Implicit Gender Bias in Patient Care: Let's Address, Not Dismiss

Jennifer L.W. Fink, BSN

Disclosures

October 11, 2018

In 2006, an effort to improve blood clot prophylaxis at Johns Hopkins Hospital revealed a disturbing disparity: Male patients were more likely than female patients to receive appropriate clot prevention.[1]

According to chart reviews, 69% of male trauma patients were properly treated for blood clot prevention compared with 55% of female patients. Statistically speaking, women were almost 50% more likely than men to miss out on clot prophylaxis, an evidence-based intervention that has been shown to reduce complications and improve outcomes.[2,3]

No one on the Hopkins team expected to uncover a gender difference in patient care, especially on something as straightforward as clot prevention in trauma patients. But the numerical evidence was stark—and when the gender disparity disappeared after the introduction of a mandatory computerized checklist that recommends appropriate treatment based on patient characteristics, researchers and quality improvement experts began to wonder whether unconscious thinking doesn't sometimes affect clinicians' care of male and female patients.

The very thought of treating male and female patients differently on the basis of their gender is abhorrent to most physicians. "People who work in clinical care want to do the right thing. They want their patients to get good care—to get the medication, tests and procedures they need," says Elliott Haut, MD, PhD, a trauma surgeon who was involved in the Hopkins project and serves as Johns Hopkins' vice chair of quality, safety, and service in the department of surgery.

But the human brain relies on all kinds of shortcuts to make quick decisions, including a tendency to sort people into groups and make predictions based on stereotypes. Past experiences and social learning subconsciously color physicians' perceptions of their patients, and those perceptions can influence care, particularly in crisis situations. In fact, so-called implicit bias—unconscious thoughts and beliefs about groups of people—is most likely to influence behavior when someone is cognitively strained or under time pressure.

In other words, physicians' working conditions are exactly the sort that allow implicit bias to flourish. Unfortunately, implicit bias can lead to errors in judgment, so physicians who want to provide the best possible care must take explicit steps to circumvent unconscious bias.

"Implicit biases affect all of us. The fact that they exist is not a reason for shame," says Maya Dusenbery, author of Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed & Sick.[4] "The question is, are you going to deny bias exists and continue on with the status quo, or will you come up with creative ways to address bias?"

Evidence of Unconscious Gender Bias in Healthcare

Analysis of medical records and anecdotal evidence suggest that hospitalized men and women experience different care. A 2001 University of Maryland review found significant differences in pain management; compared with men of similar weight, women were less likely to receive pain medication after surgery and more likely to receive sedative medication.[5]

In a 2007 article published in the Canadian Medical Association Journal, researchers found differences in the care of critically ill male and female patients.[6] The retrospective study of 24,778 patients found that fewer women than men (39.9% vs 60.1%) were admitted to intensive care units, despite similar severity of illness. Female patients were also less likely to receive mechanical ventilation (52.3% vs 57.8%) and pulmonary artery catheterization (20.3% vs 29.8%).

It's possible that these differences reflect patient preferences and priorities; perhaps the female patients (or their caregivers) were less likely to choose aggressive medical treatment. But medical studies also show that female cardiac patients are less likely than male patients to be prescribed antiplatelet, beta-blocker, or lipid-lowering medications[7,8] and a 2009 study published in Canadian Medical Association Journal that utilized standardized male and female patients with identical clinical backgrounds found that 42% of physicians recommended total knee replacement to the male patient but not to the female patient, even though the physicians stated that gender did not influence their decisions.[9]

"Once you begin to review the data, it's rather difficult to dismiss the possibility of gender bias," says René Salazar, MD, professor of medical education and assistant dean for diversity at Dell Medical School at the University of Texas at Austin.

Haut, the Johns Hopkins researcher, agrees. "There are people in medicine who still don't agree there's a disparity. I can't understand how people think that. I think there's an overwhelming amount of data that shows there's disparity between patient types, whether it be man or woman, or black or white, or socioeconomic status."

Learning to Listen to Women

Dusenbery, the author, says her reporting uncovered "a trust gap, where women's own self-reports of their symptoms are not taken seriously." As a result, she says, "the time period before providers really recognize what the problem is, is arguably the most dangerous time for women."

Hospital medicine physicians (and other healthcare providers) need to exercise caution when a patient takes a turn for the worse. Tennis star Serena Williams, for instance, knew almost instantly that the sudden shortness of breath she developed one day after giving birth by C-section was probably a pulmonary embolism; she'd had one previously, in 2011.[10,11,12] If her medical team had dismissed her concerns as anxiety or hysteria, the resulting delay in care could have cost her her life; instead, they quickly ordered an ultrasound of her legs and a chest CT scan and began a heparin drip as soon as the scan revealed clots in her lungs.

"Women patients are at risk for getting dismissed, particularly around issues of pain and stress," says Vineet Arora, MD, MAPP, an academic hospitalist and assistant dean for scholarship and discovery at the University of Chicago in Illinois. When treating a female patient, stop and ask yourself: How would I handle this situation if a male patient presented with the same concern?

Taking an implicit association test (IAT) can help you uncover and better understand your implicit biases. According to Project Implicit, a nonprofit organization founded by three scientists, these tests "measure the strength of associations between concepts (eg, black people, gay people) and evaluations (eg, good, bad) or stereotypes (eg, athletic, clumsy)." Available IATs can reveal your unconscious attitudes regarding gender and science and gender and careers; the tests are free, available online, and can be completed in about 10 minutes.

"Awareness is absolutely one of the first steps that individuals need to take in order to really understand and start the process of addressing implicit bias," Salazar says.

Improving Care—for All Patients

Awareness, of course, is not enough to eliminate bias. And, to date, it's not clear if implicit bias training improves patient care and outcomes.

What we do know: standardized evidence-based protocols can improve care for all patients. The Johns Hopkins blood clot prevention checklist is based on the best available evidence and integrated into physicians' workflow. Haut describes it as a "computerized support tool" that is built into the electronic medical record.

"The computer helps by pre-checking some of the information, such as the age of the patient. Then it gives you this checklist of risk factors—surgery, cancer, whatever their risk factors are, you're literally clicking on a box. You click on any relevant contraindications and up pops the answer," Haut says. "It makes it easy to give the perfect optimal care for the patient, individualized to their situation."

After widespread, mandatory implementation of the tool, clot prophylaxis increased from 26% to 80% for surgical patients and from 25% to 92% for medical patients—and the gender gap closed.[2]

"Standardized protocols reduce the potential for biases to influence care," Dusenbery says, because they interrupt the brain's tendency to make snap judgments.

Haut and other Johns Hopkins clinicians and researchers are currently working on a decision support tool that will help physicians decide whether to prescribe antibiotics. "It reminds people of things like, 'You can only give it for 24 hours for this indication, or you shouldn't need to give it at all, but you want to give it, we're stopping at 24 hours,' " Haut says.

Regularly encountered patient scenarios are "low-hanging fruit" that hospital medicine physicians can address through the creation of standardized protocols, Dusenbery says.

Haut agrees. "If you improve care for everybody to 100%, if there was a disparity before, the differential goes away."

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