When it comes to bias, doctors need to do their homework [PODCAST]

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“I have no doubt, given my extensive experience in health care and being a Black woman in America, that we as health care professionals have made the same mistakes as Chris Harrison with our patients. Instead of listening to and validating our patients’ concerns, we make excuses for ourselves or the people who have caused the injustice that our patients are experiencing. Effectively we delegitimize or invalidate their concerns, and we exacerbate their pain due to the experience. In some ways, our role as clinicians, combined with the reason for them seeking health care, magnifies and even eclipses the pain from the original experience causing an even more damaging effect. Whether or not we believe their experience is real or perceived is irrelevant. We are no authority to know the difference, and when a patient is in our care, it is our responsibility to place their needs first.

As health care professionals, we should strive to validate our patients’ feelings and offer comfort whether or not we agree about the etiology. Resist the urge to justify or defend the perceived abusers. I believe that this could potentially improve our relationship with our patients and improve their care and, as a bonus, make us more empathetic to the other people in our lives.”

Monique Rainford is an obstetrician-gynecologist.

She shares her story and discusses her KevinMD article, “When it comes to bias, doctors need to do their homework.”

This episode is sponsored by Tradeoffs, available on your favorite podcast platform.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Monique Rainford. She is an obstetrician-gynecologist, and she wrote the KevinMD article “When it comes to bias, doctors need to do their homework.” Welcome to the show.

Monique Rainford: Thanks for having me here, Kevin. Very nice to be here. Yeah, I wrote that article, and really what it’s about is causing us as doctors to examine our own implicit bias. The key is that implicit bias, we’re unaware of it, and we can’t access it through the conscious mind. So we could be very well-meaning and think we have no implicit biases, no biases, but we could be wrong. Sometimes that’s more dangerous, because if we think we have no biases, and we think we have no implicit biases and no hidden biases, and we act as if we don’t, but we really do have them, it really has been shown that we give worse care to, frankly, Black people because of these biases. Without trying to do the work to get to understand these biases better, that will continue.

Kevin Pho: Now, give us an example or a case study of implicit bias in health care settings that physicians, of course, may not be aware of.

Monique Rainford: So they did a study a few years back, and they looked at the treatment of acute coronary disease with thrombolytic therapy. They found that Black patients did not receive the same level of care, or the correct care, as white patients. What is interesting is that was one study, but last year, in 2020, this study came out in Florida. It was kind of controversial, because there was a lot of controversy when it came out, and it talked about the fact that if Black babies are cared for by a Black physician, their mortality rate is significantly better than if they are cared for by a white physician.

When you look at this, who would really discriminate? Which doctor would really discriminate, knowingly discriminate, on the care of a baby? I don’t think any doctor will. So to me, one of the explanations for something like this is implicit bias. If we’re given less care because of biases that we’re not aware of, it can impact the care and survival of people, babies right through to adulthood, and that’s obviously very dangerous.

When you look at this study, it’s not to say that somebody has to be cared for by a person of their race. The key thing is to make sure that we examine our biases, we do the work to find out if we have implicit bias, and we work to improve or eliminate those biases in how we take care of patients.

Kevin Pho: So when you say that we have to put in the work to see whether we have any implicit biases, what exactly can clinicians do?

Monique Rainford: So Harvard has an Implicit Association Test, and that’s a start. You could do that test. I don’t know the website by heart, but you could certainly Google it, and you could do that test and find out what kind of biases you have, like whether you’re, you know, pro-white or pro-Black biased, for example, when we talk about race. Then after you do that, you can do some research about how you can improve how you take care of patients, knowing whether you actually do have a bias or that bias exists.

Now, it’s a little controversial in some ways, because there’s a lot of funding and a lot of energy going into implicit bias training, and there’s some research that suggests it may not work. That being said, a few years back, there was a study that did some implicit bias training that was only 45 minutes, and when they examined it a few weeks later, they realized that the training works for people who care about their biases and want to do something about it. So I believe that any physician who really cares about examining if they have implicit bias and wants to do something about this implicit bias can do the work, and they can make a difference in how they take care of all of their patients.

Kevin Pho: So when you go for training to fight implicit biases, what are some typical things that they do? I’m just trying to imagine a typical primary care setting. I’m a primary care internal medicine doctor. What are some things that I can do to check to see whether I have any implicit biases, and any techniques that I can use to stop it if I do?

Monique Rainford: Well, these are not certified techniques, but I can tell you some practices that I found helpful in my personal practice, which is how I view the patient, different ways I view the patient. One way, like when I teach or share with medical students or staff, I might say, “Give the patient the kind of care that you would want your loved one to get, someone you love.” In different settings, when I was more in an FQHC setting and I was talking to the general staff, I said, “Treat every patient like they’re a VIP,” because sometimes it’s just not about race.

It’s about accents, it’s about culture, it’s about religion, it’s about dress. So this bias, implicit bias, can even come into the care of all kinds of patients we take care of. If we pay attention to how we’re treating the patients or how we’re viewing the patients, and instead of putting on the normal lens, we put on a lens of, “OK, I want this person to get the kind of care that I would want somebody who’s very close to me to get,” I think that could be helpful in how we care for patients.

Kevin Pho: As you well know, the concept of implicit bias is heavily politicized in areas, of course, outside of health care. Now, whenever you talk about implicit biases in the health care setting, do you encounter any pushback against that concept?

