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

Introduction

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.

B—Black

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

I—Internet

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—Access

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.