Overcoming Bias


I had a patient write me about a problem and ask for advice on how to prevent the problem from happening.

The patient has a medical condition – bipolar disorder. The patient has also been to the emergency department a few times and perceives that, once the staff learns that he is bipolar, a bias develops. To quote him,

I’ve seen a hesitation when it comes up while they are taking my history. Perhaps I’m reading too much into it, but it feels like they are mentally recalibrating their general impression of me.

The patient asks whether the bias really exists (“is there a tendency to immediately give
more consideration to a diagnosis of drug abuser or drama queen?”) and, if so, asks for suggestions on what to do to to overcome that bias.

I don’t think that anyone can say they don’t develop some type of bias from a patient’s history. Some instances of bias are worse than others, but they all go back to the healthcare worker’s previous experiences. For example, if a young child is attacked by a dog, that child will have a future fear of other dogs – no matter how friendly the dogs are in the future. Previous experiences have shaped future perceptions.

We have one schizophrenic patient who frequently comes to the emergency department for “antibiotics” to get rid of the “infection” caused by his previous interactions with various tadwry women in his life from years past. He believes that he is unable to get their “secretions” (my word, not his) off of his body. So once a month or so he comes in for his antibiotic shot and he leaves after getting a shot of “norMAL sahLEEN” or the really good stuff – “dihydrogen oxide” – which are “normal saline” or “H2O” respectively. And getting those medications helps him. Really. He’s happier. He thanks us, and he goes on his way.

But my experiences with that patient do give me a bias when I see in someone’s history that they are schizophrenic. I can’t help wondering – are they going to be like “him”? No matter what I do, that’s the bias that I sometimes start with.

When I meet a patient, their actions either refute or confirm any bias that exists. In other words, I may be inclined to think one way, but my mind isn’t set in stone. Be pleasant with me, interact normally, say “thanks, doc” and the bias is gone. Swear at me, pretend that you’re passed out from severe pain, or engage in floor throwing and the bias is substantiated.

I guess the bottom line is that I do believe a bias exists toward certain aspects of a patient’s history. I don’t believe the bias is huge, although with some providers – and depending on the complaint –  I suppose it could be.

How to overcome the bias?
Be nice. Say “please” and “thank you.” You’d be surprised how much someone’s attitude about you will change if they think you appreciate what they are doing for you.
Don’t exaggerate your problems. Most doctors and nurses can tell when you are doing so.
Don’t act like a “drama queen” and in most cases, you won’t be treated like one.
If you have a history of going to the emergency department for pain complaints, be up front about it. You may not get the narcotic prescription to take home, but if you are in pain, most docs will do what they can to get you out of pain as long as you aren’t there every week. If you have been hopping from hospital to hospital and don’t tell the staff about it, most of the time the staff in the ED will call around to other hospitals to check you out. Once you’re caught hospital hopping, at most places you’ll go on The List and it will be harder for you to get your problem treated anywhere.

Hope this helps.


  1. From a nursing standpoint, there is nothing like personal experience from the patient-side of the bed to change biases.
    My wife is bi-polar, I see it every day, and she deals well with it…mostly.
    It used to be I treated psych patients as ‘crazy’, but now I treat them as I would hope my wife would be treated, should she ever come to that point….
    without bias,
    with compassion and
    with dignity.
    And to take it a bit further, isn’t that the way we should treat all patients? (At least until they themselves give us reason not to!)

  2. I am the person that wrote in the question. Thank you for taking the time to post and answer it.

    You are absolutely right; “please” and “thank you” go a long way. What patients need to remember (but often forget) is that the doctors and nurses are there to help. They didn’t cause your problems. No matter what the pain, worry, or impatience I may be feeling, I also feel gratitude and thankfulness that you are there.

    For those of us that have a chronic condition, the most important care taker is ourselves. When in the middle of a soul-crushing depression, just knowing (at an intellectual level) that the bleakness I feel is an illusion, a nasty trick that my own mind plays on me, makes a difference.

    Too many times I’ve been faced with a choice: the ER and a week on the floor without metal utensils or death. I know it can’t be easy on you, to see the decent guy that can barely hold it together. Blood and broken bones you can deal with, but what can you do for the person that you know is in pain, but that can’t be helped by any pill or treatment that you can offer? There is only one thing you can offer: hope.

    I’ve met plenty of people going through severe depression. The sickest people don’t yell or scream in agony and don’t throw things. It is just too much effort. Myself (and I know I’m not alone in this) will even make the effort to be polite, to smile, maybe even laugh and joke. We are holding on to any shreds of humanity we still have. I’ve probably confused more than one doctor doing a differential because I didn’t act the way they expected (“Do you know what year and month it is.” “Yes, its May, 200x. Oh, you might want to move the calendar.”)

    Perhaps that hesitation that I’ve seen isn’t them recalibrating their opinions of me. Perhaps they are recalibrating their opinions of what someone with bipolar disease looks like.

  3. Medical student on

    If it means anything, your thoughtfulness has totally ratcheted up my opinion of people with bipolar disorder, and has probably prevented me from establishing biases about them in the future.

  4. I am bipolar too… (actually bipolar II-giggles). I have SEVERE anxiety. I don’t go to the ER, but when I go to the doctor or urban care place chest pains, I tell people that I aware that it could be just anxiety.

