In the midst of a global public health crisis, medical providers find
themselves on the frontline of unprecedented circumstances caring for
patients as they fight the coronavirus disease 2019 (COVID-19) pandemic.
Pediatricians are faced with the reality that COVID-19 positions
marginalized groups of children and youths at an increased vulnerability
to health care inequities. These at-risk groups include children and
youth who are ethnic and racial minorities, immigrants, LGBTQ, homeless,
in foster care, as well as those who have medically complex health
conditions and/or mental health and substance use disorders (1, 2, 3).
Now more than ever, health disparities have the potential to result in
fatal health outcomes and healthcare professionals have the power to
advocate for and protect their young patients. Given the urgent and
pressing impacts of the current pandemic, Tsai and Kesselheim offer a
timely and critical dialogue in this issue of Pediatric Blood & Cancer,
focused on the effects of provider implicit bias that contribute to
health disparities.
Tsai and Kesselheim underscore the well documented literature on
implicit bias in pediatric medical oncology and note the limited
research in pediatric hematology-oncology, despite the complexities that
exists in prognosis and treatment plans for this clinical population.
Additionally, the case examples are thoughtful, transparent
self-reflections from the authors personal clinical experiences with
implicit bias in the field of pediatric hematology-oncology. The authors
then outline a plan of action towards mitigating implicit bias in
healthcare. They first emphasize the importance of acknowledging
implicit bias, which is ubiquitous in human nature and exists under many
circumstances. Subsequently, upon acknowledgment of existing implicit
bias, providers should cultivate self-awareness via medical education in
order to have the autonomy and ability to identify and detect implicit
bias that negatively affect patient care. Moreover, the authors deduce
that diversifying the medical team, both demographically and
interprofessionally, can optimize detection of implicit bias. The
authors go on to conclude that more research is needed in the specialty
field of hematology-oncology to identify how implicit bias specifically
affects provider’s ability to communicate complex diagnoses, prognoses,
and treatment options.
Derived from social psychology research, implicit bias refers to
unconscious, unintentional, and automatic positively or negatively
skewed classifications people make based on their own experiences and
demographic background which then influences behavior and perceptions.
The Institute of Medicine published a pivotal report illuminating how
implicit bias can negatively influence patient care and may lead to
health disparities (4). Examples of implicit bias affecting health
outcomes include biases toward race, weight, sexual orientation,
socioeconomic status, age, marital status and history of drug use (5,
6). There are two paths that may explain how implicit bias amongst
medical providers may contribute to health disparities (5, See Figure
1). Path A suggests provider judgements and decisions regarding patient
care can result in health disparities. Path B proposes that implicit
bias amongst providers can lead to ineffective communication which
affects the providers ability to cultivate a trusting relationship and
environment. Patient’s distrust with their providers affects their
willingness and ability to adhere to treatment recommendations which
subsequently leads to health disparities. Moreover, this model also
explains the conduit for interaction effects between path A and B. That
is, compromised judgment leading to poor medical decisions may
strengthen the probability of poor communication and distrust in the
provider-patient relationship or the inverse. Also imperative to the
discourse of health disparities and bias, not discussed by Tsai and
Kesselheim, is the notion of “privilege” that, unlike minorities, many
non-minorities may experience in their rise to becoming a medical
professional as well as their medical decision making (7). Such
privilege can inadvertently bias providers to behave in ways that
illuminate implicit bias. Therefore, the ability to acknowledge
privilege is essential to increasing one’s proclivity to recognize their
implicit biases. The authors provide vignettes that pointedly describe
the importance of self-awareness. Practicing self-awareness promotes the
ability to detect implicit biases that may affect patient care and
result in unintentional health disparities. Moreover, central to the
author’s argument, it is fundamentally important to identify and
implement practical steps to address provider implicit bias.
The use of research to inform best clinical practice by implementing
skills training is key in addressing health disparities related to
provider implicit bias. A potential barrier to successful training and
education on provider implicit bias is limited support from
institutional leadership (8). Committed leadership on curricula related
to implicit bias at an institutional level is likely to reflect
long-term systemic change (9, 10). Furthermore, providing a
nonjudgmental and safe environment for providers to address difficult
content is also key in fostering self-awareness that is more likely to
result in long-term change (10). Considering the role of power dynamics
in practice and training is also fundamental for cultivating a safe
environment for self-disclosure and self-awareness and bringing about
systemic long-standing modifications. Tsai and Kesselheim highlight the
importance of building demographically diverse and interdisciplinary
medical teams. Purposeful team development can also reveal and mitigate
any systemic workforce and recruitment biases (11). Having various
perspectives while discussing a treatment plan can combat implicit bias.
For example, if a complex case is presented at morning rounds with a
team that is homogeneous in background and trainings there is potential
for groupthink that is anchored in one or two individuals’ implicit
biases. Specific to complex cases in pediatric hematology-oncology this
can be critical especially during a pandemic that is particularly
impacting vulnerable populations, who are often less likely to be
represented among medical decision makers. A diverse team can provide
insight for culturally competent care as well as provide important
perspectives that could optimize diagnostic and treatment outcomes.
As a clinician, it is not an easy task to be open to becoming vulnerable
to exploring self-awareness as it relates to implicit bias. It is also
our ethical duty to do no harm. Acknowledging implicit bias as a
catalyst to health disparities while implementing effective skills
training to address implicit bias is crucial to protecting our most
vulnerable pediatric patients.
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