Recognizing and Reducing Implicit Bias: Strategies to Improve Equity in Dermatology by Susan Massick, MD

 

Recognizing and Reducing Implicit Bias: Strategies to Improve Equity in Dermatology
By Susan Massick, MD

Implicit Bias in Dermatology

The Merriam-Webster definition of “bias” is “an inclination of temperament or outlook.” By itself, bias is a neutral term, but one can harbor biases that are positive or negative aimed toward a person, an object, or a concept. “Explicit bias” pertains to our beliefs on a conscious level—we are aware of them; however, “implicit bias” refers to our unconscious beliefs and attitudes outside of our conscious awareness that may positively or negatively impact our behavior, our actions, and our decisions.

What are examples of common implicit biases?

·         Gender

·         Race/Ethnicity

·         Age

·         Religion

·         Sexual orientation

·         Socioeconomic

·         Disability

It may be helpful to try to identify your personal implicit biases. Consider taking an implicit bias test, such as the Implicit Association Test (IAT) through Project Implicit, a collaborative research effort between Harvard, University of Virginia, and University of Washington aimed at studying implicit biases. (You will need to sign in using your email address, but your answers are strictly confidential and you will not be contacted). Categories that you can choose for self-assessment include race (white/black), skin tone (dark/light), religion (Jewish/Christian/Muslim), sexuality, age, and body type (Project Implicit , 2024). You may be surprised to find that you have automatic associations that run counter to your conscious thoughts.

Click on the link to proceed: https://implicit.harvard.edu/implicit/takeatest.html

 

 How does this manifest in the dermatology setting?

Unconscious bias can potentially influence patient care and our professional interactions with peers, staff, and trainees. An implicit bias may impact decisions that reinforce real-life barriers to equity and exacerbate existing disparities particularly in marginalized populations. For example, implicit bias may play a role in gender inequity in career advancement or may bolster racial disparities seen in patient care management decisions.

Implicit bias does not equate discriminatory behavior per se; however, consider for a moment how an unconscious bias could shape a doctor-patient interaction and lead to disparities in access to care, in the diagnosis, delivery, and management of care, and ultimately in our patient outcomes.

·         Medical decision-making and management of care

•       What options we discuss with patients

•       What treatment recommendations we give patients

•       Our behavior

•       How we interact with our patient in the exam room and the time spent in these interactions.

•       Are we empathetic? abrupt? dismissive? impatient?

•       Our perceptions

•       Making premature assumptions based on prior experiences

There are examples of implicit bias in the dermatology literature which illustrate the impact that implicit bias can have on patient care. One study published in JAMA Dermatology examining health care use and treatment patterns for acne “found racial/ethnic, sex, and insurance-based differences in health care use and prescribing patterns for acne that were independent of other sociodemographic factors” and that “despite being more likely to see a dermatologist and having a similar number of visits for acne, black patients generally received fewer prescriptions for acne, were less likely to receive prescriptions for systemic treatments (ie, oral antibiotics, combined oral contraceptives, spironolactone, and isotretinoin), and were more likely to receive topical prescriptions [over systemic treatments] than white patients” (Barbieri, 2020).

The potential impact of implicit biases can manifest as a delay in accurate diagnoses, shorter patient visits, less patient interaction with physicians, underdosing of medications, or limited treatment choices offered. This could have serious implications for conditions such as melanoma skin cancers or chronic skin conditions like psoriasis.

 

So, what can we do to mitigate this unconscious bias?

Recognizing our implicit biases is a critical step toward eliminating their potential impact—becoming conscious of these unconscious biases. Check out this wonderful article by Wilson et al published in the WDS’s International Journal of Women’s Dermatology in 2020: “Bridging racial differences in the clinical encounter: How implicit bias and stereotype threat contribute to health care disparities in the dermatology clinic.” Included is an overview on implicit bias as well as a toolkit on personal and implicit bias awareness and tips for use in the clinical setting to mitigate implicit biases (Wilson, 2020).

• Cultural Competency and Implicit Bias Training with regular training sessions to educate ourselves and our staff about the diverse backgrounds of patients, cultural factors that affect the patient experience, and social determinants of health and their impact on patient outcomes.

o   Online training modules, such as The Ohio State University Kirwan Institute for the Study of Race & Ethnicity’s Implicit Bias Module Series: https://kirwaninstitute.osu.edu/implicit-bias-module-series (Implicit Bias Module Series, 2024)

 

• Standardized protocols with evidence-based guidelines for diagnoses and treatment algorithms balanced with patient-centered and inclusive decision-making.
  
  
• Seeking patient feedback, not just patient satisfaction scores, to understand patients’ personal experiences and their perceptions of how care was provided to them.

Useful tips to incorporate in the clinical setting are relevant to every patient interaction highlighted by Wilson include:

·         Introductions: introduce yourself, ask your patient what name they prefer, and sit down.

·         Discussion:

o   Ask open-ended questions and actively listen to responses before interjecting, particularly regarding the patient’s understanding of their condition and prior treatments.

§  “What can I help you with today?”

§  “What do you think has been most helpful?”

·         Decision-making: Include your patient in the decision-making process by reviewing options. It is a conversation not a lecture.

Recognizing and overcoming implicit bias will make us better clinicians, build a more equitable and inclusive environment, improve the patient experience and the delivery of care of all patients across our specialty.

References

Barbieri J.S., Shin D.B., Wang S., et. al. Association of Race/Ethnicity and Sex With Differences in Health Care Use and Treatment for Acne. JAMA Dermatol 2020; 156: pp. 312-319. Mar 2020. DOI: 10.1001/jamadermatol.2019.4818

Implicit Bias Module Series. (2024, 09 20). Kirwan Institute at The Ohio State University. Accessed 09/20/2024. https://kirwaninstitute.osu.edu/implicit-bias-module-series

Project Implicit . Project Implicit. Accessed 09/20/2024. https://implicit.harvard.edu/implicit/takeatest.html

Wilson, Britney N et al. Bridging racial differences in the clinical encounter: How implicit bias and stereotype threat contribute to health care disparities in the dermatology clinic. International Journal of Women's Dermatology 7(2): p