How medical professionals’ implicit biases contribute to health care disparities

Area health care organizations have invested in seminars, other training in recent years.

The implicit biases of health care professionals toward people of color compound other racist treatment they receive daily and could have deadly consequences, experts said.

For instance, implicit bias, which is cumulative, can add stress that leads to changes in pregnant women and makes them more predisposed to preterm labor, said Dr. Marc Belcastro, a neonatologist and system chief medical officer at Premier Health.

“How much more damaging is it to say that we’re losing infants at two times or three times the rate in populations of color versus Caucasians?” he asked. “That’s damaging, it’s very damaging.”

Credit: Will Jones

Credit: Will Jones

Dayton-area health care organizations, including Premier, Kettering Health Network, Children’s Hospital and the Greater Dayton Area Hospital Association, are taking steps to reduce implicit bias in their staff. They’ve invested in classes, seminars and other training in recent years.

Some are also working to increase the number of Black doctors in the region; they make up only 5% of physicians nationwide. In comparison, 56% of the country’s doctors are white.

The Dayton Daily News Path Forward project investigates the most pressing issues in our community, including race and equity. This story digs into how implicit bias among health care professionals affect people of color and what’s being done to change that.

What is implicit bias?

Wright State University Medical Sociologist La Fleur Small defines implicit bias as attitudes or stereotypes that affect people’s understanding, actions and decisions in an unconscious way, sometimes making them difficult to control.

“There’s the argument that social behavior is largely influenced by unconscious associations and judgments,” said Small, who is also associate provost for faculty and staff affairs at the university. “So outwardly, we can have a perceived belief or value system, but then we act in a way that’s contrary, contradictory, unconsciously to those value systems.”

Implicit bias is prevalent in society in general, and it affects everyone, regardless of race. However, when those unconscious attitudes and stereotypes manifest in the medical profession, people of color who already are grappling with health care disparities are disproportionately affected.

Stereotyping patients has always been a significant problem in the medical profession. But the level of implicit bias toward Black people hasn’t changed much over the decades, said Dr. Alonzo Patterson, a Dayton-area pediatric specialist who has been practicing medicine for nearly 30 years. At times, he acknowledges, it’s difficult to distinguish whether it’s issues of socioeconomics or race.

Credit: Lark Photography

Credit: Lark Photography

How implicit bias affects health care for people of color

One of many ways implicit bias affects Black patients is that it perpetuates existing health care disparities in the nation, experts said. Some things as simple as language and cultural barriers can lead to patients feeling as if they aren’t being properly served, Small said. They could then opt not to return to the physician or change health care providers.

Implicit bias also influences people’s treatment decisions, whether or not they’ll adhere to the protocol that the physician recommends and ultimately impact the patient’s health outcomes, she said.

Stigmatizing phrases written in notes added to medical records to describe patients have long-term affects on the person and how other medical professionals treat them, according to a 2018 study published in the Journal of General Internal Medicine. Researchers found that resident physicians who read stigmatizing language chart notes prescribed pain medication less aggressively than those who read neutral language chart notes.

Stigmatizing phrases in the notes included comments such as, “narcotic dependent,” “insisting pain is still a 10,” “cursing at nurse” and “girlfriend requests bus token.” Neutral notes included phrases such as, “girlfriend is by his side,” “in distress,” “describes pain history/regimen,” “he believes/potential causes” and “does not question patient’s pain.”

‘Black people have a higher tolerance for pain’

Some physicians, believing Black people have a higher tolerance for pain, prescribe lower doses of medication, experts say. Based on stereotypes, other medical professionals are dismissive of patients when they describe their pain, even when it requires life-saving procedures.

Dayton native Ty Stone, who is Black, has experienced implicit bias from doctors many times in her life. Stone recently was in severe pain, had a fever and other symptoms associated with her medical condition and visited a doctor.

However, the doctor, who was white, did not tend to her according to her level of pain she described, nor did he treat her fever. Instead, he sent her home. She returned to the hospital less than six hours later and had emergency surgery after a CAT scan revealed the severity of Stone’s illness.

The doctor later told Stone he didn’t feel she was exhibiting the symptoms, especially the level of pain that he “thought you would be exhibiting if this were a legitimate illness.”

“One of the problems that we face is that even if we say we’re in pain, it is not legitimized or that the threshold or the pain level is as high as we say it is,” said Stone, now president of Jefferson Community College in Watertown, New York. “I do feel that as a Black woman, when I go to the doctor and I complain about pain, I think one of the first things they’re looking at is, ‘OK, does she want some drugs?’”

Three years ago, doctors at a Dayton-area emergency room were dismissive of Myla Cardona-Jones when she described her illness and pain level. The then-32-year-old, an avid runner, was training when a sharp pain in her stomach doubled her over, said her mother, Helen Jones-Kelley, executive director of Montgomery County Alcohol, Drug Addiction and Mental Health Services.

