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Joey Wahler (Host): We hear so much nowadays about minority bias, but how can that impact medical treatment? We're discussing minority health, recognizing implicit biases and providing optimal patient care.

Welcome to the American College of Osteopathic Internists podcast, Docs Off the clock. Juggling the business of medicine and caring for patients means doctors always seem to be on the clock. Docs Off the Clock features some of today's best voices in healthcare with tips on how to live a better, balanced life. Thanks for listening. I am Joey Wahler. Our guest, Dr. Watson Ducatel, Chair of the ACOI Committee on Health Equity and Inclusion in Medicine. Dr. Ducatel, thanks for joining us.

Watson Ducatel, DO, MPH, FACOI (Guest): Thanks for having me.

Host: So this is obviously a very important topic and to start us off, as it relates to minority care, what do we mean in your view by implicit bias?

Dr. Ducatel: So, implicit bias is kind of this big term that was coined back in the 1990s by two individuals, Dr. Banaji and Dr. Greenwald and what they were doing, they were studying how we think and how we have these things these, these biases, these preferences that we're completely unaware of that comes into play or have an effect on our decision-making, our attitudes towards different things that we may find ourselves doing.

So, you know, whenever we have to make a decision about a particular thing, or whenever we have to execute an action, there are these unconscious evaluations, associations that are influencing what type of decisions and attitudes and actions we take. So that's what we mean by implicit biases.

Host: Gotcha. So what would a couple good examples of that?

Dr. Ducatel: So a good example would be, and I like to tell this story and I'll try to make it quick. Father and son are coming home and they're driving and on their way home, they unfortunately get into a very bad car accident. And the father is severely hurt. And the son is hurt as well. The father emergency response is at scene. The father is actually pronounced deceased or dead at the, at the scene of the car accident.

The son is taken to the hospital and rushed to the ER, rushed into the emergency room, evaluated. Subsequently it's being shuffled to the operating room because of his injuries. The surgeon comes in and starts to do their thing. And the son is on the table and the surgeon says, wait, I cannot go through with this surgery. And when asked why the surgeon says I can't operate on my son, now a lot of people when they're hearing story they're confused because they're like, wait, I thought you said the father died. And in fact I reacted that way initially. And the question then was, or the, or the, or the understanding after that wait no one said the surgeon was the father, the surgeon was the mother. But if you are like most people who will make the assumption that the surgeon had to be the father, then you like most people hearing this story, had an implicit bias where we associate men with surgeons and we associate men with careers and women with the children or at home.

So that's an example of an implicit bias. What we mean when we say people, we all have these unconscious evaluations or associations or judgment that come into play that affect our attitudes and our actions and decisions.

Host: And it's interesting doc, that you told that story, because I've heard that before told in a slightly different way where it's more almost in the form of kind of a I guess, a brain teaser, right? Where you'll tell someone that same story and get to the punchline. I can't operate on my son. And then you say to the person you're telling the story to what happened here? And they're often stumped because they don't think that the surgeon, as you said, could be a woman.

So having said all that, how much of implicit bias in the medical field is based on one's background, such as where you grew up, things that affected you coming up the world as a younger person, just as would be the case in other sorts of areas of life, where people are guilty of implicit bias?

Dr. Ducatel: Well, here's the thing that I want people to know about implicit bias. Implicit biases are not negative or positive things per se in themselves. Certainly the people's implicit biases can lead to outcomes that can negative and or positive. But the, the having the bias, the bias itself isn't necessarily a bad thing or, or, or, or good thing.

In other words, people that are well-intentioned that have egalitarian type views, who, who wouldn't consider themselves a discriminatory person or a person that holds views that see people unequal equitably. They, themselves may not believe that, you know, say they have some bias. Implicit biases can affect anyone and does affect anyone or in all of us.

