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When It Comes to Implicit Bias, Neurology Has Some Blind Spots

What the AAN Is Doing About Them

Shaw, Gina

doi: 10.1097/01.NT.0000557714.76259.f8
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Participants in the AAN Diversity Leadership Program discuss implicit bias—where and how they've observed it in themselves and others—and the AAN efforts to address it.

Despite what many would say are decades of progress, disparities in care based on race, ethnicity, gender, and sexual identity remain prevalent in medicine in general and in neurology specifically, according to a paper published in Neurology on February 5 by members of the 2017 AAN Diversity Leadership Program.

Among the statistics cited in the review, for example, the authors of the paper noted that black and Hispanic patients were 30 percent and 40 percent, respectively, less likely than white patients to see an outpatient neurologist. And black patients had greater neurology-related emergency department visits, inpatient hospitalizations, and hospitalization costs compared with white people. Moreover, black patients were 70 percent less likely than white patients to undergo epilepsy surgery, and race was a significant determining factor for appropriate intervention for trigeminal neuralgia, even when controlling for insurance and socioeconomic status.

“It's very hard to accept the idea that people who are health care professionals, especially within our own field, would provide different care to someone based on race, gender, or sexual identity. That goes against everything that we believe in and the ideals we hold dear as physicians and neurologists,” Jeffrey C. McClean, MD, FAAN, neurology program director at the San Antonio Military Medical Center and assistant professor of neurology with the Uniformed Services University of the Health Sciences.

“It's a very difficult concept for us to face and to accept. But the fact remains that if you look at the statistics, the literature and available evidence, time and time again, in study after study, it has been shown that patients from certain groups—including blacks, Latinos, Native Americans, women, and those with different sexual identities—are subjected to lower quality care and lower access to care, even within the field of neurology. This is indisputable. While our demographics as a nation are becoming more diverse, that doesn't mean that these historic trends automatically just disappear.”

That also doesn't mean that neurologists, or any physicians, are deliberately providing inferior care to members of these groups. Far more often, these disparities are the result of unconscious or implicit bias, which individuals may not even be aware that they harbor from attitudes and systems they've grown up with, as a white person, and/or male, and/or heterosexual, cisgender person; even those from within these groups often hold implicit biases, Dr. McClean told Neurology Today.

Indeed, just one week after the article from the AAN Diversity Leadership Group was published in Neurology, an essay in the journal's Humanities Section, “Lucky and the Root Doctor,” was retracted after readers quickly responded on social media and in letters and calls to the author's depiction of an African-American patient and his partner, which they deemed to be negative racial stereotypes.

“I don't believe the author's intent was to be offensive or reinforce these harmful stereotypes,” Dr. McClean said. “Nonetheless, that was the result. This is why it is so essential that we as physicians examine ourselves for implicit bias.”

Indeed, in a letter to readers published on February 18, Neurology Editor-in-Chief Robert A. Gross, MD, FAAN, acknowledged that the journal's review process had failed in detecting that bias. “The error has compelled us to seriously re-examine our editorial processes, informed by conversations with a number of diversity leaders within the AAN. Our goal is to provide the best material possible for our readers, and we failed in this instance,” he wrote. “I would like to express again my deep regret and apologize for our error in publishing an article that was offensive. It should not have happened and will never happen again.”

The fact that a neurologist wrote such an essay, and that none of the neurologists who reviewed it for the journal called attention to these characterizations, dramatically illustrates how implicit bias affects even highly educated professionals who have dedicated their careers to caring for the health of others, several neurologists told Neurology Today.

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Early Exposure to Implicit Bias

Erika Marulanda-Londoño, MD—assistant professor in the vascular neurology division at the University of Miami's Miller School of Medicine, a 2016 participant in the AAN Diversity Leadership Program, and a current member of the AAN Diversity Officers Work Group—recounted for Neurology Today her own early encounter with implicit bias. Dr. Marulanda-Londoño said it occurred in her first year of medical school at Columbia University Vagelos College of Physicians and Surgeons in New York's Washington Heights neighborhood, a primarily Hispanic neighborhood.

“They were talking to us about participating in the student-run clinic, and someone mentioned social issues like diet and exercise,” Dr. Marulanda- Londoño said. “Someone commented, ‘Well, you don't have to talk about diet because everyone here eats rice and beans.’ We all stayed quiet and didn't know what to say, until someone who grew up in that neighborhood spoke up and said that was a really offensive comment. The school sent out an email that provided some education afterward, but I don't really remember having any formal discussion of implicit bias in our curriculum. I think that would have been really helpful.”

