Health-care providers and organizations bear the responsibility for rooting out bias in medical care, experts say. In the meantime, though, there are steps patients can take to shield themselves.
Research shows that patients of different genders, colors, sexual orientations and sizes don’t always receive the same quality of care during a doctor visit — a disparity recently showcased on a recent episode of HBO’s T, +0.31% “Last Week Tonight with John Oliver.”
For instance, female patients and black patients are both less likely to be prescribed pain medication, and doctors are twice as likely to underestimate black patients’ pain “compared to all other ethnicities combined.” Experts have connected implicit bias among doctors (i.e., attitudes and stereotypes that often unconsciously impact how they act) with black women’s disproportionate maternal mortality rate, as celebrities like Serena Williams and Beyoncé have recounted their own harrowing childbirth experiences.
A 2018 study found that “American clinicians rated a hypothetical white patient, compared to an identical black patient, as significantly more likely to improve, adhere to treatment, and be personally responsible for his health.” The researchers found no such pattern among French clinicians, in comparison.
Bias in health care isn’t limited to race, religion or gender. One 2015 American Journal of Public Health study, for instance, concluded that “implicit preferences for heterosexual people versus lesbian and gay people are pervasive among heterosexual health care providers.” Many providers “hold strong negative attitudes and stereotypes about people with obesity,” noted a separate 2015 study in the journal Obesity Reviews.
“We have these biases that are inherent in how we practice — and they can come out in terms of how much time we spend with patients, how much credibility we give to patients when they’re explaining their story and struggles, and how much we’re able to enhance the physician-patient relationship to ensure that they achieve optimal health outcomes,” Fatima Cody Stanford, an obesity medicine physician at Massachusetts General Hospital and assistant professor of medicine and pediatrics at Harvard Medical School, told MarketWatch.
Nearly a third of African-American respondents to a 2017 NPR/Robert Wood Johnson Foundation/Harvard T.H. Chan School of Public Health poll felt they had been “personally discriminated against” because of their race during a doctor or health clinic visit; one in five Latinos reported the same. Almost one-third of Muslims surveyed for a 2015 study in the Journal of Muslim Mental Health said they had perceived being discriminated against in a health-care setting.
Researchers have floated a variety of strategies to address implicit bias in health care, including implicit bias training for both medical students and practicing physicians and greater diversity among health-care professionals. “Ultimately, a big chunk of the problem-solving is up to the physicians and the hospitals to try to curb their biases,” said Sylvia Perry, an assistant professor of psychology at Northwestern University.
But while institutional change takes its course, there are steps patients can take to guard themselves against implicit bias, experts say:
Educate yourself on treatment options. Do some research to see what cutting-edge treatments exist for your condition, said Sean Phelan, an associate professor of health services research at the Mayo Clinic. While a good doctor will engage in a shared decision-making process and educate you on the pros, cons and alternatives surrounding a treatment, that won’t always be the case, he said — and “the more you know, the better the ultimate decision is.”
“You can sort of force them or encourage them into a more shared decision-making process, instead of them just making a decision for you,” Phelan said.
If your doctor is using medical jargon you don’t understand, ask him or her to explain the concept in different or simpler terms, added National League for Nursing president Rumay Alexander, a professor of nursing at the University of North Carolina who previously served as the school’s chief diversity officer.
Make sure your provider understands who you are, what you believe and what you value. Your provider should be performing some sort of cultural assessment to learn more about you — and if she or he doesn’t, volunteer the information yourself, Alexander said. Maybe you hold religious beliefs that govern your medical care, use alternative medicine associated with your culture, or live in an area impacted by food deserts or environmental hazards.
Relaying this information allows your provider to take a more culturally informed approach that’s tailored to how you actually live, Alexander said, reducing your risk of being labeled noncompliant or difficult if you don’t follow the doctor’s orders. If it takes you four bus changes to access fresh groceries, for example, your doctor may think twice before putting you on a diet that would be difficult to maintain.
Prepare for a potentially rushed doctor visit by bringing as much information as possible in writing, so you don’t waste valuable time reciting it aloud, she said.
Make sure your doctor is asking questions and listening to you. “Do you feel like they’re seeing you as an individual and listening to your individual experience, instead of making assumptions based on your group membership?” Perry said. “If you challenge your physician — if you ask questions about their recommendations or even about some sort of assumption they’re making about you, or you try to correct them or ask critical questions — do they seem to internalize the feedback? … Do they accept it, and do they respond to your needs as a result?” If you don’t feel like your doctor understands you, you may want to look for another provider, Alexander said.
In the same vein, pay attention to how much time the doctor is spending with you, Alexander said — after all, the less time you spend together, “the more likely that assumptions are being made” based on their previous experience treating patients they perceive to be like you. “It’s in the assumptions that the problems occur, particularly around bias,” she said. It’s OK to ask for more time or a follow-up appointment in a non-emergency situation, she said.
Bring an advocate. Comedian Wanda Sykes, who guest-starred in Oliver’s medical bias piece, suggested that patients whose doctors ignore their concerns “just bring a white man to repeat everything you’re saying.” The show enlisted “Curb Your Enthusiasm” star Larry David for pre-recorded clips in which he complains about various maladies.
But you can also bring a trusted family member, friend, community or religious leader, doula or other health advocate to your appointment, said Swapna Reddy, a clinical assistant professor at Arizona State University who studies health disparities and teaches an unconscious bias course at the Mayo Clinic. “Often when we’re in the patient [role], we’re not in the greatest position to speak for ourselves,” she said.
Choose a provider and facility that will make you the most comfortable, if possible. Research shows that patients can detect implicit bias in their providers, Phelan said, and that can impact their experience. “If you have a provider that you just don’t get a good feeling about, it could be evidence that you’re detecting bias,” he said. On the flip side, a provider who makes you feel comfortable and satisfied could potentially have a lower tendency toward implicit bias.
Perry suggested seeking out doctors who you think have cultural overlap or similar experiences to your own, a trait that could mean they have a greater understanding of your cultural experience and are less likely to rely on stereotypes. For example, a 2018 experimental study distributed by the National Bureau of Economic Research suggested that having a black doctor could reduce black men’s cardiovascular mortality. But Perry emphasized that a patient’s experience with the clinician, and not necessarily their identities, is what matters most.
And while not everyone has the ability to choose their health-care institution, try to find one that has made a formal investment in creating an inclusive culture, Reddy said. “Everyone will say that diversity is a value, but how are they operationalizing that value?” she said. “Are they actually training their providers [and] their leadership in things like bias; in things like cultural humility?” A facility’s website may include information on patient demographics, Alexander added, giving you insight into the patient populations its providers have the most experience in treating.
Don’t be afraid to challenge your doctor. “What patients have to remember is they are the experts on themselves,” Alexander said. Use “I” statements to push back — like “I’m sensing that you’re not hearing me,” or “I’m concerned that you believe I’m exaggerating the intensity of my pain” — if you feel your concerns are being minimized. “People should remember that even though this person is in a position of authority … they still have the right to speak up; to ask questions,” Perry said.
Find out your specific institution’s process for lodging a bias complaint, Reddy added, which might involve contacting a general-feedback email or phone number or designated diversity and inclusion officers. You can also report complaints to the head of an organization or to regulatory boards that license providers, Alexander said.
“If you think that you were discriminated against and received health care that was not optimal, or you weren’t heard or [it] didn’t feel like a shared decision, you should absolutely feel that you have the ability to advocate for yourself — and be very explicit about what you think happened in that interaction,” Reddy said.