ARTICLE IN BRIEF
Neurologists discuss their experiences of implicit racial and ethnic bias from patients, peers, and administrators and discuss what can be done to address the problem.
When Yazmín Odia, MD, walks into an examination room wearing a white coat, a suit, and a stethoscope, the patient may ask her to clear the tray.
Similar things happened more frequently during her residency years, said Dr. Odia, a brain tumor specialist who in August was appointed the lead physician of medical neuro-oncology at the Miami Cancer Institute at Baptist Health South Florida. But they continue today. “Even now, I'm confused even by other physicians as a PA or RN,” she says.
The AAN recognized that the field as a whole could do more to provide a pathway for more diverse leadership in the field, and established a diversity leadership program in 2015 at the behest of then-outgoing AAN President Timothy Pedley, MD, FAAN. He had observed that the AAN had made inroads in promoting gender diversity among its leadership, but had lagged in doing the same for ethnic diversity.
Participants in the six-month interactive program meet at the AAN Annual Meeting and work together during the year on a project that that they propose to the Academy to promote diversity within the neurology workforce. The program includes monthly conference calls with professional consultants and suggested readings and activities. The goal is to support the development of leaders that reflect the demographics of AAN members and the patients they serve.
This is a promising step in the right direction, five neurologists in different specialties and areas of the country — four of whom are participants in the diversity leadership program — told Neurology Today. But they said challenges remain. They agreed to discuss their experiences on the condition that others involved not be named or identified. These were their experiences, they offered, with the caveat that their observations can't necessarily be generalized to the field as a whole.
Indeed, bias was by no means a universal experience among the participants in the diversity leadership program at the AAN. “I have not experienced or witnessed any bias [firsthand],” said Edgar A. Samaniego, MD, MS, clinical assistant professor of neurology at the University of Iowa, but, he said, he had heard from other colleagues who had.
“Bias can be hard to address because it's so subtle, said Temitayo Oyegbile, MD, a pediatric neurologist at Georgetown University Hospital. “Especially in situations where [bias] is peer-to-peer, it never comes off completely as, ‘Oh, he called me this name. Oh, he said something racist.’ It usually happens as something subtler – like a ceiling effect” that gradually becomes apparent, she said.
And it isn't always subtle, Dr. Odia said. “I have personally had patients who have refused my care because I am a woman and a Latina. They say, ‘I'll take service from the other guy,’ even when I was the chief and the other guy was a resident,” Dr. Odia said.
The neurologists said they have had these experiences not only with patients, but with colleagues, supervisors, and administrators, as well.
THE PREVALENCE OF BIAS
One of the inherent challenges in changing that trajectory is the paucity of represented minorities in the field. Despite a US population that has become increasingly diverse, the pool of underrepresented minorities in medicine in general and neurology, in particular, is small. According to the Association of American Medical Colleges (AAMC) 2014 Diversity in the Physician Workforce report, just 2 percent of all practicing neurologists identify as African-American, 4 percent as Hispanic, and 0.2 percent as American Indian or Alaska Native. Those numbers fall behind those reported in almost every other medical specialty and likely contribute to the problem of bias, neurologists told Neurology Today. For decades, much of the research into bias in medical practice focused on bias that non-white patients experience from white doctors, not the bias that non-white physicians experience, said Laura Castillo-Page, PhD, acting chief diversity and inclusion officer at the AAMC, which oversees the application process to medical school and regularly collects data on the physician workforce.
But in recent years, she said, “We're seeing more reporting of bias from the other side. The coin is flipping. Physicians are talking about the bias they experience. We're hearing about lots of instances where patients refuse to have a doctor care for them.”
Jerome Lisk, MD, a neurologist and movement disorders specialist in Pasadena, CA, recounted an incident when he was the only African-American neurologist at a practice in Springfield, MO. Another doctor's young patient had a pump implanted to treat her muscle spasticity, but the pump had flipped and couldn't be refilled, posing a risk of multiple organ failure. After Dr. Lisk corrected the flipped pump, the patient's delighted mother requested a follow-up appointment from a nurse. But the nurse asked her, “Are you sure you want to see him? Do you know he's black?”
