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