Since its beginning in 2010, the Council on Medical Student Education in Pediatrics has contributed articles to the Monthly Feature with tips about pediatric education for great clinical teachers. Although we will continue to offer practical articles for pediatric teachers, the article presented here represents the first of what we hope will be many articles coauthored by a medical student and a faculty member, which will present students’ perspectives. This article begins with a coauthored introduction, followed by individual reflections about bias in pediatric care from a faculty member and a student.

Evidence demonstrates that minority populations in the United States face disparities in regard to healthcare access, quality of care, and health outcomes1 —disparities that are exacerbated when healthcare professionals exhibit explicit or implicit bias toward these populations.2,3  Implicit biases, defined as attitudes or stereotypes that unconsciously affect behavior, contribute to healthcare disparities by affecting medical decision-making, treatment recommendations, birth outcomes, and quality of communication.4  Medical school, where most physicians begin their formal clinical training, may provide an optimal opportunity to increase awareness of implicit biases in healthcare as a step toward mitigating the effects of such biases.

Recognizing this, the Liaison Committee on Medical Education, which accredits all medical schools in the United States and Canada, requires opportunities for students to recognize biases in themselves, others, and the healthcare system.5  The Council on Medical Student Education in Pediatrics also recognizes the importance of teaching medical students to mitigate bias when caring for patients.6  New resources are needed to address the effects of implicit bias in clinical environments. Incorporating debiasing strategies, which interrupt decision-making at the unconscious level, offers one way to help minimize the impact of clinician bias,4,7  and may also provide a way to support medical students to recognize and minimize biases during clinical learning.

Education in the clinical years of medical school is less standardized than during the preclinical years,8  with learning occurring through clinical experiences, formal didactic sessions, and a “hidden curriculum.” The “hidden curriculum” conveys attitudes—including biases–through the values and behaviors exhibited by those in senior roles.8  Though rarely explicitly included during clinical instruction, bias education can occur if a senior member of the team explicitly addresses bias, allowing for the “hidden curriculum” to become explicit on this topic, highlighting the value of discussions about bias and helping students activate debiasing strategies. In this article, we share a faculty member’s creation of an approach to teaching medical students about bias, along with a student’s perspective on this approach, which we call “bias checks.”

As a pediatrician educator, I often observe learners developing assessments and plans based on assumptions about family dynamics and social needs. These assumptions may include decisions about who might benefit from social worker involvement, or which families may be less able to adhere to medical advice upon hospital discharge. These assumptions are often unfounded, with evidence demonstrating that clinicians allow biases to incorrectly influence their care plans.4  These assumptions influence decisions about children’s care, such as how families are educated about their children’s diagnoses, when medical teams involve social work and other services, and decisions about appropriate pain control.9,10  Knowing this, I felt a responsibility to address these biases in our patient care discussions in an effort toward improving healthcare equity. I introduced a brief “bias check” into each patient presentation on morning rounds in which I asked learners to consider biases that might influence our team’s response. I introduced the concept in the beginning of the week, reminding learners that implicit biases are natural but hard to identify. I sought to normalize this process by acknowledging my own biases that might influence my care, such as questioning if bias influenced my decision to decrease pain medications or if I was missing components of the history in my working diagnoses. I invited team members to identify whether I might be introducing bias into my treatment recommendations. I received their input with appreciation and without defensiveness to help model this approach and to create an environment in which learners could more freely express concerns about their own potential biases in each patient scenario. In many cases, the bias check lasted under a minute, yet illuminated important considerations.

These bias checks led to robust discussions. On one occasion, we debated if we would suspect nonaccidental trauma in a family from a different socioeconomic or racial and ethnic group. In another instance, we discussed if we might escalate pain management more aggressively if the adolescent patient was a younger child. Sometimes, these discussions led to changes in management. Other times, they allowed us to proceed with caution, more mindful of the risk of bias but in agreement that we were making a decision we felt was in the best interest of the patient. I learned from my team and believe they each grew in their capacity to consider bias before implementing plans.

