Impacted Care

Nov impact

Physician biases can have devasting consequences for a patient's care. 

In the article “Forty Years Since ‘Taking Care of the Hateful Patient,” the authors discuss a patient referred to as Old George, a 45-year-old alcoholic whose frequent visits over the course of six years were a source of frustration to a hospital emergency staff. During the last week of Old George’s life, he was seen nearly every day, with issues ranging from multiple lacerations to a fractured arm to merely needing to “sleep it off” in the back room. Finally, on Friday of that week, he was admitted with “wildly bleeding esophageal varices,” which claimed his life.

 Once George was pronounced dead, a health care team member uttered, “Thank God,” and another added, “Amen.” The authors point to George’s experience as an example of how care is often focused solely on the episodic management of acute problems. Further, Old George is treated as an object of ridicule rather than a human being who has just lost his life. “No one evinces an awareness of the life Old George leads outside the hospital or the possibility that a better understanding of the man might open up opportunities to make a bigger difference in his life and health.”1 In short, these physicians may have believed Old George was at fault for his problems. This bias may have resulted in a stunted level of care.

Patients at Fault

Although the story of Old George may seem extreme, biases (whether conscious or unconscious) against patients do exist in the health care spectrum, and they can have devastating consequences for a patient’s health. Biases are everywhere, and we all have them. Having a bias does not make a person evil or uncaring, says Richard B. Gunderman, MD, PhD, FACR, vice chair of the department of radiology at Indiana University in Indianapolis. Often, these assumptions are driven by societal stereotypes and therefore occur without a physician’s realization.2

Other examples of bias in health care include an article surveying attitudes about lung cancer patients compared to breast cancer patients across the health care spectrum. The survey found greater levels of stigma and shame associated with lung cancer, due to the idea that these patients had caused their disease by smoking.3 Obese patients may also be seen as lazy or noncompliant; a number of obese women have reported inappropriate remarks from their providers, leading them to avoid seeking care. Patients who do not speak or understand English well may be seen as unintelligent at first glance.2

“Try to think of the patient like you would a family member.”
— Richard B. Gunderman, MD, PhD, FACR

Problematic Effects

How do physician biases affect their patients? M. Elizabeth Oates, MD, FACR, chair of the department of radiology and chief of the division of nuclear medicine and molecular imaging at the University of Kentucky College of Medicine in Lexington, remarks that patients who are viewed as non-compliant, whether because they do not keep up with recommended therapies or other reasons, might be unconsciously punished because they are perceived as making the health care worker’s job harder. Gunderman adds that biases may affect the patient-physician relationship, due to the health care provider being less emotionally invested in the patient. Physicians may not go the extra mile to ensure patients receive the right care at the right time due to their feelings about the patient.

Other disparities in a patient’s care may also occur. For example, LGBT patients who feel they are being discriminated against may fail to seek care, believing their needs will not be adequately addressed or because they are afraid of discrimination.2 Lung cancer patients may also fail to seek care because they feel they deserve their fate.3 Biases can also factor into differences in treatment. For example, studies have shown pain management differs in patients of color and women compared to white male patients. Minority patients may receive less pain medication.2

Katarzyna J. Macura, MD, FACR, chair of the ACR Commission on Women and Diversity, remarks that in her career, she has seen physicians fail to complete full body examinations for obese patients because they immediately assume the patient’s size made the examination impossible. “They needed to make an attempt,” she notes. “Even had they failed to complete it, an incomplete exam could still have yielded information that would have been valuable to the diagnosis.”

“Taking the extra minute to ensure you are communicating well may make all the difference in the way a patient views the situation.”

— M. Elizabeth Oates, MD, FACR

Areas for Improvement

“We all have biases, whether we like it or not,” says Gunderman. “The key is to become aware of them and take them into account.” How can radiologists do that? Gunderman, Oates, and Macura all stress taking a step back and practicing empathy. “We need to remember the patient is the one who has the health issue,” says Oates. Macura adds, “Try to think of the patient like you would a family member. Try to imagine the care that you would like that family member to be receiving.”

Gunderman also recommends personally assessing yourself for biases that may have occurred in the past. “Can you look back and think of any time you made an assumption that was proved wrong?” he says. “That may have been because of bias.” Once you’re aware of your potential biases, you may be able to counteract them. Online tests to highlight unconscious bias also exist, such as Harvard University’s Project Implicit . Practices can also examine feedback from patients to assess where certain biases may lie. Are there certain ethnic groups or patients who are reporting problems?

As practices address potential biases, Macura stresses training and awareness. She points to a variety of courses and online training tools available to practices. However, she stresses the importance of treating the issue of bias as a practice-wide improvement initiative, rather than calling out certain individuals for biases they may hold.

Effective Communication

Bias can also crop up in radiology reports. For example, Oates says, “One of the common situations we can avoid involves an obese patient. We tend to refer to ‘body habitus’ in reports to qualify the quality of the examination and the limitations imposed on it by obesity. Some radiologists will state ‘limited by large body habitus’ while others simply state ‘body habitus,’ with the implication that the body size is large although not stated.” Other examples include uncooperative patients. Oates advises using “unable to cooperate with imaging” as opposed to “did not cooperate” or “unwilling to cooperate” because the latter two imply blame.

Body language and communication styles may also affect a situation and reflect bias. “It may be a physician feels rushed in their workload or is even unaware that they are being perceived as unfriendly,” Oates says. “But taking the extra minute to ensure you are communicating well may make all the difference in the way a patient views the situation.” She advises taking the time to ensure patients have understood information and avoiding intimidating language. Although recognizing and combating bias may be difficult, it’s a critically important issue. “We’re all subject to bias,” says Oates. “It’s all too easy to like some patients and to dislike others. Yet we need to be objective. A patient’s life could depend on it.”


 By Meghan Edwards, freelance writer, ACR Press

ENDNOTES
1. Gunderman RB, Gunderman PR. Forty years since “Taking Care of the Hateful Patient.” AMA J Ethics. 2017;19(4):369–373. Accessed July 15, 2017Hateful Patient.” AMA J Ethics. 2017;19(4):369–373. Accessed July 15, 2017
2. Unconscious bias: impact on patients. An online continuing education activity. Pfiedler Enterprises. 2015. Accessed July 30, 2017.  activity. Pfiedler Enterprises. 2015. Accessed July 30, 2017.  
3. Sriram N, Mills J, Land E, et al. Attitudes and stereotypes of lung cancer versus breast cancer. PLOS One. 2015;10(12). Doi: 1371/journal.pone.0145715.

 

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