August 11, 2020

Studies Point to Implicit Bias in Healthcare

Clinician Leadership | Leadership Development

Reading Time: 5 minutes

Recent events and mounting industry data illuminate an uncomfortable truth: Implicit bias is prevalent in healthcare, say researchers, and many are unaware. More importantly, it’s hurting patients.

As a healthcare leader, we trust that your aim is to ensure that every patient — regardless of background, ethnicity, race, education, sexual orientation, or other factors — gets the absolute best from you, your team, your organization. To make that possible, conscientious leaders should be aware of the ramifications of implicit bias, how to recognize and counter it.

We’ll link to relevant resources throughout, plus a sampling of related studies and industry voices at the end of this post.

Clarifying implicit bias

First, it’s helpful to clarify what we mean by implicit bias. The Ohio State University defines it as “attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.” OSU researchers also list the following characteristics of implicit bias:

  • Implicit biases are pervasive. Everyone possesses them, even people with avowed commitments to impartiality such as judges.
  • Implicit and explicit biases are related but distinct mental constructs. They are not mutually exclusive and may even reinforce each other.
  • The implicit associations we hold do not necessarily align with our declared beliefs or even reflect stances we would explicitly endorse.
  • We generally tend to hold implicit biases that favor our own ingroup, though research has shown that we can still hold implicit biases against our ingroup.
  • Implicit biases are malleable. Our brains are incredibly complex, and the implicit associations that we have formed can be gradually unlearned through a variety of debiasing techniques.
Studies: Implicit bias in healthcare is widespread, and effects can be devastating.

There’s no shortage of data pointing to implicit racial and ethnic bias among medical professionals. In one 2015 study, results showed implicit racial bias scores among healthcare workers are like those in the general population, summed up as “positive attitudes toward whites and negative attitudes toward people of color.”

Though unintentional, unconscious bias affects patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes. Put another way, “racial and ethnic minorities and women are subject to less accurate diagnoses, curtailed treatment options, less pain management, and worse clinical outcomes,” reports Project Hope, a global health and humanitarian relief organization.

The authors, both people of color, describe what that looks like up close and personal:

“We have witnessed black children not being treated as children at all, or not being given the same compassion or level of care — even the use of topical anesthetics — provided for white children. We have witnessed care teams express frustration with the patient’s cultural views, such as forgoing blood transfusions or other clinical interventions, that did not align with ‘common’ or ‘traditional’ views. One of us was reflectively smacked by a frustrated anesthesiologist while she was in active labor for not bending down far enough for an epidural.

For many white patients, these kinds of experiences would be inconceivable. But for black or Hispanic patients, maltreatment can be routine, almost ubiquitous, and those patients are often unable in the moment to seek redress.”

We have much work to do to ensure every patient who comes our way receives the care we’d wish on our loved ones. Healthcare leaders play an essential role in expanding awareness of implicit bias and addressing it.

Spotting the unseen

Me, biased? I don’t discriminate,” you might think. It’s a common reaction. It’s tough to contemplate the possibility that we harbor implicit (unconscious) bias.

The reality is that our brains function on certain “algorithms” or shortcuts that manifest automatically, “at a level below conscious awareness and without intentional control,” explains the Institute for Healthcare Improvement. Your job as a caring leader is to acknowledge, explore and address this reality.

One physician uncovers his unconscious bias

Earlier this year, The Philadelphia Inquirer reported the disadvantages that children of color have experienced in dealing with white medical teams. Dan Taylor, a physician who shared his perspective with the Inquirer, recounted his own shock at learning his unconscious bias.

Taylor, who leads the pediatrics clinic at St. Christopher’s Hospital for Children, is widely published and respected in his profession. “Yet when he took an online bias test offered by Harvard, he was stunned to discover that he viewed white and black patients differently,” the article reads. The test measured how test-takers associate groups of people with various traits such as intelligence, athleticism, and goodness.

The realization changed how Taylor approaches his patients and the medical students he supervises, though he acknowledges it’s not a simple switch. “It’s a different way of retraining your brain to listen a different way, to pay attention to very subtle expressions or words or emotions that families express,” he told the newspaper.

Tackling bias: general recommendations

We’re not where we need to be and have much to learn about addressing bias in ourselves and our teams. It’s a difficult but urgent charge in our calling as healthcare leaders.

Below we’ve compiled potential next steps, based on recommendations from three sources: Project Hope, Institute for Healthcare Improvement, and “Seeing Patients: Unconscious Bias in Healthcare” by Dr. Augustus White. Healthcare leaders can take these next steps and advocate for them among their followers. Some are amenable to organizational policy reforms, others to innovative programs, and still others to personal advocacy.

  • Know your implicit bias. Take a free, two-minute test from Harvard’s Project Implicit to understand how your brain is primed to make split-second decisions.
  • Take a social inventory. Do all your friends and associates look like you? Do most come from similar backgrounds? Expand your social and professional networks, increasing your contact with individuals from different groups, backgrounds, and traditions.
  • Practice counter-stereotypic imaging, where you imagine the patient as the opposite of the stereotype.
  • See the patient as an individual rather a stereotype. Learn about their personal story and the context that brought them to your health facility.
  • Frame your interaction with the patient as a partnership between collaborating equals, rather than a high-status person and a low-status person.
  • Know the National Culturally and Linguistically Appropriate Services (CLAS) standards, designed to reduce health disparities and respect the whole individual.
  • Diversify the pipeline for healthcare workers so minorities are well represented in your organization.
  • Practice the Teach Back method to confirm the patient understands healthcare instructions.
  • Practice evidence-based medicine. Understand healthcare utilization data and performance outcomes.

Lastly, we’ll leave you with a short video by the Institute for Healthcare Improvement. We hope it will bolster your understanding of implicit bias and help you address it in your life and work.


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About the author

Michael S. Hein, MD, MHCM, ACC

Michael S. Hein, MD, MHCM, ACC has over 20 years of healthcare leadership experience in multi-specialty practice, large integrated health systems, academic medicine, and start-up companies. He has extensive clinical leadership experience and deep knowledge in transformational change.

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