Practising medicine requires quick decision-making on an almost constant basis. Some of those decisions have a life-changing impact on patients - and occasional implications for us as well.
Our decisions are based on experience, training and our background. We don't all have the same experiences and we don't all come to the same decisions. This diversity should be celebrated, but it is also possible for some decisions to reflect gaps in our experience. We don't always know what we don't know, and it is these gaps that can introduce a bias to our decision making without us realising.
What is unconscious bias?
Unconscious bias is a bias, assumption or prejudice against or in favour of a group, that you are not consciously aware of. All decisions are potentially at risk of unconscious bias. Looking at the medico-legal implications of implicit biases, there is no reason to think that unconscious bias does not apply to relationships between colleagues and it may also have an impact on complaints about doctors.
Impact on decision making
Unconscious bias is also likely to apply to clinical decisions, as studies have shown doctors have similar biases to the general population1. Assumptions about a patient's understanding of symptoms, risk-taking behaviour or risk for a particular illness could mean the correct diagnosis is missed. They can also affect the treatment offered - for example, if a patient's behaviour is challenging or contributed to their presentation.
It is good practice to consider demographics where the evidence base suggests doing so, as part of a conscious, considered process based on evidence and not prejudice. Decisions influenced by unconscious bias about a group of people could be discriminatory and lead to inequity in care. That in itself is a reason to consider reducing unconscious bias - but if that discrimination is of a characteristic protected under the Equality Act 2010, then it is also unlawful, whether the doctor is aware of the bias or not.
Types of bias
A number of types of bias have been proposed, such as confirmation bias. This is where a person identifies selective evidence in support of a decision and ignores any evidence that conflicts with it, but without any conscious awareness of either step.
Research in a simulated environment2 has suggested that doctors are susceptible to confirmation bias where a diagnosis is given to them. In busy practice, this can easily happen if assumptions are made. It can be partly managed by being consistent in taking a full history and considering this in line with recognised guidelines.
Reviewing an incident
It is difficult to know for sure that an incident has arisen from unconscious bias, but after a complaint or query it may be something to consider.
For example, did you assume the parents of a child knew more than they really did about healthcare because they were well dressed, or because of their ethnicity? Did you make assumptions about a patient's sexuality because of their religion? Did you assume because of recreational drug use that a person engaged in other risk-taking behaviour?
There can be an overlap with clinical experience of likely associations between these factors, but the only way to know that an association exists is to ask the individual patient.
We are all the product of our own experiences and the gaps in that experience often indicate our potential biases. If you are seeing a patient for the first time from a background you are unfamiliar with, it is more likely for the brain to make implicit assumptions about them. Recognising this in the moment can be challenging. The evidence base for reducing unconscious bias is still in its infancy3, but there are some promising strategies.
The first step should be recognising what biases you might have. The Harvard Implicit Association Test is extensively used in research as a metric for unconscious bias. You can access this for free here.
Decisions influenced by unconscious bias about a group of people could be discriminatory and lead to inequity in care.
Training in recognising biases
Another option is to seek out training in this area. If you're aware of your blind spots, this creates the opportunity to reflect on your decisions and to ask yourself if you would make the same decision if the patient's demographics were different.
The MDU offers training in this field, and the feedback from members themselves has been both encouraging and positive. As one consultant radiologist commented after attending our course, "I am surprised it is not essential for all healthcare professionals to attend unconscious bias training."
Dr Shazad Amin, a consultant psychiatrist who also took the course, went into greater detail about what the training opened up. "By challenging assumptions we all make day to day in an unconscious way and examining different biases, we can be more mindful and approach clinical scenarios in a different way," he explained.
"Such assumptions may involve patient stereotypes, so that we may downgrade the seriousness of the presenting complaint from the patient. Or we may be undertaking a review of a serious untoward incident and knowing the serious outcome may lead us to demonstrate hindsight bias - for example, viewing colleagues as being more blameworthy by not considering what was a reasonable course of action at the time."
For more information on our range of courses, see the full list on our main website at themdu.com/learn-and-develop