Bench to Bedside | September 2017

Promoting Equity in the ED: Why We Need to Understand Implicit Racial Bias

Tiffani Johnson, MD, a physician in the department of Emergency Medicine at Children’s Hospital of Philadelphia and PolicyLab member, is driving clinical practice one step closer toward equity for children, regardless of their race.

To better understand the factors that contribute to disparities in care, Dr. Johnson’s most recent research unravels the unconscious biases that, despite the best of intentions, can affect how a physician in the emergency department (ED) might treat a child of a particular race or ethnicity. Known as implicit racial bias, these unconscious attitudes can unknowingly surface when doctors default to heuristic thinking under pressure.

“Children are one of the most vulnerable populations. I think we like to think that they’re immune to disparities and discrimination, but this research shows that unfortunately, they aren’t,” Dr. Johnson said. “Most pediatricians have egalitarian attitudes and really want to treat everyone the same, but these implicit biases can live below the level of our consciousness and impact the care we provide.”

With her team at PolicyLab, Dr. Johnson’s powerful research spotlights a field of research previously focused on adults outside the healthcare setting and one which can begin to drive mindful change.

How Does Implicit Racial Bias Work?

If we think of the mind like an iceberg, a small portion of its mass remains visible above the water – clear as day and easily accounted for. This is where our conscious mind lives. Our brains, however, consist of more than what we can self-report or see. Below the waterline, a large part of the iceberg lies submerged, and this is where our unconscious biases exist.

In certain pressure-filled situations, (like a crowded pediatric emergency department at 2 a.m.), these biases can emerge to intuitively affect how physicians behave and make decisions. For physicians, they can impact everything from how providers communicate with patients, to differences in treatment, to a family’s satisfaction with their ED visit, and their decision to adhere to the treatment recommendation.

Implicit racial bias, however, does not equal racism – and this is one point Dr. Johnson hopes to make clear to potentially concerned parents. Implicit racial bias goes unnoticed in our consciousness, and parents and providers alike bring some form of it to the table.

“The goal isn’t to point fingers and ask someone what their biases are, but to understand how biases impact care and then try to reduce that impact,” Dr. Johnson said.

Exploring Implicit Racial Bias

In the first phase of her research, Dr. Johnson documented how heavy cognitive loads affect the way that ED physicians might treat a variety of different patients. In a study published in Academic Emergency Medicine, Dr. Johnson and her colleagues gave residents in the ED an implicit association test (IAT) before and after their shifts. An IAT test is a powerful tool for revealing how our minds associate certain images and words as good or bad, preferable or non-preferable.

Often taken online, the test prompts its participants to categorize a series of words and pictures that appear on the screen by clicking one button or another on their keyboard. In a Race Attitude IAT, participants must match pictures of faces – black and white in varying turns – with positive words like “love,” “laughter,” and “pleasure,” or negative words like “horrible,” “hurt,” and “evil.”  Because participants are asked to complete the task as fast as they can, they often default to mental shortcuts and intuition, providing researchers with a valuable insight into the mental associations existing below their consciousness.

After giving the residents the Adult Race IAT, the researchers found that when the ED was more crowded or residents had taken care of more patients, residents exhibited more pro-white/anti-black bias at the end of their shift.

“It makes sense that when you’re making lots of decisions, you’re tired and stressed out, so you’re more likely to rely on your heuristics, which can include bias and stereotyping,” Dr. Johnson said.

As a pediatrician, Dr. Johnson’s next goal was to examine the implicit racial attitudes that providers have toward children. She enlisted the Child Race IAT, initially designed for children to determine when they develop racial bias. Instead of black and white adult faces, the IAT showed those of children. Dr. Johnson gave it to residents in the pediatric ED.

The results proved eye-opening: 91 percent of residents had a pro-white bias toward children – a very similar level to the 85 percent of residents who had pro-white/anti-black bias toward adults in Dr. Johnson’s earlier study, with no significant difference in IAT scores.

“[The IAT] had pictures of these cute little brown kids and these cute little white kids, and I thought residents would have no bias on the Child Race IAT,” Dr. Johnson said. “I was wrong.”

In a clinical setting, implicit bias may play out in a physician’s perception and management of patients who are presenting with painful conditions such as fractures, sickle cell disease, or appendicitis. Using this example, Dr. Johnson wondered whether unconscious attitudes become activated when caring for African American patients – so that physicians don’t assess a patient’s pain, don’t believe when they report it, or even jump to perceptions about drug-seeking behavior that result in inadequate management of that pain. Studies have shown that ED physicians often cite drug misuse as one reason they do not prescribe analgesics – despite the fact that no evidence exists showing minorities are more likely to abuse prescription drugs.

Implicit bias may also emerge when physicians communicate with parents. Unlike primary care pediatricians (to whom families become familiar with after routine visits), parents meet doctors in the ED for the first time – and often under stressful circumstances. Without an established doctor-patient relationship, patients and parents may be more prone to mistrust, while doctors may rely on bias and stereotyping. This may affect how physicians communicate and how patients and their parents follow treatment recommendations.

Identifying Interventions

The good news, however, is that unconscious attitudes are not fixed like the DNA we carry throughout our lifetimes. Though our biases can be influenced by what we are exposed to in the media, the households and neighborhoods we grow up in, and the people we interact with at work or play, they are far from fixed.

“We’re all exposed to lots of things on a daily basis that subconsciously prime us and impact our unconscious attitudes,” Dr. Johnson said. “There’s actually a growing body of evidence, however, that shows our biases are malleable.”

While more work must be done to understand implicit bias and how it specifically impacts pediatric care, a few strategies can reduce the impact of these unconscious attitudes. Studies conducted outside the healthcare setting suggest that mindfulness meditation is one method that has helped to reduce implicit racial bias. Researchers from Central Michigan University gave participants an IAT test for age and racial bias after listening to either mindfulness or a control audio track and found that mindfulness may have resulted in a decrease in both age and racial bias.

Emergency departments may also actively implement strategies to prevent overcrowding and ease a resident’s patient load. In a PolicyLab blog post, Dr. Johnson outlines several suggestions, including some that the ED team at CHOP already incorporate: Hospitals can open an after-hours clinic or place a team of providers in the ED waiting room to get a jumpstart on care until a room is available. On top of that, specific guidelines for clinical effectiveness can reduce variability in care, while a little self-care (such as staying hydrated and eating healthy) may go a long way in helping physicians cope with ED stress.

Finally, precision medicine may help to reduce the impact of implicit bias on care. By individualizing care to each child, precision medicine becomes a tool to reduce clinical uncertainty on the part of providers, thereby helping to reduce disparities in care.

“The less uncertainty, then the less likely we are to rely on our heuristics that can include bias and stereotyping,” Dr. Johnson said. “Precision medicine is an important opportunity to give the proper treatment to the right patient at the right time, and we’re making decisions based on our interactions with individuals and not necessarily group-based stereotypes.”


www.research.chop.edu

Produced by The Children’s Hospital of Philadelphia Research Institute.

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