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DIEP

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A1. You must listen to patients and respect their individuality, concerns and preferences. You must be polite and considerate with patients and treat them with dignity and courtesy.

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A1. You must listen to patients and respect their individuality, concerns and preferences. You must be polite and considerate with patients and treat them with dignity and courtesy.

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I have learnt to actively listen to each patient as they are all individual and have different concerns and preferences. At the beginning of year 3, I would take notes as the patient was talking and not spend as much time actively listening, this meant I would have a lot of information but not all of it was necessary. In the middle of year 3 a tutor had a discussion with me to spend more time listening than writing and since then I have practiced and gradually gotten better at actively listening. This has made it easier to write down the necessary information but also to understand when I needed to divulge further with questioning. I also feel this gave the patient more time to announce their concerns and by actively listening rather than constantly note taking I am showing a better level of courtesy towards the patient hopefully making them feel more relaxed especially when talking about more sensitive subjects. In decisions such as having other student observers in the room and the treatment modalities and management available for the patient, it is important to ensure the patient feels in control and allow them to choose their preferred approach.

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A2. You must work in partnership with patients, adapting your communication approach to take into account their particular needs and supporting patients in expressing to you what is important to them.

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A2. You must work in partnership with patients, adapting your communication approach to take into account their particular needs and supporting patients in expressing to you what is important to them.

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similar to A1, each individual has their own independent concerns and worries. Communication with patients can be more than just verbal, even when their persona may bring them across as confident and happy within the appointment room their body language may show otherwise. In the consultation room patients are in a vulnerable position, having their full medical history available to the practitioner and they can be visibly exposed more than usual during the examination and treatment. It is important to adapt your communication and body language when appropriate. Fortunately having similar experiences as a patient and a student osteopath I have been exposed to what it’s like when in this situation. There have been a few cases in which I noticed non-verbal cues that a patient was uncomfortable, even when they insisted that everything was fine. The most common situation was involving observers; whenever this was noticed I would tell the patient I needed to clarify something with my tutor and needed to walk out. This would involve my peers joining me in which I would ask them not to join me back in the room. Most of the time I would walk back in with the patient expressing ease after finding out my observers wouldn’t be joining me. Fortunately as a student this is something I was aware of early on in clinic and will continue to do so.

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A3. You must give patients the information they want or need to know in a way they can understand.

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A3. You must give patients the information they want or need to know in a way they can understand.

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a common low back working diagnosis is a Disc herniation, in one of my pieces of coursework i had to present a disc herniation poster. i have used this as an aid in giving patients information based on their diagnosis. this includes
-what it is
-why i think it is a disc herniation
-the different levels of severity
-causes
-what management can be in place
-prognosis
learning about this condition and breaking it down into subheadings has made it easier to break down information to the patient.

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A4. You must receive valid consent for all aspects of examination and treatment and record this as appropriate.

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A4. You must receive valid consent for all aspects of examination and treatment and record this as appropriate.

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Two of the main complaints made towards osteopaths in 2013 and 2014 involved obtaining informed consent and inappropriate or ineffective communication. Throughout my education at the ESO, consent has weighed highly on assessment mark sheets for practical exams in clinic and Boxley, up to 25%. Ensuring us as students take the informed consent process seriously and practice it as part of our lead up to our exams. Making it second nature. Fortunately it is rare for my consent gaining to be questioned at clinic as it is something I believe needs to be held to a high standard. This includes adverse effects from treatment, why certain examinations need to take place and ensuring that the patient fully understands what I am doing. In some cases I ask them to repeat what I am about to do and why to ensure they didn’t just sporadically consent to everything whilst I was explaining it.

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International Journal of Osteopathic Medicine

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Background

All regulated health care professions have formal procedures for dealing with complaints. We often hear about the major complaints but we have few data about the everyday concerns reported, that can if not managed well, escalate into major issues.

Objective

To collect information about concerns and complaints made about osteopaths to encourage reflective learning and better understanding about how to avoid such incidents.

Design

A two year review of concerns and complaints made about osteopaths and their osteopathic care.

Method

Osteopathic professional indemnity insurance providers, the osteopathic regulator and the professional representative organisation in the UK collected and categorised data about any concern or complaint they received. A standardised system was used to classify concerns relating to: conduct, clinical care, criminal convictions and adjunctive therapy.

Results

A total of 203 complaints and concerns were raised in 2013 and 257 in 2014. In 2013 and 2014, 55% and 42% respectively were about conduct including poor communication resulting in failure to obtain informed consent, and communicating inappropriately or ineffectively. Concerns raised about clinical care (42% of all concerns in 2014 and 54% in 2014) focused on treatment causing new or increased pain or injury, inappropriate treatment, or treatment not justified.

Conclusions

Most concerns were related to patient practitioner communication and the application of treatment. Improving the management of expectations, seeking informed consent, and communicating with patients professionally about the treatment they receive and why, coupled with competent technique application may reduce the number and types of concerns reported.

To read this article in full you will need to make a payment

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What can osteopaths learn from concerns and complaints raised against them? A review of insurance and regulator reports

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All regulated health care professions have formal procedures for dealing with complaints. We often hear about the major complaints but we have few data about the everyday concerns reported, that can if not managed well, escalate into major issues.

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A5. You must support patients in caring for themselves to improve and maintain their own health and wellbeing.

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A5. You must support patients in caring for themselves to improve and maintain their own health and wellbeing.

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During an Osteopathic consultation it would be limiting to only offer a patient with physical treatment.  Involving the holistic view of the profession it would be appropriate to pick up small talk with the patient, this could be to do with them wanting to lose weight or give up smoking which in turn can aid many mechanical issues such as OA in the knees or hips and be a risk factor for lumbar disc herniation’s respectively. An example for this is one of my on-going patients that I have seen since the beginning of year 3. They came in with chronic lower back pain which initially improved, that then got worse after a Road traffic accident during the covid lockdown. At this moment in time their pain has improved with a mixture of treatment and lots of prescribed exercises. The reduction in pain has allowed them to move more which in turn has made it easier for them to lose weight. The combined contribution of specific exercises and reduction in weight has helped with their lower back pain and a long standing knee issue. This has visibly improved their outlook on life and general wellbeing with verbal confirmation from the patient. This hasn’t only allowed me to follow the OPS guidelines but has been very rewarding throughout. To get the most out of the time available for the patient I sent emails with video instructions for exercises outside of the treatment time and would check at the beginning of the next consultation to ensure they were being done correctly. The patient initially ruled out activities and sports that they enjoyed as they were very active before coming to the clinic, but is now able to take on light impact activities and is looking to the future for possible low impact sports such as golf or walking football. On reflection I have been very lucky to have a patient for such a long time as a student, I was able to help the patient with pain management as a short term goal but improve their quality of life with long term aims of making them stronger which in turn aided them to improve their body composition and general wellbeing.

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A6. You must respect your patients’ dignity and modesty.

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A6. You must respect your patients’ dignity and modesty.

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Dignity and modesty is something highly focused on in clinic; part of the dignity and modesty process is the informed consent process so patients know why they may need to get undressed if appropriate. This whole process starts off with the patient being made aware at the beginning of the consultation that getting undressed may be necessary, I have also witnessed receptionists recommending that patients bring shorts/leggings if they may be more comfortable. When it’s time for the examination process I offer to step out of the room whilst they dress down to an appropriate level of clothing, and ask them to keep certain areas of clothing on if it is not of concern. The patient is fully aware that they have the option to keep all clothing on if they feel more comfortable that way, meaning I have treated a patient fully clothed a few times. During the pandemic cameras have been installed for tutor observation, the patient needs to consent for the live feed cameras to be on before they are turned on, these cameras are also switched off during the undressing stage of the consultation. Even as a student practitioner I like to keep a friendly but professional persona between myself and the patient; if it is deemed necessary to do so and the patient consents with intimate areas I like to use couch roll to keep a professional, safe and comfortable barrier between myself and the patient. A common example of this is when using soft tissue treatment on the gluteal muscles, I would use techniques such as inhibition with an elbow or knuckle contact so there is less sensory input compared to using my hands. Another example is using the patients hand as a barrier during examination, if I need to contact areas to stabilise the patient whilst they are standing I will ask the patient to place their hand on their chest or abdomen and ask for consent to place my own hand over the top.  Fortunately I feel like this isn’t something I need to work on but just keep to a good level, I have noticed, especially with my female patients, that this has kept a comfortable, professional and friendly persona with my patients as I want to make the patient feel like their dignity, modesty and personal space is respected.

