Black women are three to four times more likely to experience a pregnancy-related death than white women (Howell 2018). Why is this? Due to implicit bias in physicians and a health care system that is rooted in racism and discrimination; the US has a long history of systemic racism in healthcare. Racism within the healthcare system paired with doctors’ implicit bias, which refers to the attitudes and stereotypes that contribute to the way we act in an unconscious manner (The Ohio State University 2015) create major disparities among different groups of people. The way that we respond to others is largely based on how we perceive them. A recent study conducted by the department of psychology at Virginia Commonwealth University (VCU) suggests that certain words physicians use indicate their level of implicit bias which can be applied to the disparities we see in healthcare.
Can certain words indicate levels of implicit bias? If so, what are those words? The present study is a secondary analysis of a study that took place at an inner-city primary care clinic in the Midwest. The parent study was conducted by Karmanos Cancer Institute and Department of Family Medicine and Public Health Sciences at Wayne State University Research Center for Group Dynamics University of Michigan. In total there were 150 black patients, both male and female and 15 physicians in which three identified as white and the remainder identified as Asian. Physicians completed an Implicit Association Test (IAT) which evaluates individuals’ unconscious bias by presenting distinguishing subjects such as gender, religion, or race with a series of words and stereotypes associated with that topic. For example, the participant must pair the topic with words like, “pleasant” or “cruel”. Physicians took this test prior to their interactions with patients. Interactions between physicians and their patients were recorded. Following the interaction, all participants completed a questionnaire, but patients completed an additional one. In the present study, conducted by researchers at VCU in 2017, researchers transcribed the video interactions between non-black physicians and their black patients conducted in the parent study mentioned above. To transcribe the video recordings, researchers and transcriptionists used a tech analysis tool called Linguistic Inquiry and Word Count (LIWC). LIWC categorized the words used in the interactions and calculated the frequencies of them. This tool was a key component to their secondary analysis of the parent study.
Researchers conducting this study drew from other literature that suggests that implicit bias affects the relationship between physicians and patients. In particular, one hypothesis of this study was that doctors who are non-black and have higher levels of implicit bias are more likely to express social dominance in conversation with black patients (Cooper et al 2012, Hagiwara et al. 2013). This social dominance can be seen through the language of physicians. Another prediction in this study was that physicians with higher levels of implicit bias would be more prone to use anxiety induced words such as “worry”, “nervous”, or “tense”. The use of first-person plural pronouns and anxiety induced words affect the interactions between health care workers and their patients. In addition to copious amounts of research concerning implicit bias, there is also a fair amount of research that “provides strong evidence that word use can reflect a variety of psychological processes… “(Chung & Pennebaker 2007; Tausczik & Pennebaker, pp. 343–359 2010). Word choice largely dictates the outcomes of interactions and is of much importance when it comes to something as vital as healthcare.
As hoped for, the results from this study were consistent with the researcher’s predictions. There was a positive correlation between doctors that displayed high levels of implicit bias with a high use of first-person plural pronouns. In addition, anxiety induced words were also found to be associated with physicians with more implicit bias than others. It would be easier to ignore an issue that did not have some sort of effect on each individual, but this is not the case for implicit bias in healthcare. In some way or another, each American citizen relies on the health care system and the disparities affect not only minorities, but also majorities. Making this study, and issues relating to this study, important. All citizens are affected by the reality of bias in healthcare: those who are minorities who are inaccurately diagnosed and receive poor treatment, and those who benefit from an institution that perpetuates inequality and ensures they receive the best care. This study emphasizes the power that words have on the way that people perceive others. In addition, it gives the general public hope that implicit bias, while it is a large issue, can be resolved by teaching doctors that their word choice matters when dealing with all patients.
With the current racial climate, this issue is relevant to making the changes this country needs in regard to racism. The larger implications of this study are: the effect implicit bias has on our population through unnecessary and avoidable deaths and how physicians that patients of color have experienced may deter them from pursuing a career in the medical field. In general, increased diversity generates better outcomes for all people. More diversity in the medical field would arguably decrease disparities and bias.
While this study does provide clarity and promises for ways to improve health care, there were some flaws. Due to this study being a secondary analysis, the scientists could not directly ask why the physicians chose certain words or reacted to different situations. This is harmful to the study because it cannot be inferred exactly what the physicians meant. In addition, the study does not point to an exact answer as to why physicians with high levels of implicit bias use certain language such as anxiety related words or first-person plural pronouns. Furthermore, the black patients used in the study may also have some implicit bias towards their physicians. This bias may have influenced their behavior towards their physicians which in turn may have affected the language the physician used in their responses. One way this study could improve is by increasing the amount of white physician participants. The majority of physicians in the United States are white yet in this study, the majority of the physicians observed were Asian. While this does not change the fact that physicians have implicit bias, it can be inferred that the results would drastically change should the majority of the physicians observed be white.
How does the US healthcare system move forward? Earlier this year, the state of California passed a law that mandated that hospitals and birth facilities begin evidence based implicit bias training to combat maternal mortality disparities. While this specifically caters to the disparities seen in maternal mortality, other medical schools are following suit by implementing implicit bias training for students. At Harvard Medical school, professors have created a course that covers topics such as culture, self-reflection and medicine that were said to improve increased awareness of blind spots and biases in first, second- and fourth-year medical students (Milan 2019). Implicit bias training in conjunction with courses taught to increase cultural awareness would decrease levels of implicit bias in physicians which would in turn reduce disparities in health care. It only makes sense to provide equal and fair healthcare for all, so the US healthcare system has some work to do.
References
California bill mandates implicit bias training for perinatal healthcare professionals. Zerotothree.org. [accessed 2020 Sep 10]. https://www.zerotothree.org/resources/2977-california-bill-mandates-implicit-bias-training-for-perinatal-healthcare-professionals
Hagiwara N, Slatcher RB, Eggly S, Penner LA. 2017 Physician racial bias and word use during racially discordant medical interactions. Health communication. 32(4):401–408.
Howell A 2018. Reducing disparities in severe maternal morbidity and mortality. Clinical Obstetrics Gynecology [accessed 2020 Aug 17] 61(2):387-399.
Milan F. The movement to include teaching about implicit bias in healthcare Education. Einstein.yu.edu. 2019 Apr 25 [accessed 2020 Sep 10].
Pennebaker JW, Chung CK. The psychological function of function words. In K. Fiedler (Ed.), Social communication: Frontiers of social psychology (pp. 343–359).
Penner LA, Dovidio JF, West TV, Gaertner SL, Albrecht TL, Dailey RK, Markova T. Aversive racism and medical interactions with Black patients: A field study. Journal of experimental social psychology. 2010;46(2):436–440.
Understanding Implicit Bias. Osu.edu. [accessed 2020 Sep 10]. http://kirwaninstitute.osu.edu/research/understanding-implicit-bias/
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Jacobs, Celia. “The emotional toll of negative experiences can lead Black women to distrust doctors, and eventually, some people just stop going.” TODAY, 2020 [accessed 2020 September 16]. Drawing. https://www.today.com/health/what-implicit-bias-invisible-racism-hurts-black-women-doctor-s-t189105