So, when we talk about medicine, particularly of course, physicians are just like everyone else. And we have shortcomings just like other humans and in the many different disciplines and professions that exist. And we too have to deal with our implicit biases when we are encountering our patient care. I personally have been on receiving end of implicit biases and certainly have had have biases myself like each one of us. But speaking from a perspective of, you know, specific groups who according to the research, bear the brunt of kind of the bad outcomes that are associated with implicit biases.

There are three main groups that are severely affected it seems based on the research and that is brown skin, people who are women and people who are considered advanced age or old or older. Those three groups suffer from the consequences of implicit biases, perhaps at disproportionate rates than other groups of people or groups in general in which, their, their, you know, biases come to play or have some type of affect and effect on on their, on their existence, on their social wellbeing, on their physical wellbeing.

So, it definitely has a profound impact in, in what we do in medicine, we are just now learning about that impact. We're trying to find ways to measure that impact. And we're trying find ways to measure, you know, once we become aware what we put in measures to make, you know, to, to prevent one from using these or relying on these implicit biases in their practice of medicine; what type of effect does it have or does it have an effect on all? So all that still very much underway in the research.

Host: Well, speaking of which, since you alluded to it there, in what ways can implicit biases impact both patient care and maybe even the patient doctor from your experience?

Dr. Ducatel: That's it. That's a great question. So the research is, is very clear on there. There have been hundreds and hundreds of studies throughout the last three decades on the effects of implicit biases in healthcare, particularly. But there, there are two major studies that kind of were very famous was, was reported all throughout the national press, local presses. One came in the form of an article that came out in 1999. And it was it's titled The Effect On Race and Sex on Physician Recommendations for Cardiac Catheterization. And what this said is that basically when they looked at men and women, and they looked at who were around the same age but had different skin tones; the recommendations were different for going on and having these cardiac procedures. And they concluded that this was likely due to implicit biases based off the way they designed the study. And when this article came out, it was, it was highly controversial because it was the first big article to suggest that doctors were treating people differently based off the way they looked.

And of course, most doctors that I know, at least pride themselves on treating everyone fairly. So this was a shock to the system. So that was the first article. And then after that, Congress actually commissioned a committee to understand and eliminate racial and ethnic disparities in healthcare in the, in the early two thousands.

And as a consequence of that, what came out of that was a report called Unequal Treatment. And that report detailed disproportionate outcomes in health and in clinical outcomes when it came to certain groups of Americans and those groups where if you are again, part of Americans who have a brown or dark skin tone, or you are, you know, women or other factors you suffer from, other factors like low unemployment, low income, low education, levels of food, low, low access to healthcare that you too, suffered from these disparities. And they found that after that, after you controlled for education, after you controlled for income, after you controlled for environment like housing, transportation, after you controlled for things like food, made everything the same essentially, that these disparities still existed.

That there is a disproportionate amount of negative health outcomes and clinical outcomes in people with browner skin tones, and that the end conclusion that these are due to implicit biases, more likely. And so that was the second big study that really brought this to the forefront.

Host: So having said that, you also mentioned earlier that you have been on both ends of this yourself.

Dr. Ducatel: Yes.

Host: What are we about specifically usually? Give me a few examples, either from your own experience or otherwise of how that impacts patient care.

Dr. Ducatel: So that's a great question. So what I was trying to do is introduce kind of the concept of implicit biases. But so there's the aggressor, if you will. And I'm just using that term for lack of better right now. There's a person committing the implicit biases, relying on the implicit biases to make decisions about things and, and attitudes and evaluations judgment et cetera.

And then there's the person on the receiving end of that person having used their implicit bias. So being on the receiving end, what we see, how, how do they manifest? They manifest in forms and ways that we now recognize is things like microaggressions. These everyday subtle insults and validations that people find themselves experiencing, and so one way that I've experienced those things, I remember being in medical school and after the grades came out, I had professors pull me aside and say, oh my God, you did a lot better than we would ever expect from someone of your background. You know, I didn't know how to take that.

