Physicians and implicit bias

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Although the medical profession strives for equal treatment of all patients, disparities in health care are prevalent. Cultural stereotypes may not be consciously endorsed, but their mere existence influences how information about an individual is processed and leads to unintended biases in decision-making, so called “implicit bias.” 

Research suggests that implicit bias may contribute to healthcare disparities by shaping physician behavior and producing differences in medical treatment along the lines of race, ethnicity, gender or other characteristics.

People base their perceptions of reality on received information and experiences reinforced until they become automatic. This ability makes human decision-making efficient and likely provided an evolutionary advantage. Stereotypes are well-learned sets of associations between some trait and a social group. 

Implicit bias is also called “unconscious” or “non-conscious” bias and often differs starkly from explicit beliefs. Multiple studies with randomized, controlled designs confirm that simply knowing about a stereotype distorts processing of information about individuals.  

Implicit bias develops early in life from repeated reinforcement of social stereotypes. Implicit pro-White bias occurs among children as young as three years old throughout the world.

The most commonly used measure of implicit bias is the Implicit Association Test (IAT), a computerized timed dual categorization task that measures implicit preferences by bypassing conscious processing. Participants press different computer keys to sort photographs of African American and Caucasian American faces as either “Black” or “White” and then sort words like “joy, wonderful, glorious” and “agony, horrible, evil” into “Good” and “Bad” categories, respectively. 

Next, participants repeat the task, sequentially being asked to press one key when shown a “Black” stimulus or a “Bad” word and a different key when shown a “White” stimulus or a “Good” word, and vice versa. Overall, the 2,535 participants who reported having an MD degree showed significant pro-White bias. Others have confirmed that even in the absence of explicit race bias, implicit preference for Whites among physicians is common.

The degree of implicit race bias varies by a physician’s race and gender. The presence of pro-White bias was significant among physicians of all racial groups except African Americans, who were neutral, while women showed less implicit race bias than men. Less—but not zero—pro-White bias has also been found among non-White vs. White resident physicians and medical students. 

It was also found that the perception of an interaction between White physicians and Black patients was affected by a physician’s implicit race bias, even in the absence of explicit biases. Such negative perceptions could alter their behavior in ways that reduce adherence, return for follow-up, or trust, and thus could contribute to disparities in care.

With growing evidence that implicit bias in physician decision-making makes a significant contribution to perpetuating health care disparities, it is critical to find ways to reduce its impact. Conceptualizing implicit bias as a “habit of mind” provides a useful framework for developing interventions. 

Although awareness is important, as with clinical efforts to change patients’ undesirable health behaviors, it is not sufficient to reduce the automatic, habitual activation of stereotypes and the subsequent impact of implicit bias in medical decision-making.

Despite the best intentions of physicians to provide equal treatment to all, disparities linger and may lead to unacceptable increases in morbidity and mortality for some. Many factors have helped create these disparities, including implicit bias, an unintentional, unacknowledged preference for one group over another. 

Implicit bias is present in physicians and correlates with unequal treatment of patients. We suggest the contribution of implicit bias to healthcare disparities could be reduced if all physicians acknowledged their susceptibility to such bias and deliberately practiced perspective-taking and individuation. 

Additionally, increasing the number of African American/Black physicians could reduce the impact of implicit bias on some healthcare disparities because they exhibit significantly less implicit race bias.

David Hamlar MD, DDS is an assistant professor in the Department of Otolaryngology, Head and Neck Surgery at the University of Minnesota. He specializes in craniofacial skull base surgery. He attended Howard University College of Dentistry (DDS) and Ohio State University (MD), and came to Minnesota for his fellowship in facial plastic and reconstructive surgery. Besides medicine, he is a retired Minnesota National Guardsman achieving the rank of major general. His passion today is empowering students of color to achieve their dreams of entering the medical professions as well as other STEM-oriented careers.

Adapted from: J Gen Intern Med. 2013 Nov; 28(11): 1504–1510, “Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health Care Disparities,” Elizabeth N. Chapman, MD, Anna Kaatz, MA, MPH, Ph.D., and Molly Carnes, MD, MS

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