Discussions about implicit bias can provoke immediately defensive reactions, of the “Are you calling me a racist?” variety, she said. But there's a difference between explicit and implicit bias.

“I don't think there are too many physicians who are explicitly racist or explicitly anti-gay, although there certainly are some. But implicit bias is different; these are views developed throughout our life that affect the decisions we make, views shaped by our parents and our upbringing, where we went to school, and the neighborhood we grew up in,” said Dr. Marulanda-Londoño.

“They're unconscious, that's the point, but we need to check them because they do affect how we treat people, not just our patients but our colleagues and everyone involved in taking care of the patients as well. This is something that everyone in a medical school class and residency program needs to be educated on.”

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Ingrained Biases

These biases can be so ingrained into medical culture that even those physicians with a particular interest in diversity can miss them, said José G. Merino, MD, MPhil, FAAN, associate professor of neurology at the University of Maryland in Baltimore and the physician lead for the AAN's Diversity Leadership Program.

“There are subtle attitudes and framing that can be hard to put your finger on,” Dr. Merino said. “For example, we practice in an underserved area with a very diverse population, and there can be implicit bias in how diagnoses are approached. This is something I also noticed while practicing at other inner city hospitals serving a diverse population in the Bronx and downtown DC. It's the idea of the inner city and crime and people with drug problems—jokes about who your typical patient is.”

In another example, he cited a 2013 study in Neurology conducted at Henry Ford Hospital in Detroit—another institution serving an “inner city” population—in which patients with stroke and transient ischemic attack (TIA) who were young and black were reported to be more likely to have urine toxicology screening than other patients.





“Of course, this can just serve to perpetuate stereotypes, because the more you screen for drug use, the more likely you are to find it—and if the populations you screen are disproportionately black, that reinforces the implicit bias that led to that kind of screening in the first place,” said Dr. Merino, who wrote an accompanying editorial to the 2013 Neurology paper. “Drugs are used by people of all races and ethnicities. The authors suggested that all stroke and TIA patients receive screening, in order to avoid this kind of profiling.”

José Posas, MD, a sports neurologist at Ochsner Medical Center in New Orleans, told Neurology Today that participating in the AAN Diversity Leadership program in 2017 has opened his eyes to unconscious bias at his own institution.

“Part of the process of correcting this is looking at what we do in our own practice and communities across the country, asking hard questions, and trying to do better. For example, at Ochsner, we have a very good rate-adjusted mortality index [RAM] for stroke,” he said.

“All seven of the hospitals in our hub-and-spoke stroke system have better survival rates than most hospitals in the Louisiana comparison group, and our RAMI scores show that. But just yesterday, I asked the person who calculates our RAMI scores if they had ever examined the effects of race and ethnicity on those scores. He said, ‘No. No one's really asked us to.’ You have very smart people who are doing their best and they're not even tracking that metric. Fortunately, the powers that be at my institution have been receptive to this self-policing, in an effort to deliver the most equitable care we can to the community that we serve.”

Dr. Posas said he is also more aware of implicit bias in his own work. Dr. Posas frequently serves as a sideline neurologist at football games—a role that he now realizes has its own unconscious gender bias. “My attention is on the football players in front of me. But behind me are cheerleaders doing aerial stunts, and if they fall and get concussed, I'm the one who's going to examine them. So why are my eyes always focused on the boys playing on the football field?”

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The Impact on Treatment

There are many ways in which these implicit biases may lead physicians to make decisions that lead to the health disparities that have been documented time and time again, said Dr. McClean.

Figure. “I

Figure. “I

“One example is the unconscious belief that African-Americans are uneducated regarding health care or less compliant with medication regimens. It's been shown to be held by many in the health profession. If someone holds those beliefs, even without being aware of it, they may choose a therapeutic option that favors simplicity over efficacy, which may not lead to the best care. That's why the [retracted] Neurology [essay] was so disturbing—because it portrayed a patient in a way that reinforced those very stereotypes that can lead to poorer health outcomes. This is where we have an opportunity to make positive change: The only way to overcome implicit biases is to talk about them, understand them, realize they exist, and make conscious efforts to overcome them.”

Referring to the retracted essay, Dr. Marulanda-Londoño added: “It was disheartening that this happened, in the background of everything that the AAN has been trying to do to enhance diversity within neurology, to support neurologists of color and female neurologists. At the same time, I don't think it erases the efforts they have already put in place. I do find it hard to understand how such a paper got through, but I think the response to it was quick, appropriate, transparent and not superficial, and that the whole thing was taken very seriously.”

