Over the past several years, overdue conversations about implicit bias in medicine and the need for health equity have emerged, and workplaces are increasingly developing strategies to address the problem. PubMed searches of the terms “implicit bias” and “health equity” reveal that the number of articles published on this topic has increased exponentially over the last decade. Health care workers are talking about and working on these issues now more than ever. As awareness grows, many professionals are looking for tools and techniques to unlearn harmful thought processes, correct common misperceptions, and address bias when it arises.

Workforce diversity in medicine is a public health issue. Research shows that physicians from Black, Hispanic, and Asian backgrounds play a critical role in providing care to underserved patient populations.¹ The physician workforce in the U.S. is becoming more diverse, but it is still predominantly white and male.² Those with different identities can often feel that they are on the outside, and the constant struggle to belong or be included can feel exhausting. Representation matters because it enables those with non-dominant identities to see others like them in medicine and recognize that they, too, belong.

Making medical education more accessible to those from underrepresented groups is a key step, but physicians continue to face bias in their work environments throughout their training and career.

This article aims to equip physicians with four skills and tactics to spot and tactfully handle discrimination in the health care setting.

FOUR SKILLS AND TACTICS

Think about a time when you witnessed discrimination in a health care setting, whether toward yourself or someone else. It might have involved a hurtful and unjust interaction with a patient or a colleague based on age, race, gender, ethnicity, religion, sexual orientation, body type, physical or mental ability, education, language, etc. Reflect on how you handled (or didn't handle) the situation, and how challenging it might have been.

All too often, discriminatory behaviors go unaddressed because we either fail to recognize them or feel unable to respond, like a deer caught in the headlights. In the moment, it can be difficult to come up with the right response — something to say or do. Practicing the following skills and tactics can help us be better prepared in the future.

1. Spot it. The first step in handling discrimination is to develop a lens for identifying it at the individual and organizational level. Although discriminatory behavior can be overt, often it is more subtle, indirect, or implicit. If you are not personally the target of the discrimination, it may be difficult for you to recognize that it is happening to others.

A helpful exercise is to think through a number of privileges you may or may not be afforded by your personal identity. The list below is not exhaustive (it is borrowed from a longer list by Holm et al³), but it covers a number of different aspects of identity and privilege that you may not have previously considered:

• If I ask to talk to the person in charge, I will be facing a person similar to me,

• If I walk toward a security checkpoint in the airport, I can feel that I will not be looked upon as a suspect,

• I can easily find posters, postcards, picture books, greeting cards, dolls, toys, and children's magazines featuring people who look like me,

• I can feel confident that my customers/patients feel that I am qualified upon first impression,

• My employer gives days off for the holidays that are most important to me,

• I can speak in a room full of hospital leaders and feel heard.

Often, our feelings are the first indication that a discriminatory action has occurred. If something makes you or someone around you feel uncomfortable, scared, angry, etc., it can be helpful to name the feeling. You don't have to have a perfect analysis of the situation or a perfect response ready before you say how something made you feel.

2. Don't ignore it. Incidents of bias may seem small to others in the moment, but they are often harmful because of the cumulative impact they have over time. This is particularly true of small comments or behaviors referred to as “microaggressions,” which unwittingly affect others. By sweeping them under the rug, we give implicit approval for them, perhaps in front of colleagues, learners, or patients who were harmed.

Those harmed shouldn't have to interrupt the discriminatory behavior themselves. Something we hear over and over from those who have been on the receiving end of these incidents is that the single most important thing we can do for our colleagues is to do something. It can be easy to let an uncomfortable situation pass without comment because we are unsure of the perfect response, but this only adds to the harm. Particularly in situations where faculty members or others in positions of relative power have witnessed the behavior, it is meaningful to hear them address the other person in real time or at least acknowledge later that something harmful occurred. It can be as simple as checking in on the person affected and saying, “I heard what that patient said, and I'm sorry. I didn't know exactly how to respond, and I'll need to reflect on that, but I recognize that it was harmful and want you to know that you are a valued member of our team.” If needed, help the person who was harmed navigate your institution's process for reporting concerning situations or inappropriate behavior.

3. Call in vs. call out. One helpful tactic for addressing discrimination is the concept of “calling in” versus “calling out.” Instead of attacking someone for a behavior, which puts the other person on the defense and shuts down the conversation, start from a place of curiosity and assume good intent. This may give the person a chance to learn something new if they were unknowingly causing harm and can help preserve the relationship, which can be important in a work setting. Additionally, this tactic can be used when you have missed the moment but decide you need to offer feedback retrospectively to someone about a discriminatory action.

When “calling in,” here are some suggestions to consider:

• Start from curiosity, not certainty,

• Recognize that we all make mistakes, and speak from this shared experience instead of shaming or blaming,

• Be specific and direct, using personal stories if possible,

• Choose a time and place that supports conversation and learning,

• Disagree with the statement or action, not the person.

Here's what a “calling in” conversation might look like between colleagues:

Dr. A: “Hi, Dr. B, I'm curious about an interaction we had this morning, and I wondered if you had a couple minutes to talk.”

Dr. B: “Sure. What's the problem?”

Dr. A: “When you introduced me to the new staff member, I don't know if you realized this, but you mimicked my accent, which felt hurtful.”

Dr. B: “Oh, that was nothing. I was just joking.”

Dr. A: “I understand that. I have accidentally hurt others before by teasing as well. I just wanted you to be aware of how it made me feel. When I came to this country as teenager, I could not speak the languageat all. I worked very hard to learn it but couldn't get rid of my accent. I used to feel ashamed of it, but now I'm quite proud of it. My accent means I can speak multiple languages, and it often helps me connect with others who feel misunderstood.”

Dr. B: “I didn't realize that. I apologize.”

Dr. A: “Thank you. And thanks for hearing me out. I enjoy working with you, so I just wanted to clear the air.”

Dr. B: “No problem.”

Not every conversation will go this smoothly, of course, but resist the urge to call people out for their behavior. You may be justified, but you won't be effective.

4. Use your judgment. The situations health care professionals face every day in their institutions can be challenging. While it is natural for people — particularly doctors — to crave checklists or concrete guidelines for handling tricky situations, the reality is that this is messy work. When we address issues of race, gender, and other identifying characteristics, we often collide with complex power dynamics. There are no “right answers” for handling these situations, but unfortunately there are some wrong ones. So much of our approach to addressing discrimination depends on context. For example, should you address a racial slur made by a 93-year-old patient with dementia who isn't oriented to time or place? Should a student tell an attending a comment was harmful when that attending will be filling out the student's evaluation later that week? Is it important to acknowledge a harmful comment immediately, or is it better to wait until later when emotions aren't as high? Is humor an acceptable way to address a situation, or does that minimize the harm? These are the types of questions you will have to wrestle with and decide what is best for each situation.

MOVING FORWARD

We are all learning and growing in this work to create a more equitable health care environment. Take a few minutes to pause, reflect, and determine a specific next step you will take on this journey, and share it with someone else. Look at yourself, your team, and your institution to determine what the next step should be. Perhaps it is simply talking about these situations with your colleagues or practicing potential responses so you feel better prepared when these moments occur. No matter how small the step, it will help us all move closer to our ultimate goal: building health care institutions where patients and colleagues of all identities can thrive.