Implicit Bias and Health Care

Implicit bias can influence health and health care through several pathways. It can impact decisions and behaviors related to interpersonal and team dynamics, as well as play a role in shaping institutions and systems in ways that might not be immediately apparent. These biases may not reflect the expressed values or intentions of the individuals or organizations involved and might even contradict them. Yet, implicit bias can contribute to problems that patients, providers, and healthcare systems want to see addressed such as the lack of diversity in the physician workforce, challenges in provider-patient communication, disparities in outcomes between certain groups, and quality of care issues. 

The healthcare environment is highly interactive, often involving people with different roles and backgrounds (e.g., patients, doctors, nurses, staff, family members) trying to understand and address pressing problems or conditions. This type of stressful and demanding circumstance can increase the chance that existing implicit biases held by individuals are activated, which may raise the likelihood that those biases will influence decision-making or behaviors. 

It has long been documented that stereotypes and explicit prejudices within medicine and health care have negatively impacted the quality of care for many racial and ethnic minorities in the U.S. (Institute of Medicine, 2003). Research also demonstrates that implicit racial biases are just as common among healthcare professionals as the wider population (Sabin et al., 2019). Implicit biases in healthcare may also contribute to health inequities confronting other marginalized and socially stigmatized communities, such as people who identify as indigenous and/or as part of the LGBTQ+ community (Morris et al., 2019; Phelan et al., 2017; Zestcott et al., 2021). Below are some examples of studies examining implicit bias and health care. 

Examples

  • Biases in patient-provider communication. Studies examining implicit biases held toward Black compared to White individuals have demonstrated that implicit racial bias is just as common among healthcare professionals as the wider population (Sabin et al., 2009). Most of the published articles include data on Black/White attitudes and evidence from several studies shows that implicit biases can influence patient-provider communication (Maina et al., 2015). Implicit biases are typically manifested in non-verbal behaviors (e.g., speed of speech, appearing less friendly or warm) toward other individuals, including patients (Cooper et al., 2012). 
  • Biases in treatment recommendations. Some research studies have also found an association between provider implicit racial biases and treatment recommendations (Green et al., 2007; Sabin & Greenwald, 2012).
  • Bias in medical education. There are on-going efforts across the nation to address institutional bias within medical education. For example, some admission and hiring committees are examining issues of bias that may contribute to low diversity among students or faculty (Capers et al., 2017). Many schools are also revising or evaluating their curriculum to ensure biases are not present and/or perpetuated. Addressing these institutional-level issues have the potential for changing culture within an institution. 

References

Capers, Q., 4th, Clinchot, D., McDougle, L., & Greenwald, A. G. (2017). Implicit racial bias in medical school admissions. Academic Medicine: Journal of the Association of American Medical Colleges, 92(3), 365–369. https://doi.org/10.1097/ACM.0000000000001388

Cooper, L. A., Roter, D. L., Carson, K. A., Beach, M. C., Sabin, J. A., Greenwald, A. G., & Inui, T. S. (2012). The associations of clinicians’ implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. American Journal of Public Health, 102(5), 979–987. https://doi.org/10.2105/AJPH.2011.300558

Green, A. R., Carney, D. R., Pallin, D. J., Ngo, L. H., Raymond, K. L., Iezzoni, L. I., & Banaji, M. R. (2007). Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. Journal of General Internal Medicine, 22(9), 1231–1238. https://doi.org/10.1007/s11606-007-0258-5

Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Smedley, B. D., Stith, A. Y., & Nelson, A. R. (Eds.). (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. National Academies Press (US).

Maina, I. W., Belton, T. D., Ginzberg, S., Singh, A., & Johnson, T. J. (2018). A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Social Science & Medicine, 199, 219–229. https://doi.org/10.1016/j.socscimed.2017.05.009

Morris, M., Cooper, R. L., Ramesh, A., Tabatabai, M., Arcury, T. A., Shinn, M., Im, W., Juarez, P., & Matthews-Juarez, P. (2019). Training to reduce LGBTQ-related bias among medical, nursing, and dental students and providers: a systematic review. BMC Medical Education, 19(1), 325. https://doi.org/10.1186/s12909-019-1727-3

Phelan, S. M., Burke, S. E., Hardeman, R. R., White, R. O., Przedworski, J., Dovidio, J. F., Perry, S. P., Plankey, M., A Cunningham, B., Finstad, D., W Yeazel, M., & van Ryn, M. (2017). Medical school factors associated with changes in implicit and explicit bias against gay and lesbian people among 3492 graduating medical students. Journal of General Internal Medicine, 32(11), 1193–1201. https://doi.org/10.1007/s11606-017-4127-6

Sabin, J. A., & Greenwald, A. G. (2012). The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma. American Journal of Public Health, 102(5), 988–995. https://doi.org/10.2105/AJPH.2011.300621

Sabin, J., Nosek, B. A., Greenwald, A., & Rivara, F. P. (2009). Physicians’ implicit and explicit attitudes about race by MD race, ethnicity, and gender. Journal of Health Care for the Poor and Underserved, 20(3), 896–913. https://doi.org/10.1353/hpu.0.0185

Zestcott, C. A., Spece, L., McDermott, D., & Stone, J. (2021). Health care providers’ negative implicit attitudes and stereotypes of American Indians. Journal of racial and ethnic health disparities, 8(1), 230–236. https://doi-org.eres.library.manoa.hawaii.edu/10.1007/s40615-020-00776-w