The other day, during my cursory reading of Medscape News articles (like any responsible medical student looking to stay up to date on the latest research/news in medicine and also willing to give at little a little time to topics outside of the functional and integrative medicine sphere), I came across an interesting and rather pertinent title: Medical Students: False Beliefs About Black's Biology Common. Delving into the first paragraph, I was quickly made aware that from the specific research cohort studied in the original article, "Half of (the) white medical students held at least one false belief about biological differences between black and white patients, a trend that affected both their perception of the patient's pain." The article went on further to say "The more false beliefs the students held, the more likely they were to rate a black patient as experiencing less pain than a white patient in the same scenario, and the less likely they were to make an appropriate medical recommendation." While slightly disturbed by the conclusions of the research study: it was not entirely "new news" to my ears as I have often appreciated the scope of both implicit and explicit bias in medical practice. From gender and sexual orientation to weight (obesity) and race, there is often significant implicit (or what I consider subconscious bias) as well as overt explicit bias seen in taking care of patients.
Stepping back from the article as judgment was already seeping from my skin, the natural defense mechanisms started to flood forth: "Well I'm pretty sure I'm not racist, and sure I'm a medical student, but this study doesn't really pertain to me." Just as we can be easily mislead by medical abstracts and headlines when it comes to the actual population studied (yes, not everyone falls under the demographic parameters of the Nurses' Health Study [I or II]), we need to remain vigilant when making recommendations to patients from clinical “evidence,” avoiding the recommendation, for instance, that a specific drug may be helpful for them, when in actuality, the study population from which your recommendation was made, was completely different than that of the person sitting in your office.
Staying vigilant, I continued to read on, only to see from the first commentary by the researchers of the cited study that the origins of the medical students studied was none other than the University of Virginia in Charlottesville. Just as quickly as I was already defending a position that perhaps this studied was not relevant to me, I was finding out that, indeed, I was actually one of the study participants! It is not everyday you read about a medical study and find that the recommendations or conclusions made actually involved your input, and couldn’t exactly be tossed aside like the leftover meatloaf. Having already made a joke/passing comment to my mother, before realizing I could have very likely been one of those “half of white medical students,” it became quite clear that this was indeed, a time to get back to my mindfulness roots. Sticking to the idea “I’m special” and “this research study is not really pertinent to me,” was just not going to work.
Honestly speaking, judgment and pattern recognition can be incredibly helpful for clinicians in the fast-paced setting of diagnostic medicine, however, they can also be potentially detrimental and subversively harmful when carried through in a long term, continuous care setting. When we look at how a scenario involving implicit bias (not simply subconscious racial prejudice) might play out in the everyday medical world, I’d like to present a plausible and practical (constructed) example from a hard working family medicine clinic.
After following a patient for nearly 10 years, family doctor Dr. A begins to glance over a chart prior to his next 20 minute follow-up visit, giving a look at the patient’s most recent set of labs and confirming, oh yea this is Mrs. B, a postmenopausal female, some hypothyroid issues, working on the hot flashes, has never taken any hormone replacement, doesn’t seem to be interested in cancer screening by the review here, lipids looking a little off since last visit-wonder if she’s changed her diet or gained some weight? Before Dr. A even has a chance to drop a pen from his white-coat, he is already formulating questions to ask regarding her symptoms, a potential plan to rectify the perceived disturbed blood work, and further inquire into why Mrs. B is reluctant about cancer screening tests (who doesn’t want a colonoscopy on their 50th birthday?).