“There have certainly been occasions, although rare, where I've felt biased against by senior colleagues who refused my consultation advice,” said Dr. Odia. “On occasion, when I'm consulting, [a white neurologist] just refused to accept my opinion and dismissed it outright.”
Dr. Lisk agreed, saying he felt that his concerns were often dismissed when there were discussions of problems in the clinic, while other neurologists in the clinic were given the benefit of the doubt.
During his first year of neurology residency at the University of Texas Southwestern Medical Center, Dr. Lisk said he experienced bias in several contexts. As one of two African-American residents in the program, he learned that attending physicians had falsified complaints on both of their evaluations.
“This type of thing follows you your whole career,” he said. “Once this occurs, it is virtually impossible to prove to a medical board that your file was falsified.”
Several neurologists shared anecdotes when they felt their work had been unfairly questioned. One said she was accused of plagiarism by a supervisor who questioned her ability to have delivered high-quality work. A black neurologist founded a lab where he was named a co-director along with a Korean neurologist, but found that doctors in the community almost always referred their patients to the Korean doctor, not to him.
And in one case, when a female neurologist of color was asked to consult on the case of a patient who had a neurological condition related to her subspecialty, she presented recommendations for further workup to the senior neurologist — only to have them dismissed without much explanation. But when another white male doctor later offered the same advice, the senior neurologist – who was also white – accepted it.
“Peer-to-peer bias can really limit collaborative practice,” said Dr. Odia. “If bias comes from senior [staff] to their direct reports, it can inhibit career progress. And if it comes from physicians to patients, it causes poor compliance and poor outcomes.”
Bias also can contribute to burnout, already a significant problem in neurology. “Bias begins to affect people's psyches and their interest and desire and drive to move forward,” Dr. Oyegbile said.
Implicit bias “limits options and does not allow the best people to succeed,” said Dr. Samaniego. “It limits communication and the exchange of ideas and knowledge. Science should flow based on content and not appearances. If we would not have bias in medicine, patient care would improve due to better communication and understanding of everyone's needs.”
For many people, not just neurologists, recognizing bias requires abandoning the assumption “that we've made it, that we're over it,” Dr. Odia said. That means examining one's own assumptions with an honest, critical eye. It's a matter of “learning to catch ourselves,” she said.
Indeed, implicit bias — the involuntary and sometimes unconscious attitudes or stereotypes that affect our actions and decisions — may be more pervasive than we think. Residing deep in the subconscious, these biases may differ from known biases that individuals may choose to conceal for the purposes of social and/or political correctness.
The AAMC is hoping to help physicians catch themselves by making them aware of their own biases. The organization now offers one- and four-day training sessions that use training videos and interactive sessions, among other tools, to address racial and ethnic bias. Institutions can nominate faculty to participate in the sessions, and once they're certified, they can go back to their institutions and conduct training sessions with others.
One of the tools they have incorporated into their training is an Implicit Bias Test, a questionnaire designed by researchers at Harvard to measure the strength of associations between concepts (for example, black people, gay people) and evaluations (good, bad) or stereotypes (athletic, clumsy).
In a study published in the journal Academic Medicine in September 2016, researchers administered the test to all 140 members of the Ohio State University College of Medicine admissions committee. They found that all people taking the tests displayed significant levels of implicit preference for white applicants, with men and faculty members exhibiting the greatest bias. Encouragingly, though, in a follow-up survey, 67 percent of survey respondents said they thought the test would be helpful in reducing bias; 48 percent said they were more conscious of their own results when interviewing candidates in the next admissions cycle; and 21 percent said knowledge of their test results affected their admissions decisions during the following admissions cycle.
