Posted by: Baguiasri Mandane3 JAN 2018
A systematic review published in the BMC Medical Ethics in 2017 highlighted the need to address unconscious (implicit) bias by healthcare professionals towards patients1.
What is unconscious bias?
By Baguiasri Mandane
The Equality Act 2010, which legally protects all people from discrimination, assures that individuals’ characteristics (race and age, for example) do not affect the care they receive. Unconscious bias arises through associations outside of conscious awareness that lead to a negative evaluation of a person based on their individual characteristics1.
People do not always have conscious, intentional control over the processes of social perception, impression formation, and judgments leading to their actions2,3. Research suggests that the amygdala (considered the ‘emotional’ centre) and the prefrontal cortex are involved in unconscious bias4,5,6.
How does unconscious bias affect delivery of care?
There is evidence to suggest that clinicians have similar implicit biases to other members of society7. Disparities in healthcare provision are concerning, and there is a growing body of evidence on the negative impact of unconscious bias in the delivery of equitable healthcare7. More research is needed to understand the impact of these findings and to what degree these biases affect treatment choices and patient outcomes.
How can we minimise bias in healthcare?
Implicit bias can be minimised through the right support, skills training and cognitive resources8. Van Ryn and colleagues highlighted some skills that could facilitate this process:
- Perspective-taking: to inhibit unconscious stereotypes and prejudices, and adjust the clinician’s level of empathy;
- Emotional regulation skills: good emotional regulation skills can help to reduce bias towards patients’ individual attributes and embrace inclusivity towards various social groups;
- Partnership-building skills: healthcare professionals who build collaborative working relationships with patients are more likely to develop stronger team spirit and work towards a common goal.
Future research should consider the potential impact of unconscious bias and its significance to patients’ health outcomes9. There is also a need to raise awareness of unconscious bias in healthcare and put programmes into place to reduce it. The practice of mindfulness is one avenue for exploration to overcome these challenges.
What is mindfulness?
By Shivali Fulchand
Mindfulness is a very simple form of meditation that involves consciously bringing your attention to the present moment in a non-judgmental way10. It is an extension of reflective practice and the aim is to become more aware of one’s biases and judgements, to enable us to act with principles we truly identify with11. A typical meditation involves focusing on the breath as it flows in and out of the body, and observing the passing or pattern of thoughts.
The practice has increased in popularity over the last 20 years following the recognition that we are ever-distracted, with busier schedules and tighter deadlines. Mindfulness is now also a recommended treatment for depression; mindfulness-based cognitive therapy was suggested by the National Institute for Health and Care Excellence “for people who are currently well but have experienced three or more episodes of depression” to prevent relapse, without the side effects12. Since the 1990s, researchers in the United States have published extensively on mindful medical practice, and the results have been very encouraging. Healthcare professionals are well-known to suffer from compassion fatigue and burnout, and mindfulness seems to be an effective panacea13.
How can mindfulness reduce unconscious bias?
Unconscious bias harms both patients and staff. The incidence of medical errors is also shown to be increased by unconscious bias14. An estimated £2.5bn is spent annually in the UK on medication errors, so it is crucial that new techniques are explored to support staff in reducing these events15. The evidence backing mindfulness is gaining momentum, and new publications on its benefits are released continually16. A study by Lueke and Gibson looked specifically at mindfulness and implicit bias; they found a reduction in implicit age and race bias following just one 10-minute guided mindfulness audiotape17.
Mindfulness-based practice is increasingly being implemented in healthcare in the UK, although it is still in its infancy. The first ‘Mindfulness in Health and Higher Education’ conference was held in 2016 at the University of Leicester, and since then, first-year students at the medical school have also received mindfulness training18. Providers such as Breathworks also offer mindfulness training and teacher training to several hospitals across the UK.
With the growing popularity and evidence to support practising mindfulness, we should explore its use in managing unconscious bias. Our aim as healthcare professionals is to improve the care of our patients without internal bias, so perhaps we should ask ourselves: why do we not practice mindfulness?
- FitzGerald C and Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Medical Ethics 2017;18:19. doi: 10.1186/s12910-017-0179-8
- Greenwald A and Krieger L. Implicit bias: scientific foundations. California Law Review 2006;94(4):945–67. doi: 10.15779/Z38GH7F
- Powell B. Unconscious bias: 7 Top tips. Health Education England. Available from: https://www.hee.nhs.uk/hee-your-area/yorkshire-humber/news-events/yorkshire-humber-news/unconscious-bias-7-top-tips (accessed December 2017)
- Luskin B. MRIs reveal unconscious bias in the brain. Psychology Today. Available from: https://www.psychologytoday.com/blog/the-media-psychology-effect/201604/mris-reveal-unconscious-bias-in-the-brain (accessed December 2017)
- Amodio D. The neuroscience of prejudice and stereotyping. Nature Reviews Neuroscience 2014;15:670–682. doi: 10.1038/nrn3800
- Burgess D, Beach M and Saha, S. Mindfulness practice: a promising approach to reducing the effects of clinician implicit bias on patients. Patient Educ Couns 2017;100(2): 372–76. doi: 10.1016/j.pec.2016.09.005
- Blair I, Steiner J, Havranek E. Unconscious (implicit) bias and health disparities: where do we go from here? Perm J 2011;15(2):71–78. PMCID: PMC3140753
- The Joint Commission and Division of Health Care Improvement. Quick Safety: Implicit bias in health care. 2016;23:1–4. Available at: https://www.jointcommission.org/assets/1/23/Quick_Safety_Issue_23_Apr_2016.pdf (accessed December 2017)
- Moore A. Tracking down Martin Luther King, Jr.’s words on health care. Huff Post: The Blog. 2013. Available at: https://www.huffingtonpost.com/amanda-moore/martin-luther-king-health-care_b_2506393.html (accessed December 2017)
- Ludwig DS and Kabat-Zinn J. Mindfulness in medicine. JAMA 2008;300(11):1350–52. doi: 10.1001/jama.300.11.1350
- Dobkin PL and Hutchinson, TA. Teaching mindfulness in medical school: where are we now and where are we going? Med Educ 2013;47(8):768–79. doi: 10.1111/medu.12200
- National Institute for Health and Care Excellence. Depression in adults: recognition and management. Clinical guideline [CG90]. 2016. Available at: https://www.nice.org.uk/guidance/cg90/chapter/1-guidance (accessed December 2017)
- Luken M and Sammons A. Systematic review of mindfulness practice for reducing job burnout. Am J Occup Ther 2016;70(2):7002250020p1–7002250020p10. doi: 10.5014/ajot.2016.016956
- Stone J and Moskowitz GB. Non-conscious bias in clinical decision making: what can be done to reduce it. Med Educ 2011;45(8):768–776. doi: 10.1111/j.1365-2923.2011.04026.xc
- Torjesen I. Medication errors cost the NHS up to £2.5bn a year. The Pharmaceutical Journal 2014. Available at: http://www.pharmaceutical-journal.com/news-and-analysis/medication-errors-cost-the-nhs-up-to-25bn-a-year/20066893.article (accessed December 2017)
- University of California Mindful Health and Safety. Relevant research. 2014. Available at: http://sites.uci.edu/mindfulhs/relevant-research/ (accessed December 2017)
- Lueke A and Gibson B. Mindfulness meditation reduces implicit age and race bias. Soc Psychol Pers Sci 2015;6(3):284–91. doi: 10.1177/1948550614559651
- University of Leicester. Mindfulness in medicine. 2016. Available at: https://www2.le.ac.uk/offices/estates/environment/news/2016-news/mindfulness-in-medicine (accessed December 2017)