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A7. You must make sure your beliefs and values do not prejudice your patients’ care.

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A7. You must make sure your beliefs and values do not prejudice your patients’ care.

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Evidence indicates that healthcare professionals exhibit the same levels of implicit bias as the wider population with a positive correlation between level of bias and lower quality of care, this means unconscious decisions are being made based on race, gender and social economic status (to name a few). This potentially means that any decisions I have made may have had unconscious bias in them. This is something I will continue to make an effort to address.

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Abstract

Background

Implicit biases involve associations outside conscious awareness that lead to a negative evaluation of a person on the basis of irrelevant characteristics such as race or gender. This review examines the evidence that healthcare professionals display implicit biases towards patients.

Methods

PubMed, PsychINFO, PsychARTICLE and CINAHL were searched for peer-reviewed articles published between 1st March 2003 and 31st March 2013. Two reviewers assessed the eligibility of the identified papers based on precise content and quality criteria. The references of eligible papers were examined to identify further eligible studies.

Results

Forty two articles were identified as eligible. Seventeen used an implicit measure (Implicit Association Test in fifteen and subliminal priming in two), to test the biases of healthcare professionals. Twenty five articles employed a between-subjects design, using vignettes to examine the influence of patient characteristics on healthcare professionals' attitudes, diagnoses, and treatment decisions. The second method was included although it does not isolate implicit attitudes because it is recognised by psychologists who specialise in implicit cognition as a way of detecting the possible presence of implicit bias. Twenty seven studies examined racial/ethnic biases; ten other biases were investigated, including gender, age and weight. Thirty five articles found evidence of implicit bias in healthcare professionals; all the studies that investigated correlations found a significant positive relationship between level of implicit bias and lower quality of care.

Discussion

The evidence indicates that healthcare professionals exhibit the same levels of implicit bias as the wider population. The interactions between multiple patient characteristics and between healthcare professional and patient characteristics reveal the complexity of the phenomenon of implicit bias and its influence on clinician-patient interaction. The most convincing studies from our review are those that combine the IAT and a method measuring the quality of treatment in the actual world. Correlational evidence indicates that biases are likely to influence diagnosis and treatment decisions and levels of care in some circumstances and need to be further investigated. Our review also indicates that there may sometimes be a gap between the norm of impartiality and the extent to which it is embraced by healthcare professionals for some of the tested characteristics.

Conclusions

Our findings highlight the need for the healthcare profession to address the role of implicit biases in disparities in healthcare. More research in actual care settings and a greater homogeneity in methods employed to test implicit biases in healthcare is needed.

Keywords: Implicit bias, Prejudice, Stereotyping, Attitudes of health personnel, Healthcare disparities

Background

A patient should not expect to receive a lower standard of care because of her race, age or any other irrelevant characteristic. However, implicit associations (unconscious, uncontrollable, or arational processes) may influence our judgements resulting in bias. Implicit biases occur between a group or category attribute, such as being black, and a negative evaluation (implicit prejudice) or another category attribute, such as being violent (implicit stereotype) [ 1].1 In addition to affecting judgements, implicit biases manifest in our non-verbal behaviour towards others, such as frequency of eye contact and physical proximity. Implicit biases explain a potential dissociation between what a person explicitly believes and wants to do (e.g. treat everyone equally) and the hidden influence of negative implicit associations on her thoughts and action (e.g. perceiving a black patient as less competent and thus deciding not to prescribe the patient a medication).

The term 'bias' is typically used to refer to both implicit stereotypes and prejudices and raises serious concerns in healthcare. Psychologists often define bias broadly; such as 'the negative evaluation of one group and its members relative to another' [ 2]. Another way to define bias is to stipulate that an implicit association represents a bias only when likely to have a negative impact on an already disadvantaged group; e.g. if someone associates young girls with dolls, this would count as a bias. It is not itself a negative evaluation, but it supports an image of femininity that may prevent girls from excelling in areas traditionally considered 'masculine' such as mathematics [ 3]. Another option is to stipulate that biases are not inherently bad, but only to be avoided when they incline us away from the truth [ 4].

In healthcare, we need to think carefully about exactly what is meant by bias. To fulfil the goal of delivering impartial care, healthcare professionals should be wary of any kind of negative evaluation they make that is linked to membership of a group or to a particular characteristic. The psychologists' definition of bias thus may be adequate for the case of implicit prejudice; there are unlikely, in the context of healthcare, to be any justified reasons for negative evaluations related to group membership. The case of implicit stereotypes differs slightly because stereotypes can be damaging even when they are not negative per se. At least at a theoretical level, there is a difference between an implicit stereotype that leads to a distorted judgement and a legitimate association that correctly tracks real world statistical information. Here, the other definitions of bias presented above may prove more useful.

The majority of people tested from all over the world and within a wide range of demographics show responses to the most widely used test of implicit attitudes, the Implicit Association Test (IAT), that indicate a level of implicit anti-black bias [ 5]. Other biases tested include gender, ethnicity, nationality and sexual orientation; there is evidence that these implicit attitudes are widespread among the population worldwide and influence behaviour outside the laboratory [ 6, 7]. For instance, one widely cited study found that simply changing names from white-sounding ones to black-sounding ones on CVs in the US had a negative effect on callbacks [ 8]. Implicit bias was suspected to be the culprit, and a replication of the study in Sweden, using Arab-sounding names instead of Swedish-sounding names, did in fact find a correlation between the HR professionals who preferred the CVs with Swedish-sounding names and a higher level of implicit bias towards Arabs [ 9].

We may consciously reject negative images and ideas associated with disadvantaged groups (and may belong to these groups ourselves), but we have all been immersed in cultures where these groups are constantly depicted in stereotyped and pejorative ways. Hence the description of 'aversive racists': those who explicitly reject racist ideas, but who are found to have implicit race bias when they take a race IAT [ 10]. Although there is currently a lack of understanding of the exact mechanism by which cultural immersion translates into implicit stereotypes and prejudices, the widespread presence of these biases in egalitarian-minded individuals suggests that culture has more influence than many previously thought.

The implicit biases of concern to health care professionals are those that operate to the disadvantage of those who are already vulnerable. Examples include minority ethnic populations, immigrants, the poor, low health-literacy individuals, sexual minorities, children, women, the elderly, the mentally ill, the overweight and the disabled, but anyone may be rendered vulnerable given a certain context [ 11]. The vulnerable in health-care are typically members of groups who are already disadvantaged on many levels. Work in political philosophy, such as the De-Shalit and Wolff concept of 'corrosive disadvantage', a disadvantage that is likely to lead to further disadvantages, is relevant here [ 12]. For instance, if a person is poor and constantly worried about making ends meet, this is a disadvantage in itself, but can be corrosive when it leads to further disadvantages. In a country such as Switzerland, where private health insurance is mandatory and yearly premiums can be lowered by increasing the deductible, a high deductible may lead such a person to refrain from visiting a physician because of the potential cost incurred. This, in turn, could mean that the diagnosis of a serious illness is delayed leading to poorer health. In this case, being poor is a corrosive disadvantage because it leads to a further disadvantage of poor health.

