The Role of Implicit Bias and Culture in Managing or Navigating Healthcare

Adapted from a presentation at the SLE Workshop at Hospital for Special Surgery

Research shows that disparities, or differences, in health and healthcare outcomes are widespread in the United States. These gaps are caused by various social and economic factors. Many of those are difficult to change. But one key factor, known as "implicit bias," can be improved through education and awareness.

In healthcare, implicit bias can have an impact on medical decision making, communication, adherence to medical advice and provider-patient interactions. It can also ultimately impact patient care and health outcomes. The more that both healthcare professionals and patients understand about how implicit bias affects all of us, the more likely we are to approach a fair healthcare system.

In a May 2020 presentation at HSS, Jillian A. Rose, PhD, MPH, LCSW, provided a detailed overview of implicit bias to empower patients who may experience it.

 

What is implicit bias?

Implicit biases are assumptions a person makes unconsciously or unintentionally – without meaning to make them or thinking about them. They are based on different factors such as age, race, ethnicity, religion, sex, gender, language, weight and economic status. Research shows that all people have these types of biases, which are based on their individual experiences and perceptions.

How is implicit bias defined?

Bias refers to the attitudes or stereotypes that affect our understanding, actions, decisions and interactions. Biases can be both favorable and unfavorable. "Implicit bias" is activated involuntarily, without a person’s awareness or intentional control. This is different from "explicit bias," in which people are aware of certain biases they have.

How are implicit biases formed?

There are a number of circumstances that can shape a person’s biases. These circumstances can be:

  • individual (such as immigrant status, sexual orientation and cultural background)
  • historical (such as the Holocaust, slavery and unethical medical or scientific research practices)
  • systemic (such as lack of access to care, mass incarceration and the crack cocaine epidemic)
  • environmental (such as neighborhood demographics and pollution)

How does implicit bias affect society?

Implicit associations can cause us to have feelings and attitudes about other people based on certain traits. These include language, gender, appearance, race, ethnicity, age and class.

Implicit associations can include the following:

  • "Most nurses are women."
  • "Most doctors are men."
  • "Men are better at math."
  • "More women than men are caregivers."

How does implicit bias affect healthcare?

Implicit bias can influence many of our interactions. Medical encounters are no exception. These biases contribute to disparities in healthcare by affecting the quality of care that different patients receive, which resuls in unequal treatment.

Research shows that implicit biases based on race, gender, sexual orientation, weight, health insurance and other group identifications can affect how healthcare providers interact with patients in several ways. These include:

  • the quality of the clinical interview
  • the diagnostic decision-making
  • symptom management
  • treatment recommendations
  • referrals to specialty care
  • interpersonal behaviors – communication, empathy, trust, etc.

How can my implicit biases affect my own healthcare?

Our own beliefs, values and biases can impact our interactions with others, including those on our care team who may be different from us. This may lead us to:

  • make assumptions
  • shift our tone and body language
  • feel frustrated with our level of care
  • develop mistrust
  • fear the negative impact of treatment on quality of life
  • avoid seeking healthcare
  • delay picking up prescriptions

The intricacies of bias, and their effects

The impact of implicit bias on specific communities: Exploring the evidence-based literature

Racial bias

Research shows that clinicians have more implicit bias against Black and Hispanic/Latinx groups. ("Latinx" is used as a gender-neutral or nonbinary alternative to "Latino" or "Latina" and refers to a person of Latin American origin or descent.)

Implicit bias toward Black and Hispanic/Latinx groups can lead to poor patient assessments, less serious diagnoses, less effective treatment recommendations, poor pain management, fewer referrals of patients to medical specialists, and less patient engagement.

Age and disability bias

Unconscious age biases are also well -documented, with older adults often receiving less treatment for the same diagnosis as compared with younger patients.

In several studies, negative implicit bias towards the people with disabities was stronger than toward the average population.

LGBTQ+ bias

  • LGBTQ+ patients face both explicit and implicit bias in healthcare.
  • Several studies have reported that transgender people did not see a doctor when they needed to due to fear of being mistreated as a transgender person.

