Blog | Monday, October 28, 2019

Bias landmines

12:01 P.M.

My intern was presenting this patient to me at this exact time. My tumbly was feeling pretty damn rumbly and lunch couldn't come soon enough. But we were almost there. Last patient of the morning. Fairly straightforward. Acute decompensated heart failure—one of the most common things we see.


I have to admit that I was glad it was something “bread and butter” and not something exotic. Nothing about this seemed to be a diagnostic conundrum. And that was a relief considering it had already been a long morning of medical mysteries. On top of that, I was hungry.

Real hungry.

Yup. I'm human so yes, I get hungry. And that can feel more urgent as the noon hour approaches. My mind wanders off for a second and then I mentally smack my own face. Terrible, I know. I shadowbox internally, ignore my growling stomach, and keep listening.

He described a youngish guy admitted for severely elevated blood pressure, heart failure, and fluid on his lungs (name and details changed to protect anonymity).

“He takes his medications faithfully,” my intern said. “And, for the most part, he eats right. Not really sure why this current set back happened.”

“Okay,” I said. “Where does he get his meds?”

“Grady,” he replied quickly. “Right at our pharmacy. And I checked to see if he's filling his meds and he totally is.”

“Hmmm. Okay.” I thought for a second. “And you said no dietary indiscretions?” My intern shook his head. My belly made another audible protest. “Chest pain?”

“Fleeting chest pain—but his EKG and cardiac enzymes are all normal.”

Just then, there was an interruption. A man in a hospital gown shuffled past us, IV tubes dangling from his wrist and forearms. Definitely not much older or younger than me. The ashiness of his skin was amplified against his espresso-colored complexion. He looked over at my intern and smiled revealing the tell-tale dentition of limited resources and a hard life. “Just hitting this commode,” he said in our direction.

“We'll be right there,” my intern spoke back to the man. “Just telling my team about you.”

And the patient nodded and disappeared behind the sliding door to his room.

“Hey—did you check a urine drug screen?”

My intern paused. “I actually didn't, Dr. M. But I did ask him about illicit drug use. He doesn't do any of that.”

I nodded and twisted my mouth. “I'd recommend checking anyway.”

He looked perplexed. “Check a UDS?”

“Yeah. Cocaine could unify all of this, honestly.”

“But … he doesn't use cocaine.”

“I've been burnt many times.”

My intern's face flushed crimson. “Oh. Okay. Sorry about that.”

And that was it.

Of course, you know what happened next. I walked in and met this gentleman who told me the exact same story. And the pharmacy record and his appointment history supported what he said. He denied any drug use and, on top of that, had prior screens that all were negative.


He just had bad heart failure. Period. And sometimes bad heart failure just misbehaves without much provocation. And yeah—he had eaten a little bit too much salt but that wasn't on purpose. It was because eating fresh, non-processed foods is expensive and hard. But the brother was trying. Damn, he was.

I gritted my teeth and felt my masseter bulging. Between my stomach growling and my intense remorse about the microaggression I'd just committed against my patient, it was hard to think straight.

Hallelujah for bread-and-butter medical problems.

We gave him IV diuretics to get fluid off. We optimized his blood pressure meds. We restricted his fluids. And we consulted the heart failure team. And that meant rounds were over. The team broke up and that was it. Before I could even think of a way to right my wrong.


I walked into our team room a few moments later and was relieved to find everyone there. They were all getting their lunches and preparing for the resident conference. I could already feel my face getting hot.

“Umm … guys? Can you give me a minute of your time?” They all sat down and obliged me. Even though I'm certain they were hungry, too. I cleared my throat and spoke. “I was wrong.”

Their eyes all widened.

“Ummm. So yeah … when Mr. Mackey walked by I sized him up. I saw a youngish, poor black man walking through Grady. And my bias was at play when I asked for that UDS. I looked at him and considered crack cocaine. I was wrong.” My intern was staring intently. “I know if he was a white woman at Emory or even an insured black patient somewhere else, I probably wouldn't have suggested that. Please cancel the urine drug screen if it hasn't been collected yet.” I sighed hard and looked at the patient's name on my list. “I'm sorry Mr. Mackey.”

No one said anything. So I went on. “Look y’all. I'm a work in progress. I'm still messing it up sometimes, too. But I want to own my biases and do better, y’all.”

My team was so gracious. After that, we discussed “bias landmines” such as being hungry, tired, rushed, or stretched too thin. We also talked about owning your biases and trying to do better. It was super powerful.

I cried as soon as they left the room. Not out of shame but more because I honored my patient and believe that I taught my team more about bias through that one moment than any lecture they could ever get.


Look, man. I do NOT have all this stuff figured out. Mr. Mackey fell in a group that I believe myself NOT to be biased against. Still, my actions said otherwise. That's what's so troubling about implicit bias. The heart feels one thing but the mind goes rogue.

And so. I call it what it is and vow to keep fighting. Fighting the monsters that hurt my patients and my community—even when that monster is me.


Kimberly Manning, MD, FACP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.