By Danielle D. Jones, AAFP Director of Diversity and Health Equity
Implicit biases are the unconscious associations individuals form in response to social conditioning and audiovisual cues. In primitive persons, they were a useful tool in quickly triggering the flight or fight reaction in response to danger, but now the reaction is often triggered in response to race and ethnicity. In the delivery of health care, implicit bias has been shown to directly drive disparities in many diagnostic and treatment recommendations, including pain, coronary artery disease, kidney dialysis, contraception and prenatal care[1-3]. More recently, it’s been suggested that implicit bias may be influencing clinicians’ decision-making about testing for and treating COVID-19[4]. Family physicians need to understand that they are not immune to the neurological phenomenon of implicit bias despite their best intentions. By raising their awareness, they can learn skills to minimize its influence on their clinical decision-making process.
The AAFP has developed training resources to assist its members in recognizing and overcoming implicit bias. The training covers the neurobiological process that leads to the formation of implicit biases, which makes it easier to understand during current medical education and training. It also includes the perspectives of patients who share their experiences with bias in the clinical setting. Those perspectives help physicians relate the concept to patient-centered care. Lastly, the training provides a set of skills physicians can practice in and out of the clinical setting to further reduce their reliance on implicit associations. While designed primarily to address implicit associations that arise during physician-patient encounters, the same skills can be used in the relationships between physician peers, especially in the context of employee relations such as hiring and promotion. The training was developed using resources cited in the medical literature as effective for training in the health care setting. It includes self-assessments and case study examples similar to those used in medical education and training.
The AAFP started piloting this training with the board of directors, commissions, executive leadership and staff. The response was overwhelmingly positive and appreciated as it allows for a deeper dive than most have experienced with this type of learning. As the second phase of implementation, we’ve recently launched a program with 12 AAFP Chapters around the country to provide technical support in offering the training to members locally between now and the end of 2021. As part of this program, chapters will be working collectively on an evaluation that measures learning outcomes and engagement as part of our compliance with being a continuing medical education provider. We plan to share anything we learn as part of our effort to inform future education on this topic.
While implicit bias training may be an effective intervention for targeting health care inequities that result at the level of physicians, additional upstream interventions are needed that target a) the use of race as a proxy in medical decision making and b) the health care system more broadly. Currently, the way race is used as a proxy in medical decision-making allows for differential diagnosis and treatment recommendations for which there is no biological or genetic justification. The AAFP opposes race-based medicine and encourages its members and other clinicians to investigate alternative indicators. In addition, interventions that aim to implement more equitable policies, procedures and processes in delivering care must also be considered.
To address the root cause of health inequities will require structural change on multiple levels.
We hope that members see implicit bias training as an opportunity to be part of the solution. By first acknowledging and then actively working to address personal biases, we can collectively begin to engage and dismantle the systems that impact them and their patients.
- Hoffman, K.M., et al., 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): p. 4296-301.
- Daugherty, S.L., et al., Implicit Gender Bias and the Use of Cardiovascular Tests Among Cardiologists. J Am Heart Assoc, 2017. 6(12).
- Kogan, M.D., et al., Racial disparities in reported prenatal care advice from health care providers. Am J Public Health, 1994. 84(1): p. 82-8.
- Milam, A.J., et al., Are Clinicians Contributing to Excess African American COVID-19 Deaths? Unbeknownst to Them, They May Be. Health Equity, 2020. 4(1): p. 139-141.
Danielle D. Jones, MPH, is director of the Center for Diversity and Health Equity at the American Academy of Family Physicians. She guides the strategic priority of AAFP’s board of directors toward a leadership role in addressing diversity and social determinants of health as they impact individuals, families, and communities across the life span as the board strives for health equity.
This story appears in Issue 2 2020 of the UAFP Journal.