    I was actually had esophageal spasms (diagnososed on a barium swallow) that can actually feel pretty serious.

    But I have had a few ekgs in my life….

    ironically, the only time I have gone to the ER was for suicidal feelings. I have been admitted twice (It does suck). I felt ashamed-both times.

    ….oh I did nearly break my arm in the middle of the night…just a bone bruise (UGH!!! those hurt)

  5. what a shame somebody has to feel badly about feeling suicidal and seeking help…we might as well be applying leeches and other such interesting medieval medicine as far as we have gotten in treating true mental illnesses.

  6. For Dienw,

    I do apologize for throwing levity into a discussion of such seriousness. My heart goes out to you and all who struggle with bipolar. Our “help” system is so difficult to navigate for you! I have an acquaintance in a forum (for thyroid disease) to which I have belonged for many years. She is bipolar, and has struggled most of her life to be taken seriously and treated with respect.

    Perhaps some of the difficulty in dealing with bipolar is simply that we do not yet have a complete understanding of it. And as you said about health providers you see, Perhaps they are recalibrating their opinions of what someone with bipolar disease looks like.

    Best wishes to you.

  7. I have a bipolar friend, and one of her things is thinking random people don’t “like” her, kind of a low-level paranoia about this. This is the kind of concern that she would have. “Oh, I just said I’m bipolar, now they don’t take me seriously/like me.”

    I’m guessing you’re reading too much into it.

  8. Dienw,
    Thanks for sharing your comments and concerns. Please allow me the opportunity to share mine.

    Is there a bias among ED physicians and nurses regarding bipolar patients in particular and mental illness in general? Yes. Absolutely. Here’s my unscientific opinions as to why:

    1. We are forced to search for the true needle of those with true bipolar disorder in the vast haystack of those labeled with bipolar disorder but really suffer from personality disorders, substance abuse, or are manipulative sociopaths. We are threatened, assaulted, and treated in a manner that would normally result in removal from any other premises, or incarceration and a criminal record, yet a mental illness label seems to be a pass. Just ask one of my nurses who is sweating out an HIV test after a needlestick created by an intoxicated and assaultive person whom the police dropped off at our doorstep because they found Klonopin and Effexor in his pocket. Last I heard his assault charge – in a state where supposedly under the law assaulting a health care provider is the same as assaulting a police officer – was dismissed by a judge. This leads to a fair amount of compassion fatigue and eventual callousness when dealing with the mentally ill.

    2. No one wants to see anyone with a mental illness languish in an emergency department, deprived of their liberty and dignity, waiting for a bed. We are frustrated with the passive-aggressive delaying tactics used by psychiatric facilities in denying these patients. Leaving residency I couldn’t stand surgeons because of their arrogance and obstinacy. Over time the psychiatrist and his/her minions have replaced surgeons in my eyes.

    3. The entire mental health system is an utter failure. Doing away with long-term institutions in favor of a “community health” approach was and is a disservice to those members of our society who lack the coping mechanisms to function in an increasingly difficult and stressful world. Someone wiser than me once said the definition of insanity is repeating the same process and expecting a change in the outcome. Do our mental health professionals really believe a few days’ stay in an inpatient setting will give someone with bipolar disorder the coping mechanisms to deal with the issues that got them admitted in the first place? Or is it because that’s the length of stay their insurance will cover?

    In closing yes, Dienw, there is a bias. We’re not psychiatrists; we’re trying to do the best we can with what we’ve got. We truly do want to help you in your struggle to get help from a system that only cares if you are suicidal. I just hope we can have enough compassion left for you after dealing with the dozen or so charlatans who have used a mental health label to shield themselves from accountability for their actions.

  9. Hmmm. unless someone is in a very severe psychosis…in which a symbolic delusion is identified. Mental Illness should not be used as an excuse for violence. I’ve worked with many very sick individuals with psychotic disorders. Often, they are reacting or absorbing the energy of the staff. A soft voice is often effective of desculating the situation. However, it doesn’t always work like that. Especially when the psyhcopath gets his kicks off acting the part of the mentally sick.

  10. Do you think a sense of entitlement, the “drama queen (or king)” syndrome, or other extremism is always associated with schizophrenia? Or is it just bad parenting?

    I have a relative who is schizo so I know he can act oddly, but he is not dangerous.

  11. “The sickest people don’t yell or scream in agony and don’t throw things. It is just too much effort. Myself (and I know I’m not alone in this) will even make the effort to be polite, to smile, maybe even laugh and joke. We are holding on to any shreds of humanity we still have.”

    Dienw is right, and he’s not alone: I could still be polite, smile and occasionally joke with people I didn’t know well enough to trust with how I was feeling, right through the worst of my depression – including the day I overdosed. (Shocked the hell out of my therapist; even he didn’t know I was that close to the edge. And I was too far down to tell him.)

    The p-docs were great, but the nurses (especially one on the psych ward – God bless you, Bryan!) were the ones who really deserve the credit for helping me get through both the embarrassment of the attempt, and the sheer terror I felt at being involuntarily held behind locked doors. (Oh, sure, there was plenty of room to roam so I wasn’t claustrophobic by any means, it was the complete loss of the freedom to leave if I so chose that triggered a long-standing paranoia.)

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