Table 2. Measures With Worse Outcomes for Black Patients
|Cervical cancer diagnosed at an advanced age|
|Colorectal cancer diagnosed at an advanced age; colorectal cancer deaths|
|Breast cancer diagnosed at an advanced age; breast cancer deaths|
|Children with obesity|
|Vaccination (pneumococcal in older adults, influenza in adults, diphtheria-tetanus-pertussis) in children ages 19-35 months|
|Postoperative respiratory failure, acute kidney injury requiring dialysis, or sepsis following elective surgical hospital discharges in adults|
|Hospital admissions for urinary tract infection (UTI)|
|Hospital admissions for short-term complications of diabetes in children and short- or long-term complications of diabetes in adults|
|Hospital admissions for asthma in children and adults|
|Hospital admissions for hypertension in adults|
|Hospital admissions for heart failure|
|New HIV cases and HIV-related deaths|
|Treatment for depression in adults with a major depressive episode in the last year|
|Children given advice on healthy eating in the past 2 years|
|Children and adults with a dental visit in the past year|
An illustration of health disparity is the disproportionate effects of the COVID-19 pandemic on racial and ethnic minority communities during the early stages of the pandemic when the death rate for Black Americans was almost 2-fold higher than that for White Americans (Figure).14,15 The death rate among Latino populations was also higher than that for non-Hispanic White individuals.
The pandemic also showed the effects that concerted outreach efforts can have on balancing out health disparities as this statistic has changed. White Americans now have a 14% higher COVID-19 death rate compared with Black Americans and a 72% higher rate than that among Latino Americas, according to the latest data from the Centers for Disease Control and Prevention. Among the successful outreach efforts were those that led to an increase in vaccination rates.
Another recent correction of implicit bias in health care is the removal of race from the calculation of estimated glomerular filtration rate (eGFR) recommended by the National Kidney Foundation (NKF)–American Society of Nephrology (ASN) Task Force in 2021.16 The inclusion of race in eGFR estimations has been linked to disparities in care such as delays in kidney disease diagnosis and the eligibility for kidney transplant.17
Thus, negative biases toward marginalized groups give rise to social disadvantages and imbalances and, in some cases, poor health outcomes. Health care disparities signify the failure of this system at many levels. However, change can be made.
What Can Providers Do?
With the knowledge that unconscious bias exists, measuring and mitigating its effect is a new area of focus that is needed for health care professionals.18 Amazon, Microsoft, and Zillow have announced plans and initiatives to increase Black representation in their boardrooms and CEO positions.19
In health care, more than “just” diversity training and cultural competency training is needed — organizations like DNPs of Color are calling for more people of color in the C-suites of hospitals and health care systems. Similar to Fortune 500 companies, health care providers need to modernize their approach to understanding cultures that they are not familiar with. Individual strategies of reflection, mentorship, and sponsorship initiatives as well as a commitment to cultural awareness and humility are some of the proposed calls to action.20 In medicine, it is so easy to link a specific behavior or disease pattern to a specific racial/ethnic group and this may lead to negative attitudes toward certain minority populations. Clinicians must commit to the normalcy of treating all patients equally.
Research suggests that biased behaviors increase during medical education in part because of biases shown by professors that are picked up by medical/nursing students.21 Medical education is also missing the mark in terms of representation of diverse patients in core medical courses. The Mayo Clinic has targeted bias in medical education by studying the environment and training provided in 49 medical schools in the US and the change in student attitudes and values over time.22
As noted previously, positive interaction with health care providers can improve patients’ attitudes surrounding their medical care and improve communication, trust, and knowledge. Learning to connect with patients by understanding their perspectives begins in the classroom. Through the development of practical and tangible clinical skills and learning exercises, students can practice vital communication skills before using these skills in clinical settings with patients.23 This type of training may be provided annually instead of as a one-time workshop. In addition to promoting clinicians’ awareness of implicit biases, training also can offer strategies to reduce associations and even control the influence of such associations on judgment and behavior.
The American Medical Association (AMA) and the American Academy of Family Practice (AAFP) have developed strategies for clinicians to address possible bias. These include debiasing techniques through training, taking the perspective of others, emotional expression, counter stereotypical exemplars, and intergroup contact.24,25
Despite significant advances in the diagnosis and treatment of medical conditions, Black Americans and other minority groups, on average, tend to receive lower-quality health care and have greater morbidity and mortality rates compared with White Americans. This is primarily because of the long-term effects of racism regardless of one’s socioeconomic status. Health disparities can be reversed; however, it will require authentic commitment to remove racial bias and improve training from medical/nursing school through practice.
Recently, the attitudes and biases of health care professionals toward disadvantaged groups have become the focus of research. As the United States becomes more diverse, racial bias and discrimination may increase as well; thus, continued research on implicit bias is required. All providers should be aware of their bias when providing care to patients, as this can affect patient outcomes. Mitigating personal bias and improving clinician perceptions are self-directed pursuits and require reflection and commitment to counter stereotypes.
|Institute for Healthcare Improvement |
• How to reduce implicit bias
• How can providers reduce unconscious bias?
• Does racism play a role in health inequities?
|Sukhera et al. Implicit bias in health professions: from recognition to transformation.|
|Murry-Garicia J. Cultural humility and the prehealth professional student.|
|Edgoose et al. How to identify, understand, and unlearn implicit bias in patient care.|
|Association of American Medical Colleges. Unconscious bias resources for health professionals.|
Leah D. Moss, PA-C, DMSc, MSPAS, is a Navy physician assistant.
