The Diagnosis of Bias

Diagnosis is the daily practice of identifying illness through signs and symptoms.⁽¹⁾ All clinicians are trained to excel at diagnosing, yet one pervasive pathology often escapes detection and remains undiagnosed: Bias.

Bias is defined as an inclination or predisposition for or against an object.⁽²⁾ It forms from a lifetime of accumulated information, including our personal life experiences, societal influences, and cultural contexts.⁽³⁾ In the healthcare context, bias can affect cognition and lead to distorted decision-making. As a result, clinicians conduct consultations and make decisions that deviate from clinical reasoning and are not supported by medical evidence.⁽⁴⁾ Even more concerning is that we are unconscious of our biases, which complicates efforts to address them.⁽⁵⁾ Hence, it is crucial to examine how bias manifests within our healthcare system and explore how they  can be addressed.

Gender bias occurs in healthcare in multiple ways that harm both providers and patients. Studies indicate that female physicians often feel their work is perceived as less valuable than that of their male colleagues, with up to 92% reporting experiences of gender discrimination.⁽⁵⁾ This bias extends beyond the healthcare workforce and directly affects the quality of patient care. For instance, 20% of female patients report that their requests are ignored, while 17% say the information they provide is doubted by physicians.⁽⁶⁾ The effect of gender bias is similarly damaging for males. Patients often prefer female nurses over male nurses, refusing care from the latter solely based on traditional gender stereotypes.⁽⁷⁾ Furthermore, male patients are less likely to be diagnosed with depression despite presenting similar symptom scores, as emotional distress is seen as a feminine trait - resulting in an under-recognition of their condition.⁽⁹⁾ Taken together, these examples demonstrate how gender bias in healthcare undermines both the workforce and the patients they serve, highlighting its pervasiveness and damaging impact. 

While gender bias is a significant challenge, bias arising from socioeconomic status (SES) presents another critical layer of clinical risk as it creates a two-tiered experience within the healthcare system. For example, it is shown that patients with high SES enjoy privileges that are unfair to other patients. On average, their waiting time can be 15% shorter than that of patients with lower SES.⁽¹⁰⁾ Beyond hospital logistics, this bias can further extend into clinical interaction. Physicians adjust their approach when facing different patients; their tone is generally warmer and more familiar towards patients from higher SES groups, and they are more likely to put effort into building a relationship between the two.⁽¹¹⁾ The consequences of these implicit assumptions can be visualised with a real-world example: despite having a universal healthcare system in the UK, patients from deprived areas are 30% less likely to receive cancer screening invitations, due to implicit assumptions about their follow-through.⁽¹²⁾ This figure indicates that healthcare professionals may harbour implicit bias towards patients with low SES,thus further exacerbating the issues of stereotyping and heighting health inequalities, and reflecting the urgent need to resolve these disparities. 

In addition to gender and socioeconomic factors, pejorative labelling of patients can also lead to bias in healthcare. Pejorative labels are negative or disrespectful expressions towards a person or group based on their characteristics.⁽¹³⁾ Common examples in the healthcare system include drug abusers and smokers. Research shows that health professionals associate the terms “substance abuser” and “addict” with strongly negative connotations, which in turn influences their perceptions of these patients and the quality of care provided to individuals with substance use disorders.⁽¹⁴⁾ The power of such labeling is further illustrated by one study aiming to measure the degree of implicit bias amongst healthcare professionals in referring chronic obstructive pulmonary disease (COPD) patients with smoking history to pulmonary rehabilitation. Results showed statistically significant implicit bias among the professionals.⁽¹⁵⁾ These findings therefore underscore the need to eliminate pejorative language from healthcare practice

According to the UK General Medical Council, doctors are expected to “provide a good standard of practice and care, and work within competence”.⁽¹⁶⁾ Hence, medical students must cultivate an intrinsic awareness of bias and develop the ability to uphold high standards of practice in order to reduce misjudgment due to bias. One guideline encourages medical students to adopt patients’ perspectives and engage with positive representations to challenge stereotypes.⁽¹⁷⁾ Universities can implement structured ethics training, which has been shown to successfully raise awareness among first-year medical students.⁽¹⁸⁾

“Equity in the exam room means treating each patient as if they were your most important patient, regardless of gender, sexual orientation, race, ethnicity, or personal appearance.” ⁽¹⁹⁾ Although completely eliminating bias might not be feasible, it is a diagnosable, treatable clinical risk factor when parties put effort into preventing its occurrence. Successful management can ensure that clinical judgment is guided by evidence, not prejudice.

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