In my work in palliative care, I try not to make assumptions. I start each patient encounter like I start a new book or movie: I settle in and let them tell me the story. I allow a narrative to unfold; I lean in, engrossed as I experience something that is not about me. This is not my story, I tell myself. I can’t presume to know what leads a person to do the things that they do, act the way they act, or make decisions in the manner they have. I take what they tell me at face value, and try to hold my judgments at bay.
When it comes to COVID-19, however, that work gets complicated.
Today, most of my notes have the same cadence: “42-year-old male with no significant past medical history, COVID-19 positive, unvaccinated, admitted for respiratory failure/pneumonitis, in critical condition.”
A statement that feels neutral, yet contains an implicit bias: This man is unvaccinated, therefore he had it coming.
Implicit bias is when we are unaware of an attitude toward people or positions that may affect our actions. It is different from a stereotype because with it comes a belief that is rooted in our inner core values.
Medical professionals do not receive enough training to identify or overcome implicit biases. We are often taught to charge through each patient encounter like a bull in a china shop. We are not trained to slow down and reflect, to ask ourselves, Did I treat this patient differently? Did I use a different tone than I should have? Am I providing or withholding treatment that I might offer to someone else? Do I recognize that this patient’s values and decision-making may be different from mine without judging them? In short, we are not always trained to remember our compassion.
As COVID-19 creeps on, I’ve turned to experts to help me overcome my implicit biases. One social psychologist in particular, Jonathan Haidt, offers a framework that I find useful. Haidt’s “Moral Foundation Theory” includes five basic foundations: Care/Harm, Fairness/Cheating, Loyalty/Betrayal, Authority/Subversion, and Sanctity/Degradation. Together, these serve as the building blocks of morality. When an implicit bias comes up, it may be because one of these foundations was challenged.
Medical professionals in particular may relate to many of these foundations. First and most obvious is Care/Harm: We are trained to alleviate patients’ suffering by providing treatment designed to cure diseases or alleviate symptoms. Next is Fairness/Cheating: With the Delta variant on the rise, our sense of altruism may be challenged; we may unconsciously feel that those that did not get vaccinated were cheaters. We may also believe that they were not team players (Loyalty/Betrayal), or that they didn’t listen to the medical advice that had been given to them (Authority/Subversion). Finally, we may not understand a patient’s religious or ethical values (Sanctity/Degradation).
With Haidt’s foundations in mind, I have developed a series of steps to recognize and overcome implicit bias in the age of COVID-19. These are included below.
1. Rate your bias. I call this the gut check. Knowing that we all have implicit biases, take a moment before each patient encounter to do an honest assessment. On a scale of 1-10, how do I rate my discomfort with this patient?
2. Identify your bias. Which moral foundation is being challenged right now? Which one resonates?
3. Listen to the patient’s story. We often drag our biases around with us, shoving them into the patient room before we enter. Or we wait for the first few answers to our questions and then decide we already know the rest of the story, filling in the gaps in our head. Lean in. Watch the movie. Connect with the characters. Be moved by the plot line.
4. Breathe. Yep, breathe. I literally will put one hand on my chest, another on my belly, and exhale. I will whisper a quick prayer that I can be present in this patient encounter.
5. Honor the patient’s humanity. We are all connected in the human experience, put on this earth to experience the rise and fall of life. Universal suffering and loving kindness are in each of us. We don’t have to understand or even agree with the patient to do this.
6. Walk away. Just as a movie ends, so does this patient encounter and experience. Remember: It is not our story, so we will not lose anything by engaging for this one moment in time. When it is over, we should all take a moment to feel it, reorient ourselves with our world, and leave the story with the patient. This set of actions will allow us to have one heartbreaking patient encounter after another without actually breaking our hearts.
7. Re-Align. I have created an internal compassion fatigue barometer for myself and when it is low, I re-align myself. For me, this is about hugging my children, going for a run, oil painting, or calling my friends to laugh about something ridiculous. I pray and journal. Re-alignment will look different for each of us. It is simply the act of re-plugging into our life story to fill our tanks back up.
Implicit bias, and the compassion fatigue that follows, are real. We do not have to feel guilty or ashamed of these natural human tendencies, provided we work to address them. In the age of COVID-19, we clinicians are doing something we never imagined when we were in training. And yet, that person who saw their first patient with awe and wonder is still there, maybe more jaded and tired, but waiting to be given permission to re-engage. With humanity and compassion.
How do you overcome implicit bias or compassion fatigue at work? Share your thoughts in the comments below.
Preeya Desh, MD is a board certified Hospice and Palliative Care physician, with a background in Pediatric Hematology/Oncology, practicing in West Palm Beach, Florida. She is founder of Wabi Sabi Health Foundation, a nonprofit that facilitates and supports training in developing countries.