The presence of implicit biases among healthcare professionals and the effect on quality of clinical care is a cause for concern [ 13- 15]. In the US, racial healthcare disparities are widely documented and implicit race bias is one possible cause. Two excellent literature reviews on the issue of implicit bias in healthcare have recently been published [ 16, 17]. One is a narrative review that selects the most significant recent studies to provide a helpful overall picture of the current state of the research in healthcare on implicit bias [ 16]. The other is a systematic review that focusses solely on racial bias and thus captures only studies conducted in the US, where race is the most prominent issue [ 17]. Our review differs from the first because it poses a specific question, is systematic in its collection of studies, and includes an examination of studies solely employing the vignette method. Its systematic method lends weight to the evidence it provides and its inclusion of the vignette method enables it to compare two different literatures on bias in healthcare. It differs from the second because it includes all types of bias, not only racial; partly as a consequence, it captures many studies conducted outside the US. It is important to include studies conducted in non-US countries because race understood as white/black is not the source of the most potentially harmful stereotypes and disparities in all cultural contexts. For example, a recent vignette study in Switzerland found that in the German-speaking part of the country, physicians displayed negative bias in treatment decisions towards fictional Serbian patients (skin colour was unspecified, but it would typically be assumed to be white), but no significant negative bias towards fictional patients from Ghana (skin colour would be assumed to be black) [ 18]. In the Swiss German context, the issue of skin colour may thus be less significant for potential bias than that of country of origin.2

Methods

Data sources and search strategy

Our research question was: do trained healthcare professionals display implicit biases towards certain types of patient? PubMed (Medline), PsychINFO, PsychARTICLE and CINAHL were searched for peer-reviewed articles published between 1st March 2003 and 31st March 2013. When we performed exploratory searches on PubMed before conducting the final search, we noticed that in 2003 there was a sharp increase in the number of articles on implicit bias and so we decided to begin from this year. The final searches were conducted on the 31st March 2013. We used a combination of subject headings and free text terms that related to the attitudes of healthcare professionals (e.g. "physician-patient relations", "attitude of health personnel"), implicit biases (e.g. "prejudice", "stereotyping", "unconscious bias"), particular kinds of discrimination (e.g. "aversive racism", anti-fat bias", "women's health"), and healthcare disparities (e.g. "health status disparities", "delivery of health care") which were combined with the Boolean operators "AND" and "OR".

Study selection

3767 titles were retrieved and independently screened by the two reviewers (SH and CF). The titles that were agreed by both after discussion to be ineligible according to our inclusion criteria were discarded (3498) and the abstracts of the remaining articles (269) were independently screened by both reviewers. Abstracts that were agreed by both reviewers to be ineligible according to our inclusion criteria were discarded (241). When the ineligible abstracts were discarded, the remaining 28 articles were read and independently rated by us both. Out of these, 27 articles were agreed after discussion to merit inclusion in the final selection. One article was excluded at this stage because it did not fit our inclusion criteria (it did not employ the assumption method or an implicit measure). Additionally, the reference lists of these 27 articles were manually scanned by CF, and the full text articles resulting from this were independently read by both reviewers, resulting in the inclusion of a further 11 articles that both reviewers agreed fitted the inclusion criteria. After a repeat process of scanning the reference lists of the 11 articles from the second round, the final number of eligible articles was 42. All disagreements were resolved through discussion.

The inclusion criteria were:

1. A method identifying implicit rather than explicit biases.

2. Participants were physicians or nurses who had completed their studies.

3. Written in English or another language spoken by CF or SH (CF: French, Italian, Spanish, Catalan; SH: French, Italian, German).

There is no clear consensus on the meaning of the term 'implicit'. The term is used in psychology to refer to a feature or features of a mental process. We chose a wide negative definition of implicit processes, assuming that implicit social cognition is involved in the absence of any of the four features that characterise explicit cognition: intention, conscious availability, controllability, and the need for mental resources. This absence does not rule out the involvement of explicit processes, but indicates the presence of implicit processes. While most institutional policies against bias focus on explicit cognition, research on implicit bias shows that this is mistaken [ 6].

There is broad agreement in psychology that methods known as 'implicit measures', including the affective priming task, the IAT and the affective Simon task, reveal implicit attitudes [ 19]. We included articles using these measures. We also included studies that employed a method popular in bioethics literature that we label 'the assumption method'. It involves measuring differences across participants in response to clinical vignettes, identical except for one feature, such as the race, of the character in the vignette. There is no direct measure of the implicitness or non-explicitness of the processes at work in participants; instead, there is an assumption that the majority are explicitly motivated to disregard factors such as race. If there is a statistically significant difference in the diagnosis or treatment prescribed correlated with -for example- the race of the patient, the researchers infer that it is partly a result of implicit processes in the physicians' decision-making. The assumption method of measuring implicit bias has been used in a variety of naturalistic contexts where it is harder to bring subjects into the laboratory. It is recognised by psychologists who specialise in implicit cognition as a way of detecting the possible presence of implicit bias, if not as an implicit measure in itself [ 6].

Studies that used self-report questionnaires were not included because, although they can use subtle methods to estimate a subject's attitudes, they are typically used in psychology as a measure of explicit mental processes. There are potential problems with the implicit/explicit distinction as applied to psychological measures and it may be preferable in future research to speak of 'direct' and 'indirect' measures, but for the purposes of the review we followed this convention in psychology. The original idea behind implicit measures was that they attempted to measure something other than explicit mental processes, whereas self-report questionnaires ask a subject direct questions and thus prompt a chain of explicit conscious reasoning in the subject.

Data extraction

Data were extracted by CF and reviewed by SH for accuracy and completeness. All disagreements with the information extracted were resolved through discussion. We contacted the corresponding author of an article to obtain information that was not available in the published manuscript that related to the nature of the presentation given to recruit participants, but received no response.

Results

Identified studies

The eligible studies are described in Table 1 and their main characteristics are outlined in Table 2 . The most frequently examined biases were racial/ethnic and gender, but ten other biases were investigated (Table 2 ). Four of the assumption studies compared results from two or more countries to explore effects of differences in healthcare systems.

Table 1

Year

First author

Country

Method

Population

Recruitment

Response rate

Main findings (relevant to systematic review)

Age

AIDS patients

Brain injured patients who have contributed to their injury

Disability

Gender

Intravenous Drug Users (IDUs)

Mentally ill

Multiple biases

Racial/ethnic

2013a

Blair [ 44]

US

IAT (prejudice) and interpersonal interaction measures

134 clinicians

Data for clinicians collected in the Blair [ 44] study. Primary data from patients in a broader study on hypertension.

60%

Clinicians with greater implicit bias against blacks were rated lower in patient-centred care by their black patients as compared with a reference group of white patients.

Weight

Table 2

Studies (N = 42)

Method

Assumption method

25 [ 25- 41, 43, 58, 59, 61, 63- 66]

(of which: IAT combined with behaviour or decision)

9 [ 23, 24, 42, 44- 48, 67]

Setting and type of test

IAT - implicit stereotype

5 [ 23, 45- 47, 50]

IAT - standard

13 [ 22- 24, 42, 44- 47, 50, 60, 62, 67, 68]

(of which: photos in addition)

1 [ 43]

Assumption method - controlled setting

16 [ 27- 39, 41, 58, 63]

Assumption method - uncontrolled setting

8 [ 25, 26, 40, 43, 61, 64- 66]

Bias(es) studied

Racial/ethnic

27 [ 20- 24, 27- 41, 43- 47, 67]

Gender

14 [ 27- 38, 63, 66]

Mental illness

4 [ 26, 42, 64, 65]

Country of study

US

27 [ 20- 24, 27- 41, 43- 47, 62, 66]

UK

8 [ 26- 29, 31, 32, 58, 59]

Participants ( N  = 15148)

Profession of participants

Physicians

12156

Nurses

740

Either physicians or nurses

1404

'Clinicians', or 'mental health professionals' (at least some of whom were nurses and physicians)

834

Psychologists

12

Medical Students

2

The 14 assumption method studies examining multiple biases investigated interactions between biases. They recorded the socio-demographic characteristics of the participants to reveal complex interactions between physician characteristics and the characteristics of the imaginary 'patient' in the vignette.

All IAT studies measured implicit prejudice; five also measured implicit stereotypes. When implicit prejudice is measured, words or images from one category are matched with positive or negative words (e.g., black faces with 'pleasant'). When implicit stereotypes are measured, words or images from one category are matched with words from a conceptual category (e.g. female faces and 'home').

Nine IAT studies combined the IAT with a measure of physician behaviour or treatment decision to see if there were correlations between these and levels of implicit bias.

The subliminal priming studies were dissimilar: one was an exploratory study to see if certain diseases were stereotypically associated with African Americans, using faces as primes and reaction times to the names of diseases as the measure of implicit association; the other study used race words as primes and tested the effect of time pressure on responses to a clinical vignette.

A variety of media were used for the clinical vignette and the method of questioning participants within the assumption method. One unusual study used simulations of actual encounters with patients, hiring actors and using a set for the physicians to role-play. Physicians' treatment decisions were recorded by observers, and the physician recorded his own diagnosis, prognosis and perceptions after the encounter.

