What Is Implicit Bias, How Does It Affect Healthcare?

October 16, 2020 - The recent focus on racial health disparities and health equity has brought to the forefront another key concept in healthcare delivery and patient care: implicit bias.

Implicit bias, a phrase that is not unique to healthcare, refers to the unconscious prejudice individuals might feel about another thing, group, or person.

According to the Kirwan Institute for the Study of Race and Ethnicity at the Ohio State University, implicit bias is involuntary, can refer to positive or negative attitudes and stereotypes, and can affect actions without an individual knowing it:

Also known as implicit social cognition, implicit bias refers to the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.  These biases, which encompass both favorable and unfavorable assessments, are activated involuntarily and without an individual’s awareness or intentional control.  Residing deep in the subconscious, these biases are different from known biases that individuals may choose to conceal for the purposes of social and/or political correctness.  Rather, implicit biases are not accessible through introspection.

Implicit bias can be a factor in any aspect of our everyday lives: when we interact with colleagues, make new friends, or meet parents at our children’s schools. That means the interactions providers and medical workers have with patients are likewise not immune from implicit bias.

READ MORE: What is the Difference Between Health Disparities, Equity?

In 2015, a group of researchers conducted a literature review to understand the pervasiveness of and impacts of implicit bias. Through the review, the team was able to conclude at least moderate implicit bias in most medical providers. The Implicit Association Test, which measures implicit bias, detected about equal bias across Black, Latinx, and dark-skinned patients.

To be clear, implicit bias is unconscious, and most researchers investigating the subject assert that very few medical professionals maliciously seek to do harm to some of their patients.

But that 2015 review showed that implicit bias does have some consequences, not least of which are strained patient-provider relationships and clinical outcomes. This, like other clinical quality challenges, warrants a closer look from the medical community.

Below, PatientEngagementHIT will outline what implicit bias looks like in healthcare, how it can affect patient-provider communication and outcomes, and how the healthcare industry is beginning to recognize its own implicit biases.

What is implicit bias in healthcare?

In healthcare, implicit bias can shape the way medical providers interact with patients. Because everyone is susceptible to implicit bias, even clinicians, these unconscious preconceptions will naturally seep into patient-provider communication.

There is already some evidence indicating such. In September 2020, the Regenstrief Institute published data from the Department of Veterans Affairs (VA) suggesting that veterans accessing mental health treatment could sense some non-verbal cues that signaled implicit bias.

The survey of 85 Black veterans showed that most had good patient-provider relationships, but many expressed some issues that indicated race could play a role in their healthcare.

“They explained that structural characteristics such as the physical space of an institution project how welcoming an institution might be to minority patients, and that staff diversity, especially in position of power, reflects the facility’s values and culture related to racial equity,” the researchers reported.

Other patients reported feeling stereotyped by mental health providers. Some reported clinicians as being physically distant.

“Some participants also shared that because of their physical appearance, they felt stereotyped as ‘angry, big Black men,’” the research team said, quoting a respondent. “They explained that some providers viewed them as a physical threat and react fearfully.”

The researchers did specifically acknowledge that most clinicians are committed to providing excellent medical care to all of their patients, regardless of race, gender, sexual orientation, or ability to pay. But again, since nobody is immune to implicit bias, it is at play in many medical encounters.

“Some of it may be born of just encountering people who look or speak or act differently than we do, some of it may be because we have family environments that have encouraged a certain way of thinking, some of us may have picked up perspectives from education or things we read or the internet for that matter,” Janice Huckaby, MD, chief medical officer of Maternal Health at Optum, said in an interview.

“But the scary thing about implicit bias is that oftentimes people are unaware that it's shaping some of their reactions,” Huckaby stated.

Huckaby has heard implicit bias show itself in conversations with doctors treating Medicaid patients, referring to patients as “Medicaid Queens” or using other language that can suggest the patient is someone who is “less than.” Implicit bias can also shape the tone with which a clinician speaks to a patient, the content of their communication, and the types of tests or referrals clinicians order.

What are the consequences of implicit bias in healthcare?

As with any interaction, implicit bias can have adverse effects on the patient experience. By damaging patient-provider interactions, implicit bias can adversely impact health outcomes.

In many situations, patients are able to pick up on a provider’s implicit bias, and patients often report a poor experience for that. And naturally, a patient who picks up on a provider’s implicit bias may feel less inclined to engage deeply with care.

Patients with similar experiences as the veteran from the Regenstrief study, for example, could be dissuaded from visiting a provider if he feels the provider treated him like an “angry, big Black man.”

This kind of implicit discrimination has born itself out in many Black and Brown patients lacking trust in and being reticent to engage with the medical institution.

Additionally, implicit bias could put a cap on how well a patient understands her own health or is invited to engage in her care. For example, some providers may limit the depth of shared decision-making or explanations of medical concepts because their implicit bias tells them a patient does not have the health literacy to fully engage with her care.

This, coupled with some implicit biases that tell providers a patient may not be able to afford specialty care, can decrease the odds a patient gets the depth of medical care she might need.

“The other component of this is for general practitioners and general OB to understand when to refer a pregnant mom because she is high-risk. They cannot let their unconscious bias or cultural competency issues interfere with referring a woman of color to a maternal-fetal specialist,” Lavdena Orr, MD, FAAP, market chief medical officer for AmeriHealth Caritas District of Columbia, explained in a previous interview. “Not deciding that, ‘oh well she can't afford it or she won't go,’ but referring that mom so she gets the best care for the high-risk condition that she may have.”

Again, it is the rare clinician who acts out of malice, according to Huckaby.

“It is probably the rare clinician who wakes up in the morning and figures, ‘I'm going to mistreat some of my patients today,’” she said.

But implicit bias is still a sneaky specter infecting healthcare interactions and contributing to the racial health disparities being seen today. Organizations working to close health disparities must incorporate implicit bias and cultural competency training into their practice.

Addressing implicit bias

Eliminating implicit bias is a challenging task, because as the experts at OSU’s Kirwan Institute said, one’s own implicit bias is not something most people are aware of. Implicit bias is not purposeful—purposeful discrimination is referred to as explicit.

But a strong education campaign can be a good first step to helping clinicians pick up on their own biases.

“A lot of implicit bias training could just start with the awareness that we all have some kind of implicit bias for many, many different reasons from how we grew up, what we're supposed to do,” Stacy Millett, the director for the Health Impact Project at the Pew Charitable Trusts, said in an interview. “But it's about how we behave and what we can do.”

Other organizations use cultural competency training to help providers acknowledge their own implicit biases. That cultural competency training should begin with education about the dangers of discrimination and the changing racial landscape in the US.

Organizations should also look at the communities they serve, the needs of those communities, and the resources organizations need to tap to fill those needs.

The process of identifying and acknowledging implicit bias in healthcare is only in its infancy. But as more organizations commit to ending racial health disparities and working toward health equity, this will be an important step toward that end.