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ER Goddess

ER Goddess

The Racial Biases Lurking in Our Subconscious

Simons, Sandra Scott MD

doi: 10.1097/01.EEM.0000695548.75277.d7
    racism, racial bias

    American society is deeply fractionated, and racial inequality is more pervasive than many of us believe or admit. We physicians can no longer turn a blind eye to racial disparities in our health care system. Acting like everyone is treated equally disrespects the struggles of our minority patients and allows us to continue in blissful ignorance instead of trying to do better. We must start trying to change any discriminatory care within our control.

    Of the many opportunities to diminish the struggles of minority patients, the one most within our control may be addressing the detrimental effects of unconscious racial bias, to which none of us is immune. I wrote last month about how unconscious bias infiltrates clinical encounters, resulting in discriminatory care. (EMN. 2020;42[7]:1;

    EPs are vulnerable to implicit bias because what we do requires rapid pattern identification and categorization of people we have never met to diagnose medical problems swiftly. Under the time constraints and high cognitive demands of a busy ED, we are more likely to make snap judgments based on subconscious stereotypes we've internalized. This puts us at risk for statistical discrimination—applying population statistics to conclude that something true about some members of an ethnic group is also true for the patient in front of us, even when that is not supported by anything the patient says or that is in his chart. Such discrimination is not intentional. It's natural for our minds to generalize and simplify input to reduce our cognitive load when we are bombarded with complex stimuli.

    Fortunately, unconscious prejudices are malleable. Once we're aware of the automatic cognitive processes that lead to inadvertent discrimination, it's possible to change if we're willing to work at it. When physicians recognize their own unintentional bias, they are able to neutralize its impact on treatment decisions. (Matthew, D.B. 2015. Just Medicine: A Cure for Racial Inequality in American Health Care. New York University Press.)

    Physicians in one study who knew the research was evaluating the influence of implicit bias on clinical decisions were more willing to prescribe thrombolytics to Black patients than physicians who were unaware. (J Gen Intern Med. 2007;22[9]:1231; Encouraging personal awareness of the racial biases that lurk in our subconscious is the first step toward overcoming their effect on our clinical judgment and conduct.

    Neutralizing Bias

    We owe it to our patients to combat systemic racism by taking the next step too: incorporating and teaching active strategies for neutralizing bias. Just as we learn negative stereotypes through repeated exposure, we can learn to reduce the activation of ingrained stereotypes through repeated exposure to new and positive counter-stereotypes. One study found it possible to reduce negative attitudes by more than 50 percent by repeatedly showing participants photographs of famous and admired Black people such as Martin Luther King or Denzel Washington and photographs of infamous and disliked white people such as Charles Manson. (J Pers Soc Psych. 2001;81[5]:800; Video images of Black people engaged in positive activities such as going to church or enjoying a family barbecue also reduced implicit bias. (J Pers Soc Psych. 2001;81[5]:815;

    Understanding the benefit of counter-stereotypical images, the Virginia Museum of Fine Arts in my hometown of Richmond recently commissioned a statue of a young Black man to counter the city's statues of white Confederate generals, helping to reset pervasive stereotypes.

    Counter-stereotypes do not need to be externally introduced; they may also be internally generated by one's own deliberate imaging. This is priming, a phenomenon in which exposure to a stimulus, such as a word or an image, influences behavior by triggering conscious or unconscious awareness of a specific attribute. Intentional priming with stereotypes has been proven to affect social behavior.

    We can combat unconscious racial bias by thinking about positive counter-stereotypes of minorities. The next time you head to a minority patient's bedside, prime yourself with thoughts of admired members of that minority. We still have a long way to go to dismantle systemic racism, but strategies like these are at least baby steps in the right direction.

    Strategies that stress ignoring differences rather than eliminating and replacing stereotypes simply don't work. Merely instructing people not to think about race backfires and actually causes an increase in implicit bias. (J Pers Soc Psych. 2001;81[5]:8; Saying things like, “I don't even notice race” is not positive; thinking and talking about race is required to overcome bias.

    Cultural Sensitivity

    Medical schools have taken positive steps by funneling time and money into cultural competency training to counteract bias. What medical students learn in the classroom does not counteract transferring bias to them at the bedside, however. Senior physicians modeling racist behavior on the wards—even if it was an unintentional manifestation of implicit bias—can rapidly undo cultural sensitivity training in the classroom.

    A concerning study showed that the decision-making of physicians who were farther along in their training was significantly more tainted by implicit bias than the decision-making of incoming first-year medical students. (JAMA. 2011;306[9]:942; This raises a legitimate concern that the egalitarian objectives in medical school are at war with the clinical education our future doctors receive.

    Groupthink affects us all. When it comes to unconscious racism, our colleagues' views matter more than we realize. Studies show that negative implicit attitudes and behaviors were greatest for students who believed their views were widely shared. Just as bias can spread from senior to junior physicians, willingness to denounce ingrained negative stereotypes can also spread. People are more likely to inhibit racial prejudice when feedback indicates that the majority of others disagree with racially prejudiced opinions. (Pers Soc Psych Bull. 2001;27[4]:486; Because social consensus can reinforce or diminish stereotypes, we can start breaking the cycle of bias by setting a better example. If a colleague makes a racist joke, call him out. If a minority voice is being ignored, highlight it so others will listen. Together we can propagate another narrative.

    Ask yourself why most physicians are white and most patients are Black in so many urban hospitals in our country. The old narrative was that white physicians worked hard or were smart. Perhaps the narrative should be that racism creates disadvantages for people of color and advantages for white people that make success easier to achieve. Perhaps many of the benefits we've enjoyed in life are the direct result of someone else not having the same benefits. Yes, becoming a physician was a result of my drive, but that doesn't mean that minorities without the same achievements don't have the same drive. The reality is that racism puts the starting line much farther back for some, making it much harder for them to cross the finish line.

    It's painfully clear from everything that's happened so far this year—from COVID-19 disproportionately affecting people of color and the protests prompted by George Floyd's death and the deaths and mistreatment of many other Black people—that it is time for all of us to start making intentional efforts to correct our own unconscious racial biases. We can only neutralize them when we acknowledge the ubiquitous effects of these implicit biases. Don't turn the page and ignore the issue. Inaction is action too. The fact that this article likely made a few people uncomfortable or even indignant is precisely why we need to continue this discussion.

    Dr. Simonsis a full-time night emergency physician in Richmond, VA, and a mother of two. Follow her on Twitter@ERGoddessMD, and read her past columns at

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