White paper, grey literature, black box warning. The nature of our medical research, presentation, reporting, and publication has defined the values associated with colors.
A white paper is defined as an “authoritative” report on a subject. Grey literature is described as being “non-conventional, fugitive, and sometimes ephemeral.” And a “black box” warning alerts physicians and patients to potentially fatal side effects of a medication. Even in seemingly benign verbiage we perpetuate the notion that white is the authority, grey must be approached with caution, and black is dangerous. This colorful language is an example of the widespread implicit bias in medicine and science. Whether in the murder of George Floyd or the racial disparities evident in the COVID-19 pandemic, systemic racism pervades our institutions, leading to fatal consequences.
As physicians and scientists, we like to think we are immune to stereotype and prejudice. We are not.
Implicit bias
Implicit bias (or unconscious bias) refers to “the attitudes or stereotypes that affect our understanding, actions or decisions in an unconscious manner.” These attitudes, while pervasive and resistant to change, are malleable if identified, called out, and explicitly challenged.
In the medical profession, research has shown how implicit biases can interact with our conscious (or explicit) reasoning to negatively affect health care delivery and outcomes. Many healthcare professions have recognized this and have begun to implement curriculum to make their students more aware of their own biases and teach them strategies to overcome them. Yet, will implicit bias training be effective if we perpetuate these same biases in our medical language and scientific publications?
Implicit bias is just a comfortable way to say bias
It is not surprising that healthcare professionals have subconscious biases against individuals of a particular race, ethnicity, gender or socioeconomic status when subliminal messages are perpetuated in the words we commonly use. Even our use of the word “implicit” in front of bias communicates a subliminal message. It makes our bias seem somehow more innocent, less overt. Perhaps in order to really change how we view people of different race, ethnicity, gender and socioeconomic status we need to start by calling implicit bias what it is: bias.
Bias in medical advertisement
A famous advertisement in the 1960’s for the anti-psychotic Haldol featured an angry looking black man holding up a fist, a common symbol for black power. The words above the advertisement read: “Assaultive and Belligerent, Cooperation often begins with Haldol”, overtly conflating black anger with psychosis. Advertisements for other anti-psychotics such as Thorazine and Stelazine also included African tribal imagery, connecting African ancestry with psychosis. Not surprisingly, a series of studies showed that Black patients in this time period were significantly more likely than White patients to receive a diagnosis of schizophrenia, and were on higher doses of antipsychotics, when compared to white patients.
Although these images may be viewed as overtly racist in 2021, there are still many ways we perpetuate racial bias in medicine and medical research. Check your home cabinet, the medical clinic, or the local pharmacy for adhesive bandages. White flesh-toned products predominate.
“Flesh-toned”
Even the phrase “flesh-toned,” which has become a commonplace descriptor, is defined by Merriam-Webster as “having the color of a white person’s skin.” Look in medical textbooks for images of patients. Light skin tone is overrepresented, and a study showed that imagery of 6 common cancers for people of color or dark skin tones is non-existent. These images (or lack therof) perpetuate the notion that White race is what we care about in medicine.
Perhaps more critical may be the image of the typical physician and the message that sends about who can become a doctor. Most TV physicians are white. Google the words “doctor” or “physician” and only the minority of images show Black examples. Even in “real life,” only 6% of all physicians are Black. Why? The answer is multi-faceted, but start by examining most admission committees for medical school in the United States. They are overwhelmingly white and it has been hypothesized that this is one reason for the lack of diversity in medical schools.
Flexner report generated significant race disparities in medical education
Recently, we have been reminded that the early 20th century Flexner report, which attempted to codify professionalism in medicine, resulted in the closure of nearly every historically black medical college. In fact, many studies have shown that doctors, who have strong representation on admission committees, show an implicit preference for White Americans compared to Black Americans. Lack of racial diversity in medicine creates the image in our minds of the White doctor and sends the not-so-subtle message to patients and students aspiring to enter medicine about the capability of the White race to achieve the “status” of physician.
Bias in medical literature
Medical literature and research publications may contribute to implicit bias. Most research reporting uses the white male as the reference category. In many articles, tables list males first and white race first, to which all others are compared. Why not just list demographics alphabetically?
In research, we also have the “Area Deprivation Index” and “Social Deprivation Index” to denote neighborhoods with less wealth, less education and more unemployment. But are people in these neighborhoods deprived? Do they see themselves as lacking the necessary tools to live a fruitful life? Or is this a judgement statement masked as research terminology?
Stop using the term “white paper”: Changing our words is important
We can all fight bias. Authors may include in their methods the reasons why particular demographic variables were chosen as the referent. Reviewers and editors should require this in all manuscripts. If there is not a compelling reason to use a particular demographic variable as the referent, researchers and analysts may randomly select the referent, and this should be included in the methods.
We should stop using terms that may invoke racial stereotypes. For example, instead of the term “white paper”, perhaps position paper, policy brief, or just report. Instead of “black box warning,” perhaps just a warning, or boxed warning, or alert. Advertisements and media should never use racial or gender stereotypes and should use caution in the use of potential bias in language and images.
Words are important. The images we create matter. The way we represent our research is crucial to address racial bias and racism in medicine. Each instance of implicit bias on its own may not create the disparities we see in medicine, but taken altogether, we cannot deny the influence this has on healthcare professionals and researchers.
Racial equity is important in all aspects of our life. Medical research and healthcare delivery may lead our collective efforts by declaring our values and intentions, changing our language and images, and commit to eliminating the racial disparities that are crippling our nation.
Table 1: Examples of Words/Imagery with Bias
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Yalda Jabbarpour
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Jack Westfall