A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.

“Diversity is being invited to the party. Inclusion is being asked to dance.”
– Verna Myers, diversity advocate

Fostering a culture of diversity and inclusivity in health care professional organizations is important for many reasons, and thus should be a priority. First and foremost, compelling evidence shows that increasing diversity in the health care workforce improves health care delivery, especially to underrepresented populations. Second, diversity in the U.S. population is increasing and is reflected in the patients whom we treat. Unfortunately, this diversity is not always represented by the demographic characteristics of health care professionals themselves. Last but not least, this mismatch can lead to unintended health care inequities due to cognitive and unconscious biases, which can negatively impact our understanding, actions, and decision-making. The idea that people do not have control over their own prejudices and beliefs was believed to be a radical concept when it was introduced. Academic research now proves that hidden biases do in fact influence clinicians’ perception, attitude, and actions.

Consider the following scenario, to test your own unconscious bias:

A patient presents to your emergency department after suffering gunshot wounds to their abdomen, back, and foot.

Now, envision what this patient looks like.

The patient immediately undergoes imaging, which determines the patient may be actively bleeding and require emergency surgery. A surgery resident huddles over the gurney bed, hastily attempts to get informed consent for surgery, using common medical jargon to explain the details of the procedure.

Next, envision the appearance of the surgery resident.

The patient refuses to consent to surgery. Two additional physicians attempt to convince the patient to have surgery, including a psychiatrist who deems the patient competent to make his or her own medical decisions. The patient’s family also try to convince the patient to have surgery. When the patient continues to refuse, arguing, “I ain’t letting y’all stab and cut me up,” the surgery team gives up and sends the patient to the intensive care unit (ICU) instead.

What do you guess is the education level or socioeconomic status of the patient?

Finally, one member of the patient’s health care team goes alone into their ICU room, pulls up a chair, sits down at eye level with the patient, and calmly explains in simple terms, “Do you want to eat again? Well, the only way that may happen is if you allow the surgeon to put back together your broken up belly.” The patient finally agrees to proceed with emergency surgery.

Imagine the demographics and characteristics of the health care team member who convinced him to have emergency surgery.

Now re-read the scenario, noting each person’s lack of descriptive characteristics, including their gender, race, culture, religion, and socioeconomic status. Yet, despite this, you were able to clearly envision each person in the story, correct? 

In this case, the surgery residents likely offered surgery intending for the patient to have a good outcome, but failed to garner the patient’s trust, reach the patient’s level of understanding, and connect in a meaningful way to achieve results. Understanding the behavior, thoughts, and tendencies of others, free of judgment or bias, especially in critical situations, ultimately can mean the life and death of a patient.

Does a person’s appearance or education level factor into critical health care decisions? Universally, I think most would argue that a patient’s race, gender, ethnicity, sexual orientation, and personal preferences should not matter in their treatment decisions. But what if these factors contribute to their lack of trust or understanding in the health care system? The ability to recognize these hidden biases can help us be more intentional in our interactions with patients and may increase the likelihood that our practice and communication with patients align with favorable outcomes.

Cultural stereotypes, stigmas, and prejudice may influence the way information about an individual is perceived, leading to unintended biases and disparities that have real consequences in patient-clinician interactions. Interestingly, many of these biases may be unintentional. The ability to rapidly categorize every person we encounter is thought to be an evolutionary development to ensure survival; early ancestors needed to decide quickly whether a person, animal, or situation encountered was likely to be friendly or dangerous. When dealing with patients, however, these tendencies may lead to more harm than good.

Evolution has wired our brains with unconscious bias so that we may identify with others, culturally, socially, professionally, or recreationally. Naturally, we are drawn to similarly minded individuals – those we can connect or relate to, with similar interests and backgrounds. But unconscious bias can also be harmful in certain situations, such as in recruitment and selection committees for hiring, promotion, and leadership opportunities. Even though you may not be aware of it, unconscious bias may draw you preferentially towards one candidate over another. It’s also going to factor into decisions on whether you believe a person is deserving of hire, advancement, or promotion. Such opportunities given to a person reflect their value. Thus, it is especially crucial for organizations to get this right.

Increasing diversity in the health care workforce strengthens our ability to care for a culturally sensitive and diverse patient population. In order for organizations to succeed in diversifying, they need to recognize and overcome their own unconscious bias. Efforts should be made to select the best candidates and the best interviewers for those candidates. One way to achieve this goal is by intentionally diversifying the panel of interviewers who will be responsible for the recruitment and selection of candidates during the hiring process. The panel should be comprised of varying backgrounds of people that represent the demographics of the entire organization – this exemplifies an organizational culture of diversity, one which prioritizes inclusivity, and aims to ensure a fair and equitable selection of candidates from diverse backgrounds. An organization should acknowledge the existence of unconscious bias by building recruitment strategies to mitigate potential unknown disparities in order to welcome diverse perspectives.

Unconscious bias in health care describes associations or attitudes that reflexively alter our perceptions, thereby unintentionally affecting behavior, interactions, and decision-making. Health care organizations need to be actively discussing this subject at the highest level to find gaps and learn where to dedicate resources for improvement, even if it means confronting awkward topics and having uncomfortable conversations. The time has come for organizations to be deliberate in their efforts to improve diversity in their workforce and active in their outreach to improve inclusivity. The problem does not improve if we choose to ignore it, or worse, deny it.

Brooke Trainer is an anesthesiologist.

Founded in 1905, the American Society of Anesthesiologists (ASA) is an educational, research, and scientific society with more than 60,000 members organized to advance the medical practice of anesthesiology and secure its future. ASA is committed to ensuring anesthesiologists evaluate and supervise the medical care of all patients before, during, and after surgery. ASA members also lead the care of critically ill patients in intensive care units, as well as treat pain in both acute and chronic settings.

For more information on the field of anesthesiology, visit ASA online at asahq.org. To learn more about how anesthesiologists help ensure patient safety, visit asahq.org/madeforthismoment. ASA publishes Anesthesiology, Anesthesiology Open, and ASA Monitor, and stays connected with members and the public on Facebook, X, Instagram, Bluesky, and LinkedIn.

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