Unconscious cognitive processes influence, shape and alter human behaviour, beliefs and attitudes. With no conscientious thinking, we archive and recover information to decipher and decode contexts, people and their behaviours. Preconceived notions influence our judgments resulting in bias. The term ‘bias’ refers to both tacit stereotypes and prejudices that mostly arise from the subconscious mind.
Unconscious bias in medical practitioners occurs in two key areas – clinical reasoning leading towards diagnosis and perceptions of patients. Notably the second, patient perception, influences subsequent interactions between medical practitioners and patients, and ensuing clinical decisions. How does bias work and where does it come from?
Two kinds of decision-making processes generally prevail that remain integrated in our teaching and practice of clinical reasoning. Type 1 processes are fast driven by intuition, utilising less cognitive skills. These are the mental shortcuts or heuristics, which allow fast decision making. Type 2 processes involve decision making based on slower analytical methods that are consciously derived.
Many clinical decisions made using Type 1 processes lead themselves to errors. Despite the pitfalls of Type 1 processes, such pattern recognition and automatic decision making seem to be favoured as vitally necessary for human function.
Much research in human decision making strongly suggests that our intuitive biases are formed early in life, reinforced by social interactions, and influenced by our learning experiences.
Unconscious bias plays when a health-care professional intuitively decides and categorises a patient as a member of a group and applies stereotypical label, either positive or negative, to that individual. Often, these are more likely to be activated when cognitive skills are challenged, by limitations on time and resources, compounded by physical and emotional stress.
Unconscious biases of concern are even more blatant in vulnerable groups. For example, minority ethnic groups, new immigrants, women, the elderly, children, individuals from lower socio-economic sectors of the society, and those with low health literacy, mentally ill and sexual minorities. Recent systematic reviews indicate implicit biases among clinicians and nurses are highly similar to the general population.
Conscious and unconscious beliefs about the patient play a pivotal role in interpersonal behavioural actions in a clinical context, interpretation of information, and the ensuing decision making. When unrecognised, the unconscious bias can lead to health management disparities.
How can we minimise unconscious bias while teaching clinical medicine?
Developing self-awareness of the unconscious bias and its control provides opportunities to evaluate the clinical interaction based on paying attention to our thought processes, responding to subtle cues, and knowing how they may influence our decisions.
Two key techniques
First is relating to patients as individuals and not stereotypes. Cultural training emphasises knowledge acquisition about common cultural groups (e.g., understanding care for patients of Aboriginal or Torres Strait Islander {ATSI} descent). This can promote reliance on stereotypes rather than individual information.
The teaching focus should be interacting with each patient as an individual with a set of social and cultural uniqueness and context. For example, ATSI patients may not be comfortable having eye contact with the clinician during consultation, which may lead to lack of trust between the patient and the clinician. It would be more useful to learn to skilfully recognise this with the patient and build a cord of trust in a cross-cultural context.
Second is reflective practice. Perspective-taking exercises (real or simulated) involving looking through the eyes of the patient, to consider how they may have perceived and interpreted the clinical interaction. Other reflective practices that have gained traction include imaginary exercises that counter common stereotypes and questions challenging assumptions during history taking.
Once a stereotype is activated, human nature focuses on confirming evidence (confirmatory bias) actively seeking and interpreting information that confirms the stereotype. Understanding unconscious bias can help identify our judgments and this is likely to help deliver better patient outcomes.
Key messages
- Unconscious cognitive processes influence, shape and alter human behaviour, beliefs and attitudes
- Unconscious beliefs about the patient play a pivotal role in interpersonal behaviour in a clinical context, interpretation of information, and ensuing decision making
- Developing self-awareness of unconscious bias provides opportunities to evaluate the clinical interaction objectively, rendering better patient outcomes.
– References available on request
Author competing interests – nil