Analyze what advantages and resources we have as physicians to help mitigate racial disparities.
The last thing I wanted to do was to write an article on racism. Not being an expert on the topic, any time I even contemplated writing something, I was crippled by self-doubt. But even more, I was paralyzed by fear. All I could think of were the buzzwords floating around social media. If I wrote against racism, would I be accused of “virtue signaling?” If I didn’t go far enough in condemning racism, would my words be perceived as insufficient, a mere “dog whistle?” What if I unintentionally wrote something that smacked of “white fragility?” Worse yet, I found myself avoiding the topic because of my own discomfort. What if in researching the issues of systemic racism I found myself unintentionally complicit in hurting people I cared about? How would I face this guilt and shame?
But the universe has a way of forcing us to face the unpleasantness that we dread, and when my editor specifically asked me to write an article for doctors on facing implicit bias in medicine, I knew that I had to answer the call. I’m glad I did. Because after speaking with multiple physician experts, I now have the tools to begin to identify and overcome my own implicit biases, and so can you.
Acknowledging blind spots
Every one of us has a certain degree of implicit bias, or subconscious automatic thoughts about others that stem from our upbringing and social framing. Having these thoughts does not mean we are inherently bad or evil. But if we fail to identify areas of implicit bias — blind spots in our knowledge and understanding of other groups of people — we risk inadvertently providing them with lower-quality care. Because this is the antithesis of what most doctors strive for, realizing that we have blind spots may be hard for us to admit.
Christina Girgis, M.D., a consultation-liaison psychiatrist in Chicago, Illinois, and founder of the Psychiatry Network, an educational group and advocacy resource for psychiatrists, says that one of the biggest challenges of acknowledging implicit bias is the cognitive dissonance that it creates. “We all want to think that we are good. Recognizing that we have automatic negative thoughts about certain groups of people does not fit with that belief. That’s why it can be so hard to recognize and accept this within ourselves.”
But everyone struggles with bias, including doctors of color. Brian Dixon, M.D., is a Fort Worth, Texas, psychiatrist, author and founder of Together Forward, a nonprofit think-tank focused on improving health and alleviating cultural disparities. Dixon discovered during a test of implicit bias that he, a black person, was biased against black people and in favor of white people. “I already knew it,” says Dixon, who grew up in a predominantly white area and attended medical school and residency with few other black people. “My biases, like those of anyone, are a result of my environment and the societal messaging I have received in my lifetime.”
Wamda Ahmed, M.D., a neurologist in Houston, Texas, with a special interest in racial disparities, agrees. “Even African American physicians face similar bias, because we receive the same messages and social framing that our white colleagues experience.” Ahmed notes that she sometimes even struggles to overcome automatic negative thoughts about herself that stem from her social conditioning. “I have to challenge my ‘imposter syndrome,’ and consciously transform the negative thoughts of ‘I am not good enough’ into ‘I can do better.’”
“Having bias doesn’t make you a bad person,” says Nicole Christian-Brathwaite, M.D., child adolescent and adult psychiatrist and CEO and founder of Well Minds Psychiatry & Consulting in Boston, Massachusetts. “Identifying bias is an opportunity to become aware and act.” To help recognize our inherent bias, psychiatrists like Christian-Brathwaite and Dixon suggest taking the Harvard University’s Implicit Associations test, which, although imperfect, can at least begin to raise our self-awareness. Another good way to avoid blind spots is to focus on patients as individuals. “Ask your patients about their cultural backgrounds. Listen to your patients’ stories. The more you individuate, the less likely you are to stereotype,” says Christian-Brathwaite.
Maiysha Clairborne, M.D., an integrative family physician, physician coach, neurolinguistic programming expert and founder of Stress Free Mom MD, says that one of the keys is to not only listen to patients but to watch their responses carefully when you talk with them. “Don’t dismiss patients’ reactions as sensitivity,” advises Clairborne. “If you see your patient react, ask them about it.” Clairborne uses the technique of emotional mirroring and validation, labeling the response that she sees the patient exhibit and asking for clarification. “Check in with your patient. If I see a patient flinch, I might say, ‘I just observed your face change, what happened there?’” She recommends asking specifically, “Was that a racially insensitive thing I just said? I’m sorry; I’m still learning.” This takes the pressure off and gives the patient space to respond.
Get help with processing your emotions
One of the reasons that we fail to examine our biases is because of the emotions they can produce. These emotions can be immensely powerful, and without help in processing them, we may develop maladaptive coping mechanisms, including denial or anger. “Trauma begets trauma,” Dixon says. “If we are not careful in dealing with our emotions, we can risk traumatizing others. It becomes a vicious cycle unless we learn to break it.” Dixon believes that this trauma is one of the reasons it has been difficult to have a reasoned discussion about racial issues. “We cannot even begin to have a public debate or discourse about racism when tensions are high, because traumatized people can’t act in an even-keeled manner. When you feel afraid, you have a biological imperative to run away or lash out.”
