Abstract
Implicit bias in healthcare professionals is a widespread phenomenon that leads to worse healthcare outcomes for marginalized patient populations. One tool that can help providers identify when biases are impacting the clinical care they are providing and enable them to take corrective action in real time is the “Ladder of Inference” (LOI). The LOI is an instrument that elucidates the process by which we take in information about another person, filter that data through our own interests, needs, perspectives and biases, and then use it to draw conclusions about the individual. These conclusions are often profoundly inaccurate, yet we then act upon them. Thus, we propose the LOI as an “implicit bias detection tool” for neonatal intensive care unit (NICU) clinical practice. We demonstrate on two common NICU cases how utilizing the LOI can uncover mechanisms by which positive and negative feedback loops secondary to unregulated implicit bias lead to a stepwise increase or decrease in the quality of care. As the cases demonstrate, the subtle differences in individual steps up the ladder can lead to care differences of a large magnitude in either direction, hugely positive or detrimentally negative. This shift in the quality of care, then, may contribute to the significant neonatal outcome disparities in infants from minoritized groups. Using the LOI as a practical tool, we demonstrate how it becomes possible to detect one’s own implicit biases and thus to consciously monitor the inferences we are making about patients and their families in order to counteract them.
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References
FitzGerald, C. & Hurst, S. Implicit bias in healthcare professionals: a systematic review. BMC Med. Ethics 18, 19 (2017).
Johnson, T. J. et al. Comparison of physician implicit racial bias toward adults versus children. Acad. Pediatr. 17, 120–126 (2017).
Coulter-Thompson, E. I. Bias and discrimination against lesbian, gay, bisexual, transgender, and queer parents accessing care for their children: a literature review. Health Educ. Behav. 50, 181–192 (2023).
Hagiwara, N., Elston Lafata, J., Mezuk, B., Vrana, S. R. & Fetters, M. D. Detecting implicit racial bias in provider communication behaviors to reduce disparities in healthcare: Challenges, solutions, and future directions for provider communication training. Patient Educ. Couns. 102, 1738–1743 (2019).
Williams, D. R., Lawrence, J. A. & Davis, B. A. Racism and health: evidence and needed research. Annu. Rev. Public Health 40, 105–125 (2019).
Clayborne, E. P. Racism, not race: a physician perspective on anti-black racism in America. Hastings Cent. Rep. 52, S29–S31 (2022).
Argyris C. & Schön D. Theory in Practice: Increasing Professional Effectiveness, (Jossey-Bass Publishers, 1974).
Senge P. The Fifth Discipline: The Art and Practice of the Learning Organization (Currency, Doubleday, 1994).
Pilette, P. C. Collaborative capital: conversation for a change. Nurs. Manag. 37, 24 (2006).
Schlegel, D. & Parascando, J. What’s happening in your head: overcoming our assumptions to work better together. MedEdPORTAL 16, 11034 (2020).
Fiester A. The “Ladder of Inference” as a Conflict Management Tool: Working with the “Difficult” Patient or Family in Healthcare Ethics Consultations. HEC Forum. 36, 31–44 (2024).
D’Eon, M. F. The Ladder of Inference re-visited: “Don’t jump to confusions!”. Can. Med. Educ. J. 13, 1–5 (2022).
Samuels N. D. Diversity and Inclusion and the Ladder of Inference. In Handbook for Strategic HR: Best Practices in Organization Development from the OD Network, Vogelsang, Townsend, Minahan, et al, eds. AMACOM Division of American Management Association International; 2013. https://www.jstor.org/stable/j.ctt1d2qzmw. Accessed October 2, 2023.
Karvonen, K. L. et al. Structural racism operationalized via adverse social events in a single-center neonatal intensive care unit. J. Pediatr. 260, 113499 (2023).
Olszewski, A. E. et al. Disparities in clinical ethics consultation among hospitalized children: a case-control study. J. Pediatr. 258, 113415 (2023).
Centers for Disease Control and Prevention. Infant Mortality. 2020. https://www.cdc.gov/reproductivehealth/maternalinfanthealth/infantmortality.htm Accessed October 2, (2023).
Profit, J., Edwards, E. M. & Pursley, D. Getting to health equity in NICU care in the USA and beyond. Arch. Dis. Child Fetal Neonatal Ed. 108, 326–331 (2023).
March of Dimes. Peristats. Preterm birth rate by race/ethnicity: United States, 2019-2021. Published 2023. Accessed 6/20/2023. https://www.marchofdimes.org/peristats/data?reg=99&top=3&stop=63&slev=1&obj=1
Gary, F. A. et al. Medical mistrust among black women in America. J. Natl Black Nurses Assoc. 32, 10–15 (2021).
Hostetter M. & Klein S. Understanding and Ameliorating Medical Mistrust Among Black Americans. https://www.commonwealthfund.org/publications/newsletter-article/2021/jan/medical-mistrust-among-black-americans. Published 2021. Updated January 14, 2021.
Giroux H. A., Lankshear C., McLaren P. & Peters M. Counternarratives, Cultural Studies and Critical Pedagogies (Postmodern Spaces: Routledge, 1996).
Solorzano, D. G. & Yosso, T. J. Critical race methodology: counter-storytelling as an analytical framework for education research. Qual. Inq. 8, 23–44 (2002).
Bamberg M. Considering Counter-Narratives (John Benjamins Publishing Company, 2004).
Lather, P. Critical pedagogy and its complicities: a praxis of stuck places. Educ. Theory 48, 487–498 (1998).
Miller, R., Liu, K. & Ball, A. F. Critical counter-narrative as transformative methodology for educational equity. Rev. Res. Educ. 44, 273 (2020).
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Lechner, B.E., Kukora, S.K. & Fiester, A. The Ladder of Inference as a tool to reduce implicit bias in pediatric clinical practice. Pediatr Res 96, 1829–1833 (2024). https://doi.org/10.1038/s41390-024-03278-1
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DOI: https://doi.org/10.1038/s41390-024-03278-1
