Addressing Implicit Biases in Health Care
Implicit and explicit biases are among the many factors that contribute to disparities in health and health care.1 Explicit biases, attitudes and assumptions that we recognize as part of our personal belief systems can be assessed directly through self-reports. Explicit, openly racist, sexist and homophobic attitudes often underlie discriminatory actions. Implicit biases, on the other hand, are attitudes and beliefs about race, ethnicity, age, ability, gender or other characteristics that operate outside of our awareness and can only be measured. indirectly. Implicit bias surreptitiously influences judgment and can, without intention, contribute to discriminatory behavior.2 A person may hold explicit egalitarian beliefs while harboring implicit attitudes and stereotypes that contradict their conscious beliefs.
Moreover, our individual biases operate within larger social, cultural and economic structures whose biased policies and practices perpetuate systemic racism, sexism and other forms of discrimination. In medicine, discriminatory practices and policies based on bias not only have a negative effect on patient care and the medical training environment, but also limit the diversity of the health workforce, lead to an inequitable distribution of funding for research and can hinder career advancement.
A review of studies involving doctors, nurses, and other healthcare professionals found that implicit racial bias among healthcare providers is associated with diagnostic uncertainty and, for black patients, with negative assessments of their clinical interactions, less patient-centeredness, poor communication with provider, insufficient pain treatment, opinions of black patients as less medically adherent than white patients, and other adverse effects.1 These biases are learned from cultural exposure and internalized over time: In one study, 48.7% of American medical students surveyed said they had been exposed to negative comments about black patients by attending physicians or residents, and these students demonstrated significantly greater implicit racial bias in Year 4 than they had in Year 1.3
A review of the literature on implicit bias reduction, which looked at the evidence for many approaches and strategies, found that methods such as exposure to counter-stereotypical examples, acknowledgment and understanding of others’ perspectives and appeals to egalitarian values have not led to a reduction in implicit biases.2 Indeed, no intervention aimed at reducing implicit bias has been shown to have lasting effects. Therefore, it makes sense for healthcare organizations to forego bias reduction interventions and instead focus on eliminating discriminatory behaviors and other harms caused by implicit bias.
Although pervasive, implicit biases are hidden and hard to recognize, especially in and of themselves. It can be assumed that we all have implicit biases, but individual and organizational actions can combat the damage caused by these attitudes and beliefs. Awareness of biases is a step towards behavior change. There are a number of ways to increase our awareness of personal biases, including taking the Harvard Implicit Association Tests, paying close attention to our own faulty assumptions, and thinking critically about the biased behavior we engage in or that we suffer. Gonzalez and her colleagues offer 12 tips for teaching the recognition and management of implicit bias; these include creating a safe environment, presenting the science of implicit bias and evidence of its influence on clinical care, using critical thinking exercises, and engaging learners in exercises and skill-building activities in which they have to accept their discomfort.4
Education about implicit biases and ways to manage their harms should be part of health system-wide efforts to standardize knowledge in this area and recognize and manage biases. Research conducted at the Center for Health Workforce Studies at the University of Washington (UW) School of Medicine (where I work) evaluated whether a short online course on implicit biases in the clinical and learning environment would increase bias awareness in a national sample of academics. clinicians. The course was found to significantly increase bias awareness among clinicians, regardless of their personal or practice characteristics or the strength of their implicit racial and gender biases.5 Evaluation is ongoing of the course’s lasting effects on clinicians’ awareness of bias and their reports of subsequent behavior change.
Beyond awareness, examples of actions that clinicians can take immediately to manage the effects of implicit bias include practicing a positive, mindful formal and informal role model; undergo active bystander training to learn how to manage or interrupt microaggressions and other harmful incidents; and training to eliminate negative patient descriptions and stigmatizing words in case notes and direct patient communications. Academic medical center faculty may develop educational materials with inclusive and diverse images and examples and may strive to use inclusive language in all written and oral communications.
At the organizational level, the cornerstone of institutional bias management initiatives should be a comprehensive and ongoing program of interactive Diversity, Equity and Inclusion (DEI) skills-building education that incorporates recognition and management of implicit biases for all employees and trainees. throughout a health system. Organizations need to collect data to monitor equity. Organizations can also implement best practices to increase workforce diversity (https://diversity.nih.gov/); recognize commitment to antibias education and practices as necessary and meritorious criteria in their policy of professionalism; and create hiring, evaluation, and promotion policies that recognize and credit candidates for their DEI activities. Many US health agencies have codified these practices, but not all have.
Some healthcare organizations have developed bias reporting systems. For example, UW School of Medicine and UW Medicine have established an online tool for the target or observer of a biased incident to report concerns (https://depts.washington.edu/hcequity/bias-reporting-tool/). These incidents are then assessed by a trained incident response team who gather more information and escalate the issue to an existing system, such as the Human Resources department, or refer the incident for further investigation and appropriate follow-up. . Because transparency is key, UW Medicine publishes a quarterly report on the number of incidents of bias that have occurred, the groups (faculty, patient, caregiver, staff, student, trainee, visitor, or some combination) that have been affected by the incidents, the groups reported as having perpetrated them, the locations of the incidents reported and the themes or types of incidents reported. An initial assessment of the data collected by the reporting tool identified four priority areas for immediate institutional intervention: biases affecting pain management, response to microaggressions and implicit biases, biased comments or actions of patients towards the members of the medical team, and the opportunities to make our institution more inclusive. These elements are now priorities in our prejudice management action plan.
Innovative research is underway on strategies to interrupt the effects of implicit biases in healthcare. Indiana University researchers are developing objective blood biomarkers of pain severity to open the door to accurate pain management (https://pubmed.ncbi.nlm.nih.gov/30755720/). These objective measures hold promise for reducing subjectivity and the intrusion of implicit bias in pain assessment. Harvard researchers have proposed methods to minimize unintended biases embedded in artificial intelligence algorithms that lead to health inequities (https://www.hsph.harvard.edu/ecpe/how-to-prevent-algorithmic-bias-in-health-care/). Researchers from UW (biomedical informatics and medical education) and the University of California, San Diego (computer science) are collaboratively developing technology to help address implicit biases in clinical care; the tool being developed will automatically detect non-verbal social cues that convey clinicians’ implicit bias in real-time interactions with patients and provide accurate feedback to the clinician or clinician-in-training so that an individualized program to develop communication skills can be designed (https://www.unbiased.health/).
American health care organizations vary widely in the extent to which they have embraced the need to address the effects of implicit bias. The steps outlined here can help health care systems and clinicians begin or continue the process of reducing, and ultimately eliminating, the harm caused by implicit biases in health care.