What Bias in Medicine Really Looks Like

I remember being a third-year medical student rotating through dermatology in San Diego. The last patient of the day was an unhoused man - young, with a history of IV drug use, HIV-positive - who came in for evaluation of a fungating mass bulging from his left cheek. I remember the resident’s posture as she interviewed him: arms crossed, leaning back, keeping her distance, as if she were just getting a formality out of the way.

“How long has it been there?” she asked.

“A year, maybe two. My wife keeps putting her finger in it when she’s pissed at me,” he said, dabbing serous fluid from the side of his face.

“We’re going to need to do a biopsy,” she replied flatly.

As we gathered supplies - a 3 mm punch, Adson forceps, curved scissors, silver nitrate, specimen cup - she muttered in my direction, “That’s for sure a squame,” then glanced at her watch. “We’ll biopsy this quick and be out before three.”

Back in the room, we got started. The patient reacted strongly to the most painful part: injecting lidocaine. He swore loudly and jerked his head away. I would later learn that many people with opioid use disorder respond this way. The resident stepped back and sighed, her eyebrows knit in irritation. Each additional injection provoked more swearing. Eventually, the area was numb.

She punched out a fleshy core of tissue from the friable tumor and dropped it into the open formalin container, as if it were hazardous waste. A few sticks of silver nitrate controlled the oozing.

As she discarded the punch and needle into the sharps bin, she spoke more to the container than to the patient. “Tylenol and ibuprofen for pain, apply pressure if it oozes, and we’ll see you in a week to go over the results.” She left the room without waiting. I followed.

I think about that experience whenever my mind urges me to dismiss a patient because of socioeconomic status, insurance, disability, lifestyle, or any other distinguishing feature.

Recently, I saw a man with an intellectual disability, and the thought flashed: He won’t notice if I don’t wash my hands. Then there was a woman in her twenties with hirsutism, several missing teeth, and a BMI in the morbidly obese range. I felt the impulse to rush the history, to skim the checklist I usually move through carefully. And yet, I never consider skipping steps when I see the philosophy professor or the yoga teacher. With them, I linger.

This is what bias actually looks like.

Not overt cruelty or conscious malice, but the surreptitious sorting of people into those who receive our full presence and those who receive what’s left.

The unsettling part isn’t that these thoughts arise. They appear automatically, shaped by training, hierarchy, and culture. The danger is letting them go unexamined, allowing them to unconsciously shape how we practice. Choosing not to buy into bias isn’t only about doing right by patients. It’s also about doing right by ourselves.

Because every time we cut corners or ration our care based on who we think someone is, we become a little less of the clinician - and the human - we want to be. Integrity isn’t lost in one moment; it’s worn down by small, rationalized decisions, like water against stone.

I don’t interrupt these thoughts because I want to be virtuous. I interrupt them because I like who I am when I don’t let them guide my decisions. The work isn’t to eliminate bias. The work is to notice it, pause, and choose differently.

When I do, patients surprise me.

Like the fifty-year-old man with sun-leathered skin and a smoky odor clinging to his clothes who came to see me as a new patient. After finishing the exam, I sat back down across from him while placing the CT order.

“What do you do for work?” I asked.

“I’m a lobsterman,” he said, sitting up straighter. “Up in Maine. Get the freshest seafood right off the boat.”

That opened a conversation about warming waters, disappearing shrimp, and the changing rhythm of work along the coast. It was unhurried, unexpected, and deeply human. The kind of connection that only happens when, instead of sorting people, I put my human hat on and simply meet them where they are.