Implicit bias affects all of us, and it can affect how healthcare practitioners perceive and interact with others. This can ultimately influence the way we deliver care to our patients.
Implicit bias refers to the attitudes and stereotypes that affect our understanding, actions and decisions in an unconscious manner. The implicit associations we have in our unconscious can cause us to have feelings about others based on characteristics such as language, gender, appearance, race, ethnicity, age and class.1 These associations develop over the course of a lifetime beginning at an early age through exposure to direct and indirect messages about what we are supposed to think and feel.2 These associations can have a subtle effect on how we, as healthcare providers, perceive, interact with and deliver care to our patients.
Unfortunately, with the spread of the coronavirus, or COVID-19, there have been increased reports of bias, both explicit and implicit. Stereotypes and assumptions can perpetuate negative biases that can put others at risk for harm or isolation, or prevent people from accessing needed care. It is important to be mindful of:
Diseases like COVID-19 can make anyone sick, regardless of race or ethnicity, and one way we can ensure that we are providing the highest quality of care for all people is by becoming more aware of our own biases and taking action to address them.
Two landmark reports by the Institute of Medicine, Crossing the Quality Chasm (2001) and Unequal Treatment (2002), highlighted pervasive racial and ethnic disparities in the US healthcare system.3,4 The reports found that even when they had the same insurance and socioeconomic status as non-minorities – and when comorbidities, stage of presentation and other confounders were controlled for – minorities often received lower quality healthcare.
Research shows that part of what causes disparities are the implicit biases of healthcare workers, which can unintentionally lead to providing lower quality care for patients. The literature shows that implicit bias based on race, gender, sexual orientation, weight, insurance and other group identification can affect providers':
Reports indicate that the coronavirus does not discriminate; however, people who are disproportionately affected by health disparities and poor social determinants of health – such as low access to healthcare, poverty, housing and food insecurity – with consequent higher comorbidities, have a significantly higher risk of being affected by COVID-19 with worse health outcomes.
Research shows that various factors can put us as risk for implicit bias. These include the following:
The COVID-19 pandemic unfortunately puts us at risk for experiencing several factors that contribute to implicit bias. Therefore, it is important that we are aware of the unintended biases that can affect our work with patients and how to address them.
"People fail to get along because they fear each other; they fear each other because they don't know each other; they don't know each other because they have not communicated with each other."
– Martin Luther King Jr.
The doctor-patient encounter is often mediated by cultural norms and beliefs, stereotypes, stigma and implicit bias. Both patients and providers can bring factors such as stress, mistrust, time pressures and poor communication to the doctor-patient encounter that can lead to biased treatment decisions, poor adherence and, ultimately, negative outcomes.
Implicit bias has been described by Banaji and Greenwald as our “blindspot.”7 Being aware of what we bring to our interactions with patients and being intentional about how we engage patients to build trusting relationships are key to avoiding those blindspots. We are the most important tool in our interactions with patients. It is important that we start where the client is and practice from a patient-centered care model. This often allows the clinician to see and consider the whole person versus negatively labeling the patient or making assumptions.
Addressing implicit bias is not always easy; it is a process. However, as clinicians we are often seen as having the power and influence over decision making for patients, and there are steps we can take to learn how to identify and address unconscious thoughts that can unintentionally influence patient care.
Jillian Rose, PhD, MPH, LCSW – Understanding Implicit Bias and Its Impact on Clinical Practice, Decision-Making and Achieving Optimal Health Outcomes.
C. Ronald MacKenzie, MD – Impact of Mindful Practice by Physicians and Patients, HSS Playbook.
Juliette Kleinman, LCSW, ACSW – Assessing and Addressing Health Literacy: A Critical Skill for the Healthcare Team to Improve Patient Outcomes.
Nancy Violette, PhD, LCSW, LCADC, ICCS – Motivational Interviewing: Creating Collaborative Conversations with Patients and Their Families to Enhance Healthcare Outcomes. Presentation at HSS, March 4, 2014.
1. Staas, C., Capatosto, K., Wright, R. A., & Jackson, V. M. (2016). State of the Science: Implicit Bias Review. Kirwan Institute for the Study of Race and Ethnicity. http://kirwaninstitute.osu.edu/implicit-bias-training/resources/2016-implicit-bias-review.pdf
2. The Joint Commission, Division of Healthcare Improvement. (2016). Implicit Bias in healthcare. Quick Safety. Issue 23.
3. Institute of Medicine, Committee on Quality of healthcare in America. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington. DC: National Academy Press.
4. Institute of Medicine. (2002). Unequal Treatment: Confronting Racial and Ethnic Disparities in healthcare Washington, DC: National Academy Press.
5. FitzGerald, C., & Hurst, S. (2017). Implicit bias in healthcare professionals: a systematic review.BMC medical ethics,18(1), 19.
6. Casey, P. M., Warren, R. K., & Elek, J. K. (2012).Helping courts address implicit bias: Resources for education. National Center for State Courts.
7. Banaji, M. R., & Greenwald, A. G. (2013). Blindspot: Hidden Biases of Good People. New York: Delacorte Press.
8. Apfelbaum, E. P., Sommers, S. R., & Norton, M. I. (2008). Seeing race and seeming racist? Evaluating strategic colorblindness in social interaction. Journal of personality and social psychology, 95(4), 918.
9. Welcome to the Always Use Teach-back! training toolkit. (n.d.). Retrieved from http://www.teachbacktraining.org/
10. Ask Me 3: Good Questions for Your Good Health. Institute for Healthcare Improvement. Retrieved from http://www.ihi.org/resources/Pages/Tools/Ask-Me-3-Good-Questions-for-Your-Good-Health.aspx