The impact of implicit bias on musculoskeletal health

Gender bias and total joint replacement

  • Patient gender plays an in important role in the process of referral and recommendation for total joint replacement, such as a hip replacement.
  • Doctors were more likely to recommend total knee replacement surgery to male patients than to female patients. This suggests that gender bias may contribute to the sex-based disparity in the rates and use of total knee replacement.

Bias in drug treatment for rheumatoid arthritis

  • Many studies have shown there to be racial and ethnic differences in the use of biologic disease-modifying antirheumatic drugs (DMARDs).
  • It has also been found that patients of color receive lower-quality doctor-patient communication and inadequate patient education about the benefits and risks associated with the best available treatments.

The role of culture in managing chronic illness

Defining culture

Culture refers to a system of shared beliefs, values, customs, behaviors and artifacts that the members of society use to cope with their world and with one another. These systems are transmitted from generation to generation of families and greater communities through learning. Culture is the "lens" through which we view the world. It is central to what we see, how we make sense of what we see and how we express ourselves.

Understanding the role of culture

There are a number of ways that culture can influence our views on health and our approach to healthcare.

Culture:

  • defines for each of us what is "normal," why a particular problem exists and how to treat or address it
  • influences our understanding or interpretation of medical symptoms and, as a consequence, the manner in which health problems are treated
  • determines how we behave
  • determines which family members make medical decisions
  • can influence how we dress, what we eat, what we value and how we interact with others

How culture can affect our views on disease

The manner in which culture can shape our views on health can be explained through these three different perspectives on disease:

  • The Personalistic Perspective
    • Suggests that supernatural spirits or people cause disease. (Disease is "personified.")
  • The Naturalistic Perspective
    • Views health as a state of harmony between human beings and their environment. When this balance is upset, illness will result.. Traditional Chinese medicine is based upon this perspective.
  • The Western Scientific Perspective
    • This is a cause-and-effect perspective on disease that seeks analytical and physiological explanations and cures for disease, like identifying a virus or bug. Western medicine is based upon this perspective.

The Impact of culture

Failure to take cultural considerations into account and to address potential cultural issues with your care providers can lead to negative effects, such as:

  • feeling isolated
  • anxiety and worry
  • poor doctor-patient communication
  • treatment nonadherence (choosing to stop one’s prescribed medical treatment)
  • high nervous energy (which can be a way for people to self-sooth, even if they don’t have true anxiety)
  • feelings of helpless
  • poor patient heatlh outcomes

How can I address the impact of culture and implicit bias in my healthcare?

The first step is to become educated about the healthcare risk factors that implicit bias can create. The second is to talk with your doctors and other members of the healthcare team about any implicit biases that you have experienced during your care.

Risk factors

There are several factors that may increase the likelihood that implicit bias and culture will impact your healthcare. These include the following situations:

  • The patient or healthcare provider exhibits a strong emotional state, such as anger, anxiety, fear or disgust.
  • There is ambiguity in the healthcare encounter.
    • There may be no concrete guidelines for decision making or a lack of patient-provider collaboration.
  • The provider or patient is distracted or pressured.
    • This may be caused by long working hours, a fast-paced work environment, having to deal with crises, or by feeling tired/fatigued.
  • There is a lack of feedback.
    • Neither the provider nor patient is actively discussing with others the decisions they have made.

Recommendations to help reduce the impact of culture and implicit bias in healthcare

Recommendations for patients

  • When appropriate, share your social history with your doctor, so that they can better support and understand the challenges you may face.
    • Not sharing social history or challenges can led to an inappropriate care plan.
  • Seek out information on implicit bias.
    • Develop a good understanding of the potential for unconscious bias, and be alert.
    • Do not support jokes that disrespect any group of people.
  • Be conscious of your decision-making process, and check for bias.
    • Don’t make assumptions based on "eyeballing"(looking at a person’s physical features and guessing their social history or how they imay dentify).
    • Be aware of the reasoning behind your decisions.
  • Use shared decision-making strategies.
    • Shared decision-making tools allow for enhanced communication, education and patient input related to the care plan.
  • Acknowledge differences and diversity.
    • Cultivate cultural awareness and sensitivity. This can be effective in acknowledging and taking into account the perspectives of others.
  • Identify sources of stress and factors that contribute to pressure in your environment.
    • Work to minimize stressful situations that can cause you to rely on automatic thinking and lead to biased decisions.
    • Practice mindfulness. Take a few moments throughout the day, especially during appointments, to clear your mind and refocus care concerns or plan for what’s next.

