Reducing Unconscious Bias in the Emergency Room

Bias is a neutral word.  A bias is a belief, a thought, a preference.  In and of itself, it has no leaning towards right and wrong, or best and worst.  Personal and social judgment assigns the bias a nuanced meaning.  In health care, these beliefs can turn into a missed diagnosis, an inappropriate treatment strategy, or a patient’s untimely death.  The most critical aspect of bias for health care providers is realizing that our unconscious beliefs guide our behavior towards other people, often unconsciously.  We often make decisions about how we interact with people through our biased lens.  We choose subconsciously whether we will lead with respect, or with dismissal, or even disdain.   It is crucial to recognize whether our biases are reality-based or a reflection of inaccurate assumptions about our patients, our colleagues, or ourselves. 

During the night shift in the Emergency Room internship year, I had an experience that illustrated my bias towards “inconsiderate” people.  It would become an AHA moment for me, with a conscious decision to do better.  As an intern, I managed the non-urgent side of the emergency room.  The night unfolded into the typical frantic evening with a stream of patients, procedures, multitasking and plenty of decisions to make.  A grandmother came in with her 10-year-old grandson for the evaluation of a rash. I’d been up all night; I was tired and impatient.  As I entered the exam room, I thought to myself as I read the chief complaint on the front page of the chart, why would anyone be coming into the emergency room at three in the morning for a rash?  Immediately, I smelled a distinct body odor.  The child was visibly dirty, wearing tattered clothes and avoided making eye contact.  His grandmother dressed in office attire that was upscale and clean shared the history.  I began to lecture the older woman about coming in at three in the morning for a simple rash, and I scolded the boy about his hygiene.  She watched me jot down my notes and let me finish with my tirade before she informed me that her grandson lived with his mother, and that they were homeless.   She shared that daily hygiene became challenging without access to water, and family relationships remained strained.  She was doing what she could.  She worked during the day and could not afford to take time off. She searched my face for empathy.  She said calmly, “Doctor, could you please stop scolding us . . . and just help us?”   A rush of warmth filled my cheeks, and I felt ashamed.  When had I become so insensitive? Why hadn’t I been curious about their situation instead of judgmental?

Discussions about unconscious bias in healthcare decision making started in 1991 with the seminal article by Shulman et al.[1] Unconscious bias is more likely to guide behavior when we are tired, hungry, multitasking or experiencing acutely stressful situations.  It is at these moments when our sympathetic nervous system activates to ensure “our primitive need for survival.”  Any strategy that can bring our parasympathetic system on line will help us to make better decisions, maintain awareness, and remain creative in the chaotic moments. [2]   So, what would I have done differently had I known what I know now? Before moving from each exam room and encountering a new patient and their family, I would have taken one extra minute to engage privately in three mindful breaths. I would have taken another 30 seconds to prime my brain with positive intentions for providing the best care possible to the next patient waiting for me. Both of these actions would have decreased the chance of my operating through my unconscious bias and provided a better experience for my patient and his family.

[1] Schulman et al., “The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization.”

[2] Ma et al., “The Effect of Diaphragmatic Breathing on Attention, Negative Affect and Stress in Healthy Adults.”

Stacie L. Walton MD, MPH, recently retired from Kaiser Permanente as a clinical Pediatrician serving in the roles of both Diversity Champion and Communication Consultant. She served as a medical consultant in diversity issues for healthcare providers and institutions for over 25 years.

Currently, her cultural competency themes highlight the impact of implicit bias and privilege in patient interactions and health outcomes, as well as, how effective patient-provider communication requires both competences and humility.