Examining the presence, consequences, and reduction of implicit bias in health care: A narrative review

“For example, Teal et al. (2010) had medical students complete a Black/White race Implicit Association Test (IAT; Greenwald, McGhee, & Schwartz, 1998) and then participate in peer discussion groups to discuss their experience with the IAT and their observations about implicit bias during ongoing…”

“…increasing awareness of the subtle ways in which bias may affect judgment and behavior, a ground-breaking report by the Institute of Medicine (IOM; Smedley et al., 2002) concluded that unrecognized or implicit bias among health care providers may contribute to health disparities, but additional…”

“Indeed, a vast amount of research shows that perceived discrimination may undermine health among stigmatized groups (for a review see Pascoe & Richman, 2009).”

“Cultural humility is another US-developed concept originating in the 1990s [22].”

“The divisive framing of cross-cultural interactions as essentially ‘ culture-clashes ’ that require behavioural adjustment from the ‘ out-group ’ only, appears to indulge our natural impulse for in-group favouritism and ensuing out-group derogation [36].”

“Moreover, the evidence for health care professional racial bias on patient outcomes is unclear [58, 59].”

“A national survey by The Commonwealth Fund (Collins et al., 2002) found that compared to Whites, Hispanics and African Americans were nearly twice as likely to report problems communicating with their providers, 14 times more likely to believe that they would receive better health care if they were of a different ethn…”

“In reality, attachment to culture varies widely – some may only ascribe to particular aspects of a culture, some may be attached to multiple cultures, others may have only a nominal or symbolic bond to a culture [28, 29].”

“This finding is consistent with laboratory research that shows stronger associations between implicit bias and nonverbal behavior than explicit statements or judgments (Dovidio et al., 2002; Fazio et al., 1995).”

“It is a more systemic approach focusing on both personal attitudes, communication and organisational policies [4].”

“This finding is consistent with laboratory research that shows stronger associations between implicit bias and nonverbal behavior than explicit statements or judgments (Dovidio et al., 2002; Fazio et al., 1995).”

“Second, careful examinations of providers’ perceptions of actual patients showed that African American patients were perceived in more negative terms than White patients (e.g., Finucane & Carrese, 1990; van Ryn & Burke, 2000).”

“Individuals with lower socioeconomic statuses face increased risk of disease, and women are more likely to be the victims of rape and intimate partner violence and suffer from depression than men (e.g., Coker et al., 2002; Nolen-Hoeksema, 2001).”

“In other research, health care providers explicitly reported that African American patients are no more likely than White patients to be noncoop-erative (Green et al., 2007).”

“Reviews and meta-analyses of both experimental and field studies (in health and non-health related disciplines) have demonstrated that changes in implicit bias (if occurring) did not translate into behavioural change [53, 55, 56].”

“…providers are not of the same ethnicity (i.e., typically White)—and they perceive significantly more bias in health care compared to Whites (e.g., Cooper, Johnson, Ford, Steinwache, & Powe, 2003; Cooper-Patrick et al., 1999; LaVeist, Nickerson, & Bowie, 2000; Saha, Komaromy, Koepsell, & Bindman,…”

“Devine, Forscher, Austin, and Cox (2012) developed a two-step intervention for college undergraduates in which, after making the participants aware of their implicit prejudice toward African Americans through IAT feedback, they instructed participants in the use of stereo-type-replacement thinking,…”

“Several reviews, including the previous section, indicate that implicit prejudice and stereotyping is present when students begin training in health care, and that the level of implicit bias remains constant or increases as students matriculate through their training (see Chapman et al., 2013).”

“Some may avoid making difficult clinical decisions (that they would ordinarily make for mainstream clients) to avoid any possible perception of racism [35].”

“…are not of the same ethnicity (i.e., typically White)—and they perceive significantly more bias in health care compared to Whites (e.g., Cooper, Johnson, Ford, Steinwache, & Powe, 2003; Cooper-Patrick et al., 1999; LaVeist, Nickerson, & Bowie, 2000; Saha, Komaromy, Koepsell, & Bindman, 1999).”

