One of the most effective ways to reduce implicit bias is to increase awareness of its existence and its impact on outcomes. This can be accomplished through education and training on topics such as unconscious bias, cultural competency, and diversity and inclusion.
Implementing procedures that support objective decision-making--such as standardized protocols and algorithms, may help reduce the influence of implicit bias. However, a study published in 2019 expressed growing concern that algorithms may reproduce racial and gender disparities via the people building them or through the data used to train them (Obermeyer et al., 2019).
Increasing the diversity of the healthcare workforce can reduce implicit bias by exposing providers to a broader range of cultural experiences and perspectives. This can involve initiatives such as targeted recruitment and retention efforts, as well as training programs that promote cultural competency and sensitivity.
Did You Know. . .
Minority health professionals are underrepresented in the workforce and health professions faculty. Only 6.2% of medical students identify as Hispanic or Latinx, and only 8.4% as Black or African American (Vela et al., 2022).
Data analytics can identify differences in outcomes and can help organizations develop targeted interventions to address disparities. This involves tracking metrics such as patient satisfaction, readmission rates, and health outcomes by race, ethnicity, and other demographic factors.
Engaging with patients and communities can reduce implicit bias by promoting cultural understanding and sensitivity. This involves initiatives such as community outreach and education, patient feedback, and the inclusion of patient advocates and community representatives in healthcare decision-making.
Health equity means that everyone has a fair and just opportunity to be as healthy as possible.
Robert Wood Johnson Foundation
Health equity is based on the idea that health is influenced by a wide range of social, economic, and environmental factors, such as income, education, housing, and access to healthcare. These factors create unfair and unjust differences in health outcomes between different groups of people.
Health equity initiatives aim to eliminate these differences by addressing the root causes of inequities and by ensuring that everyone has access to the resources and opportunities necessary to achieve good health. Looking at healthcare through a “health equity lens” is an important first step. This approach can reduce implicit bias by encouraging healthcare providers and organizations to be more conscious of the social, economic, and cultural factors that affect the health outcomes of different populations.
Developing Good Communication Skills
Effective communication is critical to good clinical interactions. Poor communication between providers and patients affects care outcomes and care quality. Good communication means both parties can speak without being interrupted, ask questions, express opinions, and understand what the other means (Kwame and Petrucka, 2021).
Miscommunication has been shown to be a consistent communication-related barrier in nurse-patient interaction, which often leads to misunderstandings. Additional communication-related barriers include language differences between patients and providers, poor communication skills, and patients’ inability to communicate due to their health state, dementia, or end-of-life care contexts (Kwame and Petrucka, 2021).
Communicating Across Cultures
Knowledge, attitudes, and skills that increase communication between different cultures is a key component of good communication. This requires a self-examination of one’s own cultural and professional background. It encourages healthcare providers to manage prejudices and stereotypes that may affect their behavior when interacting with someone from a different culture (Gradellini et al., 2021).
In the U.S., there is a high degree of linguistic diversity, with more than 59 million residents speaking a language other than English at home. Among these, more than 25 million people live in “linguistic isolation”—a term coined by the U.S. Census Bureau—in which no one in a household over 14 years of age speaks English very well (NCCC, Nd).
Understanding the languages spoken most frequently in your service area is important. Good cross-cultural communication means providers are aware of language differences, avoid assumptions about a person’s cultural or linguistic background, and avoid jargon. A single list may not be enough because the most common non-English languages vary greatly from area to area. For instance, Spanish is in the top ten languages in nearly all U.S. counties, while Turkish is in the top ten in 12 U.S. counties, Laotian in 125, Navaho in 74, Serbo-Croatian in 58, and Portuguese in 229 (AHRQ, 2018).
Employing Culturally and Linguistically Appropriate Services (CLAS)
Prior to 2000, only a few independently developed standards were available for the evaluation of cultural competence and linguistically appropriate services in healthcare. In 2000, the U.S. Office of Minority Health developed the Culturally and Linguistically Appropriate Service (CLAS) Standards, which serve as a national standard for healthcare in the United States (CDC, 2014).
Updated in 2013, the CLAS Standards are grounded in a broad definition of culture, encompassing not only race and ethnicity but also language, spirituality, disability status, sexual orientation, gender identity, and geography to ensure a strong platform for health equity. The Standards are divided into 3 sections: (1) Principle Standard, (2) Governance, Leadership, and Workforce, and (3) Communication and Language Assistance. They provide a blueprint for individuals and healthcare organizations to implement culturally and linguistically appropriate services (OMH, 2022).
The entire CLAS Standards can be accessed here (https://thinkculturalhealth.hhs.gov/clas/standards)
Using Language Assistance Services
Language assistance services facilitate communication for patients as they move through healthcare organizations. Examples of language assistance services include oral interpretation, translation of written documents, signage, and wayfinding symbols. Individuals with language needs can include those with limited English proficiency and those who are deaf or hard of hearing. Language assistance services should be provided at no cost to the patient (HHS, 2022).
