Patient perspectives on racial and ethnic implicit bias in clinical encounters: Implications for curriculum development

https://doi.org/10.1016/j.pec.2018.05.016Get rights and content

Highlights

  • Implicit bias may influence communication and decision-making in clinical encounters.

  • Patient perceptions of implicit bias are influenced by their lived experience.

  • Complete absence of perceived bias is unrealistic, and per our patients, unnecessary.

  • Physician recognition and acknowledgement of perceived bias can restore encounters.

  • This recognition can lead to increased trust and continued engagement by patients.

Abstract

Objective

Patients describe feelings of bias and prejudice in clinical encounters; however, their perspectives on restoring the encounter once bias is perceived are not known. Implicit bias has emerged as a target for curricular interventions. In order to inform the design of novel patient-centered curricular interventions, this study explores patients’ perceptions of bias, and suggestions for restoring relationships if bias is perceived.

Methods

The authors conducted bilingual focus groups with purposive sampling of self-identified Black and Latino community members in the US. Data were analyzed using grounded theory.

Results

Ten focus groups (in English (6) and Spanish (4)) with N = 74 participants occurred. Data analysis revealed multiple influences patients’ perception of bias in their physician encounters. The theory emerging from the analysis suggests if bias is perceived, the outcome of the encounter can still be positive. A positive or negative outcome depends on whether the physician acknowledges this perceived bias or not, and his or her subsequent actions.

Conclusions

Participant lived experience and physician behaviors influence perceptions of bias, however clinical relationships can be restored following perceived bias.

Practice implications

Providers might benefit from skill development in the recognition and acknowledgement of perceived bias in order to restore patient-provider relationships.

Introduction

In North America, after several decades of focus on cultural competency instruction in medical education [[1], [2], [3]], health disparities persist [4,5] and racial and ethnic minority respondents are still more likely to perceive bias when seeking medical treatment than Whites [6]. Implicit bias refers to the unconscious and unintentional assumptions people make about each other. Evidence demonstrates this bias negatively impacts patient’s perceptions of the clinical encounter [[7], [8], [9]] treatment recommendations [10], and trust [[11], [12], [13], [14]]. Although studies from various countries have explored patients’ perceptions of race and/or ethnicity and bias in medicine [6,12,[14], [15], [16], [17], [18], [19], [20], [21], [22], [23], [24], [25]], patient perspectives on and suggestions for restoring the clinical and/or therapeutic relationship once bias is perceived are not known. Understanding these perspectives could inform the development of innovations in medical student education addressing implicit bias in clinical encounters.

Implicit bias contributes to health disparities through medical decision-making and interpersonal communication [26]: Evidence demonstrates the influence of physician implicit bias on patient perspectives of encounters [[7], [8], [9]], physician communication patterns [9,27], clinical outcomes [28], and clinical decision-making [[29], [30], [31], [32], [33]]. Implicit bias regarding race has been demonstrated in medical students [34,35]. In an effort to decrease physician contributions to health disparities, curricula have been developed to teach about implicit bias across the continuum from undergraduate to graduate and continuing medical education [[36], [37], [38], [39], [40], [41], [42], [43]]. These curricular models have not explicitly provided instruction on detecting the perceptions of bias by patients during the patient-physician encounter, nor in skills to restore the encounter once bias is perceived. Our study addresses this gap in knowledge by exploring patients’ perceptions of physician bias and their suggestions for restoring the relationship and the encounter once bias is perceived.

This study is part of a comprehensive needs assessment [44] to inform curriculum development for medical students in implicit bias recognition and management. Patients represent the intended beneficiaries of any successful future curricular interventions, therefore it is critical to maintain a patient-centered perspective [45] in the development of novel curricular interventions. To inform the design of future patient-centered curricular interventions in implicit bias recognition and management, the purpose of this study is to explore patients’ perceptions of physician bias and their preferences and suggestions for restoring the relationship if they perceive bias.

Section snippets

Methods

Given that little is known about patient perspectives on implicit bias we conducted an exploratory focus group interview study using grounded theory, a systematic qualitative methodology involving the discovery of theory through the analysis of data [46]. Recruitment, data collection, and analysis were conducted iteratively to fully capture and explore variation in patients’ perspectives. All aspects of the study were approved by the Institutional Review Board of the Albert Einstein College of

Results

We conducted ten focus groups, six in English and four in Spanish, with N = 74 participants. Demographic data demonstrated successful sampling across the socioeconomic spectrum of the US (Table 1). Our analysis identified four themes relating patient experiences with discrimination to perceptions of bias in their physician encounters, the outcomes of perceived bias, and suggestions for physician actions to restore the relationships within such encounters when bias is perceived.

