Just Read: State of the Science: Implicit Bias Review 2014 (Implications for health care)

Right after I came upon the 2013 State of the Science: Implicit Bias Review by the Kirwan Institute for the Study of Race and Ethnicity at The Ohio State University (@KirwanInstitute), which I reviewed yesterday (Just Read: State of the Science: Implicit Bias Review 2013 | Ted Eytan, MD), I found the 2014 State of the Science. Things are moving that quickly, and when studying a new topic, there’s nothing better than finding a “State of the Science” document that’s well referenced, is there…

Today, I’m going to highlight some of the additional insights I gained, in semi-disjointed bullet-point format, which I’m allowed to do, it’s my blog 🙂

 Some scholars note the growing assertion that unconscious bias is the most pervasive and important form of discrimination in society today, particularly in the workplace.

Up front, a nice summary of the characteristics of Implicit bias:

  • Pervasive and robust “even people with avowed commitments to impartiality such as judges” (and I’ll add, “doctors” and “nurses”)
  • They (implicit biases) don’t necessarily align with our declared beliefs
  • They have real-world effects on our behavior
  • and, most importantly, they are malleable – they can be unlearned and replaced with different behavior

Therefore, it’s incorrect to believe that there’s a ghost in the machine and what’s going to happen is what’s going to happen. We’re studying this as health practitioners because understanding it will help us do better.

Surprising fact:

researchers have even documented this bias in children, including those as young as six years old


Not about repressing biased thoughts

Approoaches that work:

  • “Counter-sterotypic training/exposure to counter-stereotypic individuals” – developing new associations that contrast with stereotypes, via photographs or audio cues. (unclear how long lasting these efforts are, also the counter-stereotypic examples should be clearly associated with the outgroup, e.g. a photograph of a person who is transgender should be identifiable as such, rather than as a cisgender person)
  • “Intergroup contact” – Conditions necessary for this are
  • Sharing equal status
  • Sharing common goals
  • Cooperative rather than a competitive environment
  • (Note from me: Intergroup contact in a doctor-patient setting does not meet these criteria to me)
  • For the medical profession: 
  • Medical professionals, in particular, are encouraged to constantly self-monitor in an effort to offset implicit biases and stereotypes
  • “Making race salient matters” – evidence that “a colorblind ideology generates greater amounts of implicit bias than a multicultural perspective does”

    Health Care

    Physicians generally resemble the communities they serve in around having implicit bias – eg they are not less or more biased when tested

    Despite reporting very little explicit bias, approximately two-thirds of the clinicians were found to harbor implicit bias against Blacks and Latinos (Blair, Steiner, et al., 2013). In terms of Black patients’ perceptions of care, the stronger the clinicians’ implicit bias against Blacks relative to Whites, the lower the Black patients rated them on all four subscales of patient-centered care.

    Two specific approaches for debiasing physicians:

    • Focusing on health care providers, Chapman and colleagues’ review of implic- it bias research from the medical domain led them to endorse several previous- ly-established debiasing techniques. First, they call on physicians to understand implicit biases as a “habit of mind,” regarding awareness of one’s susceptibility to implicit associations as a key to behavioral changes
    • Focusing on patients as individuals, rather than part of the group that they belong in – seems obvious, but when people don’t collect history about a person’s unique traits, bias likely increases
    • “Envisioning the viewpoint of others via perspective-taking”  – this involves completing an exercise where people view a photograph of a minority group member and write a brief story about a day in the life of that person

    A recent study, in 2013, found significant anti-fat bias exists among medical students – expanding the areas where this is being studied. Interestingly, that study compares anti-fat bias to anti-LGBT bias – I’ll post on that later

    Future Trends

    Most of the implicit bias literature has a foundation in race bias. This is changing, to include groups like Latinos and Asians. As I have mentioned on here previously. there’s no research that I know of on gender identity bias (always ahead of my time by 1-5 years 🙂 ). In medicine, there is additional work underway to look at implicit bias in medical conditions like cancer.

    There are also newer techniques using technology to debias, such as seeing one’s self as a member of the outgroup

    Bias in employment

    There are several points in here that merit mention in a health care setting.

    First, Title VII, of the Civil Rights Act of 1964:

    Section 703. (a) “It shall be an unlawful employment practice for an employer –(1) to fail or refuse to hire or to discharge any individual, or otherwise to discrim- inate against any individual with respect to his compensation, terms, conditions, or privileges of employment, because of such individual’s race, color, religion, sex, or national origin; or

    (2) to limit, segregate, or classify his employees or applicants for employment in any way which would deprive or tend to deprive any individual of employment opportunities or otherwise adversely affect his status as an employee, because of such individual’s race, color, religion, sex, or national origin.” (Title VII of the Civil Rights Act of 1964)

    Relevant, because as of 2012, “sex” has been redefined to include “Gender Identity and Expression” by the Health and Human Services Office of Civil Rights: EEOC Concludes that Title VII Covers Gender Identity and Transgender Discrimination Claims: Labor and Employment Law, School Law, Lawyers, Attorneys, Franczek Radelet 

    However, it’s advised that the conversation be about “fair treatment and respect” rather than discrimination and “protected classes”

    • Having gainful employment is part of health, and now gender identity and expression is a protected class
    • Further, there’s evidence that in “ambiguous situations” implicit bias is recruited, such as when reviewing resumes where qualifications are less clear – “going with your gut” is not a feature, it’s a bug – “gut feelings” are likely to be derived from biased implicit processes.

    Some useful conclusions for Health Care

    • (Researcher Irene) Blair and colleagues noted that the implicit biases they observed did not seem to be a problem specific to health care professionals but rather indicative of larger societal issues. The question that emerged, then, was, “Is it enough for patients that no more bias is likely to appear within the health care setting than outside, or are health care providers held to a higher standard?”(Blair, Havranek, et al., 2013, p. 95) 
    • Also in a study of physicians (performed by Irene Blair, et al), 18% held no bias toward Latinos and 28% were unbiased with respect to African Americans (Blair, Havranek, et al., 2013). The researchers suggest that findings such as this provide an opportunity for a unique line of inquiry. Rather than focusing on biased individuals, perhaps there is merit in concentrating research efforts on understanding the unbiased providers, such as considering what approach or other factors allow these individuals to be both implicitly and explicitly egalitarian. Moreover, is there something about the approach of these unbiased primary care providers that can be taught to others?

    There’s a helpful section in the back that’s a conversation with an “Implicit Bias Skeptic,” and the piece is well referenced which is terrific.

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    Ted Eytan, MD