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Eliminating Explicit and Implicit Biases in Health Care: Evidence and Research Needs
Open accessAbstract
Health care providers hold negative explicit and implicit biases against marginalized groups of people such as racial and ethnic minoritized populations. These biases permeate the health care system and affect patients via patient–clinician communication, clinical decision making, and institutionalized practices. Addressing bias remains a fundamental professional responsibility of those accountable for the health and wellness of our populations. Current interventions include instruction on the existence and harmful role of bias in perpetuating health disparities, as well as skills training for the management of bias. These interventions can raise awareness of provider bias and engage health care providers in establishing egalitarian goals for care delivery, but these changes are not sustained, and the interventions have not demonstrated change in behavior in the clinical or learning environment. Unfortunately, the efficacy of these interventions may be hampered by health care providers’ work and learning environments, which are rife with discriminatory practices that sustain the very biases US health care professions are seeking to diminish. We offer a conceptual model demonstrating that provider-level implicit bias interventions should be accompanied by interventions that systemically change structures inside and outside the health care system if the country is to succeed in influencing biases and reducing health inequities.
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“By simulating scenarios that mirror real-life clinical decision-making processes, and through reading the multi-agent conversations, clinicians can be made aware of potential cognitive biases and how to correct them. This facilitates learning in a controlled, educational environment [25,26].”
From Mitigating cognitive biases in clinical decision-making through multi-agent conversations using large language models: simulation study (2024) · cites this paper as [26]
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Physician Workforce Diversity Is Still Necessary and Achievable if It Is Intentionally Prioritized
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“In addition, sustained multi-level approaches to address biases in care provision at all levels of strain (Vela et al., 2022) – which could include development and implementation of novel decision-support algorithms to improve allocation of care inputs to patients whose high mortality risks may be…”
BackgroundDoctor Decision Making and Patient Outcomes
Currie, J., MacLeod, W. B., & Musen, K. (2024) · National Bureau of Economic Research · doi:10.3386/w32788 · Cited by 13
Cultivating cultural competence in ICU communication
Siddiqui, S., & Metaxa, V. (2025) · Intensive Care Medicine · doi:10.1007/s00134-025-07829-w · Cited by 9
Reporting Sex and Gender Differences in Cardiovascular Research
Porter, K. F., Deb, B., Katyukha, A., Punnanithinont, N., Fradley, M. G., & Cook, S. C. (2024) · US Cardiology Review · doi:10.15420/usc.2024.18 · Cited by 8
Bhargava, A., & Ashwin, C. (2025) · Research in Autism · doi:10.1016/j.reia.2025.202547 · Cited by 8
Beyond Genetics: Exploring Lifestyle, Microbiome, and Social Determinants in Oral Cancer Development
Menon, A., Mutalik, V. S., Chen, Y., Ponamgi, S., Peela, S., Schroth, R. J., Ghavami, S., & Chelikani, P. (2025) · Cancers · doi:10.3390/cancers17071094 · Cited by 11
“Moreover, systemic biases in healthcare delivery can result in inequitable treatment for marginalized groups [130].”
Mundy, L. M., Judd, S. E., Clay, O. J., Howard, V. J., Durant, R. W., Ballard, E., & Crowe, M. G. (2025) · Journal of General Internal Medicine · doi:10.1007/s11606-025-09474-x · Cited by 8
The Perpetual Cycle of Racial Bias in Healthcare and Healthcare Education: A Systematic Review
Sorice, V., Mortimore, G., Faghy, M. A., Sorice, R., & Tegally, D. (2025) · Journal of Racial and Ethnic Health Disparities · doi:10.1007/s40615-025-02417-6 · Cited by 8
“Standardising clinical processes and protocols, particularly in high-stakes areas like emergency departments and triage, can help reduce the impact of conscious and unconscious bias on patient access and care quality [5, 56].”
Murza, K. A., & Buckley, P. C. (2023) · Language Speech and Hearing Services in Schools · doi:10.1044/2023_lshss-23-00081 · Cited by 8
Moyinoluwa, F. L. (2024) · British Journal of Multidisciplinary and Advanced Studies · doi:10.37745/bjmas.2022.0452 · Cited by 8
“(2022) studied the relationship between implicit bias and various factors in the healthcare system.”
BackgroundDerbyshire, D. W., & Keay, T. (2024) · Journal of Clinical Nursing · doi:10.1111/jocn.17097 · Cited by 7
Cotter, E. W., Dunford, A., Gilchrist, K., Yan, T., Deyton, L., & Essel, K. D. (2025) · Journal of Eating Disorders · doi:10.1186/s40337-025-01231-z · Cited by 7
“…term) through educational strategies such as engagement with others’ perspectives, opportunities for self-reflection, and increased opportunities for contact with minoritized groups [28–30], although structural and institutional changes are necessary to maintain improvements over time [31, 32].”
