SGIM Forum

Improving Care: Part I

Mitigating Salient Biases in Ambulatory Medicine during the COVID-19 Pandemic

Dr. Leung ( is an assistant professor of medicine in the Division of General Internal Medicine at Weill Cornell Medicine. Dr. Kozman ( is an assistant professor of clinical medicine in the Division of General Internal Medicine’s Section of Medicine-Pediatrics at UCLA David Geffen School of Medicine. Dr. Leung ( is an assistant professor of medicine in the Division of General Internal Medicine at VA Greater Los Angeles Healthcare System and UCLA David Geffen School of Medicine. Dr. Harris ( is an associate professor of clinical medicine in the Division of General Internal Medicine at VA Greater Los Angeles Healthcare System and UCLA David Geffen School of Medicine.


COVID-19 has changed the way clinical teams care for patients in the ambulatory setting. Without awareness and intention, especially in times of high stress and high cognitive load, biases start to fill in gaps and holes formed by the COVID-19 pandemic. It is important for clinicians to recognize and eliminate these personal biases resulting in disparate communication practices and influencing the assumptions of physical and technological accessibility and safety. Utilizing the World Health Organization’s characterization of intersectoral factors influencing health equity-oriented progress,1 described here is our developed B-I-A-S checklist (see table) to be used when assessing patients, especially during this unique time of the COVID-19 pandemic, to mitigate personal biases through awareness, systematic thinking, and openness.


A 36-year-old Black man declines the COVID-19 vaccine citing how his previous symptoms were incorrectly dismissed as not being COVID-19 by an emergency room physician.

Racial disparities in hospitalization and mortality during COVID-19 are thought to be the direct and indirect result of major factors such as socioeconomic inequities, racial discrimination, and systemic racism. In addition to these larger systemic issues, individual clinician biases also negatively impact the care of minoritized populations, especially Black patients during this pandemic. Early in the pandemic, reports surfaced that questioned if Black patients were more likely to be turned away from the emergency department when seeking treatment for their COVID-19 symptoms, which would be consistent with prior studies on disparate care provided to Black patients.

There are several contributors as to why these reported differences exist. Implicit racial bias towards Black patients has been linked to poorer patient-centered communication indicators, such as more clinician-dominated dialogue and negative tone with patients, that can adversely affect medical treatment and decision making. Concurrently, greater patient perceived bias in care results in higher patient mistrust and lower confidence in the clinician. This has implications for seeking care and following medical advice in the treatment and prevention of COVID-19 spread. Understanding the negative impact of these biases, clinicians must take extra steps to neutralize these biases in patient communication.

Given the insidious impact of racial bias in health care, much attention has been paid to decreasing and ultimately eliminating bias. Establishing new patterns of practice that emphasize individuation and perspective taking have been shown effective in reducing racial bias. This focus on the individual’s unique characteristics and perspectives results in increased clinician empathy and patient-centeredness which have been shown to improve patient outcomes.2


An 80-year-old man with a history of diabetes, hypertension, and prostate cancer was not offered information to sign up for the patient portal by his medical team.

Digital health inequity has been exposed and brought to the forefront by the COVID-19 pandemic. While a digital divide still exists, it is worth acknowledging that most seniors (73% 65+ years-old), low-income (82% <$30k income), and racial-ethnic minority (85% Black, 86% Hispanic) Americans have Internet access, own smartphones, and are open to using digital health tools. In particular, low-income, racial-ethnic minorities often rely solely on their device for Internet access which doubles as a digital opportunity for patients who also tend to have worse health outcomes.

Beginning March 2020, the Office of the National Coordinator for Health Information Technology’s (ONC) Cures Act aimed to increase the pace of innovation and investment in patient-facing tools.3 Clinicians need to proactively offer access to digital tools to all patients and not just those who are presumed to have Internet or to use technology. In addition, primary care teams need to support patients’ use of these digital tools and consider tailoring care delivery based on digital health delivery to maximize the end-user experience. The COVID-19 pandemic has made clear that telemedicine, patient portals, etc., are here to stay, such that clinicians need to encourage all patients to use digital health tools as part of standard care.