I was, I was insulted because I wasn't sure what they meant about background. I remember being in high school and expressing to my guidance counselor what, you know, I wanted to do for a future profession. And she said, you sure you want to do that? That's really hard. Why not consider something else? You know, I wasn't that, I felt some, some type of way, you know, because of that. And till this day, you know, these are things that you still think about, and you wonder what was the intent of the person. But learning about something about implicit biases, it tells you that person may not have meant any harm. They may have not had any intention on causing this type of concern that's still present with me, what 20, 20 past 20 plus years later. They may not have been aware of that, but the fact that it did happen and the fact that it has such an effect on me that I still remember these things 20 something years ago, tells you the importance on a receiving end and the unconscious, the unconscious effort or implicit biases that happen.

And people have no idea about them. You know, it's like, if you're, if you're Asian, oh, you know, you must be good at math. That's one that Asians experience, or, you know, if you're, if you're, if you're a brown skinned woman, oh, you know, this whole thing about, you know, ain't the angry black woman, or if you're a brown skin male walking down the street with athletic clothes on, you know, you must be an athlete or if you have access to some type of, you know, pricey high-end car, you must be a football player or, or something else.

So those are the types of things that we mean. And so it manifests itself in things that we now recognize as microaggressions and the classic mental shortcut pictures of, you know, kind of, kind of, creating these images in our mind stereotyping.

Host: Such stereotypes as you just described, of course, are going very insulting even years later, as you said. How about someone's life could be on the line or at very least their immediate health, what would be an example of implicit bias, affecting a patient that is under someone's care?

Dr. Ducatel: This is a great, great, great question. And so an example be reported in that study, well let me go back. There's another study, a famous study that occurred where it, it, it was, it was Assessing Racial Bias in Pain Assessment and Treatment Recommendations and False Beliefs About Biological Differences Between Blacks and Whites.

That was the name of the study. Essentially what they were looking for is they were looking to see what were people's attitudes and opinions about a biological difference and how that relates to pain managment. And I'll give you an example of some of the things that they'd looked at. So that they asked these doctors, doctors in training, particularly one was, do blacks age more slowly than whites and many said yes.

Does do blacks' nerve endings, are they less sensitive than whites? And many said yes. One question was, do whites have larger brains? And there were many people who believe that. Do whites have a better sense of hearing compared to blacks? There are many people who believe that. Do blacks, are blacks' skin thicker than whites, many people believe that.

And so of, these are examples of the types of beliefs that physicians themselves, things that physicians themselves believe and most of these beliefs and understanding some of which have been taught in medical school and perhaps continue to be taught in medical school have their etiology in the medicine of the Antebellum Period of American society. So we're talking, you know, the, the, the 17th, the 18th century and the 19th century, this is where the, this comes from, but it's still very much present with us today to taking the shape of perspectives that are held by younger physicians, in this case, in this study in training. Now none of these questions are actually true in biological sense, but because these physicians believe such things, it changed, at least in this study, the way they manage people's pain. And so there's this common myth that brown skin folks, you know, don't feel pain the same way.

And so we've seen study after study it be documented that if you're, if you're brown skin and you go, you know, you need pain management, your pain, you're less likely to be managed appropriately than someone who does not look like you. Kidney disease is another one where because of your skin color, it's perceived that your kidneys are, you know, work better or filter your blood better, then people with pale skin.

And therefore, even though the, the, you know, your, your, your clinical evaluation may suggest that your kidneys are really sick. Because of that, you put it you're you're, you're, you're assumed to be in this group that, ends with the conclusion that your kidneys work better and therefore you won't be referred to a more advanced type of kidney care.

And so what happens, we will catch your kidney disease at a later state when there's very little options than perhaps we could have offered you if we would have made the same type of assumptions that we would, if you were considered called white or, or with lighter skin. So we see these things happen in medicine all the time.

And it's just not in a clinical sense. Studies have also been done to show that even in selecting, who's going to become doctors, there's implicit biases at play. Even when selecting, who's going to be physician leaders. There's implicit biases at play. We find one study where residents were way more comfortable with selecting men than they were women for leaders among themselves when it to, to their training. So these are examples, I think that you're asking for.

