CBT Strategies Help Resolve Implicit Bias Related to Sickle Cell Patients

Nabil Abou Baker, MD

Implicit biases can be effectively addressed by using individual or personal strategies based on cognitive behavioral therapy (CBT) techniques. A study presented at 2021 American Society of Hematology (ASH) Annual Meeting & Exposition examined the strategies’ effectiveness on confronting implicit bias of sickle cell disease (SCD) among internal medicine residents.

“Throughout the years, patients with sickle cell disease have been subjected to biases and stigmas that have affected their care,” investigators wrote, “which then leads to them experiencing greater pain and a lower quality of life. Literature continues to show that patients suffer from their pain being discounted during hospitalizations.”

The team of investigators, led by Nabil Abou Baker, MD, General Internal Medicine, University of Chicago, developed an implicit bias module (SOAR) for the 23 internal medicine resident participants to complete.

Self-Awareness is Step 1

Implicit biases, unlike explicit biases, are subtle and often unacknowledged by the individual. The cognitive behavioral therapy techniques used to create the SOAR module utilizes concepts that are typically reserved for automatic thoughts in patients with depression or anxiety, for example.

Aiming to resolve negative implicit biases that might be held toward patients with sickle cell disease, the SOAR framework helped the residents self-identify the implicit bias, observe when it occurs, and create an action plan to address it.

Investigators observed the residents’ initial forming thoughts–indicating implicit bias, emotions, and the intensity of the implicit bias and emotion before and after completing the module.

When presented with a sample case involving a patient with sickle cell disease who needed pain medication the results revealed a range of initial thoughts reported by the residents including: failure, suspicion and opioids, pity and boring admission, chronic pain and dread of confrontation, and frustration, with an average belief of 7/10 in that thought.

Initial emotions reported by the residents included: frustration, sadness, shame, guilt, worry, and pessimism with an average belief of 5.5/10 in that emotion.

Reflection is the Next Step

After the residents completed the implicit bias module, the average belief in the initial implicit bias reduced to 4.3/10. Emotions reportedly changed to feelings of regret and sadness.

Of the total residents, 92% stated they believed implicit biases are important to address and 75% claimed that the lecture from the module was helpful. All the residents stated that they would use this framework to address their own negative implicit biases.

It’s not a secret that there are negative biases surrounding sickle cell disease. Previously, this team of investigators has shown that internal medicine residents at the University of Chicago had negative implicit biases toward patients with sickle cell disease.

Understanding and education are key to becoming aware of implicit biases which is the only way to improve the quality of care offered to patients with sickle cell disease. There are trainings that exist for understanding different aspects of implicit bias, but this framework is the first to offer the individual perspective.

“This training is not enough for addressing all the faults in the medical system that perpetuates biases and health inequities toward patients with SCD,” investigators wrote. “It can be used to supplement other methods such as education about influences and patient outcomes, increasing awareness, and making systemic changes.”