While playing basketball, Damon Tweedy injured his knees. When the swelling didn’t go down, he went to an urgent care clinic for treatment. It was his day off, and he was dressed in a T-shirt and sweatpants. “The doctor never looked at me,” he remembered. “He just had me stand up, looked at my knees and then said, You’ll be OK. Take it easy.'” He never even asked what kind of job he had. His job could be strenuous; making him prone to serious injuries. In a way, the information about his profession was important, as Damon Tweedy was a doctor himself! Everything changed when Tweedy made it clear to the doctor who was treating him. The doctor made eye contact and started asking him questions. He even took Tweedy to get an X-ray. “So it was an example of two different levels of care. I was two different persons. The first time, I was Damon Tweedy, a random black guy, not to be taken seriously. In the second case I was Damon Tweedy, M.D., and worthy of the same care as anyone else,” he said. Tweedy told his story at the Decatur Book Festival in Georgia in September and has written a book that is part memoir and part discussion of bias in medicine called “Black Man in a White Coat.” The medical profession aspires for equal treatment of all patients irrespective of race, gender or other biases and disparities in health care The medical profession aspires for equal treatment of all patients irrespective of race, gender or other biases and disparities in health care. We are all susceptible to biases, including physicians. But nobody likes to be labelled as biased. Once people acquire a bias, it becomes very hard to dislodge it. Instead of changing them, most people will make a lot of effort to preserve their bias; often dismissing discomforting evidence. With explicit or overt bias, individuals are aware of their biases and attitudes towards a certain person or a group. The person is very clear about his or her feelings and attitudes, and related behaviours are conducted with intent. This type of bias is processed neurologically at a conscious level. It is less common, but it is easy to overcome with logic and reasoning. Explicit bias can be expressed through physical and verbal harassment or more subtle means like exclusion. Overt racism and racist comments are examples of explicit biases. Implicit biases are processed at the subconscious level, so the holder is unaware of their existence, even when they are contrary to one’s conscious or espoused beliefs. Research suggests that the amygdala (considered the “emotional” centre of the brain) and the prefrontal cortex are involved in unconscious bias. A doctor may claim not to be biassed towards a certain group, but his actions indicate that he is acting against his declared beliefs. For example, few physicians espouse racially discriminatory views, yet they tend to recommend less pain medication for black patients than for white patients with an identical injury. A doctor’s implicit bias may be conveyed by his body language. He is less likely to touch sympathetically and stand close to his patient. His vocal tone, posture, and facial and body movements also reveal his bias. The use of favourable body language is a significant tool for establishing provider-patient trust and rapport. According to an article in the US News and World Report, doctors were asked to give the news to critically ill patients, who were portrayed by both black and white actors. While most doctors said the same words to each “patient,” their body language differed depending on the patient’s race. The use of negative stereotypes may lead to missed diagnoses, trust deficit, and delay in seeking curative and preventive treatment, such as flu shot. At the beginning of the Human Immunodeficiency Virus (HIV) epidemic, the high prevalence of HIV among gay men led to initial beliefs that the disease could not be transmitted beyond the gay community. This association hampered the recognition of the disease in women, children, heterosexual men, and blood donor recipients. Studies have demonstrated implicit bias against racial groups, genders, and other marginalized groups. Research suggests that implicit bias may contribute to healthcare disparities by shaping physician behaviour and producing differences in medical treatment along the lines of race, ethnicity, gender or other characteristics. Implicit bias can interfere with clinical assessment, decision-making, and provider-patient relationships such that the health goals that the provider and patient are seeking are compromised. Disparities in healthcare may lead to increased morbidity and mortality. In Pakistan, studies have not been conducted to determine the effects of doctor’s biases in healthcare. Research is needed to understand the impact of biases in health care and to what degree these biases affect treatment choices and patient outcomes. However, it has been observed that the paying capacity of the patient, his education, language, race, and social class can influence the way a doctor prescribes treatment. Poor and illiterate patients, who generally visit public-sector hospitals, suffer the most, as, if they require stents, their names are placed on the waiting list. Overcoming bias Implicit bias in healthcare can be reduced if doctors are made aware of the biases they hold. Once recognised, it becomes easier to overcome them. The study by Green and associates provides an example of how simply increasing physicians’ awareness of their susceptibility to implicit bias changes behaviour. Sharing interests and activities, and spending time with members of a group also can reduce unconscious negative bias towards that particular group. Instead of stereotyping their patients, the doctors should be trained to individuate them. The doctors should have a basic understanding of the cultures from which their patients come. To make them aware of the effects of bias in healthcare, the subject of bias may be included in the curriculum of medical colleges. Doctors may be encouraged to attend online courses designed to teach strategies to reduce implicit biases or at least the impact of such biases. The writer is a freelancer