During my pediatrics clerkship, morning rounds provided an opportunity to practice patient presentations and give my plan for my patients. A great deal of teaching occurred at this time, which was also the time when I was subject to the most scrutiny by those evaluating me. One morning, my new service attending (R.C.) announced that we would be doing “bias checks” on rounds. We were asked to give examples of biases that that could negatively impact care of each patient and consider concrete strategies for keeping these from affecting that patient’s care. One example was a patient being discharged with a new asthma diagnosis. The patient’s family did not speak English, and the potential bias discussed was that even with the use of an interpreter, we might doubt their ability to understand the physiology of asthma and their new medications as well as a patient who spoke fluent English. Without considering implicit bias, the education might have been modified to be less detailed than it would have been for an English-speaking patient. A strategy suggested to prevent this was to devote extra time for family education.

Initially I was concerned that sharing potential biases would negatively affect my formal evaluation. Although we were not sharing personally held biases, rather one that might be held by providers in our society, sharing felt like an admission that I was providing unequal care to my patients. However, our attending (R.C.) framed the exercise as a responsible action, one way of acknowledging that all providers possess some degree of implicit bias. Only by bringing these to the forefront of our consciousness would we be equipped to mitigate them. After each contribution, our attending validated the trainee’s bias concerns and encouraged learners to apply their mitigation strategy to other aspects of patient care. After participating in “implicit bias rounds,” I found myself inclined to do brief “check-ins” with myself about potential biases before going into a patient’s room or presenting to an attending, even on other rotations. As an example, I would pause before presenting my plan in the emergency department to ensure I was not dismissing a patient’s reported symptoms because of their repeated similar past presentations. Other examples, as well as potential mitigation strategies, are described in Table 1. Doing this feels like a positive step toward providing more equitable healthcare.

TABLE 1

Bias Check Frameworks

Bias Check FrameworkStep 1: Source of BiasStep 2: DescriptionStep 3: Impact on Patient CareStep 4: Active Mitigation Strategy
Example: parental absence during inpatient stay. Patient X’s parents have not been present during rounds for several days in a row. The absence of patient X’s parents could lead the team to assume that they are not interested in actively participating in rounds or receiving updates about patient X’s care. We may make less of an effort to update or involve patient X’s parents in treatment decisions. Ensure that patient X’s parents are being updated with the same regularity that a parent present on the floor would be updated. If possible and appropriate, offer to include patient X’s parents in rounds virtually. 
Example: frequent utilization of emergency department resources. The medical record shows that Patient Y has visited the emergency department several times in the last few months. Each time they were not found to require any emergent treatment and were sent home. The knowledge of Patient Y’s history could lead to the assumption that patient Y does not require urgent or emergent care. Patient Y could receive a less thorough interview and examination, which in turn could negatively impact the quality of differential diagnosis and treatment plan. Take care to give this patient the time and attention that any new patient in the emergency department receives. 
Example: adolescent nonadherence to treatment plan. Laboratory results obtained before the clinic visit show that patient Z, who is 16, has not been taking their medication as prescribed. Patient Z’s nonadherence could be assumed to be because of their being an adolescent. Providers may assume that patient Z will not be adherent to the prescribed medication and spend less time discussing barriers to taking medication or coming up with strategies to improve medication adherence. Ask patient Z what is making it difficult for them to take their medication and set aside time during the appointment to try to find a solution. 
Bias Check FrameworkStep 1: Source of BiasStep 2: DescriptionStep 3: Impact on Patient CareStep 4: Active Mitigation Strategy
Example: parental absence during inpatient stay. Patient X’s parents have not been present during rounds for several days in a row. The absence of patient X’s parents could lead the team to assume that they are not interested in actively participating in rounds or receiving updates about patient X’s care. We may make less of an effort to update or involve patient X’s parents in treatment decisions. Ensure that patient X’s parents are being updated with the same regularity that a parent present on the floor would be updated. If possible and appropriate, offer to include patient X’s parents in rounds virtually. 
Example: frequent utilization of emergency department resources. The medical record shows that Patient Y has visited the emergency department several times in the last few months. Each time they were not found to require any emergent treatment and were sent home. The knowledge of Patient Y’s history could lead to the assumption that patient Y does not require urgent or emergent care. Patient Y could receive a less thorough interview and examination, which in turn could negatively impact the quality of differential diagnosis and treatment plan. Take care to give this patient the time and attention that any new patient in the emergency department receives. 
Example: adolescent nonadherence to treatment plan. Laboratory results obtained before the clinic visit show that patient Z, who is 16, has not been taking their medication as prescribed. Patient Z’s nonadherence could be assumed to be because of their being an adolescent. Providers may assume that patient Z will not be adherent to the prescribed medication and spend less time discussing barriers to taking medication or coming up with strategies to improve medication adherence. Ask patient Z what is making it difficult for them to take their medication and set aside time during the appointment to try to find a solution. 

