Bias: Do You See What Influences You?

The idea of race is not clinical or biological in nature. It’s a social construct that, in the United States, was institutionalized in the late 1600s to make legal distinctions between “white” and “black” residents. And it’s a social construct still at work today. In most studies that look at disparities in care and outcomes based on race, the term is meant to identify a cultural group defined by ethnic heritage, skin color and personal identity.

“Race and racism in America is an issue in every part of life. And for children, our most vulnerable population, it affects health outcomes even before they leave the womb,” says Adiaha Spinks-Franklin, MD, MPH, attending physician in Developmental-Behavioral Pediatrics at Texas Children’s Hospital. “Only by talking about these issues openly, relying on facts and evidence, and confronting bias head on will we make progress toward health equity for children everywhere.”

In July 2019, the American Academy of Pediatrics released a policy statement calling for pediatricians to confront the impacts of racism on children. According to the policy statement, racism – the implicit prejudicial treatment of someone based on race – has a “profound impact” on the health status of youth and their families. The statement goes on to add, “Although progress has been made toward racial equality and equity, the evidence to support the continued negative impact of racism on health and well-being through implicit and explicit biases, institutional structures, and interpersonal relationships is clear. Failure to address racism will continue to undermine health equity for all children, adolescents, emerging adults, and their families.”

The experience of racism and racial bias should be considered an adverse childhood experience (ACE), like abuse, neglect or traumatic events that predispose a child to a negative outcome later in life. Dr. Spinks-Franklin, who is also an associate professor of Pediatrics at Baylor College of Medicine, and Jennifer Walton, MD, MPH, attending physician in Developmental Behavioral Pediatrics at Nationwide Children’s, and their colleagues spend the first part of their wildly popular workshop “Racism: Another Adverse Childhood Experience,” laying out the evidence for why this is true. The workshop was developed for and by the Society of Developmental & Behavioral Pediatrics in 2018. It was presented to a standing-room-only crowd at the Pediatric Academic Societies Meeting in April of 2019, and it has been shared around the country since then.

“The lived experience of racism – witnessing its impacts, experiencing it firsthand – has serious consequences to the emotional, physical and mental well-being of children, in addition to the known disparities in care that can arise as a result of provider bias,” says Dr. Walton, who is also an assistant professor of Clinical Pediatrics at The Ohio State University.

The way one person interacts with another is influenced by a myriad of factors, guided by complicated algorithms our brains have developed over our evolutionary and personal histories.

“We all make assumptions and categorize people in every way – gender, race, age – and all those assumptions are often useful and helpful in getting us through the day. We don’t have time to think through every encounter, so we use categories as shortcuts,” says Deena Chisolm, PhD, director of the Center for Innovation in Pediatric Practice and director of the Center for Population and Health Equity Research at the Abigail Wexner Research Institute (AWRI) at Nationwide Children’s.

Those quick assessments can become the basis for stereotypes and biases. Implicit bias refers to the unconscious attitudes and stereotypes that affect our understanding, feelings and actions – whether in a positive or negative way.

“Unchecked, bias erodes quality of care and eats away at our ability to provide care at the therapeutic level,” says Kelly Kelleher, MD, MPH, vice president of Community Health and principal investigator in the Center for Innovation in Pediatric Practice in the AWRI at Nationwide Children’s.

Bias is looking at a family and first asking for a Medicaid card instead of a card for private insurance. It is asking certain patients about drug use and not others. It is assuming an injury was caused by abuse in one patient and happened during a sporting event for another. In short, bias is allowing assumptions to override evidence.

“These small slights are sometimes referred to as micro-aggressions. When they happen to a patient, it builds scars and callouses and negative feelings,” says Dr. Chisolm, who is also vice president for Health Services Research in the AWRI. “Once or twice it’s irrelevant, but when it’s daily, weekly and monthly for a lifetime, it creates barriers to interacting. And it can create mistrust of the health care system and the people in it.”

“Bias becomes more profound, more exacerbated, when providers are tired, stressed or overwhelmed,” says Dr. Kelleher, who is also a distinguished professor of Pediatrics and Public Health at The Ohio State University. “The more cognitive demand we have, the more biased we are.”

A series of studies led by Tiffani Johnson, MD, MSC, attending physician in Emergency Medicine at Children’s Hospital of Philadelphia, investigated the role of implicit bias in the pediatric emergency department. In 2013, she published an article in Academic Emergency Medicine that showed how stress and fatigue influence bias. The study found that increased stress was associated with greater implicit racial bias.

