How to talk about racism without talking about racism (or: why ‘implicit bias’ doesn’t go far enough)

Doctors are good at naming things. Over the past three months I’ve been introduced to the names of body parts that I never knew existed, to conditions both rare and commonplace, to techniques I can name far more easily than I can perform. The extent of this new terminology feels overwhelming and rather silly at times (why can’t I just say ‘listen’ instead of ‘auscultate’?), but there is a value to it: naming to such a fine degree is, I imagine, meant to allow for specificity, to free ourselves of ambiguity when such ambiguity can mean long-lasting impacts for a patient’s health. When the difference between conditions can be as slight as a shift in the type of sound an organ makes, that precision is important.

It is frustrating to me, then, that that same act of naming isn’t used to identify root causes of other concerns that shape patients’ lives and our own practices. Since starting medical school, I have had a number of conversations about ‘bias’, specifically implicit bias that physicians have that – as data shows – can have an impact on the care they provide, and is cited as a contributor to worse health outcomes among Black patients, queer patients, poor patients, and other marginalized people seeking medical care. These conversations are important and necessary and I’m glad that there are people in the medical profession thinking deeply about the impacts bias can have and strategies we can use to combat it.
At the same time, I’m worried that the conversations are stopping there. Rarely in these discussions about bias have I heard the words ‘racism’ or ‘sexism’ or other forms of structural oppression even mentioned, and almost never are they discussed as sources of this bias. It may be that that’s assumed knowledge, but I think there is something notable about the fact that racism, for instance, isn’t explicitly named. What it shows me is that there is still a deep discomfort with talking about types of oppression that move beyond the interpersonal and into the structural. This focus on bias, what I would call a misnaming, is part of a pattern of locating the source of inequality in individual action and behaviour, rather than structures, and that conversation leads to particular ways of talking about inequality that i don’t find particularly useful. There is, for instance, an implicit argument in a lot of the conversations that we should be able to ‘leave our bias at the door’ when we work with patients, which is ignorant of the fact that that bias is not something we can just put down, but that is part of us, part of the door, part of the clinics and the systems that we’re working in. A lot of these conversations also involve some degree of minimizing the culpability that we have in supporting these structures. The argument is often made that ‘biases’ are natural cognitive processes because our brains have to make patterns to process the information we’re receiving. This to me feels like something of a red herring, because even given our brain’s tendency towards pattern-formation there needs to be something setting that pattern in the first place; not only that, but framing it as some kind of biological inevitability frees us from having to think about how we might be responsible for perpetuating the environments in which these patterns can form, by contributing to gentrification, by denying care to uninsured patients. What the language of bias does, at least when it becomes the focus and endpoint of conversations about inequality, is divert attention away from the institutions and forces actually creating that inequality and creating that bias. That’s a conversation that is more difficult, particularly because it involves some recognition that we – as individuals and particularly as medical practitioners – are complicit in supporting those very institutions.

I would very much rather medical professionals talk about bias than not. But the conversation can’t end there. If we were to have a frank, nuanced conversation about bias we would need to talk about where that bias comes from, and that would involve an act of naming that so far I have found the medical profession to be quite uncomfortable with: naming the structures of oppression that we are in, that we are affected by and that we perpetuate.

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