Inspired by an essay published in Iowa Law Review by Bartlett and Gulati from Duke Law School that succinctly elaborated on underexplored discrimination by customers.

Now, we will elaborate our thoughts as they correspond to health care.

While practicing clinical medicine, health care professionals, including physicians, may encounter implicit bias of their patients even when the payments for the services rendered to patients are by third-party payers as regulated by overseeing regulators.

While administrating academic medicine, medical school and graduate medical education administrators, including program directors, may encounter implicit bias of applicants to medical schools and graduate medical education programs. While recruiting medical staff, human resource recruiters may experience implicit bias of applicants for various medical staff positions, including positions vacant for clinicians and academicians.

It all comes full circle for populations bound to working within their systems without implicit bias. It mitigates practices when the same people are allowed to act per their implicit bias once they change their roles into customers in the same systems. Nuances inculcated by implicit bias training may be forgotten by the trained workers when they become customers.

Moreover, the implicit bias might occur when privileged degree-holding physicians who become patients prefer not to be cared for by well-skilled but marginalized non-physicians.

The same systems should evolve to mitigate rather than learn to ignore implicit bias of their customers — just like they are tediously working to mitigate implicit bias of their workers.

Although customers’ private and personal biased decisions may be challenging to regulate, the systems may have to learn not to base their growth strategies to fulfill and even stoke the biased wants of their customers. That is, even if some types of implicit and explicit bias by customers have been deemed acceptable by Bartlett and Gulati to compensate and correct the historical wrongs.

Overall, we are posing certain specific scenarios as questions that may open up discussions among the think tanks in health care to delve into and address them to mitigate implicit and explicit bias by customers.

But how do we avoid applicants and patients discriminating by where applying to work and where to get treated, respectively?

Should recruiting health care administrators and advertising health care institutions ensure that their online recruiting and advertising campaigns reflect the diversity they want to aim for and achieve rather than the reflection of the diversity that they currently have?

How can we avoid the National Resident Matching Program (NRMP) acting as an intermediary facilitator to match the overregulated choices made by recruiting programs? Will it be better if applicants do not rank programs after having been interviewed there? Because, unlike the programs’ choices, applicants’ choices cannot be regulated to mitigate their implicit bias based on their feelings during interviews in the programs they chose to get interviewed based on their implicitly biased screening of programs before applying to the chosen few.

What if programs regularly update and publicly disclose diversity data to demonstrate how their diversification strategies are neutralizing applicants’ implicit bias?

Won’t those strategies be fruitless?

Maybe, as long as interviewed applicants differentially rank equivalently accredited programs in NRMP unless in-person visits to programs by interviewees before ranking can be discarded and replaced with virtual interviews only.

Then, the interviewers’ characteristics could be incompatible with the interviewees’ age, gender, race, ethnicity, and any other implicitly biasing characteristic. For example, could all young, male, white, non-Hispanic interviewees be remotely interviewed by old, female, non-white, Hispanic interviewers?

Shouldn’t patients and their payers be asked to reimburse extra whenever they choose differently based on bias?

Will “health care for all” — under adequately funded and appropriately reimbursing inflation-corrected “Medicare for all” — resolve explicit and implicit bias? How would this favor privately insured patients and their higher reimbursement paying payers whose needs and outcomes may be superseding the needs and outcomes of publicly insured patients and their lower reimbursement paying payers?

Summarily, avenues of discrimination by customers in health care based on customers’ implicitly biased flee-fight-freeze-flop-fawn-friend strategies are immense. And they may continue to be tolerated until health care wakes up to address it. It would be like it is awakening to address discrimination by workers based on their strategies to flee-fight-freeze-flop-fawn-friend with a competitive survival mode instinctively creating implicit bias.

Deepak Gupta is an anesthesiologist. Sarwan Kumar is an internal medicine physician. Shushovan Chakrabortty is a pain physician.

Image credit: Shutterstock.com