Implicit biases are subconscious associations between two disparate attributes that can result in inequitable decisions. They operationalize throughout the healthcare ecosystem, impacting patients, clinicians, administrators, faculty, and staff. No individual is immune from the harmful effects of implicit biases. Unconscious bias-based discriminatory practices negatively impact patient care, medical training programs, hiring decisions, and financial award decisions and also limit workforce diversity, lead to inequitable distribution of research funding, and can impede career advancement.
When implicit biases are ignored, they jeopardize delivering high-quality healthcare services. A simple analogy can exemplify implicit bias in healthcare in action. Several physicians are reviewing the chest x-ray of a black man with a productive cough to determine a possible diagnosis. Another physician, not privy to the patient's demographics, joins the discussion later and quickly states that his condition most likely is cystic fibrosis. The clinicians were initially influenced by the patient's demographics and then realized the chest X-ray findings were diagnostic for late-stage cystic fibrosis, a condition more common in White populations than other races.
Explicit versus Implicit Bias
With explicit bias, individuals are aware of their negative attitudes or prejudices toward groups of people and may allow those attitudes to affect their behavior. The preference for a particular group is conscious. For example, a hospital CEO may seek a male physician to head a department due to his explicit belief that men make better leaders than women. This type of bias is fully conscious.
Implicit bias includes the subconscious feelings, attitudes, prejudices, and stereotypes an individual has developed due to prior influences and imprints throughout their lives. Individuals are unaware that subconscious perceptions, instead of facts and observations, affect their decision-making. Implicit bias and explicit bias are both problematic because they lead to discriminatory behavior and potentially suboptimal healthcare delivery.
We all hold implicit biases. Implicit bias is challenging to recognize in oneself; awareness of bias is one step toward changing one's behavior. Cultural safety refers to the need for healthcare professionals to examine themselves and the potential impact of their culture, power, privilege, and personal biases on clinical interactions and healthcare delivery. This requires health providers to question their own attitudes, assumptions, stereotypes, and prejudices that may contribute to a lower quality of healthcare for some patients. Cultural safety compels healthcare professionals and organizations to engage in ongoing self-reflection and self-awareness and hold themselves accountable to provide culturally safe care, which the patients and their communities define. Healthcare professionals and their healthcare organizations should work together to develop strategies to mitigate the harmful effects of bias and reduce bias-based decisions that contribute to barriers to healthcare access, healthcare disparities in patient care delivery, and lack of workforce diversity.
Stigmatized Groups and the Implicit Association Test (IAT)
Although we may consciously reject negative associations with stigmatized groups, it is virtually impossible to dissociate from a culture impregnated with such stereotypes. Patients from stigmatized groups may have one or more of these characteristics or conditions: advanced age, non-White race, HIV, disabilities, and substance or alcohol use disorders. Other factors include low socioeconomic status, mental illness, non-English speaking, non-heterosexual, and obesity. Implicit biases, by definition, occur in the absence of salient understanding or conscious awareness. However, we can apply harm mitigation strategies to avoid the destructive implications of implicit bias. To this end, recognition is the first step.
Implicit biases in healthcare are well-characterized by studies that use Implicit Association Tests (IAT) to evaluate medical decision-making toward stigmatized groups. The IAT measures the strength of associations between concepts and evaluations or stereotypes to reveal an individual's hidden or subconscious biases (Project Implicit - implicit.harvard.edu). The IAT is a highly validated measure for implicit biases; although vulnerable to voluntary control, the tool remains a gold standard in implicit bias research. Studies have shown that strong implicit biases hinder communication. Effective patient-healthcare provider (HCP) communication is associated with reduced patient morbidity and mortality, lower healthcare costs, and decreased rates of HCP burnout.
Implicit biases become destructive when they translate into microaggressions, defined as verbal or nonverbal cues that communicate hostile attitudes towards those from stigmatized groups. Although often unintentional, microaggressions maintain power structures and threaten the psychological safety of patients, resulting in adverse public health implications. Reducing microaggressions has been shown to reduce HCP burnout and depression.
Implicit Bias Awareness and Training
Comprehensive implicit bias training enhances the healthcare workforce's financial value, productivity, and longevity. The recognition of implicit bias is the first step in mitigating its effects. Many states in the US require implicit bias training for employment and licensure in the healthcare profession. The ongoing engagement of implicit biases among HCPs promotes cultural safety in healthcare organizations, representing a critical consciousness that welcomes accountability in the collaborative effort to provide culturally safe healthcare as defined by patients and their communities. HCPs should be aware of their implicit biases but not blame themselves when situations out of their control arise—respect for themselves, peers, and patients is the utmost priority. Progress toward reducing implicit bias is limited without personal discomfort and vulnerability.
Currently, very limited knowledge exists on how to conduct effective implicit bias training. However, studies show that incorporating mindfulness, coalition-building, and personal retrospection alongside broader structural changes is integral in reducing the harmful effects of implicit bias in the clinical environment. This article provides strategies to mitigate the impact of implicit biases among physicians, residents, physician assistants, pharmacists, registered nurses, nurse practitioners, medical assistants, medical scribes, certified registered nurse anesthetists, physical and occupational therapists, chiropractors, dentists, hygienists, licensed nutritionists, dieticians, social workers, counselors, psychologists, other allied health professionals, and healthcare trainees. Implicit bias in continuing education is required in many states.
Implicit Bias Training: State Legislation and Requirements for Healthcare Providers
California - AB241
Illinois - Sec. 2105-15.7
Michigan - R 338.7001
Maryland - HB28. Sec. 1-225
Minnesota - Sec. 144.1461
Washington - Sec. 43.70.613
Massachusetts - 243 CMR 2.06(a)3
New York - S3077
Pennsylvania - HB 2110. Title 63. Sec. 2102a
Indiana - HB 1178
Oklahoma - HB 2730
South Carolina - H 4712. Session 123
Tennessee - SB0956 and HB0642
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