“…are not of the same ethnicity (i.e., typically White)—and they perceive significantly more bias in health care compared to Whites (e.g., Cooper, Johnson, Ford, Steinwache, & Powe, 2003; Cooper-Patrick et al., 1999; LaVeist, Nickerson, & Bowie, 2000; Saha, Komaromy, Koepsell, & Bindman, 1999).”

“…show that higher body mass index (BMI), as well as male, health care providers had less implicit bias toward obese individuals (Sabin et al., 2012; Schwartz et al., 2003), and providers with more contact with patients with spinal cord injuries showed less implicit biased toward wheel-chair users…”

“Perhaps even more so in health settings where clinical encounters can impact patient actions [15 – 19].”

“For example, Cooper et al. (2012) measured providers’ implicit prejudice and stereotyping of African Americans and then audio-recorded their clinical visits with African American and White patients.”

“Moreover, the evidence for health care professional racial bias on patient outcomes is unclear [58, 59].”

“The effects of the Tuskegee study can still be seen today in that African Americans who have knowledge of the study report greater medical and research mistrust (Freimuth et al., 2001; Shavers, Lynch, & Burmeister, 2000).”

“One of the more troubling explanations for continuing health disparities is bias on the part of health care providers (Smedley, Stith, & Nelson, 2002; van Ryn & Fu, 2003).”

“Cultural safety was pioneered by Maori nurses in New Zealand in the 1990s [21].”

“For example, Sabin and Greenwald (2012) found that providers’ implicit race bias predicted less prescribed postsurgical pain medication for African American than White patients, but implicit race bias did not predict race differences in decisions for other medical issues, such as treatment of…”

“Other research outside of the health care domain suggests that exposing providers to multiple strategies could attenuate implicit bias both immediately after training, and in some cases, the effects might last for several weeks (Rudman, Ashmore, & Gary, 2001).”

“…biases, and (b) providing instruction on strategies they can use to either reduce the activation of implicit associations, or control how those associations influence judgment and behavior (Blair et al., 2011; Burgess et al., 2007; Stone & Moskowitz, 2011; Teal, Gill, Green, & Crandall, 2012).”

“Based on that work, researchers have developed a general model on the ways in which provider bias may contribute to health disparities (Blair, Steiner, & Havranek, 2011; Dovidio et al., 2008; van Ryn, 2002; van Ryn & Fu, 2003; see Figure 1).”

“For example, White, Hispanic, and Asian health care providers exhibited moderate levels of implicit bias toward African Americans whereas African American health care providers showed no such implicit bias (Sabin et al., 2009).”

“Several systematic reviews and meta-analyses have ap-praised the effectiveness of cross-cultural training interventions in health care environments over the past 30 years [2, 10, 12, 47 – 54].”

“Based on that work, researchers have developed a general model on the ways in which provider bias may contribute to health disparities (Blair, Steiner, & Havranek, 2011; Dovidio et al., 2008; van Ryn, 2002; van Ryn & Fu, 2003; see Figure 1).”

“Other findings show that higher body mass index (BMI), as well as male, health care providers had less implicit bias toward obese individuals (Sabin et al., 2012; Schwartz et al., 2003), and providers with more contact with patients with spinal cord injuries showed less implicit biased toward wheelchair users (Galli e…”

“First, ethnic/racial differences in care have been observed even after economic, educational, and access differences were accounted for, leading some to conclude that bias must be at work (e.g., Kressin & Petersen, 2001; Sheifer, Escarce, & Schulman, 2000).”

“In fact it has been found that even when physicians hold implicit racial biases, their cross-cultural clinical decision making is not necessarily impacted [57].”

“In a partial reanalysis of the Penner et al. (2010) data, Hagiwara et al. (2013) measured the amount of time that providers talked during the clinical interaction compared to the amount of time that the patients talked (i.e., talk-time ratio).”

“Bias and/or cultural differences between health care service providers and migrant/minority populations are believed to contribute to both the poor health care experiences and subsequent unmet health needs of underprivileged minority groups [3 – 9].”

“Instruction in perspective-taking shows positive effects on implicit bias in laboratory studies (Todd & Galinsky, 2014) and among health care providers (Drwecki, Moore, Ward, & Prkachin, 2011).”