Identifying Bias at Scale in Clinical Notes Using Large Language Models
Apakama, D. U., Nguyen, K.-A.-N., Hyppolite, D., Soffer, S., Mudrik, A., Ling, E. J., Moses, A., Temnycky, I., Glasser, A., Anderson, R., et al. (2025) · Mayo Clinic Proceedings Digital Health · doi:10.1016/j.mcpdig.2025.100296 · Cited by 14
Thorndike, A. L., Peterson, L., Spitzer, S., Patel, S., Smithey, A., Moore, J. E., Cook, S. C., & Chin, M. H. (2023) · Frontiers in Public Health · doi:10.3389/fpubh.2023.1104843 · Cited by 7
Self-citationAn Ethics Action Plan for Rare Disease Care: Participatory Action Research Approach
Quintal, A., Carreau, I., Grenier, A., Hébert, C., Yergeau, C., Berthiaume, Y., & Racine, É. (2023) · Journal of Participatory Medicine · doi:10.2196/46607 · Cited by 8
“These activities aim to reduce biases [63,100,101].”
BackgroundLalika, M., McCoy, C. R., Jones, C., Bancos, I., Cooper, L. A., Hayes, S. N., Johnson, M. P., Kullo, I. J., Kumbamu, A., Noseworthy, P. A., et al. (2024) · Contemporary Clinical Trials · doi:10.1016/j.cct.2024.107600 · Cited by 8
Paccoud, I., Nazroo, J. Y., & Leist, A. K. (2022) · International Journal for Equity in Health · doi:10.1186/s12939-022-01709-1 · Cited by 7
“Due to structural inequalities and racism, healthcare providers may hold implicit (unconscious) and explicit biases towards certain minorities that pervade the healthcare system and negatively affect patients [33].”
BackgroundRacial and ethnic inequities in psychiatric inpatient building and unit assignment
Michaels, T. I., Thomas, E., Flaxer, J. M., Singal, S., Hanna, L. A., Meter, A. V., Tang, S. X., Kane, J. M., & Saito, E. (2023) · Psychiatry Research · doi:10.1016/j.psychres.2023.115560 · Cited by 7
Racial and Ethnic Disparities in Home Health Referral Among Adult Medicare Patients
Yakusheva, O., Lee, K. A., Keller, A. O., & Weiss, M. (2023) · Medical Care · doi:10.1097/mlr.0000000000001945 · Cited by 7
“39 It is important to stress that the abovementioned 4 root causes of the racial disparities in HHC referral potentially responsible for the fi ndings observed in our study — cultural appropriateness of assessments, patient preferences, ineffective communication, and clinician bias — are well within…”
BackgroundMarch, M. K., & Roberts, K. E. (2024) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-024-08107-4 · Cited by 6
Khan, W. U., Alissa, M., Allemailem, K. S., Alrumaihi, F., Alharbi, H. O., Almansour, N. M., Aldaiji, L. A., Albalawi, M. J., Abouzied, A. S., Almousa, S., et al. (2024) · Current Problems in Cardiology · doi:10.1016/j.cpcardiol.2024.102964 · Cited by 6
Mulligan, D. J., Taylor, A., & Lamis, D. A. (2025) · Suicide and Life-Threatening Behavior · doi:10.1111/sltb.70003 · Cited by 7
Norris, K. L., Melton, M., Lopez, K., Rotellini, D., & Valentino, L. A. (2025) · Health Equity · doi:10.1089/heq.2024.0146 · Cited by 6
“21,22 Permeating the health care system, these biases impact patient – clinician communication, clinical decision making, level of care, and institutionalized practices.”
Beyond Traditional: Clearing the Roadblocks to Advancement in Academic Medicine
Ortega, P., Becker, M. L., Chan, T. M., & Manning, K. D. (2025) · Perspectives on Medical Education · doi:10.5334/pme.1681 · Cited by 7
Aziz, Z., Mazeh, A. C., Ilic, D., Ciardulli, M., Hadi, S. N. E., Camuccio, A., Moore, J., & Kiegaldie, D. (2026) · Nurse Education in Practice · doi:10.1016/j.nepr.2026.104711 · Cited by 4
Armstrong-Mensah, E. A., Rasheed, N., Williams, D., Moyer, K., Alema‐Mensah, E., & Tetteh, A. K. (2022) · Journal of Racial and Ethnic Health Disparities · doi:10.1007/s40615-022-01439-8 · Cited by 6
“The probability of marginalized racial and ethnic groups obtaining quality health care in Georgia depends to a great extent on the negative explicit and implicit biases and attitudes of health care providers [23].”
