A middle-aged black woman presents to her local emergency department via emergency medical services (EMS) with chest and back pains, nausea, and vomiting. She has a history of IV drug abuse and is disheveled in appearance. Prior to her arrival, EMS notes that her chest pain appears non-cardiac and provides supportive care while en route to the hospital. She is triaged to the appropriate care and an emergency provider assesses the patient.
The patient continues to have chest discomfort and nausea. The emergency team agrees with the EMS assessment and deems her symptoms as atypical for a cardiac etiology. An EKG is performed which demonstrates subtle ST-segment elevations in her inferior leads as well as faint reciprocal changes. However, the catheterization lab was not activated at this point.
High sensitivity troponin ultimately revealed a modest enzyme leak and the cardiology team was consulted. The patient was urgently taken to the cath lab to reveal an acute lesion of her proximal right coronary artery. There were no complications during the procedure and she ultimately had an uneventful hospital course.
Implicit bias refers to the attitudes or stereotypes that affect our understanding, actions and decisions in an unconscious manner. These biases are activated involuntarily, without an individual’s awareness or intentional control. Unfortunately, we are all susceptible to bias and there is extensive evidence showing how bias can lead to differential treatment of patients by race, gender, age, weight, language, socioeconomic status, and insurance status. As such, it begs the question, if our patient had no history of drug abuse or was white, would their acute myocardial infarction been treated faster?
A seminal 2007 study of internal medicine and emergency medicine residents found that, while the participants reported no explicit racial bias, Implicit Association Tests (IATs) indicated an implicit preference towards White Americans. Further, the higher the preference, the more likely that physician was to treat Whites and not treat Blacks with early thrombolysis in the setting of acute myocardial infarction.
While it is clear the effects of implicit bias in medicine, it is also clear that implicit bias is malleable. There are a number of leading strategies for combating implicit bias including stereotype replacement, counter-stereotypic imaging, individuation, perspective-taking, and increasing opportunities for contact with individuals from different groups. Further, new research must be conducted to find more innovative techniques for managing implicit bias. As clinicians, it is our responsibility to be constantly aware of our bias and to actively work to address that bias in every patient encounter.
- Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231-1238. doi:10.1007/s11606-007-0258-5
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Aubrey J. Grant, MD is currently in his second year of General Cardiology Fellowship at Georgetown University/Medstar Washington Hospital Center in Washington, DC. His Clinical interests include sports cardiology, cardiac MRI, and racial disparities in cardiovascular disease. He also runs a healthy eating food blog entitled The Doctor’s Orders: thedoctorsorder.com. You can follow his tweets @AubJGrantMD.