“…biases, and (b) providing instruction on strategies they can use to either reduce the activation of implicit associations, or control how those associations influence judgment and behavior (Blair et al., 2011; Burgess et al., 2007; Stone & Moskowitz, 2011; Teal, Gill, Green, & Crandall, 2012).”

“Many other studies have failed to find any association between providers’ implicit race or class biases and their medical judgments (Haider, Schneider, Sriram, Dossick, et al., 2015; Haider, Schneider, Sriram, Scott, et al., 2015; Haider et al., 2011; Oliver et al., 2014; Sabin et al., 2008).”

“1 The causes for such disparities are linked to three broad factors: Genetic/biological antecedents, socioeconomic predictors, and psychological processes that contribute to biased health care (e.g., Adler & Rehkopf, 2008; Sankar et al., 2004; Schnittker & McLeod, 2005).”

“For example, Phelan et al. (2014) found that whereas implicit bias toward obese patients remained constant, explicit bias increased during the 4 years of medical school.”

“In contrast, van Ryn et al. (2015) reported that having completed an IAT (with feedback) was a significant predictor of decreases in implicit bias after controlling for instruction in cultural competence and minority health.”

“Instruction in perspective-taking shows positive effects on implicit bias in laboratory studies (Todd & Galinsky, 2014) and among health care providers (Drwecki, Moore, Ward, & Prkachin, 2011).”

“Many other studies have failed to find any association between providers’ implicit race or class biases and their medical judgments (Haider, Schneider, Sriram, Dossick, et al., 2015; Haider, Schneider, Sriram, Scott, et al., 2015; Haider et al., 2011; Oliver et al., 2014; Sabin et al., 2008).”

“…biases, and (b) providing instruction on strategies they can use to either reduce the activation of implicit associations, or control how those associations influence judgment and behavior (Blair et al., 2011; Burgess et al., 2007; Stone & Moskowitz, 2011; Teal, Gill, Green, & Crandall, 2012).”

“Whereas the majority of students reported positive attitudes and beliefs about implicit bias, 22% of the sample doubted the validity of the IAT and the existence of health disparities over-all.”

“Finally, controlled experiments have found that providers’ perceptions and treatment recommendations for hypothetical Black patients differed significantly from those made for hypothetical White patients with the exact same symptoms (for a review see Paradies, Truong, & Priest, 2013).”

“Recent research indicates that positive intergroup contact is associated with reduction in implicit bias in a health care context (Burke et al., 2015; van Ryn et al., 2015).”

“…of treatment services to patients from lower socio-economic status backgrounds, patients deemed to have a lower health literacy, patients who have previously not adhered to treat-ment, patients with insufficient health care coverage, or patients with serious mental illnesses or are drug users [31].”

“Cultural intelligence is the most recent derivative of cross-cultural education and has gained prominence in business management settings [23].”

“This is almost inevitable if they work in a system that does not (or does not know how to) support or supervise the administering of the new knowledge [41, 42].”

“Many other studies have failed to find any association between providers’ implicit race or class biases and their medical judgments (Haider, Schneider, Sriram, Dossick, et al., 2015; Haider, Schneider, Sriram, Scott, et al., 2015; Haider et al., 2011; Oliver et al., 2014; Sabin et al., 2008).”

“Several systematic reviews and meta-analyses have ap-praised the effectiveness of cross-cultural training interventions in health care environments over the past 30 years [2, 10, 12, 47 – 54].”

“Reviews and meta-analyses of both experimental and field studies (in health and non-health related disciplines) have demonstrated that changes in implicit bias (if occurring) did not translate into behavioural change [53, 55, 56].”

“…biases, and (b) providing instruction on strategies they can use to either reduce the activation of implicit associations, or control how those associations influence judgment and behavior (Blair et al., 2011; Burgess et al., 2007; Stone & Moskowitz, 2011; Teal, Gill, Green, & Crandall, 2012).”

“In a partial reanalysis of the Penner et al. (2010) data, Hagiwara et al. (2013) measured the amount of time that providers talked during the clinical interaction compared to the amount of time that the patients talked (i.e., talk-time ratio).”