BackgroundPrussien, K. V., Faust, H. L., Crosby, L. E., Smith‐Whitley, K., Barakat, L. P., & Schwartz, L. A. (2024) · Pediatric Blood & Cancer · doi:10.1002/pbc.31156 · Cited by 6
Ending Unequal Treatment and Achieving Optimal Health for All
Benjamin, G. C., DeVoe, J. E., & Amankwah, F. K. (2024) · JAMA · doi:10.1001/jama.2024.14268 · Cited by 6
Wilson, M., Booker, S. Q., Saravanan, A., Singh, N., Pervis, B., Mahalage, G., & Knisely, M. R. (2024) · Pain Management Nursing · doi:10.1016/j.pmn.2024.10.016 · Cited by 6
Postoperative Outcomes After Breast Reduction: Do Racial Disparities Exist?
Knoedler, S. A., Schaschinger, T., Kiwanuka, H., Hamaguchi, R., Cherubino, M., Obed, D., Machens, H., Orgill, D. P., Panayi, A. C., & Kim, B. (2025) · Journal of Racial and Ethnic Health Disparities · doi:10.1007/s40615-025-02490-x · Cited by 6
“Variability in access to timely postoperative evaluations, inconsistencies in follow-up care, and potential health system biases in the provision of resources and attention to postoperative concerns could also influence postoperative outcomes [45].”
Linsenmeyer, M., & Long, G. (2023) · Medical Science Educator · doi:10.1007/s40670-023-01752-9 · Cited by 11
“But behaviors and beliefs can be negative, and we may behave in ways that are expressions of unconscious bias, even when those behaviors and biases are counter to our declared, conscious belief systems, such as with implicit bias [22].”
BackgroundCultural Responsiveness in Behavior Analysis: Provider and Recipient Perceptions in Ontario
O’Neill, P., Magnacca, C., Gunnarsson, K. F., Khokhar, N., Koudys, J., & Malkin, A. (2023) · Behavior Analysis in Practice · doi:10.1007/s40617-023-00825-w · Cited by 7
“Studies from other health care fields indicate that despite controlling for factors such as socioeconomic and insurance status, service providers still carry implicit racial biases towards non-White service recipients (Hall et al., 2015; Vela et al., 2022).”
Androcentric bias in surgical equipment - What challenges do women face?
Koo, Y. E., Allen, C., Ballantyne, A., & Yassaie, E. (2023) · The American Journal of Surgery · doi:10.1016/j.amjsurg.2023.09.049 · Cited by 6
Addressing gender inequalities in health: a comprehensive framework for policy and practice
Khaledian, Z., Tajvar, M., Takian, A., Yaseri, M., Hajizadeh, M., & Olyaeemanesh, A. (2025) · Discover Social Science and Health · doi:10.1007/s44155-025-00266-6 · Cited by 5
Evaluating a Codesign Process in Mental Health: ‘Harnessing the Power of Together’
Kehoe, M., Friebel, H., Rosie, K., Kremer, P. D., Shawyer, F., Meadows, G. N., & Ozols, I. (2025) · Health Expectations · doi:10.1111/hex.70371 · Cited by 5
“However, we found evidence that the issue of power existed in both implicit (unconscious) and explicit (conscious) bias [24].”
Shared decision making - a review of its evaluation, efficacy, and applicability in asthma
Piątkowska, A., Marszałek, K., Krupińska, N., Malaya, E., Adamczewska, M., Kuna, P., & Panek, M. (2025) · Frontiers in Medicine · doi:10.3389/fmed.2025.1639805 · Cited by 5
Metadata
- Authors
- Vela, M. B., Erondu, A. I., Smith, N. A., Peek, M. E., Woodruff, J. N., & Chin, M. H.
- Affiliations
- University of Illinois Chicago (US)
- University of California, Los Angeles (US)
- Hospital of the University of Pennsylvania (US)
- University of Chicago (US)
- ORCID
- Woodruff, James N.
- Venue
- Annual Review of Public Health
- Publisher
- Annual Reviews
- Published
- 2022-04-05
- Volume
- 43
- Issue
- 1
- Pages
- 477-501
- ISSN
- 0163-7525 (ISSN-L)
- 1545-2093
- PMC
- PMC9172268
- OpenAlex
- W4206528627
- Cited by
- 426
- References
- 102
- Citations by year
- 2026: 89 · 2025: 176 · 2024: 97 · 2023: 55 · 2022: 9
- FWCI
- 14.19
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Locations
- Annual Review of Public Health (publishedVersion, cc-by)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion, cc-by)
- Funders
- National Institute of Diabetes and Digestive and Kidney Diseases (P30DK092949)
- Topics
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Cultural Competency in Health Care
- Social Sciences › Sociology and Political Science › Racial and Ethnic Identity Research
- Social Sciences › Sociology and Political Science › Social and Intergroup Psychology
- Keywords
- implicit bias, explicit bias, healthcare workers, racial and ethnic minorities, health disparities, bias interventions, patient-clinician communication, clinical decision-making, organizational discrimination, structural change, conceptual model
- MeSH terms
- Attitude of Health Personnel, Communication, Health Personnel, Humans, Bias, Healthcare Disparities
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