To Provide Patient-Centered HIV Care, Train on Implicit Bias

Heather Boerner

November 12, 2018

DENVER — The key to patient-centered care is for healthcare providers to identify their own implicit biases, experts said here at the Association of Nurses in AIDS Care 2018.

"Patient-centered care is about providers trying to get into the world of the person who is being taken care of — understanding the disease from their perspective," said Mekbib Gemeda, vice president of diversity and inclusion at the Eastern Virginia Medical School in Norfolk.

As care providers, we do that better when we think about the patient's whole world, ask questions, and assume an approach of "cultural humility" by acknowledging what we don't know about a patient's life and preferences, he explained.

That is where biases come in.

Bias has a negative connotation, but it doesn't have to, said Gemeda. Unlike explicit discrimination — a conscious intent to provide worse care to patients because of certain demographic characteristics — implicit bias is really a marker of being good at learning.

Because providers "need to process a large amount of information quickly," he explained, "we need biases, we need patterns to indicate to us that this is good or bad, safe or not, nice or not."

This is just how our minds work. And biases — the unconscious frameworks we use to move through large quantities of visceral and intellectual information — "are not negative by nature; they can be negative, positive, or neutral," he added.

The challenge, said Gemeda, is that "we do the same thing when we see people."

And sometimes that can lead to differential outcomes for patients. Ever since the Implicit Association Test was developed at Harvard University and the University of Washington in 1998, researchers have been looking at the effect the short-hand ways providers use to understand their patients has on the quality of care.

Bias With No Ill Intent

Research has shown that providers with no conscious preference for white patients over black patients nonetheless had implicit bias scores in favor of white patients, and that their perception of black patients as uncooperative with care was statistically significant.

In one study, this resulted in physicians with higher scores being less likely to prescribe treatments to dissolve blood clots to black patients (J Gen Intern Med. 2007;22:1231-1238). Another study showed that physicians who scored higher on race implicit bias were perceived by black patients to be more dominating in conversations and provided less patient-centered care (Am J Public Health. 2012;102:979-987).

The key thing, said Gemeda, is that none of these people believed themselves to have any of these biases. But believing it and examining it are two separate things.

"People who marched with Dr Martin Luther King — there's no question where they are in their thinking — can fail the test," he told Medscape Medical News. "It doesn't mean that you're not consciously doing everything you need to do."

That message resonated with Rasheeta Chandler, PhD, APRN, from the Nell Hodgson Woodruff School of Nursing at Emory University in Atlanta.

A week ago, Chandler attended professional development training on implicit bias among providers, assuming it would not apply to her. After all, as a black woman and provider working in the South, it seemed like the training might be more relevant to others.

But she learned that she did need it, she told Medscape Medical News. For her to provide the best care for her patients, she realized she needed to look at her own reactions.

All healthcare providers need it because "there are other things to consider" than just race, said Chandler. For example, targeting HIV prevention messages only to gay men does a disservice to women, who are acquiring HIV at increasing rates.

"We need to stop picking and choosing who we think should have the information" about HIV prevention, she explained. "Give people the information and let them make an informed decision."

The topic of implicit bias also came up during a discussion of ways that providers can better engage Latinas in HIV care and black women in HIV prevention in a different session at the conference.

Implicit bias is there; it's the way our brains work.

A small ethnonursing study showed that providers who best met the needs of Puerto Rican women already engaged in care integrated culturally specific values of kindness and family into their practices — concepts called personalismo and familismo.

The best providers understood the "airbridge" — the travel back and forth from Puerto Rico — and coordinated care with providers based in Puerto Rico, said Michele Crespo-Fierro, PhD, RN, from NYU Rory Meyers College of Nursing in New York City.

And they were not only top-notch with HIV care, they also understood that all Latina patients aren't alike, she added.

Crespo-Fierro, who is Puerto Rican, said that the general attitude that she hopes providers understand is that "we are not a monolith and need many different things, depending on how acculturated we are."

The question of implicit bias also affects discussions of sex, said Keosha Bond, EdD, from the New York Medical College in Hawthorne. She is currently exploring how providers counsel patients of different races about sexual health.

Preliminary findings suggest that providers who don't think they are informed enough about their patients' cultures might just "ignore those issues," she said. "They are just not comfortable speaking to someone of a different race or culture or ethnicity."

These are the challenges we still need to address, said Bond.

The straightforward way to do this, according to Gemeda, is to ask all providers in a clinic to take the Implicit Association Test and then to survey all patients about ways that care could be improved.

The main thing is for providers to become aware, added Crespo-Fierro.

"Implicit bias is there; it's the way our brains work," she said. "But it's taking that step and saying, 'Stop. Don't go that way. Ask more questions. Get more information.' That's how we deal with implicit bias, by making sure we take the time not to continue on that train of thought even though it's the first one that pops into our mind."

Chandler, Gemeda, Crespo-Fierro, and Bond have disclosed no relevant financial relationships.

Association of Nurses in AIDS Care (ANAC) 2018. Presented November 9, 2018.

Follow Medscape Nurses on Twitter @MedscapeNurses and Heather Boerner @HeatherBoerner

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