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Clinicians' Implicit Ethnic/Racial Bias and Perceptions of Care Among Black and Latino Patients
Open accessAbstract
PURPOSE: We investigated whether clinicians' explicit and implicit ethnic/racial bias is related to black and Latino patients' perceptions of their care in established clinical relationships. METHODS: We administered a telephone survey to 2,908 patients, stratified by ethnicity/race, and randomly selected from the patient panels of 134 clinicians who had previously completed tests of explicit and implicit ethnic/racial bias. Patients completed the Primary Care Assessment Survey, which addressed their clinicians' interpersonal treatment, communication, trust, and contextual knowledge. We created a composite measure of patient-centered care from the 4 subscales. RESULTS: Levels of explicit bias were low among clinicians and unrelated to patients' perceptions. Levels of implicit bias varied among clinicians, and those with greater implicit bias were rated lower in patient-centered care by their black patients as compared with a reference group of white patients (P = .04). Latino patients gave the clinicians lower ratings than did other groups (P <.0001), and this did not depend on the clinicians' implicit bias (P = .98). CONCLUSIONS: This is among the first studies to investigate clinicians' implicit bias and communication processes in ongoing clinical relationships. Our findings suggest that clinicians' implicit bias may jeopardize their clinical relationships with black patients, which could have negative effects on other care processes. As such, this finding supports the Institute of Medicine's suggestion that clinician bias may contribute to health disparities. Latinos' overall greater concerns about their clinicians appear to be based on aspects of care other than clinician bias.
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“Three studies found a significant correlation between high levels of physicians’ implicit bias against blacks on IAT scores and interaction that was negatively rated by black patients [23, 24, 44]”
From Implicit bias in healthcare professionals: a systematic review (2017) · cites this paper as [44]
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“In some studies, the attitudes of patients towards healthcare professionals were recorded and used to evaluate clinical interaction [23, 24, 44].”
From Implicit bias in healthcare professionals: a systematic review (2017) · cites this paper as [44]
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“As our review shows, there is clearer evidence for a relationship between implicit bias and negative effects on clinical interaction [23, 24, 44].”
From Implicit bias in healthcare professionals: a systematic review (2017) · cites this paper as [44]
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“Four studies included participants who were not trained physicians or nurses and failed to report separate results for these categories of participants [42, 44, 49, 50].”
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“Both racial and weight-related biases are documented to influence healthcare interactions (18–20).”
From Regional trends and disparities in newer GLP1 receptor agonist initiation among real‐world adult patients eligible for obesity treatment (2025) · cites this paper as [20]
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“These biases can impact how patients communicate with healthcare providers and their willingness to seek treatment for obesity, potentially leading to underutilization of effective treatments like newer AOM (18–20).”
From Regional trends and disparities in newer GLP1 receptor agonist initiation among real‐world adult patients eligible for obesity treatment (2025) · cites this paper as [20]
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Color‐Blind and Multicultural Strategies in Medical Settings
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Dahlen, H. M., McCullough, J. M., Fertig, A. R., Dowd, B. E., & Riley, W. (2017) · Health Affairs · doi:10.1377/hlthaff.2016.0910 · Cited by 17
Association of Racial and Socioeconomic Diversity With Implicit Bias in Acute Care Surgery
Zebib, L., Strong, B. L., Moore, G., Ruiz, G., Rattan, R., & Zakrison, T. L. (2019) · JAMA Surgery · doi:10.1001/jamasurg.2018.5855 · Cited by 17
Licciardone, J. C., Ganta, S., Goehring, L., Wallace, K., & Pu, R. (2022) · JAMA Network Open · doi:10.1001/jamanetworkopen.2022.16270 · Cited by 16
Shared Goal Setting in Team-Based Geriatric Oncology
Magnuson, A. M., Wallace, J. A., Canin, B. E., Chow, S. L.-M., Dale, W., Mohile, S. G., & Hamel, L. M. (2016) · Journal of Oncology Practice · doi:10.1200/jop.2016.013623 · Cited by 16
Adegboyega, A., Aroh, A. C., Adeyimika, D., Williams, L. B., & Mudd‐Martin, G. (2023) · Journal of Racial and Ethnic Health Disparities · doi:10.1007/s40615-023-01617-2 · Cited by 16
“The results of several large studies in which clinician bias and patient experiences were examined indicate that providers use a harsher tone with and provide less time for patients who are Black to ask questions, often as a result of implicit racial bias [31–33].”
Hu, X. Y., Chehal, P. K., Kaplan, C. M., Krukowski, R. A., Lan, R., Stepanski, E. J., Schwartzberg, L. S., Vidal, G. A., & Graetz, I. (2021) · JAMA Network Open · doi:10.1001/jamanetworkopen.2021.12076 · Cited by 15
Astroth, K. S., Jenkins, S. H., Kerber, C. S., & Woith, W. M. (2018) · Nursing Forum · doi:10.1111/nuf.12276 · Cited by 15
Burgess, D. J., Hardeman, R., Burke, S., Cunningham, B. A., Dovidio, J., Nelson, D. B., Perry, S. P., Phelan, S. M., Yeazel, M., Herrin, J., et al. (2018) · Journal of Health Politics Policy and Law · doi:10.1215/03616878-7206755 · Cited by 13
Lowe, C. L., Beach, M. C., & ROTER, D. L. (2020) · Journal of Genetic Counseling · doi:10.1002/jgc4.1243 · Cited by 15
“Other studies have found similar levels of implicit bias held for both Black and Latinx people using separate IATs to evaluate both Black:White and Hispanic:White preferences among healthcare providers (Blair et al., 2013) and community members (Blair, Judd, Havranek, & Steiner, 2010; Blair et al.”
