Mitigating Implicit Biases in Certification Programs

On April 5, 2021

Implicit biases contribute to systemic racism and health disparities in minority communities, but American Board of Medical Specialties (ABMS) Member Boards can take steps to mitigate them in medical education, residency, and certification programs, noted speakers at ABMS Conference 2020 – Virtual held last September.

ABA’s roadmap to advance DEI

Daniel J. Cole, MD

“Race doesn’t cause glaring differences in health; racism does,” stated Daniel J. Cole, MD, Executive Director of Professional Affairs at the American Board of Anesthesiology (ABA). The medical community has long known that health disparities are associated with higher mortality rates among minorities, he said, citing the 2003 Institute of Medicine report entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. The report also showed that disparities were not just the result of social policy, but also of intrinsic biases in the health care system and among physicians. Sadly, despite pockets of success, not much has changed. “In 2020, our nation seems to be waking up to the fact that a culture of racial injustice and a culture of health cannot co-exist,” Dr. Cole said, adding, “This is truly a moment that we can step into, and improve the health and health care of America.”

Racism occurs at multiple levels from within individuals to throughout systems. Many people grow up with an internal conflict between the societal values of fairness, justice, and equality they are taught, and personal and social forces that promote unconscious or implicit bias, prejudice, and discrimination, he said. “The term aversive racism provides a meaningful distinction from overt or explicit racism and unconscious bias with which we all struggle,” Dr. Cole noted. It refers to individuals who support the value of racial equality and regard themselves as nonprejudiced, but, at the same time, possess unconscious biases and beliefs about other races.

At the system level, structural racism results in health disparities for socially disadvantaged minority communities. A recent meta-analysis of 293 studies between 1983 and 2013 revealed that racism is significantly associated with poorer general, mental, and physical health in minority populations. “This study demonstrates that racism is a determinant of health,” he said.

The COVID-19 pandemic has amplified the magnitude of health care inequities as demonstrated by data showing that people of color are bearing a disproportionate burden of COVID-19 cases, deaths, and hospitalizations, Dr. Cole stated. Minorities have more health risks, including body mass index, smoking, diabetes, and high blood pressure, that put them at higher risk for severe COVID-19 illness than whites, according to a recent study published in Health Affairs. Social determinants, such as living in households with health-sector workers and the inability to work from home, also play a role in COVID-19 disparities. The authors concluded that disparities in COVID-19 outcomes likely stem from structural racism on many levels.

To address implicit bias and structural racism, the Member Boards can elevate the cause and keep it a high priority; engage multiple stakeholders in these efforts; provide training on diversity, equity, and inclusion (DEI) and health disparities; and develop policy positions, particularly with specialty societies, and pathways of improvement that root out structural racism in health care.

At ABA, the board is working on collaborations with anesthesiology affinity groups to advance diversity and inclusion efforts within the specialty. It is considering how lifelong learning and self-assessment in continuing certification could address issues of racism and bias in clinical care. The board recently updated its Maintenance of Certification in Anesthesiology (MOCA®) content outline to include health care disparities and DEI, and will launch related MOCA Minute® questions this year. The board will begin collecting race/ethnicity data from candidates and diplomates later this year to enable research on exam performance and outcomes based on demographic data, including a study it plans to conduct in collaboration with the Accreditation Council for Graduate Medical Education. ABA is surveying volunteers to establish a baseline for identifying metrics to set goals and track progress of these efforts. The board is providing unconscious bias and inclusion training for volunteers and examiners, as well as focusing on DEI for its governance, volunteer, and staff groups.

“Racism is a complicated and complex issue that is pervasive in our society and will not be solved by a single presentation,” Dr. Cole concluded. “Instead, let this be a beginning of real action. Together, we can work with civic, government, religious, community, and private sector leaders to design and implement effective actions to address health care disparities.”

ABS’ focus on oral exams

Marni C. Grambau

Marni C. Grambau, Director of Examination Development at the American Board of Surgery (ABS), explained why having implicit biases is part of being human. According to the Kirwan Institute for the Study of Race and Ethnicity at Ohio State University, people act on implicit biases without any awareness or sense of voluntary control.

Studies have shown that biases are a natural part of human development in terms of seeking out others who are similar. In a study conducted by the Yale Infant Cognition Center, infants chose a stuffed toy that “ate” the same food they did. The study authors note that the preference to associate with people who are similar occurs prior to language and extensive exposure to cultural norms. Like adults, prelinguistic infants prefer those who share even trivial similarities with themselves. “To be biased is to be human,” Grambau said. “It’s how our brains work and how our social functioning works.”

Most people, however, maintain that they are not biased. Even when unconscious bias is misaligned with a person’s own values, it’s hard to identify those biases within oneself, she said. Examples of cognitive biases that people accept are anchoring, availability heuristic, and confirmation bias. The blind spot bias is the tendency to see oneself as less biased than others or to be able to identify more cognitive biases in others than in oneself. Using the Lake Wobegon effect, which is the tendency to overestimate one’s achievements and capabilities in relation to others, more than 85 percent of people believe they are less biased than the average American.

The Implicit Association Test (IAT) was used in a study published in the Journal of General Internal Medicine demonstrating how implicit bias impacts health disparities. Although none of the 287 physicians in the study reported having racial biases, their IAT results revealed that they had an implicit preference favoring white Americans and implicit stereotypes of Black Americans as generally less cooperative, especially regarding medical procedures. The higher the pro-white implicit bias, the greater likelihood the physicians used thrombolysis to treat white patients for coronary artery disease, but not Black patients. Among an outlier group of 67 physicians who were not included in the reported results but were aware of the study’s purpose, an increase in pro-white implicit bias was associated with an increase in treating Black patients with thrombolysis for coronary artery disease. The “aware” physicians understood their biases and were able to avoid them in their decision making, Grambau said, demonstrating that awareness of one’s own biases can help to mitigate them.

Accepting the fact that everybody has implicit biases, ABS set out to mitigate – not eradicate – bias in its oral exams. “We’re not fixing people, we’re improving systems,” said Grambau, who reviewed the board’s approach. ABS now provides bias training to all examiners and has an ongoing dialogue about bias. Being as methodical and data driven as possible limits room for subjectivity, and therefore bias, she said. As an example, ABS has examiners grade on a case-by-case basis, immediately after the candidate goes through a case, to facilitate their recall. Examiners are asked to focus on the candidate’s response, not their body language that may suggest over-confidence or extreme nervousness. Examiners score candidates independently without discussing their performance with other examiners.

All candidates are held to the same standard, Grambau said. Each version of the exam has the same balance of case difficulty. ABS has case-specific grading rubrics so that examiners have guidance regarding the focus of each case and severity of possible errors. ABS holds its examiners accountable, for example, by requiring them to write down candidate performance notes for all their decisions. ABS audits the process to determine whether there was possible bias based on demographic information collected. The board primes the examiners by speaking about bias before each exam and includes reading materials on the topic and reminding them of the importance of a fair and equal examination experience. Creating heterogeneity in decision-making bodies helps to ensure that everyone has a voice because people don’t share the same experiences or biases, she said. Considerations around diversity for oral examiners and item writers include race, ethnicity, accent, gender identity, orientation, training, geographic area, and practice setting.

ABMS would like to thank Bonnie Mason, MD, Vice President of Diversity, Equity and Inclusion at the Accreditation Council for Graduate Medical Education, for serving as moderator for this session.


© 2021, American Board of Medical Specialties.

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