Use the ASK Model

The ASK Model is one practical tool that patients can use to address the impact of implicit bias and the role that culture may play in our day-to-day encounters:

  • Awareness – Increase our awareness of implicit bias in order to be more flexible in the ways we communicate so that we may enhance our trustworthiness.
  • Sensitivity – Be sensitive in our approach to our similarities with as well as our differences from other people.
  • Knowledge – Improve our health literacy, which is our understanding of healthcare and our specific health conditions. Improved health literacy will inform our decisions, behaviors and our ability to ask important questions to the healthcare team.

Recommendations for healthcare professionals

Practice from a stance of dignity and respect

  • Inclusion: Everyone is valued and all contributions are welcomed.
  • View people as individuals instead of as part of a larger group.
  • Work to build partnerships with your care team and your support systems.
  • View yourself as part of a larger group to increase empathy and trust.

Additional reading for healthcare professionals

Conclusions

  • Patients and clinicians have different areas of expertise, but both should be taken into account when considering or developing patient care.
    • Clinicians have the medical, social, mental health and resource knowledge.
    • Patients have personal self-knowledge (values, goals, life experiences and challenges, etc.).
  • Both patients and clinicians need to come together in partnership to achieve the best care outcomes.
  • To address implicit bias, we as patients must recognize what we bring to the table and how it can influence our care.
  • It is important to ask key questions, share our social history and challenges we may face with our care team. This will help them provide the best treatment plan to suit our needs and build trust.
  • Each of us are able to cultivate meaningful relationships and provide key contributions that can maximize our care outcomes.

Learn about the SLE Workshop and get more information on support services at HSS available for people with lupus and their loved ones by visiting LupusLine®, LANtern® (Lupus Asian Network), and Charla de Lupus (Lupus Chat)®.

HSS strives to deliver optimal care and services to all of our patients by adopting initiatives, behaviors, attitudes, and policies that enhance cultural competency and inclusion while serving a multicultural population. We believe that healthcare services that are respectful of and responsive to health beliefs, practices, and cultural and linguistic needs of diverse patients help to foster positive health outcomes. Learn more about Diversity and Inclusion at HSS.

References

  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
 

What is implicit bias?

Implicit biases are assumptions a person makes unconsciously or unintentionally – without meaning to make them or thinking about them. They are based on different factors such as age, race, ethnicity, religion, sex, gender, language, weight and economic status. Research shows that all people have these types of biases, which are based on their individual experiences and perceptions.

How is implicit bias defined?

Bias refers to the attitudes or stereotypes that affect our understanding, actions, decisions and interactions. Biases can be both favorable and unfavorable. "Implicit bias" is activated involuntarily, without a person’s awareness or intentional control. This is different from "explicit bias," in which people are aware of certain biases they have.

How are implicit biases formed?

There are a number of circumstances that can shape a person’s biases. These circumstances can be:

  • individual (such as immigrant status, sexual orientation and cultural background)
  • historical (such as the Holocaust, slavery and unethical medical or scientific research practices)
  • systemic (such as lack of access to care, mass incarceration and the crack cocaine epidemic)
  • environmental (such as neighborhood demographics and pollution)

How does implicit bias affect society?

Implicit associations can cause us to have feelings and attitudes about other people based on certain traits. These include language, gender, appearance, race, ethnicity, age and class.

Implicit associations can include the following:

  • "Most nurses are women."
  • "Most doctors are men."
  • "Men are better at math."
  • "More women than men are caregivers."

How does implicit bias affect healthcare?

Implicit bias can influence many of our interactions. Medical encounters are no exception. These biases contribute to disparities in healthcare by affecting the quality of care that different patients receive, which resuls in unequal treatment.

Research shows that implicit biases based on race, gender, sexual orientation, weight, health insurance and other group identifications can affect how healthcare providers interact with patients in several ways. These include:

  • the quality of the clinical interview
  • the diagnostic decision-making
  • symptom management
  • treatment recommendations
  • referrals to specialty care
  • interpersonal behaviors – communication, empathy, trust, etc.