- Racism and health. Centers for Disease Control and Prevention. Updated November 24, 2021. Accessed June 15, 2022. https://www.cdc.gov/healthequity/racism-disparities/index.html
- Kochanek KD, Anderson RN, Arias E. Leading causes of death contributing to decrease in life expectancy gap between black and white populations: United States, 1999-2013. NCHS Data Brief. 2015;(218):1-8.
- American medicine was built on the backs of slaves. and it still affects how doctors treat patients today. The Washington Post. June 4, 2021. Accessed June 15, 2021. https://www.washingtonpost.com/news/made-by-history/wp/2018/06/04/american-medicine-was-built-on-the-backs-of-slaves-and-it-still-affects-how-doctors-treat-patients-today/
- (old 4) Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113(16):4296-301. doi:10.1073/pnas.1516047113
- Merriam-Webster’s Collegiate Dictionary. 11th ed. Merriam-Webster Inc; 2003. [continuously updated] https://merriam-webster.com
- Social justice guide. Howard University School of Law. Accessed June 21, 2022. https://library.law.howard.edu/socialjustice/disparity
- Thomas SB, Casper E. The burdens of race and history on black people’s health 400 years after Jamestown. Am J Public Health. 2019;109(10):1346-1347. doi:10.2105/AJPH.2019.305290
- Fiscella K, Sanders MR. Racial and ethnic disparities in the quality of health care. Annu Rev Public Health. 2016;37:375–394. doi:10.1146/annurev-publhealth-032315-021439
- Dehon E, Weiss N, Jones J, Faulconer W, Hinton E, Sterling S. A systematic review of the impact of physician implicit racial bias on clinical decision making. Acad Emerg Med. 2017;24(8):895-904. doi:10.1111/acem.13214
- Maina IW, Belton TD, Ginzberg S, Singh A, Johnson TJ. A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Soc Sci Med. 2018;199:219-229. doi:10.1016/j.socscimed.2017.05.009
- Roberts BW, Puri NK, Trzeciak CJ, Mazzarelli AJ, Trzeciak S. Socioeconomic, racial and ethnic differences in patient experience of clinician empathy: Results of a systematic review and meta-analysis. PLoS One. 2021;16(3):e0247259. doi:10.1371/journal.pone.0247259
- Shah AA, Zogg CK, Zafar SN, et al. Analgesic access for acute abdominal pain in the emergency department among racial/ethnic minority patients: a nationwide examination. Med Care. 2015;53(12):1000-1009. doi:10.1097/MLR.0000000000000444
- 2021 National Healthcare Quality and Disparities Report. Agency for Healthcare Research and Quality. Updated January 2022. Accessed June 21, 2022. https://www.ahrq.gov/research/findings/nhqrdr/nhqdr21/index.html
- COVID-19 weekly cases and deaths per 100,000 population by age, race/ethnicity, and sex. Centers for Disease Control and Prevention. Accessed June 13, 2022. https://covid.cdc.gov/covid-data-tracker/#demographicsovertime
- Leonhardt D. Covid and race. New York Times. June 9, 2022. Accessed June 13, 2022. https://www.nytimes.com/2022/06/09/briefing/covid-race-deaths-america.html
- Delgado C, Baweja M, Crews DC, et al. A unifying approach for GFR estimation: recommendations of the NKF-ASN Task Force on Reassessing the Inclusion of Race in Diagnosing Kidney Disease. Am J Kidney Dis. 2022;79(2):268-288.e1. doi:10.1053/j.ajkd.2021.08.003
- Eneanya ND, Yang W, Reese PP. Reconsidering the consequences of using race to estimate kidney function. JAMA. 2019;322(2):113-114. doi:10.1001/jama.2019.5774
- Blair IV, Steiner JF, Havranek EP. Unconscious (implicit) bias and health disparities: where do we go from here? Perm J. 2011 Spring;15(2):71-78.
- Amazon, Microsoft, and Zillow are backing an initiative to increase black representation on corporate boards. CNN. October 7, 2021. Accessed June 15, 2021. https://edition.cnn.com/2021/06/03/investing/corporate-diversity-black-boardroom-initiative/index.html
- Kerner J, McCoy B, Gilbo N, Colavita M, Kim M, Zaval L, Rotter M. Racial disparity in the clinical risk assessment. Community Ment Health J. 2020;56(4):586-591. doi:10.1007/s10597-019-00516-3
- Nolen L. How medical education is missing the bull’s-eye. N Engl J Med. 2020 25;382(26):2489-2491. doi:10.1056/NEJMp1915891
- Targeting unconscious bias in health care. Mayo Clinic News Network. April 21, 2015. Accessed June 15, 2022. https://newsnetwork.mayoclinic.org/discussion/targeting-unconscious-bias-in-health-care/
- Zestcott CA, Blair IV, Stone J. Examining the presence, consequences, and reduction of implicit bias in health care: a narrative review. Group Process Intergroup Relat. 2016;19(4):528-542. doi:10.1177/1368430216642029
- Implicit bias. American Academy of Family Physicians. Accessed June 6, 2022. https://www.aafp.org/about/policies/all/implicit-bias.html
- Health equity education center. American Medical Association. Accessed June 6, 2022. https://edhub.ama-assn.org/health-equity-ed-center
This article originally appeared on Clinical Advisor