“After going through that process, the Ohio State medical school had their most diverse admissions year yet,” said Dr. Castillo-Page. “It was very successful.”
A change in attitudes must filter down from the leadership at institutions and organizations, several neurologists suggested. Efforts to address and counteract bias should be initiated by department chiefs and lead administrators, Dr. Odia said, adding: “The culture is created by its leaders.”
Institutions should encourage open discussions about bias, and those discussions should be preemptive rather than reactive, she added. “The chair or the director can open the conversation themselves: ‘I know you as a woman or as a Latina you may have issues that come up or feel extra pressures; I want you to know we're here for you.’”
Additionally, Dr. Odia said, discussions about bias must be frank and not just seeped in “feel-good” stories. “It's important to focus on facts,” she said. “No one can dispute facts. No one can argue about statistics on stroke outcomes, for instance. And we need to set achievable metrics.”
Those discussions should happen more frequently than once a year, and should be mandatory rather than voluntary, Dr. Lisk said. “Doctors are dealing with a lot in the day-to-day practice of medicine and have to be reminded that racial discrimination exists and is a bigger problem than they may realize.”
He noted that faculty and staff do not always feel comfortable or adequately supported in reporting bias to their institution. This is why he thinks the AAN and other organizations have a responsibility to devote more resources to the problem.
Dr. Lisk suggested that the AAN should establish an office — not just a program — tasked with promoting diversity and eliminating bias from neurological practice. Currently, he said, there is no office of minority affairs at the AAN or in the hospitals where he's worked. “The last time I was at an institution that had an office of minority affairs was during medical school,” he added.
The office should have a staff member with legal experience in employment law and discrimination in the workplace, he said, so members can get advice on how to handle issues of bias or discrimination while they are occurring. “Looking back, I could have documented more or been able to navigate the situations better if I had had someone to talk to that could give me advice.”
Commenting in response to Dr. Lisk's suggestions, Christine E. Phelps, deputy executive director of the AAN Institute, said: “The AAN is fully committed to promoting diversity within the field of neurology and within its own leadership. We are fortunate to have perspectives and ideas from members such as Dr. Lisk, who was a participant in the 2015-2016 Diversity Leadership Program (DLP).”
“This intensive program is focused on promoting engagement and leadership opportunities for members from diverse backgrounds. At the conclusion of the program a few months ago, the DLP participants were invited to formally present their recommendations directly to the AAN president and other senior leaders of the Academy. Thanks to the hard work of Dr. Lisk and his fellow DLP participants, these recommendations are currently being considered at the Board of Directors level to determine how best to prioritize the Academy's ongoing efforts to ensure equality for its members and their patients.”
Dr. Lisk added that the AAN currently has nothing in their code of conduct that says neurologists will not discriminate against other neurologists' race, religion, or sexual orientation. The AAN Code of Professional Conduct does explicitly prohibit neurologists from refusing to see patients based on these factors, he said, but not from neurologists discriminating against each other.
“The code of conduct is all about how to treat the patients, not about how to treat fellow colleagues. That needs to be added,” he said.
In response, Phelps said: “This is the current version of the Code of Professional Conduct. While it doesn't specifically prohibit racial bias or discrimination in relationships between neurologists, neurologists are expected to cooperate and communicate with other health care professionals.”
“The Code is regularly reviewed by the Ethics, Law and Humanities Committee,” she said, adding: “Suggestions for revisions or additions are always welcome.”
Indeed, the neurologists interviewed said that despite the problems, there is room for hope as they believe that despite their experiences, bias is likely less prevalent than it used to be. Much of that may be due to efforts in place at the AAN, such as the Diversity Leadership Program, now in its third year, and at the AAMC. As long as diversity continues to increase, they hope, bias will continue to shrink.
“If the AAN, the university and academia are more inclusive, bias will be eradicated with time, since people will get more used to interacting with people from different backgrounds and races,” said Dr. Samaniego. “Inclusiveness is the key to break barriers among ourselves and with our patients.”