Sneaky Bias: What You Don't Know May Hurt You (and Your Patients)
By Hadiya Green Guerrero, PT, DPT
"Now that I know better, I do better."
– Maya Angelou
Recently, PT in Motion News reported on a study of 2008-2010 data from the Medical Expenditure Panel Survey-Household Survey that contained a telling conclusion. Study authors Sandstrom and Bruns reported that when it comes to outpatient rehabilitation therapy, their analysis "confirm(s) a reduced likelihood of an office-based therapy visit for Black Americans with arthritis when controlled for income, insurance, and education."
The question we need to be asking ourselves is, why?
As human beings it is unrealistic to think we can rid ourselves of all our biases, but as health care providers it is our duty to provide the utmost care to facilitate maximum outcomes for all patients. As PTs, we know this. And yet, disparities in treatment persist.
For many of us, the first thing that happens when we think about bias is to get defensive. We think about all the things we're not: all those dirty words like "racist," "bigot," "(choose your word)-phobic."
But the reality is that while we may not be any of those ugly words, we all possess biases that impact every interaction we have with our patients. We all have subconscious attitudes that can affect our behaviors. These are called one's implicit biases.
Implicit bias refers to attitudes and beliefs, both positive and negative, that occur outside of our conscious awareness and form a person's evaluations of others.
In some ways, implicit bias is like our fight-or-flight response – something that's triggered almost before we're aware of it. While it's true that these subconscious attitudes exist, they can be recognized, and the subsequent behaviors can be tamed and managed to elicit optimal patient interaction and outcomes.
It's not just health care providers who have implicit bias: it's everywhere – and when these biases meet each other, watch out.
Scene 1: You're a PT who's African American. You walk into the treatment room and introduce yourself to the mother of the nonverbal 3-year-old patient. The mother and patient are members of a white, rural family that homeschools their children. Several siblings are also present in the room.
You start working with the child and talking. You're talking a lot to the child. You're laughing in a forced way. You may even be acting a little silly.
Finally you say to the patient, "You must think I'm just crazy, don't you?"
The patient's 7-year-old brother says, "No, he's probably looking at you like that because you're dirty."
Look at what just happened: The therapist assumed/assessed subconsciously that the white rural family with multiple children who are homeschooled would be uncomfortable with her, so she became overly jovial and self-deprecating. At the same time, the patient's brother, under 8 years of age, associated brown skin with being dirty. The result: the therapeutic relationship suffers, and the mother is embarrassed by her son's offensive comment. Has the patient received the best possible treatment? And how do you think it will progress from here on out?
Of course, sometimes the implicit bias can run in just 1 direction.
Scene 2: Your patient is 6 feet tall with the build of a world-class boxer. His paperwork says his name is Cassius Clay, Jr. He asks you to call him Muhammed. You keep calling him Cassius and apologizing. What's really going on here? I mean, what's really going on inside of you? Maybe you were a victim of identity theft and this name business stirs up feelings of mistrust. Or maybe you have a fear of Muslims based on images or your experiences.
Whatever the underlying reason, your implicit bias or attitude affects the way you treat this patient. You hurriedly get through the session because you know that, ethically speaking, you have to. But really, you just want to be done with it.
Scene 3: Your patient is a 12-year-old girl in the hospital for an unknown metabolic disorder. She calls her mother "Mommy," and you assess that she is cognitively immature. You share your assessment with a colleague during rounds. Your colleague asks where the family is from. Your colleague explains that in some cultures, no matter how old you are, it is considered rude and offensive to call your mother anything but "Mommy." Given the patient's medical disposition and your implicit bias, you may have inappropriately carried out this patient's course of treatment and goals.
There are plenty more examples of implicit attitudes, but the important issue is that we can and should tease these biases out of ourselves, so that we become more aware of how they might be impacting the ways we treat our patients.
One way to begin is with an online test of implicit bias. There are several out there, but Harvard's Implicit Association Test (IAT) is a popular (and eye-opening) one you may want to try.
After that, think about getting training on implicit bias and more general cultural competence. APTA has some resources to get you started on your cultural competence journey – check them out.
In the meantime, in your day-to-day practice, try to ask yourself these questions about every patient you see:
- Did I do all that I would normally do for that condition?
- Did I elicit the patient's personal goals or just what I think they should be? (To do this you have to engage beyond the superficial level.)
- Did I order or recommend all equipment that was necessary, above and beyond, or could I have recommended something and for some reason just ... didn't?
From a big-picture/systems perspective, there are also things we can do to help minimize the effects of implicit bias, or at least make our profession more sensitive to its effects:
- Infuse cultural competence in PT and PTA schools.
- Expose young (elementary school-aged) children to the field of physical therapy as a viable option for a career to promote and facilitate diversity in applicants and students.
- Where possible, standardize personal practice. For example, if you always recommend x-rays for patients who objectively score positively for possible ankle fractures, don't avoid doing it this time just because your patient has Medicaid.
We may never rid ourselves completely of implicit bias, but we can be honest with ourselves and do whatever we can to see to it that our biases aren't making treatment decisions for us. Our patients – all of them – deserve at least that much.
Hadiya Green Guerrero is a senior practice specialist at APTA.
Explore other posts from the "Narrow the Gap" series.