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].”

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

“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).”

“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).”

“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).”

“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,…”

“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).”

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

“…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…”

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

“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.”

“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].”

“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).”

“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…”

“…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…”

“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].”

“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 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).”

“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].”

“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).”

“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).”

“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.”

“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).”

“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).”

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

“…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.”

“…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].”

“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).”

“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…”

“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).”

“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].”

“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.”

“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].”

“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].”

“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…”