“First, ethnic/racial differences in care have been observed even after economic, educational, and access differences were accounted for, leading some to conclude that bias must be at work (e.g., Kressin & Petersen, 2001; Sheifer, Escarce, & Schulman, 2000).”

“…beliefs toward stigmatized groups as found in other populations, with higher levels of implicit than explicit bias (Blair, Havaranek, et al., 2013; Galli et al., 2015; but see Peris, Teachman, & Nosek, 2008, for an example of providers showing less implicit mental health bias than nonproviders).”

“Implicit bias may be more likely to affect care delivered outside of established relationships, or in decisions made under time pressure, with limited information, and without the benefit of clear guidelines (Burgess, van Ryn, Dovidio, & Saha, 2007; Stepanikova, 2012).”

“…that providers can learn to control their implicit responses to stigmatized patients, may also encourage openness and acceptance of the information (Moss-Racusin et al., 2014) It is also important to examine how best to train health care providers in the use of strategies for reducing implicit…”

“For example, Blair, Havaranek, et al. (2013) found that while doctors held implicit bias against Latino and African American patients, negative explicit attitudes against these groups were virtually nonexistent.”

“Worse, such information may only evoke pity, and for some consolidate a view of helplessness or a downtrodden stereotype [37].”

“Naturally, extended training will require a relatively high level of commitment, in terms of instruction time and resources, by health care training programs (Penner, Blair, Albrecht, & Dovidio, 2014).”

“Many other studies have failed to find any association between providers’ implicit race or class biases and their medical judgments (Haider, Schneider, Sriram, Dossick, et al., 2015; Haider, Schneider, Sriram, Scott, et al., 2015; Haider et al., 2011; Oliver et al., 2014; Sabin et al., 2008).”

“For mental health clinicians the DSM Cultural Formulation Interview includes prompts for clinicians that may elicit answers to this question [64].”

“…responsibility for changing them, if instructors start by activating and affirming their egalitarian goals and commitment to provide equal care, before having them engage in self-reflection activities or receive feedback from an IAT (Harris, Mayle, Mabbott, & Napper, 2007; Howell & Shepperd, 2012).”

“Holding pre-conceived notions of an individual ’ s behaviour based on their cultural background may also lead clinicians to ascertain various (problem) behaviours or personal idio-syncrasies as culturally normative when they may reflect genuine psychopathology and the need for treatment [30].”

“…increasing awareness of the subtle ways in which bias may affect judgment and behavior, a ground-breaking report by the Institute of Medicine (IOM; Smedley et al., 2002) concluded that unrecognized or implicit bias among health care providers may contribute to health disparities, but additional…”

“In a similar approach, Gonzalez, Kim, and Marantz (2014) exposed medical students to a single session about the role of provider implicit bias in health disparities.”

“For example, Teal et al. (2010) had medical students complete a Black/White race Implicit Association Test (IAT; Greenwald, McGhee, & Schwartz, 1998) and then participate in peer discussion groups to discuss their experience with the IAT and their observations about implicit bias during ongoing…”

“As such, learning about the worldviews, norms practices of cultural clientele is anticipated to not only endow health care professionals with a better capacity to understand and serve their patients, but to also reduce broader health care inequities in the process [8, 10 – 13].”

“Importantly, Bean and colleagues suggested that these stereotypes may stem from health care providers per-ceiving communication difficulties as a barrier when treating Hispanic patients (Lipton, Losey Giachello, Mendez, & Girotti, 1998).”

“Blair et al. (2014) assessed implicit bias among experienced providers and then examined the medical records of a random sample of patients diagnosed with hypertension (stratified by ethnicity/ race).”

“Yet the essentialized workshop is in danger of conveying an exoticized, romanticized or over-traditionalized description of a particular cultural group [26].”

“More-over, not all cross-cultural communication breakdowns are damaging [39].”

“However, objective indicators of specific provider behaviors involved in these experiences have been more difficult to pin down (but see Hagiwara et al., 2016).”

“…beliefs toward stigmatized groups as found in other populations, with higher levels of implicit than explicit bias (Blair, Havaranek, et al., 2013; Galli et al., 2015; but see Peris, Teachman, & Nosek, 2008, for an example of providers showing less implicit mental health bias than nonproviders).”

