Halting a Crisis: When Implicit Biases Interfere

This article is the eighth in a series about the epidemic of opioid addiction and how NEOMED is training future physicians and pharmacists to help.

Gretchen Ferber, a second-year College of Medicine student, and Paula Rote, a third-year medicine student, knew they were treading in controversial territory with their presentation, “Becoming a Physician: Ethical Challenges in Medical Education,” for a medical ethics conference. But they felt strongly about their research findings: that patients with addiction are often not fairly treated, due to implicit biases on the part of the health professionals caring for them.

“People with addiction are often looked down upon,” says Ferber. “Even though there is a neurological basis to their addiction, it is viewed as a personal choice.’’

Implicit biases held by health care professionals may include believing that people with addiction have lower morals and lack self-control—or that they care less about their bodies than do other people, report the two NEOMED students. These patients are often considered poor historians of their own health regardless of current substance use. They are not trusted to follow through with post-care needs. Most troubling to the two students is that health information is sometimes withheld from such patients, due to doubts about their agency to address their ongoing health concerns.

At the second annual medical ethics conference at the Icahn School of Medicine at Mount Sinai, held in New York City last January, the students used two case studies to show how implicit biases on the part of healthcare professionals affected the way in which they treated people with addiction.

Terrence Swanson’s Story

Here’s a distilled version of one of the case studies from the presentation, “Fairly Treating & Informing Persons with Addiction: Observations from Early Clinical Experience.”

Terrence Swanson, a 63-year-old African American male, has a history of Type I diabetes, end stage renal disease and a substance use disorder that has been treated with methadone for three years. Before coming to the ER with abdominal pain, vomiting and nausea for the past two days, Mr. Swanson had been recovering in a skilled nursing facility for the last six weeks from a left transmetatarsal foot amputation due to osteomyelitis—bone inflammation—secondary to diabetes. A CT scan of the abdomen reveals pneumobilia—accumulation of air in the biliary tree (liver, gall bladder, bile ducts) —but further tests of the gastrointestinal tract (GI), physical exam and a detailed medical history review determine it is idiopathic (of unknown origin).

Unknown to Swanson, a medical student reviewing his chart found he tested positive for Hepatitis C, but the medical staff did not support the student informing the patient of this diagnosis. Ferber and Rote observed an ethical dilemma: If students want to apply the principle of justice in medicine—requiring fair treatment and distribution of information and resources to all patients—then what was their role in fairly treating and informing persons with addiction, like Mr. Swanson?

Treatment doesn’t happen in a vacuum. As students, Rote and Ferber have discovered that one mentor’s direction may be different from another’s. Furthermore, medicine students are subject to subtle and not-so-subtle directions about how to treat their patients and how much information to provide. Ferber and Rote’s presentation discussed the ethically wrenching position into which a medical student may find themselves if given an indirect instruction to withhold information from a patient.

The two students credit their ethical training in NEOMED’s Human Values in Medicine curriculum with helping them wrestle with such difficult issues. Talking with Julie Aultman, Ph.D., associate professor of family and community medicine, and Michael Blackie, Ph.D., associate professor of family and community medicine, helped Rote and Ferber thoroughly consider their positions and to prepare for people’s reactions at the conference.

“Our fear was that other medical professionals wouldn’t believe us,” said Ferber. “Having had conversations with her and Dr. Blackie on ethics, and having reviewed Dr. Aultman’s lectures on ethical principles, helped us expand our thoughts on the subject to prepare for the questions people might ask.”

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