While objectively speaking, there is almost nothing wrong with what Dr. A is thinking and hoping to achieve during this follow-up clinic visit, we can see that there would be at least few differences if we were to replace Dr. A with a third year medical student, just starting on his family medicine rotation and newly minted with coffee stains on a half-heartedly ironed white coat. While Dr. A is entering the encounter carrying a “weight” of past perceptions, past conversations, and judgments as to what Mrs. B may be thinking, the third year medical student is just seeing Mrs. B’s chart for the first time in his or her life (30 seconds maybe 60 tops), and is likely only carrying with him or her a stethoscope and shreds of paper meant for scribbling something illegible with regards to Mrs. B’s primary complaints. Following the brief “glancing over” of her chart, the third year medical student is aware that Mrs. B is a 64 y/o female here for a 6-month follow-up; her vital signs including blood pressure and oxygen saturations are within normal limits and the primary comment from the triage nurse states “happy to see the birth of her first grandchild last December.” Stepping into our third year medical student’s mind, we might find some thoughts that include: “I have to make sure I remember to listen to her heart with my stethoscope on bare skin,” and “I wonder what the drug reps are bringing for lunch today,” –so yes, we can all agree there are appreciable and explicit differences between the medical student and the doctor when it comes to this clinical encounter. And while one might say, given the depth of clinical experience of the family physician, that of course, the doctor is better equipped to help and treat Mrs. B, but perhaps, we shouldn’t be so quick to jump to such conclusions.
Research has shown that given proper education and tutorials on cardiac auscultation, medical students fair just the same and sometimes better (and at least no worse) when it comes to properly diagnosing heart murmurs as compared to attending/practicing physicians. While one might say, “Yeah, but you are talking about a measurable skill, and I don’t really see how this applies to the scenario with Mrs. B or even to unconscious bias for that matter” My simple response to this, reasonable statement is this, “Yes, you are right, literally speaking, there is really nothing about listening for heart murmurs that seems related to unconscious bias, and likely isn’t relevant for Mrs. B but what if we ask ourselves a slightly different question: “Who do you or did you think would be better at diagnosing heart murmurs- the third year student or the family doctor? While I cannot tell you or predict your answer, I have my suspicions that it was likely the family doctor, or at the very least, most of us would hope that to be true. I can tell you that when I was asked this very same question as a third year medical student just a few short months ago, I quickly realized my answer, discovered a previously unconscious belief/bias, and for the first time really recognized what it was exactly that I was carrying into Mrs. B’s room besides my stained white coat: “I am just a medical student, what do I really know and what can I really do when compared to an experienced practicing doctor?
Bringing this post to a close, I would encourage everyone to see the bigger implications of the research study I have just described, seeing beyond medical students’ bias and beyond medicine in general. As human beings we are blessed with the capacity to perceive and cursed by the capacity to know and seek truth. As much as we would like to believe our conscious perceptions are not truth, even when it comes to something we think is so clear: 2+2=4, we “truthfully” only have a personal perception of our present reality, just as the person next to us has his or her own perception of the present situation. Scary as this sounds, it only gets scarier when we realize how much our subconscious and unconscious minds are actually “controlling” our behavior (see Stephan Guyenet’s post on his blog: Whole Health Source: “How Much do You Know About Your Brain?” if you dare to “know” more.
So what are we left with when it appears that our subconscious/unconscious mind is really running the show, allowing all of these deep-seated unconscious biases and prejudices to affect our actions and behaviors? Sounds like a terrifying proposition, but I choose to see hope and an opportunity for everyone to grow beyond this supposed “cage” of thinking--and guess what: it all starts with just a little mindfulness. Realize the nature of the unconscious mind, realize your patterns of automatic thoughts and pattern recognition, realize you have unconscious bias that will likely not disappear, but that’s okay- we are not here to defeat the unconscious into unconsciousness because yep, you guessed it, it is already there. We can simply notice these patterns, biases and reactive thinking, all the while cultivating greater self-awareness, realizing that we all are carrying judgments and preconceptions (good or bad) into the inter-personal experiences of our daily lives. In the end, we must all accept a truth, perceived or not, that we can be certain there is uncertaintyin our beliefs, and perhaps, it is best to mindfully step through the murkiness of this uncertainty knowing that maybe it isn’t uncertainty that we should be fearing, but certainty itself.