A 58-year-old woman with a history of congestive heart failure and “noncompliance” does not show up to her three-month follow-up appointment.

Bias may lead clinicians to hastily describe some patients as being “noncompliant” with follow-up or treatment, indirectly implying that a patient is apathetic to their own health. This characterization is inherently problematic given the lack of specificity of what can be true barriers related to social determinants of health.

As unemployment rates reached 14.7%, the highest point since the Great Depression, concerns for people losing employment-sponsored insurance and becoming uninsured and unable to access care increased.4 High out-of-pocket costs and fewer paid sick leave will affect even the insured, forcing many to choose between their essential day-to-day living needs and maintaining health.

Further compounding these concerns, patients who rely upon public transportation to attend their appointments not only sacrifice substantial time and earnings, but they also increase their risk of viral exposure in doing so. Those with multiple comorbidities must navigate often fractured and distant networks of clinicians, placing the very same individuals at highest risk of COVID-19 complications at the highest risk for exposure during transit. Many bus and train schedules have also been reduced, making this commute more difficult than ever before.

To avoid missing these critical issues that inhibit patients from connecting with care, the best intervention is to consistently check personal biases in perceiving noncompliance by proactively screening each patient at every encounter for these barriers to access care. No patient visit should ever conclude before clinicians ask their patients if the plan of care realistically “FITS” any Financial/Food, Insurance, Transportation or Shelter barriers to access of health resources.


After you recently saw a 32-year-old woman via telemedicine for wrist pain, she was seen in the emergency department following an assault by her husband.

There are concerns about whether individuals who experience intimate partner violence (IPV) are safely able to access a safe place. At the height of the pandemic in New York City, NYPD responded to a 10% increase in domestic violence reports compared to the prior year; however, domestic violence arrests decreased by 43% as compared to the preceding months. Fundamental to identifying IPV and healing from trauma is for the care be provided in a psychologically and physically safe environment. Assuming the same privacy previously afforded in clinic exam rooms while using telehealth modalities is dangerous when screening for IPV and discussing safety planning. In addition to explicitly asking if the patients can freely speak, offering flexible and alternative times for call back that may be outside the traditional work hours will improve access to care.5

It may be assumed that patients following precautions are easily able to balance their concern about exposure to coronavirus in the healthcare setting with the need to seek care in person care for concerning medical symptoms. In the first two months of the pandemic in the United States, there was 43% drop of patient visits at community health centers even when counting telehealth visits, and reductions in emergency room visits for myocardial infarction and stroke. Given patients’ fear to return to care, clinicians must proactively reach out to patients at higher risk for disease complications, assess their fear of virus exposure in returning to healthcare settings and educate them about all modalities available to provide safe care.


With COVID-19 infection rates rising from variant strains, the B-I-A-S checklist is a tool for clinicians to facilitate care engagement more sensitively and to ensure that their most vulnerable patients are equipped with the knowledge and resources available to maintain health.


  1.  De Paz C, Valentine NB, Hoseinpoor AR, et al. Intersectoral factors influencing equity-oriented progress towards universal health coverage: Results from a scoping review of literature. Discussion paper series on social determinants of health, 10. World Health Organization. Published August 9, 2017. Accessed October 15, 2021.
  2. Williams DR, Cooper LA. Reducing racial inequities in health: Using what we already know to take action. Int J Environ Res Public Health. 2019 Feb; 16(4): 606. Published online 2019 Feb 19. doi:10.3390/ijerph16040606.
  3. Rodriguez JA, Clark CR, Bates DW. Digital health equity as a necessity in the 21st Century Cures Act Era. JAMA. 2020;323(23):2381-2382.
  4. Garret B, Gangopadhyaya A. How the COVID-19 recession could affect health insurance coverage. Urban Institute. Published May 4, 2020. Accessed October 15, 2021.
  5. Boserup B, McKenney M, Elkbuli A. Alarming trends in US domestic violence during the COVID-19 pandemic. Am J Emerg Med. 2020;38(12):2753-2755.


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