Limitations

Of specific studies

Limitations are detailed in Table 3 . Some studies failed to report response rates, or to provide full information on statistical methods or participant characteristics. Some had very small sample sizes and the majority did not mention calculating the power of their sample. Some authors explicitly informed participants of the purpose of the study, or gave participants questionnaires or other tests that indicated the subject of the study before presenting them with the vignette. For optimal results, participants should not be alerted to the particular patient characteristic(s) under study, particularly in an assumption study where knowing the characteristic(s) may influence the interpretation of the vignette. In IAT studies, this is less worrying because IAT effects are to some extent uncontrollable.

Of the field

Implicit bias in healthcare is an emerging field of research with no established methodology. This is to be expected and is not a problem in itself, but it does present an obstacle when conducting a review of this kind. The range of methods used and the variety of journals with differing standards and protocols for describing experiments made it difficult to compare the results. In addition, authors focusing on a particular bias (e.g. gender), often in combination with a particular health issue (e.g. heart disease), frequently did not appear to be familiar with one another's research. This lack of familiarity meant that often used different terms to describe the same phenomenon, which also made conducting the review more difficult.

Few of the existing results can be described as 'real world' treatment outcomes. The two priming studies involved very small samples and were more exploratory than result-seeking [ 20, 21]. The IAT and assumption studies were conducted under laboratory conditions. The only three studies conducted in naturalistic settings combined the IAT with measures of physician-patient interaction [ 22- 24]. However, many of the assumption studies attempted to make their vignettes as realistic as possible by having them validated by clinicians [ 25- 41] and also by having participants view/read the vignettes as part of a normal day at work [ 27- 36, 39, 41].

Because the studies of interest used psychological techniques, but were mainly to be found in a medical database (PubMed), the classification of the studies was not always optimal. There is no heading in Medline for 'implicit bias' and studies using similar methods were sometimes categorized under different subject headings, some of which were introduced during the last ten years, which increased the risk of missing eligible studies.

Existence of implicit biases/stereotypes in healthcare professionals and influence on quality of care

Healthcare professionals have implicit biases

Almost all studies found evidence for implicit biases among physicians and nurses. Based on the available evidence, physicians and nurses manifest implicit biases to a similar degree as the general population. The following characteristics are at issue: race/ethnicity, gender, socio-economic status (SES), age, mental illness, weight, having AIDS, brain injured patients perceived to have contributed to their injury,3 intravenous drug users, disability, and social circumstances.

Of the seven studies that did not find evidence of bias, one compared the mentally ill with another potentially unfavourable category, welfare recipients; this study did find a positive correlation between levels of implicit bias and over-diagnosis of the mentally ill patient in the vignette [ 42]. Another used simulated interactions with actors, which may result in participants being on 'best behaviour' in the role-play [ 41]. The two studies that reported no evidence of bias in diagnosis of depression found that physicians' estimates of SES were influenced by race (lower SES estimated for black patients); [ 37, 38] one reported that estimates of SES in turn were significantly related to estimates of patient demeanour (lower SES associated with hostile patient demeanour) [ 37]. A further study failed to find differences due to patient race in the prescription of opioids, but found an interaction whereby black patients who exhibited 'challenging' behaviour (such as belligerence and asking for a specific opioid) were more likely to be prescribed opioids than those who did not, an effect possibly due to a racial stereotype [ 43]. Another study that failed to find implicit race bias suggested that this was due to the setting of the study in an inner-city clinic with high levels of black patients and the fact that many physicians were born outside the US [ 24]. Finally, one study that found no evidence of racial bias in prescription of opioid analgesics presented each participant with three vignettes depicting patients of three different ethnicities, thus probably alerting them to the objective of the study [ 40].

The interaction effects between different patient characteristics in assumption studies are varied and a few are surprising. The authors of one study expected that physicians would be less likely to prescribe a higher dose of opioids to black patients who exhibited challenging behaviours; in fact, physicians were more likely to prescribe higher doses of opioids to challenging black patients, yet slightly less likely to do so to white patients exhibiting the same behaviour. Sometimes significant effects on the responses to the vignette of a patient characteristic, e.g. race, are only found when the interaction between gender and race or SES and race is examined. For example, physicians in one study were less certain of the diagnosis of coronary heart disease for middle-aged women, who were thus twice as likely to receive a mental health diagnosis than their male counterparts [ 34]. In another, low SES Latinas and blacks were more likely to have intrauterine contraception recommended than low SES whites, but there was no effect of race for high SES patients [ 39].

Implicit bias affects clinical judgement and behaviour

Three studies found a significant correlation between high levels of physicians' implicit bias against blacks on IAT scores and interaction that was negatively rated by black patients [ 23, 24, 44] and, in one study, also negatively rated by external observers [ 23]. Four studies examining the correlation between IAT scores and responses to clinical vignettes found a significant correlation between high levels of pro-white implicit bias and treatment responses that favoured patients specified as white [ 42, 45- 47]. In one study, implicit prejudice of nurses towards injecting drug users significantly mediated the relationship between job stress and their intention to change jobs [ 48].

Twenty out of 25 assumption studies found that some kind of bias was evident either in the diagnosis, the treatment recommendations, the number of questions asked of the patient, the number of tests ordered, or other responses indicating bias against the characteristic of the patient under examination.

Determinants of bias

Socio-demographic characteristics of physicians and nurses (e.g. gender, race, type of healthcare setting, years of experience, country where medical training received) are correlated with level of bias. In one study, male staff were significantly less sympathetic and more frustrated than female staff with self-harming patients presenting in A&E [ 26]. Black patients in the US -but not the UK- were significantly more likely to be questioned about smoking than white [ 28]. In another study, international medical graduates rated the African-American male patient in the vignette as being of significantly lower SES than did US graduates [ 38]. One study found that paediatricians held less implicit race bias compared with other MDs [ 47].

Correlations between explicit and implicit attitudes varied depending on the type of bias and on the kind of explicit questions asked. For instance, implicit anti-fat bias tends to correlate more with an explicit anti-fat bias than racial bias, where explicit and implicit attitudes often diverge significantly. Because physicians' and nurses' implicit attitudes diverged frequently from their explicit attitudes, explicit measures cannot be used alone to measure the presence of bias among healthcare professionals.

Discussion

A variety of studies, conducted in various countries, using different methods, and testing different patient characteristics, found evidence of implicit biases among healthcare professionals and a negative correlation exists between level of implicit bias and indicators of quality of care. The two most common methods employed were the assumption method and the IAT, the latter sometimes combined with another measure to test for correlations with the behaviour of healthcare professionals.

Our study has several limitations. Four studies included participants who were not trained physicians or nurses and failed to report separate results for these categories of participants [ 42, 44, 49, 50]. Since either the majority of participants were qualified physicians and nurses, or were other health care professionals involved in patient care, we included these studies despite this limitation. Excluding them would not have changed the conclusions of this paper. In addition, we initially centred our research on studies employing implicit measures recognised in psychology, but the majority of the included studies in the final review used the assumption method. However, the limitations imposed by the lack of consistency in keywords and categorization of articles actually worked in our favour here, enabling us to capture a variety of methods and thus to consider including the assumption method. Scanning the references of the articles that were initially retained and repeating this process until there were no new articles helped us to capture further pertinent articles. From the degree of cross-referencing we are confident that we succeeded in identifying most of the relevant articles using the assumption method.

Publication bias could limit the availability of results that reveal little or no implicit bias among healthcare professionals. Moreover, eight articles appeared to refer to the same data collected in a single cross-country comparison study [ 27- 32, 34, 35] and a further two articles analysed the same data [ 45, 47]. The sum of 42 articles thus can give the impression that more research has been carried out on more participants than is the case. The solidity of data revealing high levels of implicit bias among the general population suggest that this is unlikely to have invalidated the conclusion that implicit bias is present in healthcare professionals [ 6, 7].

However, our decision to exclude studies that involved students rather than fully-trained healthcare professionals meant that we did not include a study conducted on medical students that showed no significant association between implicit bias and clinical assessments [ 51]. Several studies post 2013 (thus after our cut-off date) have also indicated a null relationship between levels of implicit bias and clinical decision-making [ 52- 54]. The scientific community working in this area agrees that the relationship between levels of implicit bias in healthcare professionals and clinical decision-making is complex and that there is currently a lack of good evidence for a direct negative influence of biases [ 16, 17]. As our review shows, there is clearer evidence for a relationship between implicit bias and negative effects on clinical interaction [ 23, 24, 44]. While this may not always translate into negative treatment outcomes, the relationship between a healthcare professional and her patient is essential to providing good treatment, thus it seems likely that the more negative the clinical interaction, the worse the eventual treatment outcome (not to mention the likelihood that the patient will consult healthcare services for future worries or problems). This is where the bulk of future research should be concentrated.

