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What is implicit bias, how does it affect healthcare?

Healthcare leaders working toward health equity will need to recognize their own implicit biases to truly enhance patient care.

Medicine's 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 to implicit bias.

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.

The study went on to describe various subtle behaviors and microaggressions that indicated to patients that implicit biases could be tainting their healthcare experiences.

Since 2020, more studies have explored patient perceptions of implicit bias, with four in 10 patients telling a 2022 MITRE-Harris Poll Survey on Patient Experience that the perceive their providers as biased against them. Hispanic and Black patients were more likely to report this than any other demographic group.

But implicit bias is at play not just when it comes to race and ethnicity. A September 2022 Urban Institute/Robert Wood Johnson Foundation report showed that 17 percent of publicly insured people and 13 percent of uninsured people perceived implicit bias from their providers.

And nearly a third of people with disabilities said in a different Urban Institute/RWJF poll that they perceived unfair treatment in healthcare settings.

Meanwhile, a separate third of LGBT patients said they've had disrespectful healthcare experiences, indicating some bias on the part of their providers.

Again, most experts agree 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.

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. A patient who picks up on a provider’s implicit bias naturally 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 they feel the provider treated them like an "angry, big Black man."

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

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.

In December 2022, researchers from the University of Minnesota Medical School showed racial health disparities in treatment recommendation. Specifically, the team found that Black patients and other patients of color were less likely to be advised on primary brain tumor removal, which they said was likely a byproduct of implicit bias.

Another study from November 2023 showed that Black patients were modestly more likely to receive low-value care, or "services that provide little to no benefit in specific clinical scenarios yet have potential for harm," the researchers wrote in BMJ. That disparity is likewise potentially driven by implicit bias.

For example, limited patient trust among Black populations could be behind the slightly greater risk for low-value acute diagnostic tests, the researchers said. Because this population tends to report lower trust in medical providers, they may be more likely to agree to diagnostic testing because it is more reassuring than a provider’s assessment.

On the provider side, implicit or explicit biases could also impact communication, which in turn could result in misunderstandings of patient care needs and preferences.

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.

Currently, there's no standardized course for implicit bias training in hospitals and health systems. But as more governing bodies begin to require implicit bias training for things like licensure, organizations are working to build out their own curricula. Implicit bias training courses need to incorporate the existing evidence base, center key stakeholders, and hold space for participants' humanity.

In short, implicit bias training needs to be informative and actionable and avoid judgment. Organizations can potentially increase participation numbers by making it easy to attend implicit bias training, so it may be helpful to consider holding training sessions over Zoom and at various times and days to accommodate staff schedules.

Notably, implicit bias training is not just for clinicians, experts agree. Training that includes administrative, front office, and other staff like environmental services helps fortify and organizational culture of inclusion and equity.

Implicit bias training is essential, but looking into the distant future, many experts have said increasing the diversity of the medical workforce will be a key step in mitigating implicit bias. Although anyone of any demographic has implicit biases, having a workforce reflective of the community it serves may lessen the damage those biases have.

Indeed, data has shown that a diverse medical workforce can improve outcomes because it increases the odds of racial concordance, something that’s been proven to enrich the patient-provider relationship and some outcomes.

Right now, a diverse medical workforce is out of reach. Part of the issue is lack of diversity in medical education; hospitals and health systems can only hire as diverse a staff as they have applicants. Some higher education institutions are cultivating a more diverse medical school applicant pool by hosting elementary, middle, and high school STEM exposure course. Some medical schools are also beginning to offer tuition-free education.

But healthcare can only maintain a diverse medical workforce if its institutions remain inviting to all. Building out a peer-to-peer culture of belonging will be critical in this area.

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.

Sara Heath has been covering news related to patient engagement and health equity since 2015.

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