How to Reduce Implicit Bias

Addressing implicit bias is never easy. Among dedicated health care professionals, it can be especially difficult to contemplate the possibility of harboring unconscious attitudes or stereotypes.

But, to quote IHI’s Chief Scientific Officer Emeritus and Senior Fellow Don Goldmann, “the uncomfortable truth is that we live in a society in which stereotypes about groups of people are ubiquitous, and it follows that almost everyone has some implicit bias.”

As more health care organizations work toward achieving equitable care for all patients, it is not enough to focus on intentional discrimination. We must also acknowledge implicit bias and address it. Read more about how in the following excerpt from IHI’s white paper, Achieving Health Equity: A Guide for Health Care Organizations.

There is a growing literature about implicit bias in health care. Implicit bias, also known as unconscious bias, is “the bias in judgment and/or behavior that results from subtle cognitive processes (e.g., implicit attitudes and implicit stereotypes) that often operate at a level below conscious awareness and without intentional control.” In a 2015 systematic review by Hall and colleagues, researchers found that implicit bias is significantly related to patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes. The authors note that additional research is needed to examine the relationships between implicit bias and health care outcomes. They also cite several studies showing that most health care providers have implicit racial/ethnic bias at the same rates as the general population. Implicit bias is not limited to race; implicit bias can exist for characteristics such as gender, age, sexual orientation, gender identity, disability status, and physical appearance such as height or weight.

Devine and colleagues emphasize that implicit bias is “automatically activated and often unintentional.” Burgess and colleagues make the point that if health care providers understand that stereotyping and racial prejudice are “a normal aspect of human cognition,” they may be more open to learning about this phenomenon and how it impacts medical practice.

We have included [implicit bias] in the IHI health equity framework because we see it as significant. Others do, too. For example, the Association of American Medical Colleges has conducted training on this issue and produced a publication about unconscious bias in medicine. In addition, The Joint Commission published an issue of “Quick Safety” on this topic, and others have published extensive reviews about implicit bias.

Implicit Bias in Policies, Structures, and Norms

Health care organizations also have a responsibility to mitigate the effect of implicit bias in organizational decision making. For example, implicit bias affects the hiring and promotion of staff, clinicians, and faculty. This affects multiple groups, including women, racial/ethnic minorities, individuals who do not speak English as their primary language, and overweight and obese individuals, to name a few. In the journal articles noted above, Burgess and Devine also describe education and training programs that can impact the behavior of health care providers and, by extension, may serve to mitigate any adverse impacts of implicit bias.

Implicit Bias in Patient Care

To achieve health equity, health care organizations have a responsibility to mitigate the effect of implicit bias in all interactions and at all points of contact with patients. This is important because implicit bias has the potential to impact not only outcomes of care, but also whether patients will return for services or even seek care at the organization in the first place. While a majority of research on implicit bias in health care focuses on racism, other social factors such as primary spoken language, gender, sexual orientation, education, and employment status are also associated with implicit bias and differences in communication and treatment.

Implicit bias may affect how providers and other clinicians interact with patients in terms of communication, treatment protocols or recommended treatment options, or options for pain management. Implicit bias can affect both perception and clinical decision making, and studies show that implicit bias is significantly related to patient-provider interactions and treatment decisions. One study found that a substantial number of medical students and residents held false beliefs about biological differences between white and black individuals (such as believing that black skin is “tougher” than white skin), and found that these beliefs predict racial bias in pain treatment recommendations.

Since black patients are more likely than white patients to die in the ICU receiving life-sustaining treatment rather than in hospice receiving comfort care, Elliott and colleagues tested whether physicians use different verbal and/or nonverbal communication when having end-of-life care conversations with black and white patients and family members. They found that while verbal communication was similar, nonverbal communication scores were significantly lower with black patients than with white patients, with fewer positive, rapport-building behaviors. This difference can affect the outcome of the end-of-life care conversations and contribute to a higher incidence of black patients dying in the ICU while receiving life-sustaining treatments rather than dying at home.

Implicit bias can negatively affect other elements of patient interaction with the health care system. A 2015 study found that racial/ethnic minorities, individuals with lower levels of education, and unemployed individuals spend significantly longer time waiting to obtain medical care, with blacks and Latinos waiting 19 and 25 minutes more, respectively, than white patients to see a doctor. In addition, anxiety about interactions with people of color can result in white providers spending less time with patients.

Strategies to Reduce Implicit Bias

Implicit bias in individual interactions can be addressed and countered if we become aware of our bias and take actions to redirect our responses. Devine and colleagues offer six strategies to reduce implicit bias:

• Stereotype replacement — Recognizing that a response is based on stereotype and consciously adjusting the response
• Counter-stereotypic imaging — Imagining the individual as the opposite of the stereotype
• Individuation — Seeing the person as an individual rather than a stereotype (e.g., learning about their personal history and the context that brought them to the doctor’s office or health center)
• Perspective taking — “Putting yourself in the other person’s shoes”
• Increasing opportunities for contact with individuals from different groups — Expanding one’s network of friends and colleagues or attending events where people of other racial and ethnic groups, gender identities, sexual orientation, and other groups may be present
• Partnership building — Reframing the interaction with the patient as one between collaborating equals, rather than between a high-status person and a low-status person

Similarly, in Seeing Patients: Unconscious Bias in Health Care, Dr. Augustus White offers these practical tips to combat implicit bias in health care:

• Have a basic understanding of the cultures your patients come from.
• Don’t stereotype your patients; individuate them.
• Understand and respect the tremendous power of unconscious bias.
• Recognize situations that magnify stereotyping and bias.
• Know the National Culturally and Linguistically Appropriate Services (CLAS) Standards.
• Do a “Teach Back.” Teach Back is a method to confirm patient understanding of health care instructions that is associated with improved adherence, quality, and patient safety.95
• Assiduously practice evidence-based medicine.

For an extensive bibliography and other helpful resources, please consult IHI’s Achieving Health Equity: A Guide for Health Care Organizations white paper.