How can my implicit biases affect my own healthcare?

Our own beliefs, values and biases can impact our interactions with others, including those on our care team who may be different from us. This may lead us to:

  • make assumptions
  • shift our tone and body language
  • feel frustrated with our level of care
  • develop mistrust
  • fear the negative impact of treatment on quality of life
  • avoid seeking healthcare
  • delay picking up prescriptions

The intricacies of bias, and their effects

The impact of implicit bias on specific communities: Exploring the evidence-based literature

Racial bias

Research shows that clinicians have more implicit bias against Black and Hispanic/Latinx groups. ("Latinx" is used as a gender-neutral or nonbinary alternative to "Latino" or "Latina" and refers to a person of Latin American origin or descent.)

Implicit bias toward Black and Hispanic/Latinx groups can lead to poor patient assessments, less serious diagnoses, less effective treatment recommendations, poor pain management, fewer referrals of patients to medical specialists, and less patient engagement.

Age and disability bias

Unconscious age biases are also well -documented, with older adults often receiving less treatment for the same diagnosis as compared with younger patients.

In several studies, negative implicit bias towards the people with disabities was stronger than toward the average population.

LGBTQ+ bias

  • LGBTQ+ patients face both explicit and implicit bias in healthcare.
  • Several studies have reported that transgender people did not see a doctor when they needed to due to fear of being mistreated as a transgender person.

The impact of implicit bias on musculoskeletal health

Gender bias and total joint replacement

  • Patient gender plays an in important role in the process of referral and recommendation for total joint replacement, such as a hip replacement.
  • Doctors were more likely to recommend total knee replacement surgery to male patients than to female patients. This suggests that gender bias may contribute to the sex-based disparity in the rates and use of total knee replacement.

Bias in drug treatment for rheumatoid arthritis

  • Many studies have shown there to be racial and ethnic differences in the use of biologic disease-modifying antirheumatic drugs (DMARDs).
  • It has also been found that patients of color receive lower-quality doctor-patient communication and inadequate patient education about the benefits and risks associated with the best available treatments.

The role of culture in managing chronic illness

Defining culture

Culture refers to a system of shared beliefs, values, customs, behaviors and artifacts that the members of society use to cope with their world and with one another. These systems are transmitted from generation to generation of families and greater communities through learning. Culture is the "lens" through which we view the world. It is central to what we see, how we make sense of what we see and how we express ourselves.

Understanding the role of culture

There are a number of ways that culture can influence our views on health and our approach to healthcare.

Culture:

  • defines for each of us what is "normal," why a particular problem exists and how to treat or address it
  • influences our understanding or interpretation of medical symptoms and, as a consequence, the manner in which health problems are treated
  • determines how we behave
  • determines which family members make medical decisions
  • can influence how we dress, what we eat, what we value and how we interact with others

How culture can affect our views on disease

The manner in which culture can shape our views on health can be explained through these three different perspectives on disease:

  • The Personalistic Perspective
    • Suggests that supernatural spirits or people cause disease. (Disease is "personified.")
  • The Naturalistic Perspective
    • Views health as a state of harmony between human beings and their environment. When this balance is upset, illness will result.. Traditional Chinese medicine is based upon this perspective.
  • The Western Scientific Perspective
    • This is a cause-and-effect perspective on disease that seeks analytical and physiological explanations and cures for disease, like identifying a virus or bug. Western medicine is based upon this perspective.

The Impact of culture

Failure to take cultural considerations into account and to address potential cultural issues with your care providers can lead to negative effects, such as:

  • feeling isolated
  • anxiety and worry
  • poor doctor-patient communication
  • treatment nonadherence (choosing to stop one’s prescribed medical treatment)
  • high nervous energy (which can be a way for people to self-sooth, even if they don’t have true anxiety)
  • feelings of helpless
  • poor patient heatlh outcomes

How can I address the impact of culture and implicit bias in my healthcare?

The first step is to become educated about the healthcare risk factors that implicit bias can create. The second is to talk with your doctors and other members of the healthcare team about any implicit biases that you have experienced during your care.