In 2016, Dr. Johnson published a follow up in Academic Pediatrics investigating if ED physicians were less biased against children compared to adults and if the age, race, gender or level of training of the provider mattered. She and her colleagues found that most residents had pro-white/anti-black bias on both the child and adult implicit bias tests used. They also showed that the residents’ biases did not vary based on personal characteristics and mirrored the biases shown in other specialties.

Even more recently, a study published in JAMA Network Open in 2019 showed that as burnout symptoms increased so did racial bias. The study followed non-black medical residents who self-reported symptoms of burnout during their second and third years of residency. The medical residents completed tests aimed to identify explicit and implicit biases.

“With increasing rates of burnout and a growing focus on the mental and emotional health of health care providers, we should be considering how functioning in this state affects the bias experienced by patients of color,” says Dr. Walton, who is also chair of the Pediatric Section of the National Medical Association.

At a system level, algorithm-based care, protocols and standardization of care help reduce variation in care that could be caused by bias. This is particularly helpful in reducing variation due to implicit bias when a provider is tired or stressed. But experts warn that all care being equal does not necessarily achieve equity.

To get beyond the health care system level, Dr. Kelleher suggests providers and health care employees consider interpersonal interactions with patients. The social distance between the patient and the provider is an important component in how bias manifests, says Dr. Kelleher. “The more distant we are, the less likely I am to understand your culture and needs. The less likely I am to control your pain adequately, the more likely I am to prescribe one thing and not another. This social distance and the resulting impacts on care result in lower quality care.”

One way to address the challenges of social distance is to “change who we are,” suggests Dr. Kelleher.

“When our faculty and staff reflect the community around us, when we interact daily with the community outside of the hospital walls through mentoring, festivals and other events, it’s no longer them versus us. It’s just us,” says Dr. Kelleher. “That alone takes away so many of the feelings of fear, anxiety and uncertainty that surround issues of race, racism and implicit bias.”

Reflecting the community also comes down to hiring practices. At Nationwide Children’s, a concerted effort to hire members of the community in the zip codes surrounding the hospital campus has had good success. According to Dr. Kelleher, the next focus is retention.

“We’ve gotten really good at being ‘corporate.’ We need to make sure that we don’t stop being good at being part of the community,” says Dr. Kelleher. “The whole idea of becoming ‘us’ points to becoming a front porch for the community. Until we are able to achieve that, we’ll continue to struggle with social distance and implicit bias.”

Looking at changes that can be implemented at the health care system level and the provider level are the first steps to changing outcomes. But what will it take for significant, lasting change to occur?

“For a provider, where you start is recognizing your bias. Acknowledging that you have a first impression of a person or situation, but then being willing to set that impression aside and look at the specific evidence in front of you,” says Dr. Chisolm. “It might turn out that you were exactly right on your first impression, but maybe more often you might be surprised and find out that you were totally wrong.”

So, how do you identify your biases?

Implicit bias awareness tests, including the Harvard Implicit Association Test, are designed to help individuals understand personal biases.

“Using these tests is often helpful, whether people think they have bias or not,” says Dr. Walton. “Because we all have biases – it’s important to identify them.”

In their workshop, Drs. Spinks-Franklin and Walton and their colleagues lead participants through role playing exercises.

“These role playing activities are an essential part of putting what you learn into action,” says Dr. Spinks-Franklin. “Sometimes people are uncomfortable in these scenarios, doing it in a safe setting like the workshop can help them feel more comfortable when they have to deal with bias and racism in the clinic.”

Being uncomfortable, asking questions, being open to being wrong, these are all the themes that were repeated by the experts. They are the truths that are necessary to move from where we are to where we need to be.

“We invite the audience to get comfortable being uncomfortable,” Dr. Spinks-Franklin adds. “That’s how you become an active anti-racist.”

If you are not sure, ask.

• For example, ask families how they prefer that you speak to their children.
• It’s always better to ask than assume.

Attend a class or workshop.

• Many are now available at professional conferences.
• Invite one to come to your institution.

Get involved in diverse communities.

• Closing social distance is good for everyone.

Take time to reflect on your personal biases and commit to changing your actions.

• Take care of yourself so that you can have the emotional and cognitive energy to do the work.

Speak up for others.

• Be an advocate.
• If you see something, say something.