Let me be the first to admit that my mind’s internal and unspoken dialogue produces scathing critiques of the people whose behavior or ideologies are divergent from my own. This isn’t to say that I intentionally treat anyone differently because of personal differences that I observe.
On the contrary, I make a conscious effort to make my actions and spoken words consistent among everyone with whom I interact, particularly when I’m aware of the nasty judgments made in some dark part of my mind that doesn’t represent the kind of person I am or hope to be. As a physician-in-training, I know it’s vital to recognize and attempt to correct these kinds of implicit judgments, not just for my own well-being, but for the health of my patients. In its landmark book Unequal Treatment, the Institute of Medicine argues that racial and ethnic disparities in health care may arise from clinicians’ biases, stereotypes, and prejudices. Evidence supports these findings. Fortunately, many medical schools (including my own, Case Western Reserve University) are making curricular changes aimed at reducing students’ implicit biases.
Despite my intentions and the best efforts of my school, I have been unable to turn down the volume of the shameful, internal voice that unfairly and harshly judges those around me. That is, until I spent my 10-week summer break doing research in Colombia. The dramatic change made itself apparent immediately upon my re-entry to the U.S., during a layover on my way back to Cleveland. While eating dinner at what was apparently a local hangout in Fort Lauderdale, I found myself surrounded by the kinds of people and behavior that would have ordinarily launched my internal hate-monger into a tirade: the mostly overweight customers were chowing down on grease-dripping hamburgers, drinking double-shots of hard liquor, settling in to watch a UFC fight, and overtly hitting on the all-female waitstaff. Now, I didn’t suddenly think that any of what I was witnessing was necessarily healthy or appropriate, but neither did I find it repulsive in the way that I certainly would have ten weeks prior. In fact, I nearly found it inspiriting to see my fellow patrons indulging themselves in activities that I can only imagine brought them joy.
Looking around the bar and realizing that the nasty voice in my head had somehow been muted, I began to feel lighter and unencumbered by implicit judgments that I had constantly fought to keep at bay. Equally surprising, the feeling has stayed with me well after my return to Cleveland. What has also stayed with me is the question of why: Why did my summer abroad have such a profound effect on reducing my implicit judgments that I had unsuccessfully fought for so long?
I lived for ten weeks as an outsider in Colombia. This was obvious to every Colombian I encountered, as my gringo accent instantly gave away my foreigner status whenever I spoke. Obvious to me were the hallmarks of Colombian culture that sharply contrasted what I regularly encounter the U.S.: men and women kissing each other on the cheek when greeting one another, the central importance of one’s extended family that includes an immense respect for elders, and the ubiquitous influence of Catholicism, to name just a few.
By contrast to the U.S., where my security with the culture enables me to readily pass judgments on others, my experience as an outsider in Colombia forced a profound cultural humility upon me. This perpetual state of humbleness permitted me, for the first time, to navigate the world without distraction by an egotistical filter that automatically parses the people I encounter by labels of good and bad.
My medical education is indoctrinating me with a way of thinking that, at first blush, seems to be at odds with the label-free humility I enjoyed in Colombia. From what I can tell, making and acting on judgments about good and bad is central to the practice of medicine. Those judgments are frequently applied to patients, with the aim of formulating an intervention to improve health outcomes. At the same time, the IOM (not to mention intuitive morality) implores us to approach each patient with an open mind, free of preconceived labels. The challenge, then, is to make clinical judgments without making personal judgments that have the potential to become insidious sources of prejudice, lest we become characters out of Samuel Shem’s House of God. The question then becomes: How?
The experiences that helped me reduce my own implicit judgments are neither the practical nor indicated treatments for most people. Moreover, from my perspective as a 2nd-year medical student, I cannot claim to know what challenges the practice of medicine actually entails with regard to protecting one’s self from developing prejudices against certain patients. But I do feel confident in asserting that the first practical step for anyone hoping to turn down their own implicit attitudes is to gain an understanding of what those attitudes actually are. One way to begin is with an Implicit Association Test, a testing paradigm that has been used in hundreds of studies to elucidate a range of implicit judgments.
Another important step might be ensuring that we’re practicing medicine in an environment that doesn’t facilitate cynicism, a warning sounded by Dr. Tom Murphy in his eloquent piece on physician burnout. Regardless of the approach taken, I believe we have an obligation to minimize implicit judgments that are not only mentally and emotionally burdensome, but also hazardous to the health of our patients and ourselves.
The author is an anonymous medical student.