Monique Rainford: It depends where you are. In the setting where I am now, no. I do think that where I am, it is embraced. I think they’re actively trying to do a better job. But in real life, you know, it exists. The way I see it, or the way I’ve seen it throughout my life, is that you might say something to someone who may not get it, may not get that these biases exist, and then they say, “No, no, it’s not that. No, you’re reading it wrong. No, you’re misinterpreting it.”

So, for example, if a Black patient comes to, say, a non-Black doctor, or any doctor for that matter, and they say, “You know, I feel I was treated that way because of my race,” and the doctor tries to defend it or tell them, “No, it’s not because of it,” that alone is dismissive and actually painful, because their doctor is telling them that their perceptions aren’t valid, that their perceptions aren’t important. This is not to say whether the perception is, quote unquote, correct or not, but who determines whether it’s correct is the patient’s perception. You don’t have to agree with the perception, but just give them some validation. You know, most people want validation. If you try to excuse it or dismiss it, the patient, I believe, will feel doubly assaulted. They have the assault of the action that happened, and they feel doubly assaulted.

Then, when you read a lot about what patients complain about, Black women, since I do a lot of work in health disparities and reading in health disparities, a lot of them say, “I feel like they weren’t heard. I feel like they weren’t heard.” So what does that mean? When you say something to your physician, is it that they did dismiss you? That they said, “No, you don’t know what you’re talking about”? They may not say it to us bluntly, but if they don’t respond and acknowledge what you’re saying, and acknowledge understanding, and give some validation to what you’re saying, then they’ll feel like they’re dismissed.

So I think we really have to pay attention to how we’re responding to our patients, what kind of validation we’re giving them. This is not to say we agree with them, but just validating that we value their concerns, we value where they’re coming from, and really, I believe, expressing some empathy in how we do that, and then moving on to try to take care of them. I think they will feel you’re more of an ally than an adversary.

I’ve actually seen that more in my practice when, for example, somebody doesn’t want to get the vaccine. That’s very controversial. I hear their story, and somebody said recently, “I don’t want to get sick.” I said, “You know, I really understand,” because what’s true for me is I was concerned about getting sick from the vaccine itself. I was not so concerned as not to take it, but I was really concerned about the side effects. But I explained from my situation: I recognized, due to a personal situation where I had an exposure, someone in my home was exposed, I realized that the fear of getting the virus was way more than any fear I had of getting sick from getting the vaccine. Clearly, all the literature supports getting the vaccine, but I do believe that I saw a bit of a change in my patient when I shared that story. It is shown, they’ve done research to show that sharing stories is very effective in how we approach our patients, in trying to be empathetic and help them to see that you hear where they’re coming from, you respect their views.

Kevin Pho: We’re talking to Monique Rainford. She’s an obstetrician-gynecologist, and she wrote the KevinMD article “When it comes to bias, doctors need to do their homework.” Monique, I didn’t get a chance to ask you this earlier, but please share your story and journey to where you are today, and talk a little bit about the work that you’ve done with health disparities.

Monique Rainford: So my journey: I knew I wanted to be a doctor from about age seven. Then, when I was in my early high school years, I thought, “No, I’ll do something else,” you know, all these career choices. Then I got back to medicine, frankly, because of a loss of someone very important to me, my favorite teacher and principal. So I thought I was going to be a pediatrician, actually, or I thought about pediatric cardiology. I thought about all these other different careers. Then, when I assisted on a private delivery with the chairman of the department where I was at medical school, at the program I was at, that had a really big impact on me, and I went into OB/GYN. I’ve been doing that for more than 20 years.

But over the past five years in particular, since about 2016, I guess more than five years, I began reading and discovering much more about health disparities for African American women and other Black women. It’s actually something I noticed long before, in medical school, based on a slide I saw in a presentation, but I didn’t really get it. I didn’t understand. Every time I asked questions early in my career and training, I heard, “Poverty, poverty.” Then, within the last few years, I saw, no, not that that can’t play a factor, but that really is not it, and I began to understand a lot of the reasons why they exist.

So right now, because I believe in the care of women, because I believe in health and wellness for women, I don’t think you can probably make all women healthy and well if you leave some women so far behind. African American women in America are really far behind in their health and wellness because of these, frankly, mostly racially based race discrimination disparities. So what can I do to help that? That’s what I’m working on now in different areas.

Kevin Pho: So go into more detail. You certainly talk about implicit biases, but from an individual clinician level, what are some of the things that we can do in the exam room to help narrow these health disparities you talk about?

Monique Rainford: I think we have to be even reviewing the care we give our patients, and making sure, when we look at the care that we’re giving our patients: Are we giving them really the same standard of care, the same level of care? Are we missing out on any details that we shouldn’t? Are we missing out on their routine preventative screening because we’re so focused on the problem? Are we reminding them of that? Are we taking the time to say things that need to be said, or are we just avoiding it because we don’t want any controversy?

I admit it’s really difficult, because right now medical visits are super short, and there’s a lot of pressure to see a lot of patients in a short time. I think organization helps. I think being really great on the EMR helps, because we do a lot of that. But I do think that if we’re in this career, medicine, if we’re still delivering patient care, we still have a responsibility to try to make sure we’re giving each and every patient the very best care that we can, regardless of their race or their circumstance.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Monique Rainford: We need to value all our patients regardless of their race, ethnicity, sex, sexual orientation, religion, etc. I think that we should try to find the good in all our patients, despite what we may believe, and, frankly, try to give our patients the same level of care that we would want somebody we really love to get.

Kevin Pho: Monique, thank you so much for sharing your time and insight, and thanks again for being on the show.

Monique Rainford: You’re very welcome. Thanks for having me.

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