“A national survey by The Commonwealth Fund (Collins et al., 2002) found that compared to Whites, Hispanics and African Americans were nearly twice as likely to report problems communicating with their providers, 14 times more likely to believe that they would receive better health care if they were of a different ethn…”

“Second, careful examinations of providers’ perceptions of actual patients showed that African American patients were perceived in more negative terms than White patients (e.g., Finucane & Carrese, 1990; van Ryn & Burke, 2000).”

“At the extreme end, some may decide to ‘ de-professionalize ’ in order to avoid perceived power balances or curtail the impact of their intrinsic privilege of which they are taught, might be oppressing their colleagues and clients of colour [32].”

“Rubineau and Kang (2012) reported significant increases in medical students’ disparate behaviors toward Black standardized patients between their first and second years of medical school.”

“For example, a recent study found that emergency department clinicians in the Australian Northern Territory perceived their Indigenous patients to have more complex health problems and that health concerns were largely because of the patient ’ s life-styles [63].”

“Several systematic reviews and meta-analyses have ap-praised the effectiveness of cross-cultural training interventions in health care environments over the past 30 years [2, 10, 12, 47 – 54].”

“This is almost inevitable if they work in a system that does not (or does not know how to) support or supervise the administering of the new knowledge [41, 42].”

“First, clinical care has been shown to have only a small impact on patient outcomes [15] and on improving population health at large [62].”

“…(e.g., shifting group affiliations or boundaries) may be especially effective for reducing implicit bias among a non-health-care sample (also see Prati, Crisp, Pratto, & Rubini, 2016, for an example of cross-categorization as a tool to garner majority support for immigrant access to health…”

“It may be that possessing generic clinical traits such as open--ness, flexibility, customer service, listening skills and compassion induce positive experiences cross-culturally as opposed to cultural knowledge [61].”

“Self-reflexivity, often touted as an anti dote to personal bias is an entirely subjective exercise with no objective quantification [43].”

“This may not accurately portray the living reality of many people from that group whose circumstances will undoubtedly be impacted by other social phenomena [27].”

“Two excellent literature reviews on the issue of implicit bias in healthcare have recently been published [16, 17].”

“The IAT has been used to measure race/ethnicity bias and has predicts behavior including physicians’ treatment recommendations for hypothetical patients.(28,34) Although the IAT has been used to measure implicit gender bias in career and educational roles,(35,36) no study has examined the association between implicit…”

“, care, concern, and respect).(48,49) Studies have shown that health care providers have similar levels of implicit racial bias as the general population, and those with more implicit bias tend to have higher verbal dominance in communication with patients and lower ratings of patient-centered care.”

“To combat this, a significant effort has been placed in developing anti-bias training with the goal of eliminating or reducing implicit biases [23, 38, 63].”

“Because interactional discrimination is woven into institutional policies and procedures, it may be especially detrimental to provider-patient relationships where stigmatizing cultural norms manifest as medical care (Zescott et al., 2016).”

“Significant evidence has shown that physicians, much like the general population, uphold implicit and explicit biases about many stigmatized groups [48].”

“Skepticism is growing about whether assigned mandatory training and refresher courses are effective tools to combat bias, meet workplace diversity goals, and teach cultural competence in health care (25).”

“Such biases, when brought to the clinical encounter, can contribute to health disparities by influencing communication practices and medical decision-making (Zestcott et al. 2016).”

“Biased care is challenging to confront, especially, as researchers note, providers are less explicit in their biases than in prior decades (Blair, Steiner, and Havranek 2011; Bonilla-Silva 2002; Zestcott et al. 2016).”

“Healthcare professionals have been shown to manifest implicit biases similar to general population levels [23], which presents a concerning influence on decisions and judgements made by clinicians.”

“Third, implicit racial biases are a key contributor to perpetuating health inequities in healthcare [18,19].”

“Several factors contribute to the presence and persistence of these disparities; however, it remains a challenge to promote awareness of bias while not assigning blame [7].”

“ginalized may perceive that health care environments are not welcoming or affordable and may be socially averse to environments that offer the highest quality care options (80).”

