Bias and the Brainby Joseph Kim, MD, MPH | February 9, 2009
There has recently been a lot of discussion revolving around bias and medical education. Many people are asking the question, “What level of bias is appropriate?” Is it possible to educate students and clinicians without and be completely free of bias? After all, we’re only human. Or, do we do our best to identify and address bias in a way that is fair, objective, and evidence-based? As we try to rid ourselves of bias, we can’t help but to discover that our brains are naturally biased. We all know this, but we can’t help ourselves since we’re all human. Others are asking, “Is all bias bad?” Is there an appropriate level of bias that is good, acceptable, and appropriate? The sad reality is that we’ve all seen examples of bad or inappropriate bias in the medical field. The bad apples are rotting the bunch, but I don’t think that the entire basket has been lost yet.
To start this discussion, let’s clarify our definition of bias. How do you define bias? Well, Google defines bias as:
influence in an unfair way; a partiality that prevents objective consideration of an issue or situation.
The National Institute on Aging defines bias as:
A point of view or preference which prevents impartial judgment in the way in which a measurement, assessment, procedure, or analysis is carried out or reported.
This brings me to an interesting discussion on the topic of good or appropriate bias versus bad or inappropriate bias. Does appropriate bias exist in health education? If a certain drug or treatment is considered to be far better than all the others in a specific class, then doesn’t that constitute bias? After all, should all drugs be considered equal when they really aren’t? Then how do we free ourselves of bias? But what if all the evidence points to the superiority of a specific agent? That drug is biased as the best because all the evidence points that way. Is such a situation impossible?
Inappropriate bias should never be tolerated. As defined, that type of bias is inappropriate. Healthcare professionals should always be objective about the available levels of evidence when making clinical decisions. The practice of evidence-based medicine has been emphasized greatly and clinicians need to be familiar with the evidence behind specific therapies. Many doctors practice medicine based on their own experience and not based on the clinical evidence. As a result, they may become very biased in what they prescribe or how they treat a certain disorder.
National clinical practice guidelines are written by leading experts in the field as they evaluate the evidence that support the use of specific agents. Many guidelines refer to specific drugs as the “agent of choice” for specific situations. Are these guidelines biased? Some people may think that the clinician authors are being biased when in reality they are being as objective (as humanly possible) with the available amount of clinical evidence. Newer guidelines publish the levels of evidence and indicate the strength of the evidence (the highest levels represent the most robust forms of clinical studies).
Recent revisions to the PhRMA code have now taken into effect. Gone are the days of pens, notepads, soap dispensers, and other pharma-labeled freebies. Supply of such items will soon start dwindling in doctor’s offices and you may have a hard time finding a pen to sign your signature. Will the removal of such small items eliminate bias in the healthcare profession? What does the evidence suggest?
Since doctors and other healthcare professionals are human, we are all prone to bias. Our brains are all biased. What we learn during medical school is taught by faculty who are biased. What we hear from our peers and colleagues is always biased. Can we, as healthcare professionals, distinguish good versus bad bias? Can we judge what is appropriate and inappropriate? I certainly hope we can learn to so that we can do what is best for our patients.
These are just my opinions and I openly admit that I’m naturally biased since I’m human.
Pharmaceutical Research and Manufacturers of America. Code on Interactions with Healthcare Professionals.
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