2020 saw a lot of talk about implicit bias training in healthcare- and very little action. There was actually a bit of backlash to the directive from Gov. Whitmer in Michigan after she declared on July 9th that healthcare professionals will be required to take implicit bias training to obtain or renew a medical license in Michigan, with a goal of improved equity in the delivery of healthcare. Many quickly became defensive, saying that all patients are treated equally and that the directive was politically motivated. But the fact remains that health equity is something that all organizations and individuals should strive toward, directive or not.
Why is Implicit Bias Training Needed?
Healthcare organizations have a responsibility to mitigate the effect of implicit bias in all interactions and at all points of contact with patients. It’s critical to understand that the impact of implicit bias can affect healthcare outcomes, patient adherence, and even care-seeking. While a majority of research on implicit bias in health care focuses on racism, other social factors such as ethnicity, gender, sexual orientation, education, and employment status are also associated with implicit bias and differences in communication and treatment.
From the Institute for Healthcare Improvement:
Implicit bias may affect how providers and other clinicians interact with patients in terms of communication, treatment protocols or recommended treatment options, or options for pain management. Implicit bias can affect both perception and clinical decision making, and studies show that implicit bias is significantly related to patient-provider interactions and treatment decisions. One study found that a substantial number of medical students and residents held false beliefs about biological differences between white and black individuals (such as believing that black skin is “tougher” than white skin), and found that these beliefs predict racial bias in pain treatment recommendations.
Since black patients are more likely than white patients to die in the ICU receiving life-sustaining treatment rather than in hospice receiving comfort care, Elliott and colleagues tested whether physicians use different verbal and/or nonverbal communication when having end-of-life care conversations with black and white patients and family members. They found that while verbal communication was similar, nonverbal communication scores were significantly lower with black patients than with white patients, with fewer positive, rapport-building behaviors. This difference can affect the outcome of the end-of-life care conversations and contribute to a higher incidence of black patients dying in the ICU while receiving life-sustaining treatments rather than dying at home.
Implicit bias can negatively affect other elements of patient interaction with the health care system. A 2015 study found that racial/ethnic minorities, individuals with lower levels of education, and unemployed individuals spend significantly longer time waiting to obtain medical care, with blacks and Latinos waiting 19 and 25 minutes more, respectively, than white patients to see a doctor. In addition, anxiety about interactions with people of color can result in white providers spending less time with patients.
How Our Implicit Bias Training Works
We quietly launched our Implicit Bias Training service for medical staff in June of 2020. We’ve been providing Physician Sensitivity Training for several years so, and in a month will add Disruptive Physician Training as well- those two share a core component that focuses on communication techniques that emphasize listening, feedback, and empathy. The cross-over with implicit bias training is changing your mindset to focus on WHO you’re communicating with, rather than how you’re communicating.
Factors such as our ethnicity, gender, religion, etc., all create our own personal identity. Some of these identities people can easily see (such as race or weight), while other identities are not so easy to see (such as sexual orientation or education level). We focus on:
- Sexual orientation / LGBTQ
- Socio-economic status
- Political affiliation
Implicit bias training seeks to counter bias by increasing awareness and providing guidelines for redirecting responses. Devine and colleagues offer six strategies to reduce implicit bias:
- Stereotype replacement — Recognizing that a response is based on stereotype and consciously adjusting the response
- Counter-stereotypic imaging — Imagining the individual as the opposite of the stereotype
- Individuation — Seeing the person as an individual rather than a stereotype (e.g., learning about their personal history and the context that brought them to the doctor’s office or health center)
- Perspective-taking — “Putting yourself in the other person’s shoes”
- Increasing opportunities for contact with individuals from different groups — Expanding one’s network of friends and colleagues or attending events where people of other racial and ethnic groups, gender identities, sexual orientation, and other groups may be present
- Partnership building — Reframing the interaction with the patient as one between collaborating equals, rather than between a high-status person and a low-status person
Similarly, in Seeing Patients: Unconscious Bias in Health Care, Dr. Augustus White offers these practical tips to combat implicit bias in health care:
- Have a basic understanding of the cultures your patients come from.
- Don’t stereotype your patients; individuate them.
- Understand and respect the tremendous power of unconscious bias.
- Recognize situations that magnify stereotyping and bias.
- Know the National Culturally and Linguistically Appropriate Services (CLAS) Standards.
- Do a “Teach Back.” Teach Back is a method to confirm patient understanding of health care instructions that is associated with improved adherence, quality, and patient safety.95
- Assiduously practice evidence-based medicine.
Within our training, we focus on the strategies above and pair them with self-assessment, mindfulness practice, roleplaying, and scenario exploration, as well as legal policy review to ensure that organizations are covered. This is NOT boilerplate training- we customize the training, and since everything is real-time and with an instructor, the opportunity to respond and interact is far greater. We’ve found that this is far more effective than video training, and that is why we provide sensitivity training in real-time as well.
We also offer individual training as well as group training. When we implemented our physician sensitivity training, it was a response to physician clients who consistently had negative reviews. As such, we kept our program centered on the individual initially and later added group training. Ultimately, we now allow organizations to decide which would work best for their needs and use cases.
In Michigan we’re still waiting to see how the directive to take implicit bias training will unfold. The training requirement applies to all health professions under Article 15 of the Michigan Public Health Code, with the exception of veterinarians. Under the directive, the Department of Licensing and Regulatory Affairs (LARA) is tasked with establishing new rules for the training requirement. In doing so, LARA is required by the directive to, not later than Nov. 1 2020, consult with stakeholders, including licensed healthcare professionals, to gather input regarding proposed training standards. The director of LARA, Orlene Hawks, said promulgating new rules could take 6-12 months. Thus far, we’ve not heard a peep on when and how this will be implemented.