Written by: Vanessa Lopez
Edited by: Ingrid Teng
Edited by: Ingrid Teng
When visiting the doctor, whether it be for a health check-up or to receive life saving care, one would expect to be treated with compassionate, bias-free treatment. Many hospitals and medical practices have made it commonplace to require mandatory training on recognizing implicit and unconscious personal bias, as a way to diminish discriminatory behaviors and attitudes that negatively affect the quality of care given– especially towards minorities (Sabin 2022). The latter,however, is not enough to tackle said issue, given that discrimination goes beyond personal bias. While personal biases in medical professionals is a serious issue that needs to continually be addressed, it is only part of a bigger issue: bias has been incorporated directly into the very treatments and equipment used to care for others.
Before understanding how to potentially address built in bias, we should first discuss the practices that currently enforce them. One such instance consists of the gender and sex-based bias in Glomerular Filtration Rate (GFR),which is the equation that calculates a patient’s eligibility in receiving kidney transplantation, a treatment for those suffering from organ failure (Sheikh and Locke 2021). GFR uses creatinine levels to determine who is eligible and in most need of a kidney transplant. Higher than normal creatinine levels in the blood, 1.2 for women and 1.4 for men, often indicates kidney failure, entailing a higher GFR score and thus a better chance at receiving a kidney transplant (NFK 2023). The issue with GFR, however, is that it does not account for sex based differences between men and women. Creatinine is a byproduct of muscle metabolism; on average, women have less musculature than men, so they have consistently lower GMR scores. (Sheikh and Locke 2021). The consequences of this built-in gender bias are dismaying, with women being less likely to receive a kidney transplant, and 27% less likely to be waitlisted for a kidney transplant(Ahearn et al. 2021). With that said, women are more likely to pass away before being removed from the waitlist and receive a kidney transplant than men. Implicit gender bias plays a role in the latter, with its creation not having been made with consideration to women and their physiology.
Another example of built-in bias in medical practices are pulse oximeters. Pulse oximeters are devices used to measure and track blood oxygen saturation. These devices, however, often relay inaccurate readings on darker skinned individuals due to an oximeter’s light sensors not being calibrated to skin tones containing more melanin. This racial bias can have drastic consequences, in instances when dark-skinned patients can display normal oxygen levels on the oximeter, yet are suffering from hypoxemia (i.e. low blood oxygen) (Wickerson 2022). Another real world application to the consequences of this racial bias was seen during the Covid-19 epidemic. In a Northern California healthcare systemA study involving oximeter accuracy and its relationship with COVID-19 treatment outcomes was done on two groups of patients:non-hispanic white adults and non-hispanic black adults. The results showcased that blood oxygen content was regularly overestimated in the non-hispanic African American cohort (Sudat et al. 2022). With these overestimated results, the blood oxygen content may show as within regular range – when in fact blood oxygen may be lower than optimal. Given that Covid-19 symptoms include shortness of breath and other complications regarding the lungs, common treatments include dexamethasone and supplemental oxygen to help reduce inflammation and increase blood oxygen, respectively (Sudat et al. 2022). That being said, oximeters systematically overestimating blood oxygen content was associated with a lower probability in treatments being administered for Covid-19 symptoms concerning low oxygen, as well as a higher probability in increased waiting time to receive said treatments (Sudat et al. 2022). Clearly, the implicit bias behind pulse oximeters and other related devices require further testing and calibration in order to systematically work for a range of skin-tones.
With the above case studies, as with the many others that exist, one may wonder how devices and treatments have built-in biases. To note, the policies or medical equipment themselves are not biased, but rather the people who developed them were. They might not have been intentionally biased, but their Eurocentric views have made the medical field skewed in favor of the eurocentrically male. Historically, participants of scientific and medical studies were largely Caucasian males, and it wasn’t until 1986 that the NIH women and minorities to be included in clinical trials and research (FDA, 2018). That’s to say, there is a large gap in the medical field and clinical data that does not adequately reflect the diversity of the world and its people.
With that in mind, it is worth exploring what has been and can be done to work in closing this gap and fix the issues caused by biases in the medical field. For example, there are several GFR revisions that have been proposed as a way to consider differences in a patient’s serum creatinine level based on their age and sex, otherwise known as eGFR (Sabin 2022). Furthermore, there are pulse oximeters that have been designed with a wider range of wavelengths used to more accurately measure blood oxygen content in people of color of which, however, there does not seem to be widespread production or usage of said devices (Valbuena et al. 2022). To further magnify the usage of more accurate devices and procedures that minimize bias, action must be taken to pressure hospital administration, policy makers, and health professionals in regulating what is used to treat and diagnose patients to make sure that they perform equally for all of its patients (Valbuena et al. 2022). Additionally, a culture change must be made in further diversifying the medical field; pushing for legislation that assists historically marginalized groups to break into STEM and medical professions will help transform a eurocentrically focused field to one that aims at researching a variety of people that better represents the human population. The wider range of the types of people we have in medical professions will allow for widespread change in the equal treatment of all.
Ahearn, P., Johansen, K. L., Tan, J. C., McCulloch, C. E., Grimes, B. A., & Ku, E. (2021). Sex Disparity in Deceased-Donor Kidney Transplant Access by Cause of Kidney Disease. Clinical journal of the American Society of Nephrology : CJASN, 16(2), 241–250. https://doi.org/10.2215/CJN.09140620
Food and Drug Administration. (2018). Gender Studies in Product Development: Historical Overview. Available from: https://www.fda.gov/science-research/womens-health-research/gender-studies-product-de velopment-historical-overview#:~:text=While%20NIH%20has%20required%20that,polic ies%20the%20force%20of%20law.
National Kidney Foundation. (2023). Tests to Measure Kidney Function, Damage, and Detect Abnormalities. Available from: https://www.kidney.org/atoz/content/kidneytests#:~:text=Creatinine%20levels%20in%20 the%20blood,creatinine%20in%20the%20blood%20 rises
Sabin J. A. (2022). Tackling Implicit Bias in Health Care. The New England journal of medicine, 387(2), 105–107. https://doi.org/10.1056/NEJMp2201180
Sheikh, S. S., & Locke, J. E. (2021). Gender disparities in transplantation. Current opinion in organ transplantation, 26(5), 513–520. https://doi.org/10.1097/MOT.000000000000090
Sudat, S. E. K., Wesson, P., Rhoads, K. F., Brown, S., Aboelata, N., Pressman, A. R., Mani, A., & Azar, K. M. J. (2022). Racial Disparities in Pulse Oximeter Device Inaccuracy and Estimated Clinical Impact on COVID-19 Treatment Course. American journal of epidemiology, kwac164. Advance online publication. https://doi.org/10.1093/aje/kwac164
Valbuena, V. S. M, Merchant R. M., Hough C. L. (2022). Racial and Ethnic Bias in Pulse Oximetry and Clinical Outcomes. JAMA Internal Medicine: 182(7):699–700. doi:10.1001/jamainternmed.2022.1903
Wickerson, G. (2022). An Overdue Fix: Racial Bias and Pulse Oximeters. Federation of American Scientists. Available from:
https://fas.org/blogs/sciencepolicy/an-overdue-fix-racial-bias-and-pulse-oximeters/#:~:tex t=Pulse%20oximeters%20are%20medically%20transformative,light%2Dbased%20pulse %20ox%20measurements