The AAPA Health Disparities Work Group encourages a more comprehensive understanding of health equity problems using a “4D” framework that focuses on (1) access to care, (2) systems quality, (3) provider attitudes and cultural competency and (4) social determinants of health, as well as the need to integrate all four components to close gaps in care.
Provider attitudes and cultural competency is perhaps the most important dimension to address in breaking the stranglehold that health inequity holds on the health of our nation. To better understand the important role provider attitudes play, let’s look at the impact of implicit bias and unconscious stereotyping on provider decision-making.
Data has shown time and time again that unconscious bias is pervasive among clinicians, and that this can predict decision-making. Our colleagues in the social psychology field have done an enormous amount of research in this area, and there appears to be a growing consensus about this thorny topic.
Few PAs, NPS or MDs have explicit bias against any group. We don’t become PAs because we want to discriminate. We come into this field because we want to provide the very best care we can to all patients. But data suggests that even with the most noble of intentions, our unconscious biases persist and are simply reflective of human behavior.
Harboring implicit bias does not mean we are racist or homophobic, or any of that. It simply means that PAs, NPs and MDs are human beings. Human beings act in predictable ways, and one of those ways is to form unconscious biases about groups that can predict how we behave in relation to those groups.
Data looking at provider decision making in regard to pain management shows time and time again that black patients are not treated equally. Recent data even suggest this is true in our decision making about pediatric pain management. It’s not pretty, but it happens.
When a black patient receives less pain medication than a white patient with the same injury in the same ED seen by the same providers, this is clearly not an access issue, nor is it a systems quality issue. Even with excellent access and infrastructure, when a provider’s implicit bias goes unchecked patients suffer.
However, research on unconscious bias also indicates that just hearing about this issue, thinking about it and examining our own practice can decrease the likelihood of implicit bias influencing our decision-making process. The biases are still there, running silently under all or our conscious decision making, but by acknowledging them, we rely on them less and our patients receive better care.
If you have read this far, you are probably already benefitting from an inoculatory effect, and so are your patients! To put it another way, we can’t “fix” the unconscious process, but we can help make sure our patients don’t pay a steep price for our unconscious processes.
For more information about implicit and unconscious bias, check out the Implicit Association Test from Harvard. Take one of the quick tests, look at the feedback, and ponder the meaning of it all. If you do that, you are already on the way to providing more equal care to your patients.
Another resource for this issue is the “End It” project from the AAPA’s Special Interest Group Physician Assistants for Health Equity. Let me know what you think of it, and feel free to contact me for more resources at email@example.com. In my next blog, I’ll explore the fourth dimension of health disparities — social determinants of health.
Jim Anderson, MPAS, PA-C, ATC, is chair of the American Academy of Physician Assistants Health Disparities Work Group, founder of Physician Assistants for Health Equity and faculty of the Department of Anesthesia and Pain Medicine at the University of Washington School of Medicine in Seattle.