Healthcare delivery is a multidimensional, complex enterprise. Efficient and effective care requires coordinated communication and collaboration among all healthcare practitioners and the patient, their family, and support groups. Implicit biases have been shown to perpetuate healthcare disparities, which can adversely affect outcomes of care.(1-5) A recent study conducted by the Commonwealth Fund reported that more than 50% of healthcare workers felt that racial or ethnic discrimination is a major problem, and nearly 50% reported witnessing a patient receiving lower quality of care because of race or ethnicity.(6) Other recent studies have shown similar results.(7-9)
With the growing diversity in the healthcare population and clinical staff (accentuated by the COVID epidemic and the need to fill open positions related to staff resignations or premature retirement), managing diversity has become a crucial issue. Over the past several years there has been more back-and-forth discussion about the need for and value of diversity, equity and inclusion (DEI) activities in the healthcare arena.(10-14) The issue is more comprehensive than just diversity. This article discusses the hidden factors affecting physician perceptions, attitudes, and behaviors that form the core of their personality and how this influences their approach to providing medical care.
Influencing Factors
What shapes an individual’s values and perceptions? In an earlier article I outlined a series of internal and external factors that influence beliefs and actions.(15) The internal factors are more deep-seated influences related to age (generation); gender (and sexual preferences/ identity); culture, ethnicity, and religious beliefs; socioeconomic factors (economic, education, home environment); and other early life experiences that lead to certain preferences and biases defining one’s personality. The external factors include education and training, work environment, personal relationships (including social media), late life experiences, and overall stress and burnout. These factors affect one’s mood and disposition. Both internal and external factors affect individual relationships, which in healthcare can affect patient outcomes in regard to access, treatment decisions, care management, quality and safety, and overall satisfaction. Several studies have shown the negative impact of poor care relationships.(3,4,16)
Implicit bias (unconscious bias) is a term used to describe stereotypes or assumptions that a person makes about another individual even when those are contrary to one’s conscious or declared beliefs. These actions are influenced by the internal and external factors mentioned previously and may lead to stereotype biases related to physical appearance (e.g., weight, hygiene, dress, skin markings, physical impairment); social factors (e.g., economics, education, geography, other social determinants of care); habits (e.g., smoking, substance abuse); age; race, culture, or ethnicity; religion; and gender and sexual identity. These unconscious feelings may adversely affect access to care, trust, respect, communication efficiency, and team collaboration, and that may result in inequitable care management decisions that can compromise patient care relationships. It’s not an easy problem to resolve. Some of the key barriers include individual and organizational awareness of the occurrence and impact of these behaviors, belief, relevance, the need for change, motivation for change, time and priority, and resistance to change.
Barriers
One of the key barriers is the recognition of the prevalence and influence of implicit biases on decision making.(17) Physicians spend years on scientific method training, honing their clinical and technical skills to enhance performance. As a result they develop very strong, egocentric, unidirectional personalities and have little awareness as to other contributing factors that influence their decision making. Raising awareness is step number one. Step number two is acknowledgment, need, willingness, and motivation to change. Physicians need to gain a better understanding of how these traits can affect patient care and be willing and motivated to change behaviors, with a primary focus on improving patient outcomes. Time and capacity to engage in nonclinical activities is always a concern. Providing support services in a convenient setting with a priority on practice enhancement is a good path to follow. Unfortunately, there has been growing resistance and discontent with the value of DEI supportive services, and these issues need to be addressed.(18) Numerous studies support the benefits of these service offerings.(14,19,20)
Recommendations
Table 1 presents a list of recommended strategies that an organization can use to enhance care relationships.
The first step is raising levels of awareness regarding the prevalence and significance of subconscious implicit biases and how that can affect decisions influencing patient care. Performing an internal assessment can provide insight into the degree and significance of such behaviors specific to the organization. The Harvard Implicit Association test is one commonly used survey assessment tool.(21) Addressing barriers to care and providing rationale as to the need for change will help motivate receptiveness. When providing resources, make them convenient and relevant and be sensitive to physician time away from medical practice.
Training and education are key components. Training in diversity management, DEI initiatives, cultural competency, harassment, the Personalysis test, gender, age, and racial discrimination have shown benefit in improving care dynamics. Improving communication, team collaboration, and customer service skills will enhance understanding and expectations and improve care efficiency. Training in harassment, conflict management, and stress management will help reduce the stress and strain on interpersonal relationships.
One highly recommended strategy is to provide training on emotional intelligence.(22) Education in emotional intelligence is a four-part process:
The first part focuses on self-awareness, to help individuals learn how to better recognize their own biases and trigger points that influence their actions.
The second part is social awareness, which teaches individuals how to become more aware of the needs, values, priorities, and sensitivities of the person they are dealing with.
The third part is self-management, with recommended strategies on how to more effectively control and manage initial impulses.
The fourth part is relationship management, where you put it all together to maximize the effectiveness of the interaction.
Individual coaching and role play scenarios will help personalize individual recommendations.(23) When behaviors are disruptive and not amenable to training or education efforts, more focused interventions as to behavioral modification may be in order.(24)
Conclusions
Subconscious implicit biases can have a significant impact on approaches to and outcomes of patient care. Healthcare providers and patients need to recognize the impact of these biases and be better able to adjust their behaviors to achieve optimal outcomes. The problem is more evident in the physician population. Doctors give orders. Purpose, ego, and training priorities often inhibit awareness of other factors influencing their decisions. Healthcare organizations need to take a proactive role in providing support services to enhance care relationships. Making the business case for improved medical care as to access, quality, safety, and satisfaction will help motivate physicians to be more willing to accept outside advice to enhance their people management skills. Be sensitive to barriers and resistance and schedule services with respect to physician time and capacity. It’s the right thing to do.
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