Implicit bias

Imagine walking down the road at night. Your gut reaction to seeing a young black man in urban clothing will probably be different than seeing an old white lady pushing a stroller.These gut reactions occur within milliseconds, before you can consciously assess the situation.

So why does this occur? The reason your initial thoughts and feelings might be different in these two situations can be attributed to implicit biases.An implicit bias is the unconscious attitude and beliefs that affect a person’s feelings, behavior or judgement without their knowledge.Explicit, or conscious, bias is when someone is aware of their thoughts and emotions towards a specific group.

This can be seen in hate speech, discrimination, and sometimes prejudice.With implicit bias, it gets a little tricky because people are often unaware that their behavior or judgement are being affected since the bias is subconscious.In healthcare, implicit bias also plays a role and can directly affect healthcare outcomes and patient satisfaction.Now, implicit biases are formed when you make subconscious generalizations and form stereotypes that attribute certain characteristics with specific groups of people.This is a cognitive strategy that’s intended to make it faster and easier to make judgements or take action.

With enough repeated reinforcement, these can become involuntary habits that are difficult for you to detect.For example, as a new resident, you might notice that most Latinx patients refuse certain elective surgical procedures.

Throughout the years, without you noticing, you gradually stopped discussing these procedures with Latinx patients.If asked, you would probably say you’re not treating Latinx people any differently than other groups.

Implicit bias is more likely to occur in high pressure, time sensitive situations that require a lot of multitasking; something that’s common in many healthcare settings.In order to better study implicit bias, Harvard developed the Implicit Association Test, or IAT.

This is a tool that can help evaluate individually held implicit biases by measuring the strength of automatic associations between subject categories.So for example, you might be asked to associate “good at math” with the categories of “men,”and “women.” If it takes you longer to associate one category with “good at math,” then your IAT score would increase, indicating potential bias.After 8 years, 4.5 million tests were completed online by the general population, and showed that individually held impli​cit racial ​biases are pervasive, often unrecognized, and can be a predictor of behavior.When studied further in healthcare providers, similar results have been found.

Now, the validity and reliability of the IAT has been criticized.For example, the same person taking the test multiple times can lead to different results.

So the IAT might be more useful when assessing an organization or population instead of individuals.IAT has been compared to other tools designed to measure implicit bias such as vignettes, simulations, and clinical evaluations, and it produced comparable results.These and other studies have shown that implicit biases are held by a range of healthcare professionals, from physicians and nurses to counsellors, social workers, and students.These biases can be against many factors like race, ethnicity, gender, age, religion, socioeconomic status, disability, and mental health.

​To assess the impact of implicit bias, a landmark study conducted in 2003 by the Institute of Medicine showed that even when factors like race, ethnicity and socioeconomic levels are accounted for, there’s still lower quality of care and worse outcomes for people of certain social groups, and implicit bias is one of the contributing factors.Further studies have shed light on how this occurs because implicit biases are associated with incomplete patient assessments, minimized involvement in patient care, lack of thorough testing, inappropriate diagnoses and treatments, and insufficient follow ups and referrals.Others have shown providers with high IAT scores tended to have shorter interactions with black patients.

Implicit biases can also erode the patient-provider relationship on both a personal and societal level.Healthcare providers that are unaware of their prejudices may not recognize how certain behaviors, language, and actions may offend, marginalize or harm a patient.In studies that asked black patients to evaluate providers, patients reported having less respect, confidence, and trust in providers with high IAT scores; and they also reported less confidence in treatment plans, and more difficulty remembering discussions or following recommendations.So the effects of implicit bias on the patient-provider relationship can result in a lack of trust, dissatisfaction with care, incomplete follow-up and and follow-through with provider instructions, and hesitance to interact with the healthcare setting.Ultimately, high implicit bias is associated with healthcare providers not giving the best care and patients who are unhappy with the care they receive.As an example, let’s consider the following scenario of how implicit biases can play out in a clinical setting.

Jenny is a 56 year old black female and has been previously diagnosed with obesity.She came to the clinic today for chest pain and swelling in her right leg.

She arrives at the reception area to check in. She noticed that the white gentleman in front of her was greeted with a warm smile and a nod by the receptionist.When it was her turn, the receptionist was blunt in her response to Jenny’s greeting and did not make eye contact.

If you were to ask the receptionist, she would answer that she treats every person the same way.This difference in behavior that went unnoticed is an example of implicit bias.

Next, Jenny went to the waiting area and sat down next to Sam, the man before her in line.They started chatting and Jenny learned that Sam was also diagnosed with obesity and he was also there today for chest pain and leg swelling.The doctor called Sam in, and Jenny waited for 25 min before it was her turn.

The doctor asked her what brought her in today, to which Jenny said she’s been having chest pain while walking around the house and her leg was swollen.After asking several questions about her symptoms and conducting a physical, the doctor focused on if she’s been feeling anxious and if there’s been any stressful events in her life.

Although a bit confused about why the doctor was asking this, Jenny said she has been worrying about her son losing his job, and if her health insurance will cover any potential medications she’ll need.The doctor nodded and moved on to her obesity problem and finished with proper techniques for stress management.

When Jenny left the office, she saw that her appointment only lasted 12 minutes.Jenny went to the bus stop and saw Sam again.

They talked about their experience with the doctor and Jenny learned that Sam was diagnosed with congestive heart failure, prescribed medication, and was referred to a cardiologist.The doctor didn’t focus on stress or anxiety at all with Sam and spent more time on his physical symptoms.

Furthermore, the doctor was more thorough with Sam when discussing various treatment options.Jenny later went to another doctor to get a second opinion and she was also diagnosed with congestive heart failure.Now, even though Jenny and Sam had the same symptoms and eventually ended up with the same diagnosis, their experiences were very different.Doctors are more likely to attribute symptoms of congestive heart failure to stress and anxiety in women, while leaning more towards biological causes in men.They might not even realize this since much of their judgement is based on previous experience and women do have a higher risk for anxiety disorders and they are more likely to discuss the stress they’re going through in more detail with doctors.All of this can contribute to a subconscious generalization based on past experiences that lead to implicit bias when making the diagnosis.Another example is doctors can stereotype certain ethnic groups and people of lower socioeconomic levels as being less likely to follow medical recommendations.This in turn could influence the amount of time they spend with patients, the treatment options they present, and referrals or follow up.

Now, there are several ways to help address implicit bias.Healthcare professionals can undergo mindfulness training so they’ll be more self aware and present in the moment which allows them to notice their implicit bias instead of letting them go undetected.Once these biases are known it’s important to challenge the existing stereotypes.

One can accomplish this by actively taking notice of instances where people from the stereotyped group exhibit behaviors or attitudes that defy the stereotype.Next, start practicing self monitoring and self regulation regularly to catch instances where implicit bias driven behaviors can be caught and corrected.

Finally, empathy is one of the keys to mitigating implicit bias.One way to build empathy is with deep listening which is listening with curiosity and the desire to understand them without preconceptions and judgment, which will naturally limit the effects