Discussion

Our analysis revealed the multi-faceted nature of the factors leading to patients perceiving bias in their physician encounters. Their perceptions of bias may be due to actual biased behaviors or interpretations of routine proceedings as based on these multiple factors. The theory emerging from our analysis suggests the outcome of the clinical encounter once bias is perceived can still be positive. Whether the outcome is positive or negative depends on whether the physician acknowledges this

Funding

Dr. Gonzalez was supported by the Harold Amos Medical Faculty Development Program of the Robert Wood Johnson Foundation, Bureau of Health Professions of the Health Resources & Services Administration of US Department of Health and Human Services [grant number D3 EHP16488-03], NIH/NICHD [grant number R25HD068835], and by the Macy Faculty Scholars Program of the Josiah Macy Jr. Foundation. Dr. Marantz was supported in part by NIH/National Center for Advancing Translational Science (NCATS)

Disclosures

"The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government."

Conflicts of interest

The authors declare no conflict of interest.

Acknowledgements

The authors wish to thank Drs. William Southern, A. Hal Strelnick, and Clarence Braddock, III for their thoughtful feedback from study inception to completion. Ms. Josephine Rodriguez, Ms. Irene Diaz, and Ms. Yovanna Coupey, for their extensive contributions to participant recruitment efforts. Ms. Veronica Aviles and Ms. Natalia Rodriguez for their generous assistance. Dr. Paula Ross for her thoughtful feedback on previous iterations of this manuscript.

References (59)

  • R.L. Johnson et al.

    Racial and ethnic differences in patient perceptions of bias and cultural competence in health care

    J. Gen. Intern. Med.

    (2004)
  • I.V. Blair et al.

    Clinicians’ implicit ethnic/racial bias and perceptions of care among Black and Latino patients

    Ann. Fam. Med.

    (2013)
  • L.A. Cooper et al.

    The associations of clinicians’ implicit attitudes about race with medical visit communication and patient ratings of interpersonal care

    Am. J. Public Health

    (2012)
  • L.A. Penner et al.

    The effects of oncologist implicit racial bias in racially discordant oncology interactions

    J. Clin. Oncol.

    (2016)
  • A.D. Thrasher et al.

    Discrimination, distrust, and racial/ethnic disparities in antiretroviral therapy adherence among a national sample of HIV-infected patients

    J. Acquir. Immune Defic. Syndr.

    (2008)
  • E.A. Jacobs et al.

    Understanding African Americans’ views of the trustworthiness of physicians

    J. Gen. Intern. Med.

    (2006)
  • S. Saha et al.

    Patient-physician relationships and racial disparities in the quality of health care

    Am. J. Public Health

    (2003)
  • T.M. Greer

    Perceived racial discrimination in clinical encounters among African American hypertensive patients

    J. Health Care Poor Underserved

    (2010)
  • C.M. Sims

    Ethnic notions and healthy paranoias: understanding of the context of experience and interpretations of healthcare encounters among older Black women

    Ethn. Health

    (2010)
  • T. Janevic et al.

    "There’s no kind of respect here" a qualitative study of racism and access to maternal health care among Romani women in the Balkans

    Int. J. Equity Health

    (2011)
  • A.M. Napoles-Springer et al.

    Patients’ perceptions of cultural factors affecting the quality of their medical encounters

    Health Expect.

    (2005)
  • S.S. Casagrande et al.

    Perceived discrimination and adherence to medical care in a racially integrated community

    J. Gen. Intern. Med.

    (2007)
  • T. Quach et al.

    Experiences and perceptions of medical discrimination among a multiethnic sample of breast cancer patients in the Greater San Francisco Bay Area, California

    Am. J. Public Health

    (2012)
  • J. Blanchard et al.

    R-E-S-P-E-C-T: patient reports of disrespect in the health care setting and its impact on care

    J. Fam. Pract.

    (2004)
  • S.Y. Tang et al.

    ‘Race’ matters: racialization and egalitarian discourses involving Aboriginal people in the Canadian health care context

    Ethn. Health

    (2008)
  • D. Mellor et al.

    Toward an understanding of the poor health Status of indigenous Australian men

    Qual. Health Res.

    (2016)
  • K.A. Amirehsani et al.

    US healthcare experiences of Hispanic patients with diabetes and family members: a qualitative analysis

    J. Community Health Nurs.

    (2017)
  • C.A. Zestcott et al.

    Examining the presence, consequences, and reduction of implicit bias in health care: a narrative review

    Group Process. Intergroup Relat.

    (2016)
  • N. Hagiwara et al.

    Physician racial bias and word use during racially discordant medical interactions

    Health Commun.

    (2017)
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