Abstract
Providing effective treatment within a diverse population is complex and difficult. Issues such as a limited amount of time that can be spent with patients and the need to make decisions based on limited information can lead to information processing errors that have a detrimental impact on treatment outcomes. Cognitive biases (e.g., confirmation bias) may further compound this issue by making it less likely that a health care provider will make adjustments to treatment plans. Steps to minimize the potential for cognitive biases are discussed.
The United States has historically been referred to as a melting pot of cultures. Increasing rates of immigration have led to greater cultural pluralism and ethnic diversity. 1 Specifically, the most recent census data have identified the Hispanic population as the fastest growing minority group in the United States. In the past 10 years, the US Hispanic population has grown by 43% compared with only a 1% growth in the non-Hispanic white population. 2 Despite increasing diversity, health disparities remain a serious problem for Americans. 3 For example, Mexican and African Americans are at greater risk for obesity and associated problems such as cardiovascular disease and type 2 diabetes.4,5 The elimination of health disparities has been identified as a top public health priority for several years.6-8 Even with this focus on the elimination of health disparities, there is some evidence that these inequalities have worsened, particularly in terms of the prevalence of obesity in children.6,9-13
To better address health disparities among a more pluralistic population, there is a greater need for health care providers (HCPs) to be able to assess the impact of culture on symptom presentation and clinical case formulation. 14 In psychiatry and psychology, when clinicians are not skilled in the evaluation of patients from diverse cultural backgrounds, they can be prone to bias, resulting in misdiagnosis. 14 For example, African American and Hispanic patients with bipolar disorder or depression with psychotic features are more frequently diagnosed with paranoid schizophrenia compared with non-Hispanic whites.15,16
… after an initial impression of and a treatment plan for a patient is developed, HCPs are less likely to consider alternative effective treatments.
In lifestyle medicine, lack of cultural considerations is less likely to lead to misdiagnosis but more likely to lead to ineffective treatments.17,18 For example, the diagnosis of obesity is not likely to be determined incorrectly, but the treatment of obesity may not be as effective when culture is not taken into account. To address this, many steps have been taken to ensure that interventions are culturally appropriate. 19 Multiple studies have been conducted on culturally tailoring programs in an attempt to take into account specific barriers and facilitators that may affect a particular group of individuals. Even though steps have been taken to improve outcomes for individuals from various cultural backgrounds, considerable effort is still needed to provide effective treatments for groups that are experiencing health disparities.
Information Processing and Cognitive Biases
In most cases, less effective treatment is not related to knowledge gaps on the part of the HCP but is the result of information processing errors that arise during the synthesis of case-related information.20,21 One of the primary causes of information processing errors is the overreliance on the use of heuristics and biases. 20 Heuristics are important unconscious mental strategies that HCPs use to quickly and efficiently assess a patient, decide on a diagnosis, and develop a treatment plan. 22 Although the use of heuristics has traditionally been viewed negatively because of the increased risk of inaccurate information processing, more recent thinking has embraced the use of heuristics in medicine as a way of making accurate decisions based on limited information.23,24
Despite some of the clear support for the benefits of the use of heuristics in medicine, the unconscious use of heuristics predisposes HCPs to biases and the possibility of making critical errors in judgment. 25 Specifically, heuristics may predispose HCPs to cognitive biases. For example, after an initial impression of and a treatment plan for a patient is developed, HCPs are less likely to consider alternative effective treatments.26,27 This may be particularly true when HCPs have a limited amount of time to spend with their patients. 28 The tendency to rely heavily on a first impression is a type of cognitive bias.
One of the main biases that HCPs may be prone to is confirmation bias, which is an error in information processing that involves the tendency of people to favor information that confirms their opinions and to test hypotheses in a way that further substantiates their beliefs. 29 This bias may also lead HCPs to misinterpret information by disregarding contradictory information, which may ultimately result in ineffective treatment. 22 For example, a patient may be having trouble adhering to treatment recommendations or lacking motivation because of issues not discussed in initial treatment planning. Although it is clear that a HCP needs to reflect and adjust treatment by taking into account the barriers presented by the patient, confirmation bias leads the provider to focus on the initial case conceptualization and to spend less time trying to understand new factors that are affecting treatment.
The Role of Culture in the Treatment of Patients
As discussed by Gurung 30 in this issue, culture can affect the presentation of patients in a number of ways, which may then have an effect on treatment. Specifically, culture may affect the way in which patients verbally describe symptoms and the way in which HCPs interpret this information and consequently lead to a treatment that may not be as effective for the patient. To understand clients within their sociocultural context and develop the most effective treatment, HCPs should be skilled in gathering information from the clients and possibly family members. Many variables should be taken into account to develop an effective treatment for patients, including their degree of acculturation, religious beliefs, traditional values, family structure, and sources of support. 31 Given the complex nature of determining and implementing a culturally appropriate treatment plan, it is essential that HCPs routinely reassess the factors that are affecting treatment. However, information processing errors such as confirmation bias, as mentioned above, may cause a HCP to overlook critical factors that are presented later in treatment.
To minimize the potential for confirmation bias, HCPs should make it a priority to search for alternate hypotheses when considering multifaceted and unfamiliar problems. This may be especially important when treatment is not effective. HCPs should engage in hypothesis testing throughout the course of treatment. Because new issues constantly arise in lifestyle treatment, this process should ideally occur during each visit. In addition to hypothesis testing, HCPs should be in regular consultation with other specialists in the area and be knowledgeable of current literature in order to be able to develop and make adjustments to existing treatment plans. Taking these steps has been shown to improve outcomes, especially in difficult and complex cases. 32
Conclusion
In a culturally diverse society, it is important for clinicians to be able to accurately assess patients from cultural backgrounds different from their own. Having knowledge of other cultures can allow physicians to consider alternatives they may not have initially considered. However, HCPs should be aware of the tendency to make assumptions about a client based on their culture and the predisposition to fail to consider other alternatives and to seek additional information to confirm rather than test the initial hypothesis. Whereas understanding cultural norms is important, recognizing the heterogeneity that occurs within cultural groups is also of great importance. 33 When assessing complex patients from different cultural backgrounds, it is important that HCPs are proactive in minimizing the potential for cognitive biases. Taking steps to address the tendency to confirm one’s initial impressions of a patient will greatly assist in improving the effectiveness of a treatment with individuals from unfamiliar backgrounds.