To help examine your emotions, Dixon recommends finding a guide, usually a psychiatrist or psychologist. Another option is a physician coach, which may be ideal in states where the medical licensing board takes a punitive approach to mental health counseling. “It’s important to find someone to help you interpret areas of implicit bias and to remind you that having automatic thoughts doesn’t make you a racist. You may need help in overcoming the trauma of realizing that you’ve hurt someone. You have to learn to forgive yourself, and that takes work,” Dixon says.
Girgis says that physicians must work to change our thinking from “I’m a bad person” to “How can I change this type of thinking?” We can also transform our feelings from being about us to being about other people. “Reframing is one of the best tools that we can use. We need to see the realization that we are biased as a positive; now we can begin to deal with it,” Girgis says.
“The best way to deal with anxiety or fear is exposure therapy,” says Christian-Braithwaite. She compares the process to what physicians experience to M&M (morbidity and mortality) rounds during training. “We don’t go into medicine to hurt people, so when we do, it’s humiliating. We should discuss racism in medicine in the same way that we do medical errors, as both lead to negative patient outcomes. Although it’s difficult and uncomfortable, this is how we grow,” she says.
Do your homework
Once we have acknowledged that we have hidden bias, the next step is to develop a better understanding of the systemic issues that our patients face. We can do this by reading about social policies that have negatively affected black populations, such as redlining (the denial of mortgage loans in certain areas for people of color), wage inequality and unjust criminal justice policies. We must also research the effects of racism on medical outcomes. For example, Christian-Brathwaite notes that black patients are more likely to be improperly diagnosed with psychosis and schizophrenia and more likely to be restrained in an inpatient psychiatric unit than white patients. Ahmed points out that African American and female patients are less likely to be treated with tissue plasminogen activator for a stroke and more likely to have a stroke misdiagnosed as a psychiatric disorder or drug abuse reaction. African American patients are also less likely to undergo cardiac catheterization or receive a kidney transplant compared with white patients. African American and Latino patients have been found to receive less pain control in the emergency room than white patients.
Resources for learning about racial disparities include the Office of Minority Health’s Knowledge Center and the American Medical Society’s Health Disparities Toolkit. Dixon suggests checking to see if your hospital or university has a diversity officer. “Many organizations are hiring diversity officers who are trained in addressing racial disparities.”
Applying new knowledge
“Physicians have a unique obligation to address racial disparities because our patients are vulnerable and trust us with their lives,” Ahmed says. However, she notes that this is not always easy, and she often must work at maintaining her objectivity. “Sometimes my first impression may be that a patient’s symptoms are psychiatric. But I remind myself to stop and follow my usual protocols for every patient until I have excluded the most serious neurologic causes,” she says.
Once she has confirmed that a patient is not suffering from a neurological condition, she takes the next step to try to determine the root of their problems. “I ask myself: ‘If this is not a stroke, what is it?’ Often, I discover that patients have had a recent traumatic life experience or an underlying socioeconomic cause for their symptoms,” Ahmed says.
Although many physicians worry they won’t have time to address racial disparities or socioeconomic pressures, Ahmed says that even taking a moment to connect with your patients on a human level can make an impact. “Take a few minutes to be kind, give encouragement or a hug, just to show that you care.” She notes that developing emotional connections with patients also has been found to decrease physician burnout.
Christian-Brathwaite, who specializes in helping physicians fight racial disparities, suggests that doctors take time to reflect on the care that we provide. “Consider doing a chart audit to look at your plan and your goals for different patients,” she says. “Ask yourself: ‘Are my treatments consistent?’”
She notes that implicit bias increases when we are tired, rushed or stressed. “Medicine is often not conducive to being unbiased because when we are under stress, we often find ourselves resorting to shortcuts, including stereotyping our patient,” Christian-Brathwaite says.
Developing anti-racist thoughts and behaviors
I hesitated to write this article because I was afraid of saying the wrong thing. I’ve also avoided discussing racial issues on social media for the same reason. Girgis told me that this is a common concern. “Discomfort can be the worst feeling, and most of us try our best to avoid it. Sometimes you just have to acknowledge your fear and just jump in,” she says.
Girgis notes that if we stay silent, our colleagues won’t know about our support. “Most of the time, our efforts are appreciated, even if they are clunky or imperfect.” She recommends using an accountability partner such as a friend or colleague to help us evaluate our objectivity.
One of the things we can all do, Girgis says, is to analyze what advantages and resources we have as physicians to help mitigate racial disparities.
“I may not be able to go out and protest, but I can take steps to make my patients feel more comfortable, to talk with my colleagues and to mentor trainees,” Girgis says. The public pays attention to doctors, and our words and actions carry weight. “We can educate the public by writing and speaking out, or we can just be a good example in our interactions with others outside of work,” she says.
“We have to keep trying,” Ahmed says. “I see the process of developing as a physician to like that of a parent. I’m not going to be perfect every day, but I’m going to keep trying, because the stakes are too high.”
Rebekah Bernard, M.D., is a family physician and author of “Physician Wellness: The Rock Star Doctor’s Guide” and “Change Your Thinking, Improve Your Life.” She can be reached at rebekahbernard.com.