‘All You Need Is to Be Believed’: The Impacts of Unconscious Bias in Well being Care
In mid-March, Karla Monterroso flew to Alameda, California after hiking in Utah’s Zion National Park. Four days later, she developed a bad, dry cough. Her lungs felt sticky.
The fever that lasted the next nine weeks grew so high – 100.4, 101.2, 101.7, 102.3 – that on the worst night she was on all fours in the shower with ice cold water down her back ran to go to raise her temperature.
“That night I had written in a diary, letters to everyone I am close to, the things they should know if I should die,” she recalled.
Then, in the second month, a new set of symptoms appeared: headache and sharp pains in the legs and abdomen, which made her fearful she might be at risk for the blood clots and strokes that other COVID-19 patients are experiencing 30s reported.
Still, she wasn’t sure whether to go to the hospital.
“As women of color, you are often asked about your feelings and the truth about your physical condition. You are often referred to as an exaggerator throughout your life, “said Monterroso, who is Latina.” So there was the strange feeling, “I don’t want to use resources for anything”.
It took four friends to convince her that she had to call 911.
But what happened in the emergency room at Alameda Hospital only confirmed her worst fears.
On almost every corner during their visit to the emergency room, Monterroso said, providers rejected their symptoms and concerns. Your low blood pressure? That is a wrong reading. Your cyclical oxygen level? The machine is wrong. The sharp pain in her leg? Probably just a cyst.
The doctor came in and said, ‘I don’t think there’s much going on here. I think we can send you home, “Monterroso recalled.
Her experiences, she explains, are part of why people of color are disproportionately affected by the coronavirus. This is not just because they are more likely to work on the front lines, exposing them and the underlying conditions that make COVID-19 worse.
“That’s certainly part of it, but the other part is the lack of value people see in our lives,” wrote Monterroso on a Twitter thread about her experience.
I am writing this because all coverage of Latinx and black deaths from Covid is covered, as if it is ONLY the pre-existing conditions of racism that make us vulnerable. That is certainly part of it, but the other part is the lack of value that people see in our lives.
– Karla Monterroso (@karlitaliliana) May 14, 2020
Research shows how the unconscious bias of doctors affects the care people receive, with Latino and Black patients less likely to receive pain medication or be referred for advanced care than white patients with the same ailments or symptoms and more likely to die in preventable births Complications.
On that day in May in the hospital, Monterroso felt lightheaded and had communication problems. She had a friend and her friend’s cousin, a cardiac nurse, on the phone to help. They asked questions: What about Karla’s accelerated heart rate? Your low oxygen levels? Why are her lips blue?
The doctor left the room. He refused to take care of Monterroso while her friends were on the phone, she said, and when he returned he just wanted to talk about Monterroso’s tone and the tone of her friends.
“The implication was that we were being rude,” said Monterroso.
She told the doctor she didn’t want to talk about her tone. She wanted to talk about her health care. She was concerned about possible blood clots in her leg and asked for a CT scan.
“Well, you know, the CT scan is radiation right next to your breast tissue. Would you like to get breast cancer? “Monterroso remembered the doctor who said to her:” I only feel good when you say that you are well with breast cancer. ”
Monterroso thought to himself: “Swallow it, Karla. You have to be healthy. “And so she said to the doctor,” I’m fine if I get breast cancer. ”
He never ordered the test.
Monterroso asked for another doctor, a lawyer from the hospital. No and no, she was told. She began to worry about her safety. She wanted out of there. Her friends, who all called every doctor they knew to confirm this treatment was incorrect, picked her up and drove her to the University of California-San Francisco. The team there gave her an EKG, a chest x-ray, and a CT scan.
“One of the nurses came in and said, ‘I heard about your ordeal. I just want you to know that I believe you. And we won’t let you go until we know you are safe, “said Monterroso.” And I started to cry. Because that’s all you want is to believe. You spend so much time not believing yourself and then not being believed when you walk in? It’s really hard to be questioned that way. ”
The Alameda Health System, which operates Alameda Hospital, declined to comment on the details of the Monterroso case, but said in a statement that it is “deeply committed to equality in access to health care” and “a provides culturally sensitive care for everything we do. “” After Monterroso filed a complaint with the hospital, management invited her to speak to her staff and residents, but she declined.
