“Frequent Flyers” – How Implicit Bias Can Impact Clinical Care

Implications for the integration of technology in healthcare


A group of researchers recently published a commentary in the Journal of the American Medical Association on one of the ways that implicit bias about persons diagnosed with ‘mental illness’ creeps into the seemingly neutral space of patient electronic health records. They focus on the group of clients who tend to be high utilizers of services at emergency departments and psychiatric crisis centers who “often have financial problems and present with chronic or untreated comorbid psychiatric and substance use disorders. These patients are often well known to clinical staff and are sometimes colloquially labeled ‘frequent flyers.'”

“A pejorative branding, ‘frequent flyers’ are often assumed to be problem patients. In psychiatric settings, these patients are sometimes said to be ‘borderlines,’ ‘drug seekers,’ ‘malingerers,’ or ‘treatment resistant.’”

Photo by NEC Corporation of America with Creative Commons license.
Photo by NEC Corporation of America with Creative Commons license.

Implicit bias refers to errors in judgment and/or behavior that result from attitudes and stereotypes that operate below the level of direct awareness and often without particular intent.  Conceptually, this is the opposite of explicit bias, which refers to attitudes and beliefs we hold at a conscious level and are actively aware of and experience as a result of perceived threat.

The concept of implicit bias has recently become an important part of the discussion of race relations in the United States. In the present commentary, the authors note how moving beyond constructions in spoken language, which are enough to inform implicit or even explicit bias in themselves, symbols that are emblematic of bias and stereotypes are now entering the space of the electronic health record system. A system that they use as an example has an airplane icon that system administrators can use to identify to clinicians that a person is a “high utilizer” of services.

They write:

“This iconography is ethically and clinically inappropriate for 2 interdependent reasons. First, the icon reinforces and encourages the use of disrespectful and stigmatizing terminology. Second, the icon may frame the initial clinical interaction in a way that inhibits good diagnostic judgment, potentially placing the patient at increased risk of a poor outcome”

The impact of implicit bias on clinical management has been found in other studies. Stull and her colleagues, for instance, found that implicit but not explicit bias led to prescription of interventions that were more controlling of clients. They found that the prescription of such interventions are linked to more implicit endorsements of stigma toward people with mental illness being “bad” or “helpless.”

Implicit bias has also been found in the medical literature related to racial bias in the recommendation of treatment for black versus white patients. For example, unconscious bias was found by Green and his colleagues to contribute to racial disparities in the “use of medical procedures such as thrombolysis for myocardial infarction.” Moreover, Kopera et al found that even professional, long-term contact with people impacted by ‘mental illness’ does not make providers immune from negative implicit attitudes.

Similarly, in the mental health literature, it has been found that black and latino consumers of services are approximately three to four times more likely to receive a diagnosis of a psychotic disorder compared to their white counterparts. This trend is also found internationally with immigrant consumers who are diagnosed more frequently with psychotic disorders than consumers from a majority racial background. In terms of gender bias, Peters et al. found that women are almost twice more likely to receive a benzodiazepine prescription at discharge from a psychiatric inpatient unit compared to men.

Moreover, racial bias in prescriptions rates have also been observed, finding that black clients were less likely, and Asians slightly more likely, than white patients to be prescribed a benzodiazepine. These studies did not measure implicit bias directly, but these findings urge us to consider the impact of unconsciously held beliefs and attitudes on decision making, that should be based on clinical need rather than stereotypes about groups.

The authors of the present study highlight the stigmatizing clinical consequences of iconography that reinforce stereotypes of certain groups of clients. For example, one consequence is “diagnostic overshadowing” a phenomenon in which physical symptoms reported by persons will mental illness are misinterpreted as part of their mental health concerns and are undertreated as a result. This is disturbing given that people with mental health issues are known to have significantly higher medical co-morbidity as well as earlier deaths compared to the general population.

The authors write:

“These patients are less likely to receive appropriate medical care than patients without a mental health condition—their psychiatric conditions overshadow their other conditions, potentially biasing the clinician’s judgment about diagnosis and treatment such that the clinician may misattribute physical symptoms to mental health problems.”

The authors remind us that apart from electronic medical records, big data, and social media offer exciting potential for healthcare practice and patient empowerment. However, they also carry with them the potential to reflect biased social and political values. To mitigate these effects “electronic medical record systems and behavioral health care applications should be built and tested in collaboration with patients, consumers, clinicians, social scientists, and ethicists who are sensitive to the broader ramifications of iconography and language,” they conclude.



Joy M, Clement T, Sisti D. The Ethics of Behavioral Health Information TechnologyFrequent Flyer Icons and Implicit Bias. JAMA. 2016;316(15):1539-1540. doi:10.1001/jama.2016.12534 (Abstract)


Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.


