Addressing Implicit Bias in the Critical Care Workforce

The words remain fresh in the mind of Natalia Arizmendez, MD, even though the conversation took place years ago. Dr. Arizmendez, a critical care fellow at the University of Pittsburgh Medical Center, was speaking about diversity and bias with Amber Tucker, a sociology professor at Cardinal Stritch University in Wisconsin. “She told me, ‘If you start a job being silent about injustice you see, everyone will always expect silence from you,” Dr. Arizmendez remembered.
 
That message remained top of mind for Dr. Arizmendez as she facilitated a roundtable discussion on “Leading Conversations About Diversity With Trainees” as part of the Society of Critical Care Medicine’s 50th Critical Care Congress. “Conversations about diversity are challenging because it is an uncomfortable topic,” she said. “Let’s face it, no one wants to be called a racist. But we have inherent biases that can manifest as racist ideas. Data reveal clear racial disparities in healthcare, economics, and the judicial system.”
 
Dr. Arizmendez went on to explain that the year 2020 and the start of 2021 have been eye opening for many people and put a spotlight on those inequalities. “Health disparities have been highlighted by COVID-19,” she said, referring to the fact that Black people are 3.7 times more likely to be hospitalized and 2.8 times more likely to die from COVID-19 compared with White Americans, while Latinos were 4.1 times more likely to be hospitalized and 2.8 times more likely to die.¹
 
“Social injustices have burdened our Black and brown communities for decades and are only now being more frequently exposed because of video capture. Judicial inequities were further exemplified by the management of those involved in the insurrection of the U.S. Capitol. We begin 2021 with the undeniable truth that our policies in the justice, social, and healthcare systems have structural flaws rooted in racism.”
 
The question facing society—and specifically the medical community is how to resolve these structural flaws. A separate Congress discussion attempted to begin that necessary conversation. Brian T. Wessman, MD, FCCM, from the Washington University School of Medicine, moderated an educational leadership panel discussion on “Implicit Bias: Impeding Critical Care Medicine Growth.”

Implicit bias is an unconscious negative view of a group of people that can compromise relationships and, in the case of the medical community, stand in the way of good healthcare. One of Dr. Wessman’s top priorities was to drive home the point that everyone, no matter their job, age, or position, has implicit biases. “The people who scare me the most are the ones who say, ‘I don’t have any bias,’ because we all do,’’ Dr. Wessman said. “It’s as natural as sweating. We may not recognize our bias, but all of us have some sort of bias that guides our thought process. The key part about bias is to recognize it, to understand it, and to try to mitigate it in your interactions so that it doesn’t impact the way you treat your peers or patients.”

Gender inequality and racial inequality are common byproducts of these biases, but there are also subtler examples that can impede patient care as well as the overall growth of critical care medicine, such as:

• How a pulmonologist views a surgical intensivist
• The dynamics between an anesthesia intensivist and an emergency medicine intensivist
• Unintentional disrespect shown to nurse practitioners or pharmacists based on a lack of knowledge of their background and skill set

These biases are displayed through microaggressions. Marcia K. Johansson, DNP, APRN, ACNP-BC, FCCM, participated in the discussion with Dr. Wessman, and she examined what microaggressions can look like. She also offered eight approaches to overcome biases and create a healthy work environment:

1. Introspection - Before progress can be made to manage microaggression and implicit bias, it first is necessary to acknowledge their existence. This step focuses on helping critical care professionals identify and understand their own preconceptions, which can be done through self-analysis and by taking implicit association tests. Attendees of the implicit bias presentation were encouraged to take implicit bias tests hosted by Harvard University.²
2. Mindfulness - Individuals are more likely to succumb to bias-like behaviors when they are under pressure, so it is important to manage stress as much as possible through exercise, listening to music, meditation, focused breathing, or purposeful pauses.
3. Taking perspective - Consider a statement you said to a colleague or patient and think about hearing what you said from their point of view. Ask yourself how you would feel if you were on the receiving end of that same statement. 
4. Slowing down - Before reacting to a statement or an action, pause and reflect to reduce impulsive reactions. 
5. Individuation - It is critical to evaluate people based on their personal characteristics rather than characteristics stereotypically affiliated with their group to avoid group bias stereotyping.
6. Messaging - In your communication efforts, use messages designed to create a more inclusive environment and mitigate implicit bias and microaggression. One way to do this clearly is to use statements that welcome and embrace multiculturalism or other differences within your team or organization.
7. Institutionalizing fairness - Ensure that your organization has a diversity committee or group that examines policies to make sure they are inclusive.
8. Restarting - Recognize that identifying implicit bias and microaggressions requires constant attention and frequent revision and reflection. This is a change that takes time and cannot be rushed. 

“We physicians have dedicated years, sacrificed, and expended tremendous effort into becoming the best,” Dr. Arizmendez said. “If we want to learn more about structural racism in healthcare and learn how to unteach racism in academic medicine, we need to do the work. We will not make progress until we accept these facts, address our inherent biases, and listen.”

In addition to the Harvard Implicit Association Tests, Dr. Arizmendez recommends three books to help understand implicit bias and ultimately help increase diversity in the critical care workforce:

• White Fragility by Robin DiAngelo
• How to Be an Antiracist by Ibram X. Kendi
• The Broken Ladder by Keith Payne

References

1. Centers for Disease Control and Prevention. COVID-19 Hospitalization and Death by Race/Ethnicity. Updated November 30, 2020. Accessed January 29, 2021.
2. Project Implicit. Accessed January 18, 2021. https://implicit.harvard.edu/implicit/takeatest.html.