She believes her experience is an example of why people of color are doing so badly in the pandemic.
“Because if we seek help and stand up for ourselves, we can be treated as rude,” she said. “And if we don’t stand up for ourselves, we can be treated as invisible.”
Unconscious Bias in Healthcare
Experts say this is done routinely regardless of a doctor’s intentions or race. Monterroso’s doctor, for example, wasn’t white.
Research shows that every doctor, every person has prejudices that they don’t know about, said Dr. René Salazar, Assistant Dean of Diversity at the University of Texas-Austin Medical School.
“Am I asking a white man in a suit who walks in and looks like he is a pro when he asks about pain medication versus a black man?” Salazar said, noting one of his possible prejudices.
Unconscious bias is most common in high-stress environments, such as emergency rooms, where doctors are under tremendous pressure and need to make quick decisions. Add in a deadly pandemic where science changes day by day and things can turn.
“There’s just so much uncertainty,” he said. “When there is this uncertainty, there is always some degree of possibility for bias to prevail and have an impact.”
Salazar previously taught at UCSF where he helped develop unconscious bias training for medical and pharmacy students. Though dozens of medical schools are starting the training, he said, it’s not as common in hospitals. Even when a negative patient encounter such as Monterroso’s is addressed, the intervention is usually weak.
“How can I tell my clinician, ‘Well, the patient thinks you are racist? ‘”Said Salazar.” It’s a tough conversation:’ I have to be careful, I don’t want to say the racing word because it’s me I’m going to press a few buttons here. ‘So it’s getting really complicated. “
A data-based approach
Dr. Ronald Copeland said he remembered doctors who also resisted these conversations in the early days of his training. Suggestions for workshops on cultural sensitivity or unconscious bias were met with a backlash.
“It was almost seen from the point of view of punishment. “Doc, you don’t like your patients of this belief and you must do something about it.” It’s like, “You’re a bad doctor and your punishment is that you have to get an education,” said Copeland, who is responsible for health, inclusion and diversity in Kaiser Permanente’s health system. (KHN is an editorially independent program of the KFF, which is not affiliated with Kaiser Permanente.)
KP’s approach is now based on data from patient surveys that ask whether a person feels respected, whether communication is good, and whether they are satisfied with the experience.
KP then breaks this data down by demographics to determine whether a doctor is getting good results on respect and empathy on white patients but not black patients.
“If a pattern develops around a certain group and it’s a persistent pattern, then that says there’s something about a culture, an ethnicity, a gender, something that group has in common, that Don’t address them. “Copeland said,” Then the real work begins. ”
When doctors are shown their patients’ data and the science of unconscious bias, they are less likely to fight back or deny it, Copeland said. In his health care system, they have redefined the goal of training to achieve better quality care and better patient outcomes. That is why doctors want to do this.
“People don’t flinch,” he said. “You are excited to learn more about it, especially how to mitigate it.”
It has been almost six months since Monterroso first got sick and she is still not doing well.
Her heart rate continued to rise and the doctors told her that she may need gallbladder surgery to treat the gallstones she developed as a result of COVID-related dehydration. She recently decided to leave the Bay Area and move to Los Angeles so she can be closer to her family for the long recovery.
She declined the Alameda Hospital invitation to speak to her staff about her experience, and concluded that it was not her responsibility to fix the system. However, she wants the wider health system to take responsibility for the prejudices that exist in hospitals and clinics.
She admits that Alameda Hospital is public and does not have the resources that KP and UCSF are providing. A recent audit warned that the Alameda healthcare system was on the verge of bankruptcy. But Monterroso is the CEO of Code2040, a nonprofit promoting racial justice in the tech space, and even for them, she said, it took an army of support to be heard.
“Ninety percent of the people who are going to come through this hospital won’t have what I need to fight against,” she said. “And if I don’t tell what happens, people with far fewer resources will come into this experience and they will die. ”
This story is part of a partnership that includes KQED, NPR, and KHN.
Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation that is not affiliated with Kaiser Permanente.