Explicit & implicit bias, equity, barriers to quality health care, and other disparities continue to impact the quality and access to healthcare for millions of Americans. Regardless of politics and the insidious distortions associated with the term “political correctness,” a plain fact remains. People are treated differently based on their immutable physical characteristics in their access to basic and critical medical care.
The State of California has embarked upon a new strategy to acknowledge, address, and minimize the existent barriers to welcoming health care.
SB 464: The California Dignity in Pregnancy and Childbirth Act
Signed into law on October 28, 2019, SB 464, the California Dignity in Pregnancy and Childbirth Act, “aims to fill in the gaps in clinician and provider knowledge and training on implicit bias, as well as improve data collection to improve equity,” according to the January 15, 2020 edition of Health Affairs.
The SB 464 bill is aimed at reducing maternal mortality among Black women in the United States, a population with a disproportionately high maternal mortality rate. The new law requires all health care providers to provide bias training and improve data collection processes to better understand the causes behind pregnancy-related deaths.
Currently, the U.S. has the highest amount of pregnancy-related deaths in the developed world. Black women compromise a large portion of those casualties, presenting a mortality risk three to four times that of White women. California has the lowest maternal mortality rate of all U.S. states, according to the California Legislature.
As Health Affairs reported:
“This policy arrives at a time when systematized discrimination against black patients has even been documented within an algorithm used to manage care for about 200 million people across the country. While a host of factors contribute to these health disparities research consistently recognizes the persistent role of implicit bias toward women of color and under-resourced communities. Unrecognized implicit bias leads to consequences that may be mediated by our ability to consciously recognize them in the health care setting…
… Medical school represents a pivotal opportunity to learn the concepts of implicit biases, their occurrence in health care, their impact on patients, and strategies to mitigate their impact on health.”
Bias describes an attitude that projects favorable or unfavorable dispositions toward people (Source: Banaji, M. R., & Greenwald, A. G. (2013). Blindspot: Hidden biases of good people. Delacorte Press). Explicit bias refers to attitudes and beliefs that we know we have and report. Implicit bias refers to attitudes and beliefs that are not readily apparent to the individual, more automatic, unconscious, and hidden than we are unaware. As is often underappreciated, biases are common. All human beings have bias. Most biases are inconsistent with our stated, known beliefs. Biases are also not immutable. They can change over time.
The Effect of Bias in Health Care Settings
It is well-documented that implicit and explicit bias negatively affects the quality and availability of health care, raising serious risks to patient safety and well-being.
According to Health Affairs:
“Studies consistently recognize the role of implicit bias in worsening health outcomes, increasing health care costs, and exacerbating health disparities, not just in maternal health but also for a variety of other health outcomes and populations, such as substandard pain management for black patients, unequal cardiovascular testing for women, lesser mental health services for patients with mental illness, and mistreatment and avoidance of obese patients.
Populations most vulnerable to implicit bias in health care include racial and ethnic minorities, lesbians, gays, bisexual, transgender, and queer (LGBTQ) individuals, children, women, individuals who are overweight or disabled, and those experiencing behavioral health issues.”
Health Affairs reported that medical schools and medical students are a target for newly mandated bias training, emphasizing the importance of “… students learning about implicit or unconscious bias early in their training as part of their professional development: “
Studies reveal significant biases among medical students toward overweight or obese individuals, LGBTQ individuals, and false beliefs regarding biological differences between blacks and whites as it relates to pain tolerance.
These biases have resulted in inferior and inappropriate treatment recommendations, worse outcomes, and reduced trust and communication with patients. If students are not encouraged to acknowledge, examine, and learn how to mitigate their implicit biases, these false assumptions become integrated in their understanding and actions as they prepare to practice medicine…
[Having] explicit curricula that push students to acknowledge; examine; critically assess; and lessen personal, interpersonal, and systemic implicit biases as a foundational aspect of their medical education and professional responsibility is critical.
All medical schools must document how students learn to ‘recognize and appropriately address gender and cultural biases in themselves, in others, and in the health care delivery process.’
These standards link directly to the Association of American Medical Colleges’ Tools for Assessing Cultural Competence Training. Schools of medicine are also required to demonstrate how students learn to recognize the impact of health care disparities and potential solutions among medically underserved populations.”
I agree with Health Affairs that the California Dignity in Pregnancy and Childbirth Act “takes encouraging steps toward eliminating implicit bias… and closing the gap in racial disparities.”
As with any new law or policy, the proof is in the implementation and details. However, a concerted, informed effort at bias education in medical school will have significant benefits for physicians and medical students in their careers, as I know from Georgetown Medical School.
As Health Affairs concluded:
“Policy changes are important tools in improving health disparities but are often reactive to a particular issue. Including implicit bias curricula in medical education is a crucial proactive opportunity in developing future physicians that can improve and contribute to a more equitable health care system. Implicit bias training must be a continuous process across the professional continuum, from medical school into ongoing practice, and one that is responsive to the evolving evidence in the area. Implementing early implicit bias curricula in medical school is well-received by students and is a promising approach toward training the physicians we need.”