Rooting Out Implicit Bias in Pediatric Practice

In my 2017 LadyDocs Corner Cafe blog, “Let’s Talk About Racism,” I introduced my first experiences grappling with racism. I’m happy to report back after the 2019 American Academy of Pediatrics (AAP) annual meeting that many pediatricians, myself included, are freer from both intentional (explicit) and unintentional (implicit) acts of interpersonal racism and sexism. I met a happy, young pediatrician, a graduate from my alma mater, the Medical College of Georgia, who shared that female and male students are now represented in roughly equal proportions and racial and ethnic diversity is excellent. 

Later, I met Tiffani Johnson, MD, MSc FAAP, Assistant Professor of Pediatrics at the University of California Davis Health, Department of Emergency  Medicine, who led a workshop on implicit bias in pediatric practice. We explored the growing body of research on biases in healthcare and the AAP’s policy statement on racism’s effects on children’s health, and we practiced new tools to increase our effectiveness as clinicians and child advocates. We clearly now see how practice decisions, such as the quality of pain management, may vary by the race of our patients and our own levels of implicit bias for or against their race. For example, African American children are more likely to receive less appropriate and effective pain management than white children, based on the greater implicit biases and attitudes of their individual care providers.

Since then, I’ve found studies indicating that implicit bias hurts pediatricians too.  For example, pediatricians who experience severe burnout during their residency training tend to exhibit greater levels of implicit bias, including pro-White and anti-Black attitudes. The stress of long hours and other demands of training were implicated as contributing factors.  Not surprisingly, recovery from burnout was the best predictor of improvement in those attitudes. 

Discussing research about bias in pediatrics is eye opening, but changing attitudes is better addressed in small group discussions, where we feel safer to share our stories. Dr. Johnson led the way for us by sharing her story. She recalled an encounter with one father who sat quietly beside his wife during several clinic visits focused on their child. Finally, the father pulled Dr. Johnson aside to share his hurt. “Why do you avoid looking at or talking to me during our visits?” He said he felt invisible, compared to the attention and focus of his child’s pediatrician to her mother. Dr. Johnson realized he was right and searched for the cause. She believes her behavior was based on her implicit bias that fathers are not knowledgeable about their children’s health issues. She used that experience to change her practices. Workshop attendees appreciated her courage, and we discussed how ineffective communication with patients makes us feel frustrated, burdened and isolated.

Next, Dr. Johnson challenged us to find ways all the people in our small groups (8-10 people seated at round tables) were similar, and not by the obvious characteristics (e.g., we’re all pediatricians attending a workshop). My group discovered that we could find multiple such examples with a simple technique. First, we asked questions, such as: “who is on social media,” or “who had children?” If one or two people answered “not me,” we extended the questions to include others’ experiences. For example, we asked, “who has ever been on social media,” or “who has children they love in their lives?”  Our somber moods were slowly transformed by the energy of successful teamwork. 

Small group discussions, just like thoughtful and calm family discussions about racism or sexism during the holidays, may allow us to examine our own implicit biases and explore how to make changes. As we need others to be patient while we make changes, we may extend our patience to those we care for by making space for them to explore their own experiences with less harsh judgment. 

Simply put, implicit bias in pediatric practice is prevalent.  Implicit bias weakens our healthcare system, leading to waste and inefficiency. American healthcare achieves worse health outcomes for higher costs, compared to other high-income countries. Rooting out implicit bias in pediatric practice is a more promising and achievable goal than ever.