Risk factors

There are several factors that may increase the likelihood that implicit bias and culture will impact your healthcare. These include the following situations:

  • The patient or healthcare provider exhibits a strong emotional state, such as anger, anxiety, fear or disgust.
  • There is ambiguity in the healthcare encounter.
    • There may be no concrete guidelines for decision making or a lack of patient-provider collaboration.
  • The provider or patient is distracted or pressured.
    • This may be caused by long working hours, a fast-paced work environment, having to deal with crises, or by feeling tired/fatigued.
  • There is a lack of feedback.
    • Neither the provider nor patient is actively discussing with others the decisions they have made.

Recommendations to help reduce the impact of culture and implicit bias in healthcare

Recommendations for patients

  • When appropriate, share your social history with your doctor, so that they can better support and understand the challenges you may face.
    • Not sharing social history or challenges can led to an inappropriate care plan.
  • Seek out information on implicit bias.
    • Develop a good understanding of the potential for unconscious bias, and be alert.
    • Do not support jokes that disrespect any group of people.
  • Be conscious of your decision-making process, and check for bias.
    • Don’t make assumptions based on "eyeballing"(looking at a person’s physical features and guessing their social history or how they imay dentify).
    • Be aware of the reasoning behind your decisions.
  • Use shared decision-making strategies.
    • Shared decision-making tools allow for enhanced communication, education and patient input related to the care plan.
  • Acknowledge differences and diversity.
    • Cultivate cultural awareness and sensitivity. This can be effective in acknowledging and taking into account the perspectives of others.
  • Identify sources of stress and factors that contribute to pressure in your environment.
    • Work to minimize stressful situations that can cause you to rely on automatic thinking and lead to biased decisions.
    • Practice mindfulness. Take a few moments throughout the day, especially during appointments, to clear your mind and refocus care concerns or plan for what’s next.

Use the ASK Model

The ASK Model is one practical tool that patients can use to address the impact of implicit bias and the role that culture may play in our day-to-day encounters:

  • Awareness – Increase our awareness of implicit bias in order to be more flexible in the ways we communicate so that we may enhance our trustworthiness.
  • Sensitivity – Be sensitive in our approach to our similarities with as well as our differences from other people.
  • Knowledge – Improve our health literacy, which is our understanding of healthcare and our specific health conditions. Improved health literacy will inform our decisions, behaviors and our ability to ask important questions to the healthcare team.

Recommendations for healthcare professionals

Practice from a stance of dignity and respect

  • Inclusion: Everyone is valued and all contributions are welcomed.
  • View people as individuals instead of as part of a larger group.
  • Work to build partnerships with your care team and your support systems.
  • View yourself as part of a larger group to increase empathy and trust.

Additional reading for healthcare professionals

Conclusions

  • Patients and clinicians have different areas of expertise, but both should be taken into account when considering or developing patient care.
    • Clinicians have the medical, social, mental health and resource knowledge.
    • Patients have personal self-knowledge (values, goals, life experiences and challenges, etc.).
  • Both patients and clinicians need to come together in partnership to achieve the best care outcomes.
  • To address implicit bias, we as patients must recognize what we bring to the table and how it can influence our care.
  • It is important to ask key questions, share our social history and challenges we may face with our care team. This will help them provide the best treatment plan to suit our needs and build trust.
  • Each of us are able to cultivate meaningful relationships and provide key contributions that can maximize our care outcomes.

Learn about the SLE Workshop and get more information on support services at HSS available for people with lupus and their loved ones by visiting LupusLine®, LANtern® (Lupus Asian Network), and Charla de Lupus (Lupus Chat)®.

HSS strives to deliver optimal care and services to all of our patients by adopting initiatives, behaviors, attitudes, and policies that enhance cultural competency and inclusion while serving a multicultural population. We believe that healthcare services that are respectful of and responsive to health beliefs, practices, and cultural and linguistic needs of diverse patients help to foster positive health outcomes. Learn more about Diversity and Inclusion at HSS.

References

  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

Authors

Photo of Jillian Rose, PhD, MPH, LCSW

Jillian Rose, PhD, MPH, LCSW
Director, Community Engagement, Diversity and Research
Department of Social Work Programs
 

Workshop Presentation Summary by

Photo of Samantha Santamaria, MSW

Samantha Santamaria, MSW
Masters of Social Work Intern
Department of Social Work Programs
 
 

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