“Moving beyond cultural competency and including training on implicit biases is thus undeniably important (41, 42, 158, 159).”

“…instruction on how to control the use of group-based information, and the expression of bias during interaction, should enhance the audiences’ ability to change (Blair et al., 2011; Burgess et al., 2007; Teal et al., 2012; Schultz & Baker, 2017; Stone & Moskowitz, 2012; Zestcott et al., 2016).”

“Recognizing that cultural otherness may be a vehicle for transference and countertransference, it is important to remain in touch with and manage such experience (37, 38) and to work to consciously influence our egalitarian goals to reduce health disparities (39).”

“increasing awareness of implicit stereotypes and being motivated to counteract them to ensure that bias does not influence behaviour.(73,74)”

“Finally, findings based upon measures of attitudes may not be generalizable to clinical encounters, although unequivocal evidence exists that negative attitudes are conveyed in both verbal and non-verbal behaviors in the healthcare setting (Zestcott et al., 2016), and the effects on doctor-patient relationships and su…”

“Such stereotypes can negatively impact patients through increased psychosocial stress [48] and healthcare professionals’ decisions about patient care [54] with potential for suboptimal management [55].”

“Implicit bias has been shown to influence clinical decision-making and patientephysician communication, which may lead to feelings of distrust by the patient, suboptimal treatment plans, poor compliance, and potentially worse health outcomes.(24-28) Much of implicit bias is a reflection of one’s upbringing; the essent…”

“…finding in healthcare disparities research is that greater provider implicit prejudice, as assessed with the IAT, significantly predicts lower quality provider-to-patient communication in racially discordant medical interactions (Hall et al., 2015; Maina et al., 2018; Zestcott et al., 2016).”

“are subject to the same social influences that foster gender/ gender-related biases in the general population.(13) Dentists and physicians see many patients with a primary complaint of pain, yet receive relatively little formal training in pain management and rely on simple cues for pain management decisions.”

“Bias in healthcare can occur in both systematic and implicit ways based on demographic factors such as race, ethnicity, gender, sexual orientation, or socio-economic status [48, 59, 88, 137].”

“Implicit bias affects patient-provider interactions, clinical decision making, and treatment recommendations, and is a contributing factor to disparities in clinical trial recruitment.(13,15-20) Studies have found that implicit bias reduces the likelihood of offering clinical trials to racially and ethnically marginal…”

“Two important elements of successful behavioral change are (i) learning specific strategies to replace old behaviors and (ii) the opportunity to practice the strategies repeatedly over time ( 17 ).”

“Past researchers focusing on racial bias and health outcomes have predominantly done so at the individual level of analysis (for examples, see [21,22]).”

“Strategies to address identified disparities and ineq-uities include implicit bias training for staff, the implementation of culturally responsive care practices, and focused efforts to engage and support historically marginalized communities in prenatal and perinatal care (33).”

“, purposely interacting with out-group members and finding similarities between them and the self) (17,29,30).”

“Another limitation includes the omission of other psychological factors that might impact vaccine hesitancy such as health literacy, discrimination, and implicit medical biases [36].”

“Subtle bias by health care clinicians is linked to negative outcomes for racial and ethnic minority patients, particularly Black non-Hispanic and Hispanic or Latino patients [5].”

“Through analysis of notes taken during each debriefing, three themes emerged: (1) successes, (2) unanticipated pitfalls, and (3) future opportunities (Table 2).”

“Bringing awareness to one’s implicit bias alone can result in dissonance, discomfort, and defensiveness [62, 64, 65, 72], thus, interventions that raise awareness of implicit bias should be paired with strategies that help individuals to understand and reduce its impact on patient care [63, 64].”

“Discrimination can have detrimental effects on patients’ decision-making capabilities and their trust towards physicians [9, 11].”

“What is even more concerning about implicit bias is that it can also negatively impact patients’ perceptions and behaviors and create uncomfortable environments [36].”

“Systematic and narrative reviews of studies using the IAT in adult health care have demonstrated that implicit bias not only applies to race and ethnicity, but also to gender, age, and weight (Fitzgerald & Hurst, 2017; Zestcott et al., 2016).”