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  1. This article is putting an academic sheen to old old truths
    Gomers and Gomeres
    Get Out of My Emergency Room
    with feminine take
    There were other words I will not mention and this was in a non psychiatric population!
    Read “House of God@
    by I think Shem Fine
    a pen name for a man who became a shrink
    A parody but one parody that should have taught the MBA’s just out of scchool a wealth of knowledge and burden of sorrow
    St. Elsewhere was somewhat the same but the shrink and patients were not offending or protrayed as horror show characters
    It could have been much worse
    The truth on how ” the other” is treated needs to be explored
    So much for the Year of Mercy by the Pope
    We all need to reconfigure how we see and deal with difference especially unpleasant or uncomfortable difference
    We need to learn how to work with our own prejudice and fear and anger
    Not all of these folks are betrayed Angels
    Some are not at all easy and some of us here need to remember times when we were not our best selves actually everybody does!

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  2. I was a “Frequent Flyer” only after being stupid enough to trust them after my initial complaint of insomnia turned into depression anxiety ADHD and finally bipolar as the keep you sick pills were piled on.

    The only reason I was ever a psychiatric inpatient was for being ignorant of the fact the psychiatric industry is a profit driven crime against humanity that doesn’t give a crap about anyone.

    The Risperdal Story is the perfect example , Over the course of 20 years, Johnson & Johnson created a powerful drug, promoted it illegally to children and the elderly, covered up the side effects and made billions of dollars. This is the inside story. http://highline.huffingtonpost.com/miracleindustry/americas-most-admired-lawbreaker/

    I see it every day in the drug and alcohol treatment field young people drugged in school , pills piled on for ADHD or what ever else till they are all messed up from a childhood on psych drugs and turn to booze or street drugs. Of course when they get to treatment the first thing is shuffle them to the doctor for more pills.

    I was a ““Frequent Flyer” till I found websites like this one explaining what a greedy sick fraud the entire keep you sick psychiatric industry is and took my life back by saying NO MORE pills.

    The very last one was “you should try Zoloft and Abilify” … Get the F away from me.

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    • Being a “frequent flier” is just as likely to be the result of institutional bungling, as it is a necessary sign of some alleged narcissistic personality disorder (I know how big assorted personality disorders are in the DSM’s).

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  3. Cat
    I am sorry you had such a difficult time
    I always tried to avoid ER ‘s at all costs but my husband used them for me and last time I seemed to have nowhere else to go
    There are places like retreat centers that are low cost to visit but they are really not prepared for any crisis and you would have to be able to discern you are in need of r and r and that takes discernment
    From now on I know a certain month is filled with old and new triggers and I will be sure to do slot of self care next year
    Also we need short term trauma centers as a proactive approach even hospitals that have designated psych er rooms are a journey through hell
    Very few people want to use services this way
    The medical world is st fault for not being proactive in accurately and compassionately planning to care for people in need
    In the earlier times the Catholic Church was a refugee and sanctuary
    No longer!A stay in a Catholic hospital is just as bad as a public hospital or private one.
    Without true Trauma informed care it is just like prisiob

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  4. “’… diagnostic overshadowing’ a phenomenon in which physical symptoms reported by persons with mental illness are misinterpreted as part of their mental health concerns and are undertreated as a result.” Actually, today’s medical community intentionally misdiagnoses people with “mental illnesses,” and drugs people with the psychiatric drugs, so they may proactively prevent legitimate malpractice suits and cover up easily recognized iatrogenesis. And so the doctors may avoid actually correcting their easily recognized medical mistakes. This crime against patients is known as “the dirty little secret of the two original educated professions,” according to an ethical pastor of mine.

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  5. My position has for decades been that no one should ever accept any kind of a psychiatric label, or disability label.

    But along with this idea, I also say, don’t ever cooperate with talk therapists, social workers, or any form of psychotherapists.

    We should be printing up warning cards which people can carry, cards which threaten a lawsuit if there preference for privacy is ever violated.

    Part of the problem is that having moved into the Information Age and a global economy, our society no longer needs much labor. So instead it tries to create basket cases, people who’s entire lives are run by public health care and social services.

    And then often accepting these disability labels is necessary for people to get various kinds of benefits. I don’t fault those who do this either. But I do hope understanding can be spread, as right now most public assistance and disability programs are run for the purpose of shaming, humiliating, and regulating the poor.

    Back to the late 60’s, the Piven and Cloward Plan was a truly visionary approach to such problems, and we would do well to study it.

    So my advice is always zero cooperation, give them zero information, don’t discuss anything with them.

    But I also understand that most people don’t see it this way.

    We need to do political consciousness raising, and we need to be finding ways to take legal action. What we don’t need are Psychotherapy, Recovery, Healing, or Getting Saved.


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