To remedy the impact of implicit bias, we must consider factors that can be changed and improved, such as opportunities for quality education, good paying jobs, access to quality clinical care, healthy foods, green spaces, and secure and affordable housing. In Michigan, as in other states, differences in a range of health factors emerged from unfair policies and practices for people with lower incomes and communities of color at many levels and over many decades (UW, 2020).
How Bias Impacts Perception
Well, I found out that race runs deeply throughout all of medical practice. It shapes physicians’ diagnoses, measurements, treatments, prescriptions, even the very definition of diseases. And the more I found out, the more disturbed I became.
University of Pennsylvania
Perception bias is a type of unconscious or implicit bias that occurs when our perception is skewed based on inaccurate and overly simplistic assumptions about a group a person “belongs” to. This may include biases or stereotypes about age, gender, and appearance. These attitudes, beliefs, or stereotypes can affect our ability to make sound decisions.
How we perceive others can affect non-verbal behavior towards others, such as frequency of eye contact and physical proximity. Perception biases can create a conflict between what a person believes and wants to do, for example, wishing to treat everyone equally, and the hidden influence of negative implicit associations such as perceiving Black patients to be less competent and thus deciding not to prescribe certain medications (FitzGerald and Hurst, 2017).
Healthcare professionals tend to view data as if it exists in isolation from the human decision maker. Recognizing and overcoming bias is related to our underlying perception of bias. Professionals may feel they can overcome biases through sheer will power. They may feel that bias does not occur in professionals and experts—they are impartial and immune to bias. They may also perceive bias as:
- Associated with corrupt or malicious people.
- Associated with “bad apples” rather than systemic issues.
- Eliminated by technology, instrumentation, automation, or artificial intelligence (Dror, 2020).
Decision Making and Diagnostic Bias
The use of racial terms to describe epidemiologic data perpetuates the belief that race itself puts patients at risk for disease, and this belief is the basis for race-based diagnostic bias. Rather than presenting race as correlated with social factors that shape disease or acknowledging race as an imperfect proxy for ancestry or family history that may predispose one to disease, the educators we observed portrayed race itself as an essential—biologic—causal mechanism.
Amutah, et al., 2021
New England Journal of Medicine
Healthcare providers are vulnerable to a range of biases when making decisions, particularly diagnostic and treatment decisions. Many biases have been described in the healthcare literature, and many of these have been shown to influence decisions. Issues associated with the process of clinical reasoning can have a serious impact on the services provided (Featherston et al., 2020).
Bias affects patient-provider interactions, treatment decisions, patient adherence to recommendations, and patient health outcomes. Bias in decision-making can be expressed directly (explicitly) or indirectly (implicitly). This can lead to an unintentional form of discrimination that affects decision-making structurally and systematically and is hard to identify and uncover (Nápoles et al., 2022).
Reasoning biases challenge the assumption that humans make logically correct decisions when they are provided with sufficient information. Cognitive shortcuts can be efficient and accurate but are vulnerable to reasoning errors. For instance, cognitive shortcuts can produce biases because the most readily retrievable information may not be the most accurate or appropriate information to support the decision being made. It may, for example, simply reflect how recently the information was obtained (Featherston et al., 2020).
Cognitive biases can influence human decision making. Other biases arise from the interplay between cognition and emotion, as well as the external social context; a person’s emotional state can influence decision outcomes (Featherston et al., 2020).
Studies have shown that implicit racial bias profoundly influences clinical decision-making. Its affects nonverbal behaviors such as eye contact and posture and has been shown to influence the quality of physicians’ interpersonal communication with African American patients and, in turn, patients’ trust and perceptions of their physicians (van Ryn et al., 2015).
Effective health communication means providing information to an individual in an understandable and accessible way. Access to information is not enough; patients need understandable information that is also culturally and linguistically appropriate. Increasing knowledge about prevention and maintenance of good health can positively influence an individual's health behaviors and attitudes. This involves verbal, written, and nonverbal communication (HHS, 2022).
Communicating Across Cultures and Groups
There is a high degree of linguistic diversity in the United States 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).
Good cross-cultural communication skills allow healthcare providers to understand the needs, values, and preferences of their patients. Cultural differences in communication, such as preferences regarding how and when interactions take place, tone, eye contact, and other factors should be considered, even when using an interpreter (HHS, 2022).
