Why do providers become defensive when confronted with their biases?
In recent years, it has become more commonplace to discuss the impact of healthcare professionals’ biases on the individuals and communities they serve. BIPOC communities have long known what academia has begun to recognize, that “implicit bias in physician decision-making makes a significant contribution to perpetuating health care disparities” and can cause harmful, often life-altering consequences (1). Most providers enter the medical field hoping to heal, cure, comfort, and serve. They believe deeply in the ideals of not causing harm and treating patients with fairness and respect as stated by the tenets of medical ethics. Yet, we as a medical community are recognizing that we can cause significant harm through explicit and implicit biases, prejudice, and stereotyping. This contradiction results in a familiar scenario: an individual or a group of people come forward and say, ‘I think you treated/are treating me differently based on my identity and they are met with defensiveness, reference to previous communities they have served, or minimalization. Why are physicians not motivated to listen deeply, understand, and try to get to the bottom of their contribution to another person’s experience? Medicine has grown in its ability to center quality improvement measures around health and safety, but not individual racism and other forms of bias.
There are a number of reasons a provider may not strive to understand the harm they have caused. We should be curious regarding the ways many physicians equate their health professional identity to their self-worth. It becomes a part of their ego, entangled into the concept of self. When it is pointed out they are causing harm by cultural assumptions, this can be interpreted as an assault on identity and self-worth.
In addition, racism is “commonplace… the usual way society does business” and therefore, “is difficult to cure or address” (2). This may be seen as the normal standard of care, of “how I/we have always done things”. Some people may be apprehensive to humbly address previous harms due to our punitive culture within medicine and society at large. Given that a punitive culture is “based on assigning blame and punishment” (3) this will result in clinicians focusing on risk aversion rather than learning, growth and subsequently reducing further harm.
Another possible contributing factor is the lack of acknowledgment of the devastating suffering and trauma the predominantly white medical field has historically created. In many ways, medicine has been a foundational pillar for systemic racism, depicted in Harriet Washington’s Medical Apartheid, which outlines how medicine solidified and legitimized racism towards African Americans and profited from doing so. She describes how “enslavement could not have existed and certainly could not have persisted without medical science” as one of many examples (4). If providers were aware of the history of medicine validating and normalizing racism, led by physicians who all took the same Hippocratic oath, perhaps they would be less defensive and acknowledge their role in perpetuating harm through race-based medicine practices, stereotypes, or aggressions. On the other hand, by not acknowledging the harm a provider creates, they benefit by allowing themselves to disassociate with physicians of the past and ways that our medical system is built for certain people but not others.
There are likely multiple other factors that contribute to the lack of motivation to understand the harm physicians can cause through their biases. How can we get to the point where providers see it as their duty, both personally and professionally, to understand their own biases and how they may impact their patients? The solutions to this expansive issue require urgent, multidimensional approaches. Some solutions might involve integrating medical school curriculum or required prerequisites for entering medical school, with education on the history of medicine and its role in perpetuating racism in the US. Individual approaches may include exercises on cultivating curiosity and reflective practices to understand one’s biases. In addition, we must move our medical schools and health care system towards a non-punitive culture that focuses “on accountability of the individuals involved and the context in which the error occurred… [to] improve systems and prevent further errors (5).”
As medical students and physicians, it’s imperative to center the lived experiences and historical trauma of many of our patients who have been closest to harm. We should approach feedback and criticism as learning opportunities and avoid the defensiveness that is a part of white fragility and other rapid emotion-based responses. There is great opportunity in this moment in our history to examine our biases, examine some of the histories we were taught regarding how things became the way they are, and listen to the voices who have been affected by systemic racism and other forms of discrimination in our society.
Citations:
1.Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health Care Disparities- Elizabeth N. Chapman, Anna Kaatz, Molly Carnes.
https://www-ncbi-nlm-nih-gov.offcampus.lib.washington.edu/pmc/articles/PMC3797360/
2. Critical Race Theory- Richard Delgado and Jean Stefancic
3. The Right Culture- The Royal Pharmaceutical Society. https://www.rpharms.com/resources/quick-reference-guides/the-right-culture#:~:text=A%20punitive%20culture%20is%20based,stifling%20the%20raising%20of%20concerns.
4. Medical Apartheid: the dark history of medical experimentation on Black Americans from colonial times to the present- Harriet A. Washington.
5.”Non-Punitive Culture”- By Stratis Health https://stratishealth.org/wp-content/uploads/2020/08/2.2-Non-punitive-culture.pdf