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The AAN Response

Beyond retracting the article, Dr. Gross outlined in his letter to readers a series of steps that the journal has either already taken or will take promptly. These initiatives include implementing changes to the editorial process to mandate diversity review of all articles; recruiting a deputy editor for Equity, Diversity, Inclusion, and Disparities (EDID) and establishing an EDID Table of Contents Category as well as a dedicated topic site. The journal is also working on developing a strategy to increase the diversity of its editorial board and is developing a plan for EDID awareness training, among other ongoing diversity efforts.

“The ‘ongoing diversity efforts’ Dr. Gross referred to are many and wide-ranging—and that may actually be part of the problem,” said Dr. McClean. “The AAN has done quite a bit to tackle these issues from the Diversity Leadership program to the Women Leading in Neurology program, the Women's Issues in Neurology section, the LGBTQI section, the Diversity Officers Work Group, and a number of other initiatives taken on at the committee and subcommittee level. This is all in addition to the high-profile Presidential Task Forces, which have made important recommendations regarding salary disparities for women and health care disparities.”

“However, until now there hasn't been an overall strategic alignment of all these issues, so that we're not working in silos,” Dr. McClean noted. “In order to overcome these pervasive underlying issues, we really need to be strategic, consistent, and focused in our efforts.”



That's the task of a new AAN group called the Joint Coordinating Council on Equity, Diversity, Inclusion, and Disparities, created by the AAN Board of Directors in September 2018. The group is charged with ensuring that the recommendations from the Diversity Leadership Program, the Gender Disparities Task Force, and the Health Care Disparities Task Force are implemented across the entire organization.

“Right now, we're doing an environmental scan to better understand the problems that exist, the AAN's current efforts, and ways in which the AAN can do more,” said Dr. McClean, chair of the Council. “What are the disparities in care that our patients experience? Where do we have good existing information, and where can we as a council promote gathering more information to better understand these disparities and why they exist?”

In a letter to AAN members on February 21, Academy President Ralph Sacco, MD, MS, FAAN, expressed his own deep regret over the publication of the Neurology Humanities section article. Dr. Sacco described the organization's diversity and inclusion efforts in detail, including training for Academy staff on all aspects of equity, diversity, inclusion, and disparities, as well as opportunities for education on these issues at the upcoming Annual Meeting in Philadelphia.

“I am committed to ensuring we emerge stronger from this experience,” he wrote. “I want you to know that, as regrettable as this event is, it also has been instructive. It underscores that we cannot let down our guard against racism, inequities, and disparities, whether casual or overt. We must see it and call it out. We must educate and empathize. We must work toward the day when everyone is treated with the dignity and respect they deserve.”

Why We Feature Diversity

Joseph E. Safdieh, MD, FAAN

Here at Neurology Today, we have been working hard to ensure that the diversity of our field is being highlighted. In our new print redesign, we even include a full-fledged diversity section with its own icon. I believe that stories about diversity are as important as the cutting edge patient care and science advances that we cover.

To date, we have reported on tough issues such as gender disparity in national neurology awards, the gender pay gap in neurology, the lack of diversity among neurology chairs, the challenges of recruiting patients of diverse backgrounds into clinical trials, and many other issues.

I strongly believe that the best way to address diversity in neurology is to confront it head on, to write about it, to make sure that we are inclusive in who we ask for commentary in articles, and to ensure that all voices have a chance to be heard.

I am proud that two of the three associate editors of Neurology Today are women, as are seven of 16 of the editorial board members. Although our editors come from diverse backgrounds, none are neurologists of color, however, and for that I offer my own apology. I will work over the next few months to further ensure that the editorial board truly reflects the diversity of neurologists.

This has been a trying time for all of us. That said, I am confident that we will move forward as a community of neurologists who are even stronger and more united than before. Neurology is a big tent and there is space for everyone to participate and achieve success.

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Link Up for More Information

•. Marulanda-Londoño ET, Bell MW, Hope OA, et al Reducing neurodisparity: Recommendations of the 2017 AAN Diversity Leadership Program Neurology 2019; 92:(6)274–280.
    •. Silver B, Miller D, Jankowski M, et al Urine toxicology screening in an urban stroke and TIA population Neurology 2013;80:1702–1709.
      •. Merino JG. Editorial: Profiling patients Neurology 2013; 80:1632–1633.
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