When interpretation and translation services are not provided, there is strong evidence that patients with limited English proficiency are adversely impacted. Poor communication contributes to a patient’s lack of understanding of their health condition and recommended treatment. Adverse impacts can include:
- Incomplete and inaccurate health history
- Misdiagnoses of health and mental health conditions
- Misuse of medications
- Repeat visits to physician offices or emergency departments
- Lack of informed consent (NCCC, Nd)
In the example that follows, the failure of an organization to provide language assistance services (or the doctor’s failure to use available services) led to a frustrating experience for the doctor, the hospital, and the patient, and his family.
Case: Mr. Louis and His Granddaughter
Mr. Louis just celebrated his 70th birthday with his family and neighbors with lots of great food, music, and dancing. He kept everyone up late, telling stories about his childhood in Haiti. Mr. Louis was grateful to have so many loved ones close by, but he still misses Haiti after moving so many years ago.
Soon after his birthday, Mr. Louis visited his physician for a checkup. After his physician sent him for additional testing, Mr. Louis was diagnosed with prostate cancer. Let's see what happens during Mr. Louis’ appointment with the oncologist, Dr. Emily Parker.
The Initial Appointment
Mr. Louis brought his granddaughter, Suzy, to his oncology appointment at the hospital to help him speak with the oncologist. He knows some English, but he was worried that he would not understand everything that the doctor might say. Plus, Mr. Louis was nervous and wanted his granddaughter there for support.
Once the appointment began, though, Dr. Parker and Suzy did all the talking. Mr. Louis did not get a chance to speak, and he did not understand most of what Dr. Parker and Suzy were saying. After a few minutes, Suzy seemed to be arguing with Dr. Parker. This embarrassed Mr. Louis, but he stayed quiet.
After the First Appointment
After the appointment, Suzy explained to her grandfather in French that, to treat his cancer, he would undergo a procedure the next week that would implant radioactive seeds. Suzy told Mr. Louis that the procedure was simple, painless, and without side effects. She did not mention what else the doctor said or what she seemed they seemed to be arguing about during the visit.
Back at home, Mr. Louis began to worry about this procedure. He researched the procedure online and talked with his friends about it. He learned that the procedure did have side effects, including the possibility of incontinence. Remembering how Suzy had argued with the doctor, Mr. Louis wondered whether or not she had told him the truth about her conversation with Dr. Parker.
The Surgical Appointment
The next week, Mr. Louis and Suzy arrived at the admissions office at the hospital. “No surgery,” said Mr. Louis firmly. The admissions clerk looked up in surprise, and Suzy quickly started talking to her in English. She explained that Mr. Louis did not really understand the issue and that he really did want the surgery.
Suzy asked to sign the papers for her grandfather, but the admissions clerk explained that without legal standing, Suzy was not eligible to do so. Mr. Louis continued to quietly say, “No surgery.” The admissions clerk had no idea what to do. The surgical staff called to say that they were waiting for Mr. Louis. Suzy glared at her grandfather.
The clerk spent almost half an hour trying to find a hospital staff member who spoke French, but no one was available. The surgery staff called again, saying that if Mr. Louis did not arrive shortly, they would have to reschedule his procedure.
Exasperated, Suzy insisted that Mr. Louis undergo the procedure. She said, “The hospital has people ready to do this. All those people’s time will just be wasted. Come on, just sign the paper and we can get you upstairs.” Mr. Louis said again, “No surgery.” Suzy had no choice but to take him home.
Mr. Louis’s Response
“I depended on my granddaughter to help me with my oncology appointment. But she did not tell me the truth about the surgery and my options to treat my illness. I am really angry that I came very close to having a surgery I did not want! It was so frustrating to not be able to communicate directly with my doctor. All I wanted was someone who could listen to me and explain my options.”
Mr. Louis’s Doctor Responds
“These days, I see a lot of patients who don’t speak English very well or at all. I’m used to communicating with a family member or friend instead of the patient. In fact, I ask patients to bring someone who can interpret for them. It’s so much easier that way!
“But when I heard about Mr. Louis’ situation from our admissions clerk, I was shocked! I did not recommend the procedure that Suzy scheduled for her grandfather. I actually suggested “watchful waiting” as Mr. Louis’ treatment option. But, during the consultation, his granddaughter insisted that Mr. Louis undergo the procedure. Now that I think about it, I didn't speak much with Mr. Louis since Suzy seemed to be in charge. I thought I was doing the right thing by speaking with the family member that Mr. Louis brought with him. Now knowing that Mr. Louis did not want surgery scares me. I wish I had been able to speak directly with Mr. Louis without his granddaughter interfering.”
Offering language assistance services, including a competent medical interpreter, helps patients with limited English proficiency understand and make informed decisions about their medical care. Unfortunately, Mr. Louis almost had a surgery that he did not want, and the surgery could have caused side effects about which he had not been informed. Operating on a patient who did not want surgery or who was not aware of potential adverse effects could have serious liability implications for the doctor and the hospital.
Furthermore, the hospital had a surgery team and room sitting idle because a patient was scheduled for a procedure that he did not want. In this case, the cost of providing a trained interpreter would have been significantly less than the costs that the hospital incurred from this.
Think About It
- How would you feel if this happened to you or a family member?
- Could this happen at your organization?
- Does your workplace offer communication assistance?
Source: HHS, 2022