The interactions between multiple patient characteristics and between healthcare professional and patient characteristics reveal the complexity of the phenomenon of implicit bias and its influence on clinician-patient interaction. They also highlight the pertinence of work in feminist theory on 'intersectionality', a term for the distinctive issues that arise when a person belongs to multiple identity categories that bring disadvantage, such as being both black and female [ 55]. For instance, one study only found evidence of bias against low SES Latina patients, not against high SES Latinas, illustrating how belonging to more than one category (here, both low SES and Latina) can have negative effects that are not present if membership of one category is eliminated (here, low SES) [ 39]. Class may trump race in some circumstances so that being high SES is more salient than being non-white. One criticism of mainstream feminism by theorists who work on intersectionality is that pertinent issues are unexplored because of the dominance of high SES white women in feminist theory. Using our example from the review, high SES Latina women may not experience the same prejudice as low SES Latina women and thus may falsely assume that there is no prejudice against Latina women tout court in this context. This could be frustrating for low SES Latina women who have unrecognized lived experiences of prejudice in a clinical setting.

In some studies, the attitudes of patients towards healthcare professionals were recorded and used to evaluate clinical interaction [ 23, 24, 44]. It is important to remember that patients also may come to a clinical interaction with biases. In these cases, the biases of one participant may trigger the biases of the other, magnifying the first participant's biased responses and leading to a snowball effects [ 56]. Past experience of discrimination may mean that a patient may come to an interaction with negative expectations [ 57].

Our findings in the review suggest that the relationship between training and experience and levels of implicit bias is mixed. In one study, increased contact with patients with Hepatitis C virus was associated with more favourable explicit attitudes, yet more negative implicit attitudes towards intravenous drug users [ 49]. Another study demonstrated that nursing students were less prejudiced, more willing to help and desired more social interaction with patients with brain injury, when compared with qualified nurses [ 58]. Exposure to communication skills training was not associated with lower race-IAT scores for physicians [ 23]. However, individuals with mental health training demonstrated more positive implicit and explicit evaluations of people with mental illness than those without training [ 42]. Yet in the same study, graduate students had more positive implicit attitudes towards the mentally ill than mental health professionals.

We included all types of implicit bias in our review, not only race bias, partly in an effort to capture non-US studies, hypothesising that the focus on race in the US leaves fewer resources for investigation into other biases. It is possibly the case that a wider range of biases were investigated in non-US countries, but there is not enough evidence to deduce this from our review alone. For instance, two British studies examine bias against brain-injured patients who are perceived as having contributed to their injury [ 58, 59], and two Australian studies looked at bias against intravenous drug users [ 48, 49], but the sample size of studies is too small to warrant drawing any conclusions from this.

Is it possible that there are implicit associations that are justified because they are based on prevalence data for diseases? One study in our review aimed to test the statistical discrimination hypothesis by asking physicians to estimate the prevalence data among males and females for coronary heart disease in addition to presenting them with vignettes of a female or male coronary heart disease patient. It found that 48% of physicians were inconsistent in their population-level and individual level assessments and that the physicians' gender-based population prevalence assessments were not associated with the certainty of their diagnosis of coronary heart disease. There was no evidence to support the theory of statistical discrimination as an explanation for why physicians were less certain of their diagnoses of CHD in women [ 36]. Another exploratory study looked at the diseases that were stereotypically associated with African-Americans and found that many diseases were associated with African-Americans that did not match prevalence data, such as drug abuse [ 20]. The danger in these cases is that a physician may apply a group-level stereotype to an individual and fail to follow-up with a search for individuating information.

Impartial treatment of patients by healthcare professionals is an uncontroversial norm of healthcare. Implicit biases have been identified as one possible factor in healthcare disparities and our review reveals that they are likely to have a negative impact on patients from stigmatized groups. Our review also indicates that there may sometimes be a gap between the norm of impartiality and the extent to which it is embraced by healthcare professionals for some of the tested characteristics. For instance, explicit anti-fat bias was found to be prevalent among healthcare professionals [ 60]. Since weight can be relevant to diagnosis and treatment, it is understandable that it is salient. It is nonetheless disturbing that healthcare professionals exhibit the same explicit anti-fat attitudes prevalent in the general population.

The most convincing studies from our review are those that combine the IAT and a method measuring the quality of treatment in the actual world. These studies provide some evidence for a relationship between bias as measured by the IAT and behaviour by clinicians that may contribute to healthcare disparities. More studies using real-world interaction measures would be helpful because studies using vignettes remain open to the criticism that they do not reveal the true behaviour of healthcare professionals. In this respect, the three studies using measures of physician-patient interaction are exemplary [ 22- 24], in particular when using independent evaluators of the interactions [ 23]. Overall, our review reveals the need for discussion of methodology and for more interaction between different literatures that focus on different biases.

Conclusion

Our findings highlight the need for the healthcare profession to address the role of implicit biases in disparities in healthcare. In addition to addressing implicit biases, measures need to be taken to raise awareness of the potential conflict between holding negative explicit attitudes towards some patient characteristics, such as obesity, and committing to a norm to treat all patients equally.

Our review reveals that this is an area in need of more uniform methods of research to enable better comparison and communication between researchers interested in different forms of bias. Important avenues for further research include examination of the interactions between patient characteristics, and between healthcare professional and patient characteristics, and of possible ways in which to tackle the presence of implicit biases in healthcare.

Acknowledgements

Not applicable. Only the two authors were implicated in the review.

Funding

This work was carried out with the support of grants from the Swiss National Science Foundation under grants numbers: PP00P3_123340 and 32003B_149407.

Availability of data and materials

The search strategy is available in the Appendix to the paper.

Authors' contributions

Both authors discussed to select the databases and decide on the research question, based on CF's knowledge of the field of implicit bias and SH's knowledge of systematic reviews and bioethics literature. CF compiled the key words for the search strategy with constant advice and input from SH. CF drafted the inclusion criteria and received constant input on this from SH: CF carried out the search and downloaded the relevant articles to be scrutinised. CF and SH both independently read all the initial titles to select which were relevant, then the abstracts, and then the final included articles and discussed at each stage to resolve any disagreements. CF drafted the initial tables including the information from the studies and this was revised by SH. SH particularly revised the statistical methods used by the studies and both reviewed their methodology. CF drafted the manuscript and it was revised with comments by SH a number of times until both authors were satisfied with the manuscript. Both authors read and approved the final manuscript.

Competing interest

The authors declare that they have no competing interests.

Ethics approval and consent to participate

Not applicable.

Appendix 1

Search Strategy

Pubmed

PsychINFO and PsychARTICLE

CINAHL

Footnotes

¹ There are conceptual problems with this distinction as used in psychology that have been pointed out by philosophers, but we will ignore these for the purposes of this review.

² Interestingly, physicians were also asked for how they expected their colleagues to rate the vignette, and in these ratings there was a negative bias towards both patients from Ghana and from Serbia.

³ Bias against patients who are seen as contributing to their injury initially seems to be an odd category compared to the more familiar ones of race and gender. Clinicians may treat brain injured patients differently if they are somehow seen as 'responsible' for their injury, for instance, if they were engaging in risk-taking behaviour such as drug taking. Our review was intended to capture studies such as these that identify biases that are specific to clinical contexts and thus of particular interest to clinicians.

Contributor Information

Chloë FitzGerald, Phone: +34 652 447 428, Email: hc.eginu@dlaregztif.eolhc.

Samia Hurst, Email: hc.eginu@tsruh.aimas.

References

1. Holroyd J, Sweetman J. The Heterogeneity of Implicit Bias. In Brownstein, Michael, Saul, Jennifer, editors. Implicit Bias and Philosophy, Volume 1: Metaphysics and Epistemology 1. Oxford: Oxford University Press; 2016. p. 80-103.

2. Blair IV, Steiner JF, Havranek EP. Unconscious (implicit) bias and health disparities: where do we go from here? Perm J. 2011;15:71. [[ PMC free article] [ PubMed] Google Scholar]

4. Louise A. Bias: Friend or Foe? Reflections on Saulish Skepticism. In Brownstein, Michael, Saul, Jennifer, editors. Implicit Bias and Philosophy, Volume 1: Metaphysics and Epistemology 1. Oxford: Oxford University Press; 2016. p. 157-190.

