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Is Racism Affecting Our Clinical Decisions?

September 6, 2017

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Implicit racial bias is likely influencing us in the ED, but whether that translates into impacting clinical decision making remains to be seen.

Why does this matter?
Most of us don’t consider ourselves to be racist.  The Implicit Association Test (IAT) invented in 1998 uses a clever methodology to uncover potential unconscious (implicit) racial bias.  Most of us have implicit racial bias, that is, unconscious associations of positivity or negativity with skin tone.  These unconscious biases could impact the care of our patients.  A fascinating Hidden Brain podcast explored this and noted, “With practice and a bit of time to exercise conscious control, people can reduce the risk of falling prey to their implicit biases.”  Click here for the podcast transcript or audio.  We may have little control over unconscious bias (by definition), but a recognition that it is there plus a brief moment to consider how it may be impacting our decisions may allow us to act in an unbiased way toward patients of a different race.

“Doesn’t matter if you’re black or white…”
This was a literature search back to 1998 for studies of implicit racial bias and clinical decision making.  They found 9 studies, 3 of which included the ED.  Just like the IAT, an implicit preference for light-skinned people was found regardless of specialty but did not appear to impact clinical decision making, though the quality of evidence for some included studies was poor.

“The 2012 National Healthcare Disparities report showed that discrepancies in treatment continued to exist, with black patients receiving worse care than white patients for 40% of quality measures.”  This is unconscionable.  I want to acknowledge that this is a tough subject to discuss.  It is a loaded topic, and I risk being misunderstood, especially in light of recent events in Charlottesville.  But I am absolutely determined to not allow racial bias to impact my clinical decision making.  And if there are unconscious forces in play, I want to root them out and make sure this never affects my care for patients.  For full disclosure, I am a white male.  I took the IAT and was shocked to find that the test said I had “a slight automatic preference for Light Skinned People over Dark Skinned People.”  Personally, I don’t think that is true.  Before you judge, know that this test result is the case for the majority of people who take the IAT (68%, N = 864,463), including dark-skinned people.  So please don’t send me hate mail before you take the IAT yourself.  Only then may you send me hate mail. 🙂 Regardless, implicit bias is real and it may be impacting our care without us realizing it – which would be the definition of an unconscious bias.  But like the Hidden Brain podcast I mentioned, with practice and a brief moment of time, we can consciously overrule this type of implicit bias.  Forewarned is forearmed.  I never want a person’s race to affect my clinical decisions, and I know you don’t either.  So this is a step toward acknowledging and mitigating the risk of acting on the basis of implicit racial bias.

A Systematic Review of the Impact of Physician Implicit Racial Bias on Clinical Decision Making . Acad Emerg Med. 2017 Aug;24(8):895-904. doi: 10.1111/acem.13214. Epub 2017 Jun 19.

What are your thoughts?