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You don’t know what you don’t know! Watch for the cognitive biases!

Ketan Kulkarni's story on Equity
Ketan Kulkarni

As a physician of BIPOC and racially visible minority, my voice has a wide variety of notes to form a rich pattern. I feel fortunate and privileged to care for patients with blood disorders and cancers and help families with a wide variety of background! From new Canadians to not so new Canadians!

A recent experience while caring for a family with black heritage was particularly noteworthy and enlightening. It showed me the amount of work we need to do ensure a truly equitable and diverse healthcare workforce and provide quality care to all Canadians regardless of their background and socio-demographic characteristics.

I was doing ward rounds. I entered a patient room and was assessing a child with fever. The mom was by the bedside. The family has black heritage. We were engaged in a deep conservation on the child’s progress, how the child was feeling that day. I was explaining the family my plan of management.

A young professional barged into the room. There was no door knock! He did not notice me already engaged in conversation with the family. Neither did he notice my badge or my stethoscope.  Completely ignoring me, he started talking to the mother and the child asking how they were doing and what was going on. He introduced himself as a medical student. He was a young Caucasian male.

The conversation continued for several seconds. I tried to hint but to no avail! The conversation continues unabated.

Finally, I interrupt saying I’m already in a conversation with the family. I asked if he can return later. The student then realized his error and left.

On subsequent enquiry, the student assumed that I was the girl’s father. I have south Asian heritage and have brown skin color with obviously distinct heritage and physical characteristics than people with black heritage. While it would be totally possible with have family members with distinct heritage, the assumption perplexed me. Why wouldn’t the student ask who was in the room? Why wouldn’t they notice that a health care professional was already in conversation with the family despite prompts. Why would this happen?

“On deep reflection, rather than reaction, I realized that this was likely unconscious cognitive bias”

The student inadvertently assumed and considered that all persons of color are the same. It did not occur to the student that a person of racially visible minority may be the treating and most responsible physician for this family. The student did not recognize the need to assess the dynamics of the people present in the room. The student was a victim of several cognitive biases that needed recognition and correction.

First, was implicit bias that occurred automatically and likely unintentionally. However this led to the students abrupt behaviour and lack of recognition that a health care professional of a racially visible minority was in conversation with the family.

It appeared that a component of confirmation bias was also likely contributory since people with African and Asian heritage comprise of minority of workforce in tertiary and quaternary care centers in several cities in Canada.

On further analysis, the Dunning-Kruger effect was also apparent. This occurs when a person’s lack of knowledge and skills in a certain area causing them to overestimate their own competence in that area. The student likely overestimated his ability to provide care in this setting while lacking the requisite skill set for appropriate professionalism and bedside manners.

There was opportunity to have further discussion with the student and use this experience as an educational opportunity. Clearly, the student was apologetic, and the situation was unintentional. I emphasized that the discussion with this student be focused on making it a valuable educational experience rather than punitive. This highlighted the need for recognizing unconscious biases that we all potentially have. Unconscious biases are the learned stereotypes about certain groups of people that are formed outside of our conscious awareness. They often tend to be automatic, unintentional, and deeply engrained in our belief system. They do have the ability to affect our behaviour and actions.

This experience further highlighted for me the work needed to truly address equity, diversity, and inclusion on our health care. We need a strong framework for our hidden curriculum and need to highlight equity, diversity, and inclusion training from early stages of medical career, from the very beginning.

Practical steps need to be taken to include recognition of common cognitive biases, train everyone to be aware of their potential blind spots and those of others. Brining and addressing cognitive biases to the forefront of our awareness would significantly contribute to our mission of equitable, diverse, accessible health care workforce and health care for all.

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