12. De-Shalit A, Wolff J. Disadvantage. Oxford: Oxford University Press; 2007. [ Google Scholar]

16. Zestcott, C. A., Blair, I. V. & Stone, J. Examining the presence, consequences, and reduction of implicit bias in health care: A narrative review. Group Process Intergroup Relat. 2016. doi:10.1177/1368430216642029. [ PMC free article] [ PubMed]

19. De Houwer J, Moors A. How to define and examine the implicitness of implicit measures. In Wittenbrink B, Schwartz N. (eds.). Implicit measures of attitudes: Procedures and controversies. New York: Guilford Press; 2007. pp. 179-194.

27. Arber S, et al. Influence of patient characteristics on doctors' questioning and lifestyle advice for coronary heart disease: a UK/US video experiment. Br J Gen Pract. 2004;54:673-678. [[ PMC free article] [ PubMed] Google Scholar]

29. Lutfey KE, et al. Diagnostic certainty as a source of medical practice variation in coronary heart disease: results from a cross-national experiment of clinical decision making. Med Decis Making. 2009;29(5):606-18. [ PMC free article] [ PubMed]

51. Haider AH, et al. Association of unconscious race and social class bias with vignette-based clinical assessments by medical students. JAMA. 2011;306:942-951. [[ PMC free article] [ PubMed] Google Scholar]

57. Dominicé Dao M. Vulnerability in the clinic: case study of a transcultural consultation. J Med Ethics. 2016. doi:10.1136/medethics-2015-103337. [ PubMed]

64. Chow LY, Kam WK, Leung CM. Attitudes of healthcare professionals towards psychiatric patients in a general hospital in Hong Kong. J Psychiatry. 2007;17(1):3-9.

Articles from BMC Medical Ethics are provided here courtesy of BMC

# data[].attributes.attachment_link.title
Implicit bias in healthcare professionals: a systematic review

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Implicit biases involve associations outside conscious awareness that lead to a negative evaluation of a person on the basis of irrelevant characteristics such as race or gender. This review examines the evidence that healthcare professionals display ...

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B1. You must have and be able to apply sufficient and appropriate knowledge and skills to support your work as an osteopath.

# data[].attributes.subject
B1. You must have and be able to apply sufficient and appropriate knowledge and skills to support your work as an osteopath.

# data[].attributes.body
An obvious gap in my osteopathic knowledge was apparent during my time in children’s clinic. Due to limited time in clinic in my 4th year I have only been able to see 3 babies in children clinic. Fortunately the support from tutors has made it easier to catch up with information and I was able to use one of my baby patients case notes with the consent of the baby’s mother to write a case report, in which I was able to breakdown the case and learn more about the conditions, plagiocephaly and torticollis, and their links and how osteopathy can help it. Unfortunately I’m not currently comfortable with my childrens clinic knowledge, but I have put aside time after my CCA to revise more on the subjects.

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B2. You must recognise and work within the limits of your training and competence.

# data[].attributes.subject
B2. You must recognise and work within the limits of your training and competence.

# data[].attributes.body
A personal fear of mine is recognising my own limit within my knowledge. There has been occasions in year 3 with patients where I haven’t fully recognised concerns that the tutor has, in which I have had to be helped with the patient to deem if they are safe to treat or not. Fortunately nearing the end of year 4 I have been picking up concerns with my own and my peers patients which may not have been obvious to others. I still know there are limitations to my own knowledge that need to be filled, and have been logging them when I have come across them.

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B3. You must keep your professional knowledge and skills up to date.

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B3. You must keep your professional knowledge and skills up to date.

# data[].attributes.body
At the beginning of year 4 we were set an assignment to make a poster presentation for lumbar disc herniation’s. Mine and my peer’s initial thoughts was that this was rather late in our education to make a poster on such a relatively basic bit of knowledge. It was only through the process of using journals, NICE guidelines and relating that to osteopathic principles that I realised I didn’t know as much as I should about the condition. This is a format I have started to use for conditions to learn about the anatomy, clinical presentations, and guidelines towards conditions.

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B4. You must be able to analyse and reflect upon information related to your practice in order to enhance patient care.

# data[].attributes.subject
B4. You must be able to analyse and reflect upon information related to your practice in order to enhance patient care.

# data[].attributes.body
In the first 2 years of the course it has been difficult to reflect on patient care, considering we don’t have patients until year 3. However in year 1 I wrote a reflective piece about how I learnt from an older student by observing them with a patient. I concluded that it was important to reflect on personal accounts and the OPS even as a student. It makes it easier to appreciate how far you have come, what you have learnt along the way and how you would do it differently next time.

# data[].attributes.headline
B4. You must be able to analyse and reflect upon information related to your practice in order to enhance patient care.

# data[].attributes.subject
B4. You must be able to analyse and reflect upon information related to your practice in order to enhance patient care.

# data[].attributes.body
A conversion that was made between me and a tutor recently involved the tutor expression his way of reflecting. In his own time he thinks about patients he has treated and wonders about what a different osteopath would look at that may have helped this patient more and faster. It was such an easy way to reflect on each patient without fixating for hours thinking about it. It is something that resonated with me, as it allows for growth as a professional without too much stress.

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C1. You must be able to conduct an osteopathic patient evaluation and deliver safe, competent and appropriate osteopathic care to your patients.

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C1. You must be able to conduct an osteopathic patient evaluation and deliver safe, competent and appropriate osteopathic care to your patients.

# data[].attributes.body
I have had a mixed bag of results in my CEXs, going from 45% in children’s clinic and 80% in normal clinic. My osteopathic evaluation and care was suitable for me to pass in these exams, yet in the children’s clinic my reasoning and evaluation has always been a weak point for me, yet in normal clinic with a common presentation of low back pain for an adult I am more comfortable in diagnosing and managing conditions. This is something I have stated before that I need to spend time on, in which I have put aside time for after the CCA and before graduation. On top of that I have been fortunate enough to be offered time with experienced future colleagues/friends who have offered mentor sessions in their own free time which I have taken them up on before and that have been very helpful.

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C2. You must ensure that your patient records are comprehensive, accurate, legible and completed promptly.

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C2. You must ensure that your patient records are comprehensive, accurate, legible and completed promptly.

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All patient records are completed and upheld to a certain standard. These files are then stored onsite at the clinic in a lockable room in independently locked filing cabinets. Only receptionists or supervised students are allowed to obtain notes and no files are allowed off site. I have had comments previously about my handwriting on the notes, especially when stressed or in a rush. I have started making more of a conscious effort to make my hand writing more legible as in the student clinic the notes tend to go to other student practitioners quite often.

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General Data Protection Regulation (GDPR)

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Welcome to gdpr-info.eu. Here you can find the official PDF of the Regulation (EU) 2016/679 (General Data Protection Regulation) in the current version of the OJ L 119, 04.05.2016; cor. OJ L 127, 23.5.2018 as a neatly arranged website. All Articles of the GDPR are linked with suitable recitals. The European Data Protection Regulation is applicable as of May 25th, 2018 in all member states to harmonize data privacy laws across Europe. If you find the page useful, feel free to support us by sharing the project.

Quick Access

Key Issues

Table of Contents

Chapter 1 General provisions

Chapter 4 Controller and processor

Section 1 General obligations

Section 2 Security of personal data

Section 4 Data protection officer

Section 1 Independent status

Chapter 11 Final provisions

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General Data Protection Regulation (GDPR) - Official Legal Text

# data[].attributes.attachment_link.description
Welcome to gdpr-info.eu. Here you can find the official PDF of the Regulation (EU) 2016/679 (General Data Protection Regulation) in the current version of the OJ L 119, 04.05.2016; cor. OJ L 127, 23.5.2018 as a neatly arranged website. All Articles of the GDPR are linked with suitable recitals.

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C3. You must respond effectively and appropriately to requests for the production of written material and data.

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C3. You must respond effectively and appropriately to requests for the production of written material and data.

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Patients are within their right to ask for copies of their notes, I have never had to copy notes for a patient but have been asked to write a summary for an orthopaedic consultant and a few referrals when agreed between me and the patient.

