Implicit Complicity

Unconscious bias, the gaslighting demon of an equity destroyer, plays with our minds much like Plato’s cave shadows—dancing sardonically behind our cognition, scorning the idea that we know what we are, how we think about ourselves and how we know the world.

But with a skull full of introspective foresight and a mindful approach, this ubiquitous urchin can be released from its haunt. For the sake of our patients, this must be addressed: unconscious bias (or implicit bias) in medicine affects physician attitudes towards patients¹, which could lead to misdiagnoses² that are detrimental to patient health outcomes³. If the costs to health are not tangible enough, we can look at the costs to our economy: health disparities in minority populations lead to upwards of $230 billion in excess spending per year⁴. Bias should mold us no more.

Sources of Bias

Sources of bias seemingly tucked themselves away in the recesses; little worms of wariness shielded from the warmth of conscious control. These leaches, hidden in the deep, are but vestigial remnants of evolution that inhibit our community and peace; we learned as apes to distrust those that seemed different than us, triggering an amygdala reflex⁶ before we could intervene. This reflex still remains to protect us in strange and dangerous situations, evoking fight-flight-fright reactions when we come across drastically non-human beings, such as snakes and spiders.

Humanity has progressed to the point where technology supports so many of the resources we had to compete for previously. We work together with other nations via satellites to trade goods via freighters. We translate books to share perspectives and philosophies. We harness our beautiful intellects to create inventions that heal and help each other. Now if only we could just stop hating each other, stop fearing each other, stop feeding this mind-trapped parasite that prevents us from truly loving each other. So how do we conquer this inhumanly human condition? Recognizing implicit bias is the first step and actively correcting it is the second.

Recognizing Implicit Bias Within Yourself

Let us start with an example of a new patient walking through the office door and how we analyze them.

With the patient before you, you see the clothes they wear, their body habitus, their skin color; you hear their voice and whatever fluency of your respective language it carries or doesn’t; you smell what they ate for food recently or how they keep their hygiene; you know from their medical record how they keep their health. Do these impart a perception of the person on you before you get to know them? Most likely, but that doesn’t mean that the perception is inherently negative—observational exam findings are useful after all. But the trouble begins when these perceptions start to melt into medical decision making, when seemingly minor choices compile over the patient’s healthcare experience. A physician giving slightly more of their limited time to one family that looks like them over another that doesn’t, perhaps due to comradery from shared societal experiences; a nurse rolling their eyes at a call bell for a patient that “asks too many questions,” even though they do so because of their distrust in a system that was built against them⁸; or worse pain control for a patient that is believed to have the potential for abuse, with the unconscious driver for that perception being founded in race or perceived status⁹.

Unfortunately, these are among a long list of common experiences shared by the disadvantaged in our country.

Even if it seems the differences between you and another are vast, we all face something both harsh and wondrous: the happenstance of life, the serendipitous avalanche that leaves some afloat with appreciation after appreciation, while others are crushed beneath the weight of existence and its gall to bring us here at all. Yet we push for survival even when it’s unpleasant. We falter at times, times that feel like we’re stuck falling, but the fact that we’ve kept ourselves alive thus far is the greatest monument our wills can build. We are a species unrivaled in our endurance. Yet even the marathoner needs fluid and an electrolyte spark along the race.

Active Correction of Implicit Bias with Empathy

Ironically, there is a problem with that last sentiment: viewing life as a race.

Too often do we compare ourselves against others, seeking to gain an imaginary lead over imaginary competitors that need that spark just as much as we do. We struggle against each other like crabs in a bucket, never finding the rim. And what gets lost in the claws and chum is what we need most to combat our own biases: empathy.

Empathy is a universal requirement for all future and practicing physicians. How can you care for somebody if you don’t care about them, or how they feel, or how it would really feel inside if you were them? Which isn’t to say that it doesn’t already exist in a practice where unconscious bias intrudes. Medical schools across the country have been teaching empathy skills in-depth for years in order to better facilitate physician-patient relationships, helping students learn the words to say to better relay that they have the patient’s best interests in mind. We all truly feel these sentiments since this is the profession we’ve chosen—it’s just a matter of practicing how to accurately voice how you feel.

Similarly, bypassing bias is a skill that can be practiced. There are ideas circulating already on how to make specific corrections: examining data through a lens of intersectionality¹⁰; introducing further education that allows for better recognition of unconscious biases¹¹; introducing the public to ways they can combat their own biases against themselves (a.k.a. the stereotype threat¹²). These are all great initiatives in my eyes, so I’d like to add one more that I personally utilize: mindfulness. Mindfulness can be described as the practice of gaining control or awareness over our own conscious states. In my experience, this involves seeking the roots of a feeling, following those threads to their source and cutting the strings.

A Mindfulness Meditation for Physicians

To better exemplify the method behind this, sit still, close your eyes, focus on your breath, and try to group all external stimuli into one concept; the sounds you hear, the awareness of your body in space, the feeling of the chair beneath your rear, the feeling of your mind behind your face. These are all signals falling backwards into the center that is you. Now try splitting them into separate groups of ‘pleasant’ or ‘unpleasant.’ Is that one sound annoying because it keeps breaking the silence around you? Is acknowledging your breath relaxing because it is the metric that you’re still alive, or because it alone holds your focus? Recognizing the reasons behind these perceptions of feelings, good or bad, is a starting point from where we can address bias.

Pay attention to all of your feelings surrounding a patient, a person, and determine if they match the general pleasant or unpleasant sensations you felt before—if unpleasant, dig down to where that discomfort lies and find why. These sub-cognizant perceptions play equally wounding roles in the patient’s care as they do in our own heads, so undressing them is of prime importance.

See again the patient before you, as a person, and place their image in your head—just their objective being, not whatever meaning or label you hang on them like a decorative adornment—they are to be clear and glass, washed anew from your own past preconceptions. Hold now this image in your head, and hold these words in your throat—let them rumble to your palate as you fumble for the clarity you seek, feeling through them word-by-word until the glass is stained pane-by-pane:

It is our duty to provide paramount care to all we see.

However, we must first see each other in all our nakedness and simple glamour. Clearing away the plaque of unconscious bias from our minds is an important task that takes careful focus, regular practice, and rhythmic purpose.

With these meditations, I hope to have provided a frame of resistance —for without attention to our hidden beliefs, we will remain complicit to the implicit beast of bias that has fed off of life after undeserving life.