Healthcare professionals often are unaware of their own gender, racial, cultural, or religious biases, which can play a role in inequity and disparate outcomes. One tactic surgery centers could employ to raise awareness about these biases is through the Implicit Association Test (IAT), which was designed by several scientists who formed Project Implicit.
The IAT evaluates potential implicit associations between different terms, says Charles G. Rickert, MD, PhD, a surgical resident at Massachusetts General Hospital in Boston. “You can use different terms to look at whether or not there are associations between positive or negative terms with one racial group, or if you associate faster positive terms with a depiction of someone who is Caucasian,” Rickert explains.
Rickert was the lead author of a paper about surgeons’ biases.1 He and his colleagues highlighted the efforts of faculty and residents at Massachusetts General Hospital’s department of surgery to form a community health collaborative in 2016 for the purpose of improving community outreach and increasing awareness about social determinants of health.
The collaborative designed a project that administered the IAT to physician faculty and residents. “The purpose of the study was to initiate the conversation among physicians in our department at Mass General,” says Numa Pompilio Perez, MD, a study co-author and general surgery resident at Massachusetts General. “We want to have conversations that we don’t always have about social determinants of health and healthcare disparities. You forget these issues are front and center from the patient’s perspective.”
The IAT is a useful assessment that can be a catalyst for self-reflection and raise awareness of implicit biases. However, it also is uncomfortable to take, Rickert notes. “The reaction a lot of people have when doing the [IAT] is they feel bad,” he says. “They take the test and see that they have a moderate bias in one way or another. They think, ‘Oh gosh, that’s awful.’”
The surgery department’s findings highlighted some interesting differences between people who demonstrated more implicit bias and those who did not. Physicians with more implicit bias tended to say that race and social determinants of health had less bearing on outcomes than those with less implicit bias, Perez reports. “Whereas people who said issues of racial disparities had a bigger weight when it came to surgical outcomes tended to be people who had lower levels of implicit bias,” he adds.
Everyone has biases, and these do not make us bad people, Rickert notes. What is important is to become aware of these biases and learn to avoid making comments or engaging in interactions that reflect bias toward patients of particular cultures or races, he adds.
After administering IAT, researchers found the surgery department was similar to the rest of the country in its level of bias. “We would all like to think we’ll be perfectly unbiased, but it was good for everyone to see where we are and that there is a need to institute efforts to diminish those implicit biases as much as possible,” Rickert says. Experts on racial disparities offer these suggestions on how to reduce inequities:
• Generate a baseline understanding of staff’s biases. “The first step is to be aware of the problem and acknowledge it,” says Dima El Halawani Aladdin, MD, a resident in anesthesiology at Washington University in St. Louis. “Don’t turn a blind eye.”
Using the IAT, surgery centers can show staff and physicians how everyone has some biases based on race and other demographics. “It generates discussion,” Rickert says.
The next step is to know the patient population and be mindful of the staff’s biases and patients’ biases. “Say you’re a plastic surgery office in a metropolitan area. Your cliental happens to be primarily Caucasian, and you say this is a population that is looking for this type of surgery,” Rickert offers. “But when you look at the community, you see there is a wide variety of patients in the area.”
The reason the surgery center sees mostly Caucasian patients could be related to how the center advertises, he notes. “Maybe you are advertising in only certain newspapers and magazines,” Rickert says. “Are you getting most of your referrals from primary care providers in certain cloistered portions of the city?”
• Know the historical context for minorities. As strange as it might seem to those graduating from medical schools in the 21st century, there is long-standing false information about black patients. For example, not long ago, there were those who believed black patients did not experience pain or nausea as acutely as white patients, Perez says.
“These were all preconceived notions that people came to believe,” he notes. “The [false] science that generated some of these results and got propagated through many years came from one generation teaching it to the next.”
Another example of false science that leads to racial bias is the formula that determines how well a patient’s kidneys are working, Perez says.2
“To this day, they give you a correction if a patient is black. With that correction, the patient’s GFR [glomerular filtration rate] function tends to appear better,” he explains. “Because of that correction, African American patients are referred later for dialysis. This has been propagated generation after generation because of a paper from the 1960s that was based on flawed science.”
• Address trust issues. “When I was digging into the literature and reading about many different studies that look at racial healthcare disparities, one of the things I read is that black patients — because of everything they’ve been through — said they’ve lost trust in the whole healthcare system,” El Halawani Aladdin says. “It’s not a matter of what’s happening right now, but everything they’ve been through over all those years. That’s why some black patients seek treatment late in the course of disease.”
• Put rules in place to foster discussions about biases. Employers should set clear expectations and behaviors. “I don’t mean that all offices need to be super-PC [politically correct] environments,” Rickert explains. “But it’s important for workplaces to say, ‘Our mission here is to provide wonderful care to all patients, regardless of socioeconomic, racial, income, and other differences.’”
Then, once a month, hold meetings on this topic. “You’re not looking to criticize people, but [allowing] everyone to discuss it and have a recap of what’s going on in the office,” Rickert offers. “Make sure you’re making the facility as welcoming an environment as possible.”
- Rickert CG, Perez NP, Westfal ML, et al. Understanding our own biases as surgeons: A departmental effort. Ann Surg 2020;271:39-40.
- Peralta CA, Lin F, Shlipak MG, et al. Race differences in prevalence of chronic kidney disease among young adults using creatinine-based glomerular filtration rate-estimating equations. Nephrol Dial Transplant 2010;25:3934-3939.