Stereotyped to Death

Everyone has unconcious biases—but when those biases affect medical diagnoses, the results can be disastrous.

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Jul 14 2015, 2:00pm

Image: Phalinn Ooi/Flickr

It was an easily treatable bladder infection that killed Brian Sinclair in 2008 after he waited 34 hours in a Winnipeg emergency room. By the time staff found him dead and covered in vomit in his wheelchair, rigor mortis had set in.

An inquest into Sinclair's death blamed a "perfect storm of events" for the tragedy, but failed to acknowledge what Robert Sinclair said is the most important factor in his cousin's death—"institutional racism and stereotyping." Staff ignored Brian, he claims, because they thought he was a drunk Aboriginal.

It happens all the time. Aboriginal people routinely receive second-class health care in Canada. The same goes for Black or low-income patients in the US. Transgender people face health-care discrimination. Overweight patients are prescribed weight-loss regimens for unrelated ailments. Women suffer heart attacks in silence for fear of being labelled hysterical.

Social psychologist Michelle van Ryn said most health-care professionals want to provide good care to individual patients, but their unconscious systems can fall back on stereotypes they don't consciously believe in. Whether intentional or not, the effects are very real, ranging from eroded trust in the health-care system to potentially fatal misdiagnoses.

The human mental operating system is two-tiered, explained van Ryn, director of the Mayo Clinic's Research Program on Equity and Inclusion in Health Care, which examines how medical professionals' unconscious biases affect the care patients receive. At the surface, we have our conscious system, which is cognizant and rational. "It's what most people believe is all we use. But in reality, there's a second system that controls about 70 percent of what we do," van Ryn said.

That second system, the reflexive system, operates automatically and subconsciously. It's why people can drive or type or read without thinking about it—and it's very susceptible to stereotypes.

"Unconscious bias arrives because we're a social species and we have well-developed structures for organizing humans. So, what happens is, whenever we meet someone, we're immediately aware of a social identity or their category," she said. "Things we pick are age, body size, race, gender. There are others, but those are the ones that jump out."

When she was pregnant with twin boys, Cecily Kellogg said her usually low blood pressure spiked, but her midwives didn't take it seriously because of her weight

This reflexive system "will rapidly and automatically apply a lot of information" based on those categories, van Ryn said. Sometimes that information clashes with a person's consciously held beliefs. It happens to everyone. But when it plays out in a healthcare setting, the effects can be disastrous.

"I'm fat. Like serious, not-fucking-around fat. I have been dismissed by doctors more times than I care to count," Cecily Kellogg, 47, of Philadelphia told Motherboard. "But nothing was as bad as the midwives and doctors that dismissed my pregnancy-induced hypertension."

When she was pregnant with twin boys, Kellogg said her usually low blood pressure spiked, but her midwives didn't take it seriously. Because of her weight, she explained, they refused to believe this wasn't her normal condition.

As a result, Kellogg's condition only got worse, and by the time she saw an obstetrician at 22 and a half weeks, she had already lost one of her babies. She was forced to abort the other to save her own life.

"[The doctor] said it was the worst day of his career. It sucked pretty badly for us too," she told Motherboard.

Annette, a 43-year-old bipolar woman who asked not to use her last name, said she was "terrified" when she went to a Toronto walk-in clinic about a lump in her breast.

"The doctor was totally sympathetic and said things like, 'I'm sure this must be scary,' and 'Don't worry, we'll sort this out.' … Then he read the sheet you fill in that has your medical history," she said.

"He turned around and said, 'You realize you are wasting time that someone else could use? Most women have lumpy breasts,'" Annette recalled. "I had to ask him very politely if he could just check that it was lumpy breast and not anything else. Turns out it was a blocked duct."

How do you fix a health-care problem that has its roots in the unconscious brain and deeply entrenched stereotypes? One way is to retrain the reflexive system with exposure to images that run counter to those stereotypes, van Ryn said.

"If you think about common stereotypes—for example, a common stereotype and so expectation of overweight or obese people is that they are lazy and lack intelligence—you can start imagining what images might counter that. For example, a heavy person doing complex work or exercising," she said.

"I would like to flood the clinics with counter-stereotype images. I'd like those images to be all over the place, I really would."

Doctors and nurses should also be trained in the partnership-building model of health care, she suggested. That involves abandoning the traditional doctor-patient hierarchy and working with patients to find solutions.

Rather than viewing each other being members of two distinct groups, health-care providers and patients become members of the same team. This is called "creating a common group identity," and it's been proven to reduce conscious and unconscious biases. It can be as simple as using "us and we" instead of "me and you," said van Ryn.

But the most obvious solution is perhaps also the most difficult to enact—ensuring hospitals and health clinics are well-staffed and positive work environments. This is something the Winnipeg Regional Health Authority has been working on since the Brian Sinclair inquest recommended the hospital take steps to increase staffing and reduce nurses' fatigue.

"Our implicit biases are more likely to hijack our behaviour when our resources are low—when we're tired, when we're anxious, when we're busy, when there's too many demands on our time," van Ryn said.

"And that's because the whole purpose of this system is to be efficient. It's a fallback."

Modern Medicine is a series on Motherboard about how health care and medical technology can move forward so rapidly while still being stuck in the past. Follow along here.