Host: So scary information there to say the least. In summation, Doctor, what is the main tip in a nutshell, you'd give our listeners for recognizing and managing or addressing implicit bias. If they see it experience.

Dr. Ducatel: Well, implicit bias isn't something that one would readily see because the whole concept of it is it's a bias that you're unconscious of. So we're talking about that you will not be able to recognize yourself. And the only way to come to terms with this is to really seek out tools that can evaluate you from uh, a very objective way.

And there are tools out there. The most famous tool is the Implicit Association Test. Also known as the IAT. And this test was also developed by Dr. Greenwald, who's one of the two authors of the original implicit bias study and that coined the term implicit bias. And this is available out there.

All you have to do is, you know, search the web for the implicit association test. And once you come up and find the link, the actual link it's implicit.harvard.edu/implicit/selectattest.HTML. But once you go there, you can take an implicit association test. And there are all different types.

There's one for skin tone, gender, race, age, et cetera, disability. And you can take the test and you can be made aware of the potential implicit biases that you may or may not have. And we find that once you're aware of it, then the question is, okay, I have these implicit biases. What do I do about them?

There's been some research to suggest that there are some things that you can do. And I'll go through a few of them. Number one, you can replace, try to understand the stereotypes you may hold. Again stereotypes being those mental pictures you get when you think about a person you know, replacing those types of stereotypes with non stereotype of responses.

So an example of that may be you know, Asians are are better at math. Well actually saying an individual who's studied math most likely will be good at math. You know, doing a mental type of exercises that forces your brain to think that way. The second one would be visualizing images that counter the stereotypical image.

So if the stereotype is that wealthy black men are athletes and rappers, countering that with perhaps, you know, image of Barack Obama. Quote unquote, a black male, but, and by some measures definitely wealthy, but is neither a professional athlete nor a rapper. So images that counter the stereotypes that you may hold.

And then the third is evaluating individuals by individuals of a group by their own attributes in lieu of the stereotypical viewed attribute. So taking each person as a person, recognizing that they're their own person, they have their own qualities about them, their own characteristics, and using that to make your judgments and inform your opinions and trying to do that purposely for every single person.

the other would be taken perspective of a person of stereotyped group. So, if you are a male and you know, there's the stereotype that women can't do various screening with physical things. Immersing yourself in a group of women where you understand their perspective on that same activity, engaging. The other one would be engaging with people outside the groups of people that you're most familiar with. So that would be, if you are quote unquote, not an ethic minority, then immersing yourself around people who are and getting to know them on an individual level. And so all these all these things have been found to help people rely less on implicit biases because the research suggests that we rely more on these unconscious biases when we are, insituations where we have very little time to make a decision. We suffer from fatigue or lack of sleep. We have a lack of relationship with the person who we're, who we're interacting with. And we have to depend on more recalling you know, things than, than not, and we have to perform in front of an audience. Those are all things that doctors have to do every single day.

So we are really ripe for, depending on our implicit biases, when we're encountering patients.

Host: Well folks we trust you now have a better understanding of implicit minority medical bias for better patient Dr. Watson Ducatel, much to think about going for there. Thanks so much again,

Dr. Ducatel: My pleasure. Thank you for having me.

Host: Same here. And Dr. Ducatel will be lecturing on this important topic during ACOI's 2022 virtual subspecialty focused meeting scheduled for May 12th through 14th. Additional information available at acoi.org. We look forward to future podcasts where we will continue exploring issues of importance to you.

For additional information, please contact the ACOI directly at 1-800-327-5183. You can also email at This email address is being protected from spambots. You need JavaScript enabled to view it.. And you can also follow the ACOI on Facebook, LinkedIn, and Twitter. If you found this podcast helpful, please do share it on your social media. And thanks for listening to Docs Off the Clock, a podcast sponsored by the American College of Osteopathic Internists. Hoping your health is good health. I'm Joey Wahler.