Actively identifying potential sources of implicit bias can help reduce the impact of bias in healthcare.4  Although discussing bias as a clinical team can be uncomfortable, the practice can increase accountability and improve patient care. Incorporating these discussions with regularity into structured learning, such as morning rounds, helps to prioritize bias checks and frame these as a necessary component of morning workflow. Integrating the bias checks into daily medical decision-making helps them function as an additional “safety check,” much like time-out checklists that are the standard of care for procedures. Transforming this part of the “hidden curriculum” into an overt educational initiative is a crucial step in ensuring inclusive and equitable care.

We thank Dr Susan Bannister and Dr Janice Hanson for their extensive editing, coaching, and feedback for the creation of this manuscript.

Dr Carter conceptualized and designed the concept for this intervention and contributed to drafting the initial manuscript; Dr Lake is an intern who was a medical student at the time of writing who contributed to drafting the initial manuscript; and both authors critically reviewed and revised the manuscript and approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: No external funding.

CONFLICT OF INTEREST DISCLOSURES: The authors have indicated they have no conflicts of interest relevant to this article to disclose.

1
Hall
WJ
,
Chapman
MV
,
Lee
KM
, et al
.
Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review
.
Am J Public Health
.
2015
;
105
(
12
):
e60
e76
2
Maina
IW
,
Belton
TD
,
Ginzberg
S
,
Singh
A
,
Johnson
TJ
.
A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test
.
Soc Sci Med
.
2018
;
199
:
219
229
3
FitzGerald
C
,
Hurst
S
.
Implicit bias in healthcare professionals: a systematic review
.
BMC Med Ethics
.
2017
;
18
(
1
):
19
4
Schnierle
J
,
Christian-Brathwaite
N
,
Louisias
M
.
Implicit bias: what every pediatrician should know about the effect of bias on health and future directions
.
Curr Probl Pediatr Adolesc Health Care
.
2019
;
49
(
2
):
34
44
5
Liason Committee on Medical Education
.
Functions and structure of a medical school: standards for accreditation of medical education programs leading to the MD degree
.
Available at: https://lcme.org/publications/#Standards. Accessed April 21, 2022
6
Council on Medical Student Education in Pediatrics
.
COMSEP strategic plan 2020 and beyond
.
Available at: https://www.comsep.org/vision-sp-guiding-principles/#. Accessed April 21, 2022
7
Sukhera
J
,
Watling
C
.
A framework for integrating implicit bias recognition into health professions education
.
Acad Med
.
2018
;
93
(
1
):
35
40
8
Torralba
KD
,
Jose
D
,
Byrne
J
.
Psychological safety, the hidden curriculum, and ambiguity in medicine
.
Clin Rheumatol
.
2020
;
39
(
3
):
667
671
9
Luken
A
,
Nair
R
,
Fix
RL
.
On racial disparities in child abuse reports: exploratory mapping the 2018 NCANDS
.
Child Maltreat
.
2021
;
26
(
3
):
267
281
10
Anderson
KO
,
Green
CR
,
Payne
R
.
Racial and ethnic disparities in pain: causes and consequences of unequal care
.
J Pain
.
2009
;
10
(
12
):
1187
1204