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C4. You must take action to keep patients from harm.

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C4. You must take action to keep patients from harm.

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The COVID-19 pandemic is something we all had to deal with as a nation. We were quickly put into lockdown, resulting in enormous changes within a short space of time. For several months the ESO clinic was closed until the summer. A risk assessment was undertaken by the heads of the Clinic and University before we could return to study and practice.The following changes were made at clinic:
-smaller clinic groups
-masks to be worn throughout clinic
-PPE was used when in close contact to patients
-a one way system within the clinic
-spacing treatment to allow for cleaning
-swap from tunic to polo
-two receptions were opened to reduce the number of people in one building.
this was all put in place to help keep patients, students and tutors away from harm.

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C5. You must ensure that your practice is safe, clean and hygienic, and complies with health and safety legislation.

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C5. You must ensure that your practice is safe, clean and hygienic, and complies with health and safety legislation.

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Donning Personal Protective Equipment

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Centers for Disease Control and Prevention (CDC)

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Demonstration of Donning (Putting On) Personal Protective Equipment (PPE)

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C6. You must be aware of your wider role as a healthcare professional to contribute to enhancing the health and wellbeing of your patients.

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C6. You must be aware of your wider role as a healthcare professional to contribute to enhancing the health and wellbeing of your patients.

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Fortunately during the first year and a half of teaching clinic I never came across a patient that I deemed necessary to refer, this could be due to them being systemically well or the fact I had a few patients currently undergoing investigations at the time. This was a good thing for my patients but a bad thing for my professional progression. I was starting to think that I or my tutors may have missed something as most of my colleagues had at least one referral. Ironically after having this conversation with my clinic team about how to write a referral and them offering to show me how: within the space of two weeks I had referred two patients and had some help with the letter writing. The main issue I had during this process wasn’t explaining why I wanted to refer the patient, it was writing the letter to their GP. I struggled to make the letter professional and succinct but polite with asking for a specific investigation/outcome.

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D1. You must act with honesty and integrity in your professional practice.

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D1. You must act with honesty and integrity in your professional practice.

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This was not a patient of mine but I became involved at reception giving the patient information to try and calm them down. I was able to observe initially at a distance a colleague of mine having to explain to a patient why they wouldn’t be treated today and they needed to go to A&E due to a suspected fracture with a pain scale of 10/10. When the student explained that they would not be treated the patient tried to retract the statements which initially lead to the student believing it to be a fracture. The student handled the situation with stern integrity whilst keeping professionalism without being rude or condescending towards the patient. Whilst the student was writing a referral letter the patient was waiting in reception and being loud towards the receptionist, obviously agitated. Fortunately being presented the case earlier I was able to inform the patient again as to exactly why he wasn’t being treated, after being informed a few times they finally calmed down. I learnt a lot from listening to my colleague in the patient room, the volume and tone of voice of the patient in the room would’ve made me consider stopping the consultation early. Yet my colleague persisted for the good of the patient and got them referred for imaging.

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D2. You must establish and maintain clear professional boundaries with patients, and must not abuse your professional standing and the position of trust which you have as an osteopath.

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D2. You must establish and maintain clear professional boundaries with patients, and must not abuse your professional standing and the position of trust which you have as an osteopath.

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Fortunately I haven’t had any situations where boundaries were trying to be pushed myself. But witnessed an on-going patient practitioner relationship in which the patient pushed the boundaries. They started off with very mild comments towards them in which on their own wouldn’t have been an issue, it was only later after a few sessions where it became more obvious that the comments the patient was making were inappropriate. The student practitioner did the correct thing by informing those in charge and the patient was put with a different practitioner (myself). I was initially not informed of the issues with the patient but they became more apparent when I mentioned a passing comment towards that student practitioner and informed them. After this a safeguarding plan was put in place to reduce any possibility for the patient coming into contact with the student. I personally think the time it took and the initial tolerance towards the patient at reception was too much and the issue was only really resolved when the appropriate parties were informed. On reflection, if this happened during my career with more control over our actions instead of being a student, I would discuss with the patient about the comments and boundaries, and not tolerating them being overstepped a second time.

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D3. You must be open and honest with patients, fulfilling your duty of candour.

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D3. You must be open and honest with patients, fulfilling your duty of candour.

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During the beginning of student clinic there were times when I and the tutor would come to conclusions on to what the patients working diagnosis is. This would be the time after the examination and it would be appropriate to explain to the patient what we believed was going on, how severe it was and what the management was. At the start of the student clinic I found it difficult to explain what would be considered “the bad news”, even for relatively common issues I would sympathise a little too much and find it difficult to explain to the patient what was going on, even relying on the tutor to explain things to the patient. I have improved my communication with my patients in the explanation process discussing the working diagnosis. But even now I sometimes struggle with explaining degenerative processes and that we are unable to help the patient fix these processes but aid in maintaining as much as we can. As much as I know this may play a mild psychological role in their management, so I am very careful with the wording I use, but I must be honest with my patients and let them know what my working diagnosis is.

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D4. You must have a policy in place to manage patient complaints, and respond quickly and appropriately to any that arise.

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D4. You must have a policy in place to manage patient complaints, and respond quickly and appropriately to any that arise.

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Currently at the student clinic the complaints aren’t organised by the students so I am unsure how the process works. But we did get practice in replying to a complaint in one of our modules.

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D5. You must respect your patients’ rights to privacy and confidentiality, and maintain and protect patient information effectively. 

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D5. You must respect your patients’ rights to privacy and confidentiality, and maintain and protect patient information effectively. 

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All patient records and notes are kept within a secure filing cabinet at the teaching clinic, along with any other private documentation. Even when the notes are out of the filing cabinet being used they are kept with the student practitioner and if the student practitioner does need to leave the notes within the tutor room, these rooms have coded locks on them. Allowing them to be secure at all times.

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D6. You must treat patients fairly and recognise diversity and individual values. You must comply with equality and anti-discrimination law.

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D6. You must treat patients fairly and recognise diversity and individual values. You must comply with equality and anti-discrimination law.

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The benefits of being a student at a European school is that I have been exposed to a large spectrum of diversity. On top of the education that comes with the degree I have also learnt a lot from my friends and colleagues about their cultures, religions and traditions… this includes being exposed to some amazing food. It is a fortunate position to go from a small minority population town to a diverse population university. This has shown me a characteristic of mine that hasn’t been challenged before which I am grateful to have and that is acceptance. There hasn’t been a time at ESO with a student or a patient where I have struggled to accept an individual’s values or have allowed that to intervene with the conversation at hand.

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D7. You must uphold the reputation of the profession at all times through your conduct, in and out of the workplace.

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D7. You must uphold the reputation of the profession at all times through your conduct, in and out of the workplace.

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Ever since I started studying to become an Osteopath a continual theme that has come up when meeting new people, old friends or even friends of my parents finding out what I am studying is asking for private treatment out of a clinical regulated setting. Most of the conversations I have been able to politely shake off and suggested seeing a qualified primary health care practitioner. Other times I have had to repeatedly remind people that I am not qualified and don’t feel comfortable treating them. I have agitated friends and family with these conversations but I am happy within myself for keeping my current and future professional integrity.

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D8. You must be honest and trustworthy in your professional and personal financial dealings.

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D8. You must be honest and trustworthy in your professional and personal financial dealings.

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As a ESO student we don’t deal with the financial aspect of clinic. We have a business module in the third year which was assessed with a written business plan. This gave me a basic understanding of how a clinic’s financial dealings would be maintained. For any real world dealings I haven’t had any financial experiences within a clinic. This is something I am going to have to learn about when the time comes.

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D9. You must support colleagues and cooperate with them to enhance patient care.

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D9. You must support colleagues and cooperate with them to enhance patient care.

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During the Covid pandemic to reduce the contact and mixing between students, it was decided that clinic groups would be split in half and worked according to a rota of in one week and online learning the other week. Therefore this lead to certain patients being shared between practitioners. This is a prime example of student colleagues working together within a clinical setting. This in fact had some quite good treatment outcome across the board as it allowed for different osteopathic concepts and thoughts to be used between practitioners which in some cases allowed for speedy patient outcome.

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D10. You must consider the contributions of other health and care professionals, to optimise patient care.

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D10. You must consider the contributions of other health and care professionals, to optimise patient care.

