May 19, 2021

Beware of unconscious bias influence on clinical outcomes

By: Ryan Chesterman

Does compassionate care really matter? Clinical evidence points to a resounding Yes.

“When healthcare providers take the time to make human connections that help end suffering, patient outcomes improve, and medical costs decrease. Among other benefits, compassion reduces pain, improves healing, lowers blood pressure, and helps alleviate depression and anxiety,” say Stephen Trzeciak and Anthony Mazzarelli in their 2019 book, Compassionomics: The Revolutionary Scientific Evidence That Caring Makes a Difference.

Trzeciak and Mazzarelli reviewed more than 1,000 scientific abstracts and 280 research manuscripts to make their case that compassion has validity as evidence-based medicine. Even more compelling: A Johns Hopkins University School of Medicine study published in the Journal of Clinical Oncology (1999) found that it takes only 40 seconds of kindness and empathy to reduce measurable anxiety in patients.


Harnessing the power of compassionate care

Jonathan Markley, MD, is chairman of anesthesia for North American Partners in Anesthesia (NAPA) at an urban hospital serving the community of greater Newark, New Jersey. His patients come from many walks of life, and for most, managing their daily health comes secondary to meeting basic needs.

If Dr Markley weren’t acutely aware of the need to connect with patients when they are most vulnerable, it would be easy for him to make negative—and often incorrect—assumptions about his patients’ lives and health history. And it’s equally likely that when many patients come in for surgical procedures, they are making incorrect assumptions about him.

Such is the nature of unconscious bias. Dr Markley recalls a patient who came in for a hip replacement. Lacking the right care over time, the patient treated severe hip pain with opioids, and then with less expensive heroin.

“I could have told the patient that we were cancelling the case due to drug use, or the patient—fearing judgment—could have withheld critical information from me,” says Dr Markley. “Instead, I tried to build trust, which enabled us to have a deeper conversation about the need to stay clean for the surgery, and how to correctly use Suboxone® postsurgery to stop the heroin dependency.”

Dr Markley may have changed that patient’s life in a matter of moments by recognizing the potential for unconscious bias, resisting the rush to judgment, and making the decision to get closer and be empathetic. His example shows how clinicians can change the trajectory of a patient’s life simply by being compassionate in how they care for their patients.


What is unconscious bias, and how does it work?

Unconscious bias occurs when your brain quickly processes information to form conclusions. Integrating all of your life experiences and impressions, your brain may unknowingly (to your conscious self) use stereotypes to influence your decisions. In healthcare settings, evidence shows that unconscious bias can lead to negative outcomes, particularly for minority groups.

In its January 2020 cover story on “Implicit Bias: Recognizing the Unconscious Barriers to Quality Care and Diversity in Medicine,” Cardiology Magazine noted: “Everyone, including physicians and other healthcare professionals, has implicit, also called unconscious, biases that affect how they view the world and interact with others.”

“Everyone” means the clinical impact of unconscious bias is a two-way problem that arises when clinicians and patients bring their biases into the perioperative spectrum of care. Will a patient reveal an addiction problem if he/she believes that all physicians are judgmental? Will a healthcare professional jump to dismissive conclusions based on a patient’s color or lifestyle?


Use a humanistic approach

Rachel A. Wolfe, MSN, CRNA, is a NAPA nurse anesthetist practicing in Pittsburgh, Pennsylvania. She believes that clinicians have only 5 minutes to build an impression that will establish a trusting relationship with a patient. Wolfe begins every new interaction by looking for points of relatability and imagining herself in the patient’s shoes.

“The first questions I ask are never medical, they are always social. I already read the chart. I can get to the medical answers I need in seconds,” she says. “Start with humanistic questions, and instead of making quick decisions, find each patient’s story.”

The AIDET® acronym created by the Studer Group to facilitate effective patient communication can help clinicians quickly build rapport with patients and slow down an assessment that might be influenced by unconscious bias. Upon meeting a patient, AIDET encourages clinicians to:

• Acknowledge the patient: Ask, “How are you today? Are you cold? What are you watching?”

• Introduce yourself: Make eye contact at eye level, and introduce yourself to the patient and family members by name.

• Describe the duration: Discuss how long the procedure will take.

• Explain what will happen: Provide a clear explanation of the process, and invite questions.

• Thank the patient: Say “thank you” as the interaction concludes.

Research shows that taking the time to deliver compassionate care yields benefits for patients and providers alike. Studying functional MRI scans, German neuroscientists found that acting with compassion lights up reward centers in the brain, making caregivers feel better, too.


The role of clinical intuition vs unconscious bias

Are unconscious thoughts always bad? Not necessarily. Intuition is valuable to clinicians who rely on their ability to instantly integrate years of medical training and experience to assess patients and make quick clinical decisions every day.

Dr Markley calls this process the “eyeball test”: “You come in, you make eye contact with the patient, and you make 50 assumptions about the airway, the cardiovascular system, and the postoperative pain requirements. I don’t need a CAT scan of the neck if I can assimilate neck circumference, mouth opening, thyromental distance, neck range of motion, age, skin tissue resilience, and the veins in their hands. So ‘profiling’ in this sense can be helpful, if you are aware of the potential for unconscious cultural bias and can mentally guard against it. A patient assessment may trigger a stereotypical thought, but you have to remember to get the whole picture into play. Your intuition must work together with your wealth of evidence-based clinical knowledge,” he says.

Wolfe says, “In my clinical career I’ve cared for patients ranging from 2 weeks old to age 92. I’ve had patients who played professional sports and patients who were living on the street. Socioeconomic status and cultural norms can be such subtle factors in how clinicians relate to patients and how patients interact with clinicians. Providing compassionate care for all starts with having the self-awareness that unconscious bias is real, and the emotional intelligence to build a human connection and understand each patient’s individual experience.”

“The problem with discussing unconscious bias is that it’s unconscious,” says Dr Markley. “None of us want to think that we are biased. So the best antidote is to always lead with compassion and thoughtfulness and trust.” ✥





Fogarty L A, Curbow B A, Wingard J R, et al. Can 40 seconds of compassion reduce patient anxiety? J Clin Oncol. 1999;17(1):371-379.


Klimecki O M, Leiberg S, Lamm C, et al. Functional neural plasticity and associated changes in positive affect after compassion training. Cereb Cortex. 2013;23(7):1552-1561.


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