Unintended bias, Self-awareness and Palliative care
I recently learned about unintended(implicit) bias and its impact on patient care, or contribution to healthcare disparities. I always work hard providing the best care to my patients and am trying to be consciously unbiased as much as possible. During my encounters with patients and family, or interdisciplinary team meetings, I usually keep my mind focused and controlled with patience, compassion and kindness. In most cases, I manage to fulfil my duties fairly well. But there are occasions when too much interruption is happening during the meeting or some disruptive thinking arises inside my mind, I rely on the framework or information about people already stored in my brain in order to have my job done efficiently. I thought it was a kind of useful “gut sense” or my good pattern recognition skill. But I realized this can lead me to biases and stereotypes about people and even to unfair assumptions or wrong judgement. It is true that my unintended bias can affect my attitude, gesture or language that other people may recognize and develop their own emotion about. As a physician, my implicit bias may also influence how I communicate with the patients and what treatment decision I choose for them. More importantly I learned that implicit bias causes negative impact on healthcare disparities including patient-provider interactions, treatment decision, treatment adherence, patient outcomes, etc.
Looking back on my practice, I tend to prescribe opioids for white patients with much less hesitancy in my mind than black patients when they present similar pain symptoms. I also realized I don’t bring up End of Life care discussions with Asian families as often as white families because I was raised in a Korean family where children’s filial duty for their parents' care is highly regarded.
Palliative care is based on the trust of patients and families and establishing therapeutic relationships with them is one of the most important skills for a palliative care team. The implicit bias can create unintended interference for that. It can also limit our capacity caring for the patients and their family as whole persons. Therefore, identification of our biases creating unintended barriers is very important and we should keep self-awareness on this matter and use strategies to address healthcare disparities . One of the CAPC master clinician series gave me helpful insights on how to reduce unintended biases - mindfulness, perspective taking, individuation, cultural humility, and pre-brief & debrief. I also found the “STEP” approach is helpful - Stop, Think, Explore and Prepare ;
Mindfulness : When you are under pressure, practice ways to reduce stress and to increase mindfulness
Perspective taking : Consider experiences from the point of view of the person being stereotyped
Individuation : Evaluate people based on their personal characteristics rather than those affiliated with their group
Cultural humility : Recognize own personal and cultural biases and be sensitive to significant cultural issues of others
Pre-brief and Debrief : be mindful of your feelings before the meeting. Discuss your case with other team members and be open to different perspectives
STEP social skill : Stop, think, explore, and prepare. Before interacting with people from certain groups, pause and reflect to reduce reflexive actions. consider positive examples of people from that stereotyped group.
Complete Georgetown University National Center for Cultural Competence (NCCC) Module: Conscious & Unconscious Bias in Health Care (Sections 1-4, including imbedded videos)
Hall W. et al. Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. Amer J of Pub Health; 2015
Kimberly Curseen, Center to Advance Palliative Care, On-demand webinar : Managing Implicit Bias and Its Effect on Health Care Disparities. https://www.capc.org/events/recorded-webinars/managing-implicit-bias-and-its-effect-health-care-disparities/
Kimberly Curseen, Center to Advance Palliative Care, Implicit Bias and Its Impact on Palliative Care https://www.capc.org/blog/palliative-pulse-palliative-pulse-june-2017-implicit-bias-and-palliative-care-part-1/ https://www.capc.org/blog/palliative-pulse-palliative-pulse-july-2017-overcome-implicit-bias-palliative-care/
AAFP. Eight tactics to identify and reduce your implicit biases. https://www.aafp.org/journals/fpm/blogs/inpractice/entry/implicit_bias.html
Media Partners. Unintentional Still Hurts: Overcoming Unconscious Bias. https://youtu.be/Xv0-G5KbkkE