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As stated in the research below, it can be beneficial to take a multidisciplinary approach with rehabilitating patients; in this case it is low back pain. It is within the patient’s interests to combine or suggest other health care modalities or professionals if you believe that this may help their treatment outcome and optimise patient care.

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D11. You must ensure that any problems with your own health do not affect your patients. You must not rely on your own assessment of the risk to patients.

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D11. You must ensure that any problems with your own health do not affect your patients. You must not rely on your own assessment of the risk to patients.

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My own health is something I have taken much more interest in since starting university as it became more apparent there was aspects that could be improved when challenged. I have used the bio psychosocial model to assess how to keep my own health to a standard. I have gone through the lack of each of one of the camps of the models (biological, social and psychological). My physical health diminished when during my first year when I struggled to find time for physical activity, to improve this I started going to the gym in the morning before lectures, my circumstances have changed slightly in where I am now able to go in the evening most nights. My social and psychological aspects were challenged during the pandemic lockdown initially starting with the lack of socialising with family and friends that then started to affect my psychological health, since the lockdown easing these have both improved massively. Something I have learnt is to balance the three, too much or too little of one can affect the others and put them out of balance.

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The Biopsychosocial model was first conceptualised by George Engel in 1977, suggesting that to understand a person's medical condition it is not simply the biological factors to consider, but also the psychological and social factors .

Bio (physiological pathology)

Psycho (thoughts emotions and behaviours such as psychological distress, fear/avoidance beliefs, current coping methods and attribution)

Social (socio-economical, socio-environmental, and cultural factors suchs as work issues, family circumstances and benefits/economics)

This model is commonly used in chronic pain, with the view that the pain is a psychophysiological behaviour pattern that cannot be categorised into biological, psychological, or social factors alone. There are suggestions that physiotherapy should integrate psychological treatment to address all components comprising the experience of chronic pain.

The diagram below shows an example of this model.

Diagram of the Biopsychosocial model.

Physiotherapists must know how biopsychosocial factors interact in patients with chronic pain to explain the perpetuation of this condition and use it as a basis for planning the intervention program. The evidence has suggested a clinical biopsychosocial assessment for the physiotherapeutic management of patients with chronic pain in order to understand and explain the predominant mechanism of pain and psychosocial factors that may or may not be modified for the patient to improve their condition.

This clinical evaluation is carried out during the data collection at the patient's entrance. A practical guide is proposed to take biopsychosocial data using the PSCEBSM (Pain-Somatic and medical factors-Cognitive factors-Emotional factors-Behavioral factors-Social factors-Motivation) model.

Clinical identification and differentiation of the dominant pain mechanism:

Using the following tools:

1. Classification criteria for differentiating predominant pain proposed by Nijs et al.

2. Widespread pain index/Body Diagram : ≥ 7 score suggesting generalized pain, therefore, non-neuropathic pain of central sensitization

3. Central Sensitization Inventory (CSI) : 40 score suggesting non-neuropathic pain of central sensitization

For physical therapist the physical examination is a very important part of his intervention - essential to:

Be aware that some findings of clinical examinations such as mobility, strength, neurodynamics, coordination, etc. could be altered because there is greater sensitivity to mechanical stimulation and modified movement patterns in patients with non-neuropathic pain of central sensitization.

Main goal in this stage is to evaluate the quality of movement, if the pattern of movement causes the pain to persist and if there is kinesiofobia

Ask about current or previous health conditions, the disuse of body parts, changes in movement patterns, exercise capacity, strength and muscle tone during movement, the action of the drug in the CNS It is useful for data collection

C- Cognition / Perceptions

Both influence biologically on hypersensitivity in the brain by activating neuromatrix pain and also influence the emotional and behavioral factors. :

1. Ask about perceptions: expectations of the intervention, expectations of the prognosis of their pain, understanding of their situation and the strategies they have available to face their situation, what the pain represents emotionally

2. Brief Illness Perception Questionnaire (Brief IPQ)

3. Pain Catastrophizing Scale (PCS)

Ask if there is fear of specific movements, avoidance behaviors, psychological traumatic appearance of pain, psychological problems at work, family, finances, society, etc. It is also suggested to use the following scales:

1. State-Trait Anxiety Inventory (STAI)

2. Tampa-Scale of Kinesiophobia (TSK) and Fear Avoidence Belief Questionare

3. Injustice Experience Questionnaire (IEQ)

4. Patient Health Questionnaire-2 (PHQ-2), or Patient Health Questionnaire-9 (PHQ-9), or Center of Epidemiologic Studies Depression Scale (CES-D)

Can lead to avoid activity or movement due to fear, which in turn is presented as physical inactivity or disuse and, finally, disability. Therefore it is important to evaluate the behavior and adaptations that the patient has made due to the pain.

It refers to the social and environmental factors in which the patient develops, which could be useful and supportive or harmful and stressful for the improvement of the patient's health condition. The data collection can be divided as follows:

1. Housing or living situation

2. Social environment

3. Work

4. Relationship with the partner

5. Previous interventions

Evaluating the motivation in the patient and his willingness to change is useful to modify his thoughts regarding the relationship pain-kinesiophobia, pain-disability, and acceptance-catastrophism. For this purpose, the following scale can be used:

Psychology Inflexibility in Pain Scale (PIPS)

PIPS "evaluates components of psychological inflexibility (avoidance and fusion)"

Clinical Contribution

The use of the biopsychosocial model as a clinical practice guide in physiotherapy allows the physiotherapist to be aware of all the factors that influence the patient's state of health. In addition, it allows laying the foundations of pain neuroscience education

The psychosocial factors the patient deals with can mean the intervention of other health professionals besides the physiotherapist ie important to take into account the professional limits, as well as the ethical principles that ensure the comprehensive management of the patient.

The following videos emphasise the importance of using the biopsychosocial model to improve patient functionality and the problem that currently exists for physiotherapists in the use of this approach.

Criticisms of the model

There is still minimal use of the biopsychosocial model in education, clinical care, and research. The biopsychosocial model cannot be consistently defined for an individual (data is not obtained systematically, making it untestable and non-scientific).

Patient centered interview methods have been suggested to be used in practice, such that clinicians can identify a scientific BPS model specific to each patient with an agreed-upon, evidence-based patient-centered interviewing method can be more useful as these are reproducible and can elicit relevant patient information.

References

1. Gatchel, Robert J., Peng, Yuan Bo, Peters, Madelon, L.; Fuchs, Perry, N.; Turk, Dennis C. 2007 The biopsychosocial approach to chronic pain: Scientific advances and future directionsfckLR Psychological Bulletin, Vol 133(4), 581-624

2. Miaskowski C, Blyth F, Nicosia F, Haan M, Keefe F, Smith A, Ritchie C. A biopsychosocial model of chronic pain for older adults. Pain Med. 2020 Sep 1;21(9):1793-1805.

3. http://savvywillingandable.wordpress.com/2013/09/25/the-biopsychosocial-model-explained/

4. Wijma, A. J., van Wilgen, C. P., Meeus, M., & Nijs, J. 2016 Clinical biopsychosocial physiotherapy assessment of patients with chronic pain: The first step in pain neuroscience education. Physiotherapy theory and practice, 32(5), 368-384.

5. Nagasawa Y, Shibata A, Fukamachi H, Ishii K, Wicksell RK, Oka K. The Psychological Inflexibility in Pain Scale (PIPS): validity and reliability of the Japanese version for chronic low back pain and knee pain. J Pain Res. 2021 Feb 4;14:325-332.

6. Smith, Fortin, Dwamena, & Frankel. 2013. An evidence-based patient-centered method makes the biopsychosocial model scientific. Patient Education and Counseling, 91(3), 265-270.

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The Biopsychosocial model was first conceptualised by George Engel in 1977, suggesting that to understand a person's medical condition it is not simply the biological factors to consider, but also the psychological and social factors .

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D12. You must inform the GOsC as soon as is practicable of any significant information regarding your conduct and competence, cooperate with any requests for information or investigation and comply with all regulatory requirements.

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D12. You must inform the GOsC as soon as is practicable of any significant information regarding your conduct and competence, cooperate with any requests for information or investigation and comply with all regulatory requirements.

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I have not had any issues within the student clinic regarding anything to do with this practice standard, therefore I am unable to comment on this OPS. But I can appreciate how the production of written information would comply with Osteopathic regulatory requirements.

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References