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Unconscious Biases Could Be Hindering Culturally Competent Care

Culturally Competent Care

A few years ago, Duke University physician and behavioral scientist Peter Ubel wrote in Forbes about an experience he had as an attending physician at the Ann Arbor Veteran’s Affairs Hospital. During rounds, accompanied by a number of medical students, he checked in with a middle-aged African American patient. In the course of the conversation, the patient mentioned his grandchildren, and the doctor turned to the patient’s wife and said, “Impossible! How could someone as young as you be a grandmother?”  He recalled it was a common compliment he’d used over the years, without giving it much thought. That day, however, a young African American student mentioned the discussion, making him think twice about whether an innocuous comment might actually be racially insensitive. She had suggested that there was a chance that “… as an African American, she would be insulted that you are, in effect, accusing her of having babies and grandbabies at too young of an age.” He realized then that culturally competent care requires, not color blindness, but the ability to see care from the patient’s perspective. 

In fact, just this week I was talking with a friend of mine, who recounted an interaction with his primary care physician.  The physician was well-respected, technically excellent and popular among many patients.  My friend is also well-respected in the community – active in city politics and dedicated to helping the disadvantaged – and he also happen to be African American.  One would assume an interaction between these two gentlemen would be productive and mutually fulfilling.

My friend was already taking a prescription medication, and the physician felt that he should be taking an additional medication for a related issue; however, the physician was hesitant to prescribe it, saying, “Well, you probably won’t take it anyway.” Not only was this a condescending thing to say to any patient, it was especially offensive to my friend, who grew up in a cultural community where there was already a level of distrust of the healthcare system.  This technically excellent, but insensitive physician lost a member of his patient population that day.

Is Your Unconscious Bias Showing?

When doctors take the Hippocratic Oath, they affirm “…special obligations to all my fellow human beings, those sound of mind and body as well as the infirm.” Having dedicated themselves to the care of individuals, it can often be difficult for physicians to recognize their own unconscious biases and how they play a part in racial disparities in healthcare. Recently, CNN covered how diversity training is changing to address these unconscious biases. One diversity consultant told CNN that traditional training used routinely throughout the 1980s and 1990s actually reinforce prejudices, “…because they can make people feel bad about themselves and the people that make them feel that way.”

These days, unconscious bias training works to help physicians identify biases they weren’t aware of so they make more considered decisions when interacting with patients. But it’s not foolproof.  Studies have found disparities in treatment of patients.

  • African Americans are often prescribed less pain medication than white patients with similar pain symptoms.
  • African Americans complaining of chest pain are referred for advanced cardiac care less frequently than white patients.

It hasn’t gone unnoticed, either. In her book, “Beyond the Whiteness of Whiteness: Memoir of a White Mother of Black Sons,” Jane Lazarre recalled her 18-year-old son’s knee surgery. After waiting for hours to see him following the surgery, she learned as her son was coming out of anesthesia, he began flailing about—and the doctors and nurses feared he would hurt one of the staff so they put him back under anesthesia. Lazarre insisted on seeing him and saw immediately that he was confused and scared, not violent. She wrote, “I understood, certainly not for the first time, that my son—and my sons both—were viewed as being dangerous, being potentially frightening to people who were white.” She also noted that she doubted that the surgeon or other healthcare providers were conscious of this bias.

How Unconscious Bias is Being Addressed

At the University of California, San Francisco, Dr. Rene Salazar leads all first-year medical school students in a workshop designed to reveal unconscious biases and implement techniques to address those biases.  Prior to the class, students take a series of computer tests designed to measure attitudes across a range of potentially stigmatizing categories, from race and gender to age and weight. Salazar then asks students to share their results. Most are reluctant. Dr. Salazar tells the students, “Like it or not, all of us hold unconscious beliefs about various social and identity groups.” Awareness of these biases and a commitment to weigh whether a decision is made based on such biases can go a long way to addressing disparity in healthcare—whether it is with African Americans, the mentally ill or some other at risk group.

As Dr. Ubel noted in his Forbes article, his experience encouraged him to slow down and consider his words more closely. “Identifying the right diagnosis and treatment often depends as much on good communication as it does on modern medical technology,” he said. Ubel suggested that in addition to self-awareness, workforce diversity in healthcare settings helps bring potential barriers to culturally competent care to light, saying that “Had I, a white male, been surrounded in that hospital room only by a bunch of white male medical students—even ones ‘absolutely average in terms of education and income’–I would not have learned that my attempt at a harmless compliment would translate poorly across cultural contexts.” How is your organization addressing the different barriers to culturally competent care?  

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