Takeaway
We all have biases that are mostly unresectable. By practicing mindfulness, being self-aware, and building connections with patients, we can reduce the harm they might otherwise cause.
Lifelong Learning in Clinical Excellence | January 30, 2025 | 3 min read
By Som Saha, MD, MPH, Johns Hopkins Medicine
When I was a medical resident in the ICU, I admitted a middle-aged “John Doe” with diabetic ketoacidosis. He was brought in hypotensive and unresponsive after being “found down,” incontinent of urine and stool, in an apartment in San Francisco’s Tenderloin District, a neighborhood known as a hotbed of crime, sex work, and injection drug use. The patient looked haggard, with soiled clothing and a pungent odor. As we discussed his case on rounds, we cynically speculated about which substances his tests might reveal. We had taken care of so many of “these” patients.
We treated John Doe with the requisite IV fluids, insulin, and electrolyte replacements, and on day two of his hospitalization, he came to and filled in the blanks of our incomplete history. We learned that: 1) He had not previously been diagnosed with diabetes, 2) He didn’t drink or use illicit drugs, and 3) He played in the string section of the San Francisco Symphony orchestra. I remember the shift in attitude that swept over our team, from medical student to attending, once we heard this information. Everyone now wanted to talk to this man and seemed more invested in caring for him. This palpable shift forced us to confront an uncomfortable question: Did we suddenly value this patient’s life more than we had a day earlier?
The ubiquity of bias
It would be easy to wag a finger at our team for the assumptions we made about this patient. But we were just normal people with all the biases that normal people have. Numerous studies show that physicians and nurses, like everyone else, have biases favoring certain patients over others—e.g., those who are white, male, thin, or wealthy over those who are Black, female, obese, or poor—and that these biases can adversely affect the care of people from the disfavored groups. In most cases, biases are implicit, or unconscious, present even in those of us committed to equity. They lurk in our subconscious and guide much of our automatic behavior.
A harm reduction approach
The obvious question is, “If biases are unconscious, how do I control them?” Studies have found that by the time we’re adults, implicit biases are pretty hard-wired, and that efforts to purge them from one’s subconscious don’t work very well. However, even if we can’t rid ourselves of biases, we can take steps to minimize their impact on patients:
Unconscious biases are most likely to influence our behavior and decision making when our conscious minds are distracted. Being mentally present with patients allows our egalitarian conscience to take the steering wheel away from our biased subconscious.
2. Check your preconceptions.
We may read details in a patient’s record (e.g., substance use disorder, nonadherence) that shape our opinions about the patient before we have even met them. Take a moment, before walking through the door, to examine what preconceptions have formed in your mind, and then push them aside to give the patient the benefit of a clean slate.
3. Build connection.
Biases are most likely to influence our attitudes when we see patients “from a distance.” associating them with superficial characteristics about which we may have stereotypes. Learning more about patients’ lives and finding points of connection allows us to see them as unique individuals, reducing the activation of stereotypes that occurs when we categorize them.
4. Imagine the patient as your loved one.
As you look at your patient, imagine how you would want another clinician to act if this was your child, parent, spouse, or friend. Years ago, if I had imagined John Doe as my father, I would have felt more compassion and been quick to defend him against the callousness that pervaded our behavior.
We may not be able to extricate biases that our life experiences have embedded deep within our brains. But we can do our part to ensure that those biases do not compound the inequities suffered by already disadvantaged patients.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.