Cardona-Jones was put in a hospital bed, screaming and writhing in pain, but the staff did little for the woman, her mother said.

“I can imagine what she would have looked like coming into the emergency room, and she’d been out running,” Jones-Kelley said. “She was sweating profusely, she didn’t smell very good, obviously, by that time. Hair sticking straight up on her head, all those things … All those things that somebody might see and think immediately if they have a bias, ‘Oh my god, this is a drug addict.’”

After Jones-Kelley told nurses she was taking her daughter to a different hospital, Cardona-Jones was examined further and diagnosed with a ruptured ovarian cyst that would require emergency surgery.

Such treatments have led Stone, who previously was a vice president at Sinclair Community College until 2017, and others to avoid white doctors and see only Black physicians whenever possible.

Myths about biological differences

Research has shown that Black patients tend to get better health care from doctors of color, and the outcome can be a matter of life and death. A study of 1.8 million hospital births in Florida between 1992 and 2015 found that when Black newborns were cared for by a Black physician rather than a white one, their death rate was cut in half.

In addition, a 2012 report that examined 20 years of studies found Black patients were 22% less likely than white patients to be given any pain medication. Doctors are more likely to misdiagnose Black patients with schizophrenia than white patients, according to a 2019 study from Rutgers University.

A 2016 study found that more than half of the 418 University of Virginia medical students surveyed believed at least one myth about biological differences between Black and white people, including the myths that Black people have smaller brains, thicker skin and less sensitive nerve endings. The study also found that participants who believed more of these myths were less accurate in their pain treatment recommendations for Black patients.

More people of color in the medical profession

Implicit bias among health care workers might decline if more people of color joined the profession, experts said. That might take decades to be achieved, as there’s currently a major gap in the number of white physicians compared to the number of Black doctors, both locally and nationwide.

Of the 174 doctors at Dayton Children’s, about 64% are white, 20% Asian, 7% Black and 2% are two or more races, according to the hospital. Kettering Health said it does not track that data.

Premier Health declined to release data about the race and ethnicity of its medical employees. But the company said the diversity of its nursing workforce is more than 30% greater than the overall diversity of the region’s nursing workforce, according to census data. In addition, the diversity of Premier’s employed physician workforce is more than three times greater than the overall diversity of the region’s employed physician workforce.

The company recently created an equity plan that calls for such things as leveraging its internal talent pipeline and increasing the diversity of its workforce so it mirrors the communities they serve.

The Greater Dayton Area Hospital Association, which serves 29 member hospitals and health organizations in the 11-county greater Dayton area, is working to diversify health care workers in the region, said Sarah Hackenbracht, GDAHA’s president & CEO. The organization recently formed a committee to expose middle school students to the career options in health care.

The group will also introduce the students to individuals in the profession who look like them, come from the same backgrounds and neighborhoods, and talk about what it took from an academic perspective to get into the profession, Hackenbracht said.

Nationally, 56% of all active physicians were white in 2018, the latest data available, according to the Association of American Medical Colleges. In comparison, 5% were Black, nearly 6% Hispanic and 17% Asian. One percent were of multiple races and less than 1% native Hawaiian or other Pacific Islanders, according to the AAMC.

Importance of patient-doctor relationships

It’s paramount for doctors to have a good rapport with their patients, Small said. The degree of the relationship can either lead to better care for patients or it can increase the chances for medical malpractice lawsuits, she said. Mistakes happen, and if the patient and doctor have a professional relationship in which there’s mutual respect and good communication, patients are going to be less likely to file malpractice suits, she said.

In 2009, the American Medical Association Journal of Ethics reported that medical malpractice litigation studies found that communication problems were present in 70% of dispositions. The journal cited other studies that said poor relationships with providers were among the factors that led 53% of patients to contact law firms about medical malpractice.

Why some health care workers harbor negative stereotypes

Doctors and other medical professionals are some of the most intelligent people in society. They have a lot of information at their disposal and take an oath to provide the best medical care to everyone. So why do some harbor negative stereotypes or blatantly false information about certain groups, such as Black people having a higher tolerance for pain?

One factor is that some people don’t interact with other groups most of their lives. But when they enter the residency phase of the medical training, they must interact with people of color and other groups they’ve never dealt with before, Patterson, the pediatric specialist, said.

Parental attitudes, stereotypical messages and negative images directed at certain groups of people that are pervasive and carried in culture are partially to blame, Small said.

“We’re all bombarded with this and we all experience it, whether we wish to accept it or not,” she said. “The very thing about implicit bias is that we say we espouse a particular belief system. But maybe as a result of us being bombarded with these messages, our behavior reflects something that’s contrary to our spoken belief system.”