Cross-cultural communication skills can be improved when a provider is aware of language differences, avoids assumptions about a person’s cultural or linguistic background, and avoids jargon. These factors should be considered when communicating in writing and when designing written material for patients.
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 National CLAS Standards, 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 (CDC, 2014).
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
Language Assistance Services
Language assistance services facilitate communication between patients and the various points of contact within an organization. Examples of language assistance services include oral interpretation, translation of written documents, signage, and wayfinding symbols. Individuals with language needs 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. Other 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 room
- 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.
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. Mr. Louis 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, Dr. Parker. He knows some English, but he was worried that he would not understand everything that the doctor might say. Plus, Mr. Louis was nervous, he 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, and 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 started getting worried 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 if 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)
Health literacy means a person can obtain, process, and understand basic health information and services needed to make appropriate health decisions. Research by the Institute of Medicine (IOM) indicated that over 90 million people residing in the U.S. have difficulty understanding and acting on health information (NCCC, Nd).
The IOM study shifted the view of health literacy as solely the domain of the patient to include the ability of healthcare professionals and the capacity of healthcare systems to provide health information. To improve health literacy, healthcare organizations must remove systemic barriers when communicating health information to patients and the community and understand the broader socio-cultural contexts in which health literacy is experienced (NCCC, Nd).
Healthcare media must consider how racism and other forms of discrimination unfairly disadvantage certain groups and lead to social and health inequities. Implying that an individual or community is responsible for increased risk of adverse outcomes is counterproductive. Some members of disproportionately affected groups cannot follow public health recommendations due to inequitable resource allocation or a lack of inclusive infrastructure (CDC, 2021, August 24).
Developing Public Health Communications
When developing public health communications, avoid jargon and use straightforward, easy to understand language. Hire people from the communities you serve and work with community partners to identify priorities and strategies (CDC, 2021, December 9).
Avoid using images of people in traditional or cultural dress or images that reinforce inequalities in status, such as a person of color with a White doctor. Do not display caricatures of any racial or ethnic minority group or displaying images that perpetuate unhealthy body images. (CDC, 2021, December 9).
Consider the gender, ability, and race or ethnicity of the people in the images used in communications. Gender representation should be diverse. Include people with visible disabilities in any communication, not just those focused on ability status (CDC, 2021, December 9).
Assessing an individual’s language needs is an essential first step toward ensuring effective healthcare communication. More than half of those who speak another language at home speak English very well but asking about a person’s preferred language provides a window into their health beliefs and practices. Having this information for each patient ensures the quality of services in subsequent encounters, in analysis of healthcare disparities, and in system-level planning (e.g., determining the need for interpreters and matching patients to language-concordant providers) (AHRQ, 2018).
Understanding the languages spoken most frequently in the service area is important as well. 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).
Case: Katherine and Her Mother in Spain
My mother came to visit me when I studied abroad in Spain. One rainy day while we were sightseeing, she slipped on some marble steps and fell to the ground, hitting her head. She was in pain and seemed disoriented, so I decided we should go to the hospital.
While we were waiting to be seen by the doctor, I was so scared. I had asked the women at the front desk if there was anyone who spoke English, but they said no. Even though I had been studying in Spain for several months, I hadn’t learned anything about medical issues and felt uncomfortable speaking in Spanish with the staff. As I waited for her name to be called, I kept looking up medical terms in Spanish on my phone and writing them down in case I needed them. I was afraid my mother had a concussion from hitting her head during the fall. Knowing that any errors I made in Spanish could possibly affect the doctor’s decisions really upset me.
During the consultation, I was the mediator between my mother and anyone who came into the examination room. I could tell my mother was frustrated and worried by her inability to communicate with anyone, and I was afraid that I wasn’t using the correct terms to describe what happened to her with the medical staff.
The doctor mentioned something about medical tests and medications she would prescribe, and so we’re waiting in the intake room again with all the other patients. How can I be sure they correctly understand what happened? I’m not sure what’s going to happen next. My mother is so important to me. I just want to be sure she is healthy and that there were no complications.
Think About It
- How would you feel if this happened to you?
- Do you think someone could have a similar experience when seeking care at your organization? If so, who would that person be?
- What would happen if someone with language assistance needs entered your organization today?
- Would their story sound like Katherine and her mother’s? (HHS, 2022)