and capable of it and proceed with humility to try to best serve our patients.

Plan: One thing I have tried to do after taking care of patients is to reflect on whether my treatment of them would change is they came from a different racial, educational, or socioeconomic background. It is not always easy to find the time to do this but I think the very act of attempting to identify issues can have a positive, if immeasurable result in treating patients fairly and well.

[wsumed]

A is for America ~ Devin Scillian ~ 9781585360154

[Author]

Posts