Share this Article
Clinical Judgment Due to Implicit Bias Can Lead to Medical Errors
By Thomas J. Bryant, ARM
President, Physicians Insurance
April 8, 2020
With the widely reported news that the mortality rate from COVID-19 is hitting communities of color disproportionately, let’s examine a difficult topic: unconscious bias in medicine.
I don’t know a single medical professional who enters an exam room deliberately harboring prejudice against a patient, the very person they swore an oath to heal.
Yet research shows us that bias among the medical community mirrors societal attitudes towards race, gender, or other underrepresented minorities.
Surveys in studies published in the Journal of the American Board of Family Medicine (JABFM) in 2014 and BMC Ethics in 2017 found an implicit preference for white patients, especially among white physicians, consistent with bias found in the general US population.
Discrimination based on race, sex and other differences is odious, yes. But it can also be deadly. Alarmingly, the studies found a relationship between this bias and clinical decision-making. As diagnostic errors continue to be the main drivers of malpractice claims, researchers believe the environment for the error can in some cases be traced back to a medical professional’s unconscious or implicit bias against patients of a certain race, ethnicity, age, gender and/or sexual preference.
The JABFM study surveyed more than 500 physicians who were presented with vignettes of patients with severe osteoarthritis. The doctors were asked about the medical cooperativeness of the patients, and whether they would recommend a total knee replacement.
Even though the descriptions of the cases were identical except for the race of the patients (African Americans and whites) the doctors surveyed reported that they believed the white patients were being more medically cooperative than the African American ones.
In just the past year, there has been far more media coverage on how bias contributes to care inequities among women of color, particularly in maternal and fetal mortality, as well as transgendered, disabled, and other marginalized patients. Clearly, more research connecting bias to care outcomes is needed.
Moving forward with CDSS and a more diverse medical profession:
But after the pandemic, when we can pull our heads above water, what measures can a medical practice take to ensure it treats all patients with optimal care?
A very useful 2018 MedPro white paper, “Clinical Judgment in Diagnostic Errors: Let’s Think About Thinking,” suggests a number of strategies such as improving teamwork, increasing cognitive awareness, and using clinical decision support systems, clinical pathways, checklists, and debiasing techniques.
“By considering how these strategies can be implemented in everyday clinical activities, healthcare providers can take proactive steps toward managing diagnostic risks,” the authors wrote.
Use of a Clinical Decision Support System (CDSS) tool, when appropriate, is another promising option, although great care must be taken to ensure the algorithms are themselves bias-free.
Large, busy practices may actually benefit the most from CDSS tools that make sure the entire care team are on the same page in terms of avoiding implicit bias and striking the ideal balance between physician clinical judgment and effective data-driven decision-making.
As always, though, the human element will be the most important factor in top-notch patient care.
Organizational scrutiny and awareness at every level of your practice is vital. As the Journal of Infectious Diseases reported in the 2019 article “The Impact of Unconscious Bias in Healthcare: How to Recognize and Mitigate It,” health organizations should commit to a culture of inclusion and create a deliberate strategy for medical trainee admission, faculty hiring, promotion, and retention of underrepresented minorities in the medical profession.
Equity among medical practitioners will help promote more equitable health care delivery to patients. And in the current climate of upheaval, it is up to all of us in health care, from all backgrounds, to fulfill the promise of excellent care for all patients, not just for some.
Further reading and bias self-testing resources:
A selection of New England Journal of Medicine articles on race and medicine, with implications for improving patient care, professional training, research, and public health.
View Physicians Insurance’s June 2020 statement against racism
Physicians Insurance President Thomas J. Bryant, ARM, is a licensed Property, Casualty, Life, Accident, and Health broker in all six New England states and has been an adjunct clinical assistant professor in the School of Health Sciences at Bryant University since 2016. Most recently Tom developed a video presentation on malpractice basics for Harvard Medical School’s fourth-year students, and has participated in NEJM Resident 360 virtual panels on topics related to financial matters important to early-career physicians.
Mitigate risk to be prepared. For more information on how Physicians Insurance can support your practice and help you mitigate risk, visit www.piam.com or call 800.522.7426.
