The Ladder of Inference as a tool to reduce implicit bias in pediatric clinical practice

Implicit bias in healthcare professionals is a widespread phenomenon that leads to worse healthcare outcomes for marginalized patient populations. One tool that can help providers identify when biases are impacting the clinical care they are providing and enable them to take corrective action in real time is the "Ladder of Inference" (LOI). The LOI is an instrument that elucidates the process by which we take in information about another person, filter that data through our own interests, needs, perspectives and biases, and then use it to draw conclusions about the individual. These conclusions are often profoundly inaccurate, yet we then act upon them. Thus, we propose the LOI as an "implicit bias detection tool" for neonatal intensive care unit (NICU) clinical practice. We demonstrate on two common NICU cases how utilizing the LOI can uncover mechanisms by which positive and negative feedback loops secondary to unregulated implicit bias lead to a stepwise increase or decrease in the quality of care. As the cases demonstrate, the subtle differences in individual steps up the ladder can lead to care differences of a large magnitude in either direction, hugely positive or detrimentally negative. This shift in the quality of care, then, may contribute to the significant neonatal outcome disparities in infants from minoritized groups. Using the LOI as a practical tool, we demonstrate how it becomes possible to detect one's own implicit biases and thus to consciously monitor the inferences we are making about patients and their families in order to counteract them.