BackgroundKiernan, K., Dodge, S. E., Kwaku, K. F., Jackson, L. R., & Zeitler, E. P. (2022) · Heart Rhythm O2 · doi:10.1016/j.hroo.2022.09.003 · Cited by 12
“001); however, the ratings did not correlate with the clinicians’ implicit bias scores.(65) Although not specific to cardiology, biases within the patient–physician relationship like these may impact physician referral patterns and patients’ decisions.”
ResultJu, M. R., Wang, S. C., Mansour, J. C., Polanco, P. M., Yopp, A. C., Zeh, H. J., & Porembka, M. R. (2022) · JCO Oncology Practice · doi:10.1200/op.21.00431 · Cited by 14
“An estimated two thirds of clinicians have implicit bias against Hispanic people, with 51%havingmoderate to strong bias.(34) Oncologist implicit bias predicts less patient confidence in the treatments recommended and lower likelihood of completing therapies.”
BackgroundA mixed methods study of perceptions of bias among neonatal intensive care unit staff
Fraiman, Y. S., Cheston, C. C., Morales, D., Leeman, K. T., & Hansen, A. R. (2022) · Pediatric Research · doi:10.1038/s41390-022-02217-2 · Cited by 14
Contralateral prophylactic mastectomy and implications for breast reconstruction
Santosa, K. B., Oliver, J. D., & Momoh, A. O. (2021) · Gland Surgery · doi:10.21037/gs.2020.03.15 · Cited by 14
“Whatever reasons are driving these health disparities in CPM, it is important to note that racial minorities, patients from lower socioeconomic classes, and patients with less education encounter more barriers to healthcare, and experience different, often inferior, communication with their physicians (32,36-38).”
BackgroundHow to Embrace Antiracism as a US Plastic Surgeon: Definitions, Principles, and Practice
Bradford, P. S., DeGeorge, B. R., Williams, S. H., & Butler, P. D. (2020) · Plastic & Reconstructive Surgery Global Open · doi:10.1097/gox.0000000000003185 · Cited by 14
“(3) Structural—the racism created by institutions that amplifies different treatment typically for people of color and indigenous people.”
BackgroundAssociation Between English Proficiency and Timing of Analgesia Administration After Surgery
Plancarte, C. A., Hametz, P. A., & Southern, W. N. (2021) · Hospital Pediatrics · doi:10.1542/hpeds.2020-005766 · Cited by 14
Parent Perspectives on Exclusive Enteral Nutrition for the Treatment of Pediatric Crohn Disease
Mehta, P., Pan, Z., Furuta, G. T., Kim, D. Y., & de Zoeten, E. F. (2020) · Journal of Pediatric Gastroenterology and Nutrition · doi:10.1097/mpg.0000000000002847 · Cited by 13
“28 10 (19) 18 (29) 26 (49) 31 (50) 17 (32) 13 (21)”
Racial and Ethnic Disparities in Acute Coronary Syndrome: A Nationally Representative Sample
Srivastava, G., Alhuneafat, L., Jabri, A., Omar, Y. A., Abdolall, A. K., Beleny, D. O., Cunningham, C., Al‐Abdouh, A., Mhanna, M., Siraj, A., et al. (2022) · Journal of the Society for Cardiovascular Angiography & Interventions · doi:10.1016/j.jscai.2022.100451 · Cited by 13
Ranney, R. M., Maguen, S., Bernhard, P. A., Holder, N. D., Vogt, D. S., Blosnich, J. R., & Schneiderman, A. (2023) · Medical Care · doi:10.1097/mlr.0000000000001793 · Cited by 13
Metcalf, D., & Zhang, D. “. (2023) · Journal of Stroke and Cerebrovascular Diseases · doi:10.1016/j.jstrokecerebrovasdis.2023.107393 · Cited by 13
Klein, E. Y., Saheed, M. O., Irvin, N. A., Balhara, K. S., Badaki‐Makun, O., Poleon, S., Kelen, G. D., Cosgrove, S. E., & Hinson, J. S. (2024) · Annals of Emergency Medicine · doi:10.1016/j.annemergmed.2023.12.003 · Cited by 16
Mahabamunuge, J., & Seifer, D. B. (2024) · Journal of Clinical Medicine · doi:10.3390/jcm13082224 · Cited by 13
“Patients are aware and concerned about differential or inferior treatment, as studies show Black and Hispanic women face more difficulty finding a fertility physician with whom they feel comfortable, thus leading to delays in workup and treatment [27,28].”
BackgroundPsychosocial stress and cardiovascular disease
Raggi, P., Quyyumi, A. A., Henein, M. Y., & Vaccarino, V. (2025) · American Journal of Preventive Cardiology · doi:10.1016/j.ajpc.2025.100968 · Cited by 16
“The physician-patient interaction may be less cordial or be biased by stereotypes if it occurs between people of different races, especially if patients are of Black race [54,55].”
The Black Church: Promoting Health, Fighting Disparities
Rowland, M. L., & Isaac, E. P. (2014) · New Directions for Adult and Continuing Education · doi:10.1002/ace.20091 · Cited by 13
Effectiveness of gaming in creating cultural awareness
Ong-Flaherty, C., Valencia‐Garcia, D., Martinez, D. A., Borges, W. J., & Summers, L. O. (2017) · Learning Culture and Social Interaction · doi:10.1016/j.lcsi.2016.12.005 · Cited by 16
Kim, H., Price, R. A., Bunker, J., Bradley, M. A., Schlang, D., Bandini, J. I., & Teno, J. M. (2020) · Journal of Palliative Medicine · doi:10.1089/jpm.2020.0627 · Cited by 12
“27 Our study extends existing literature by showing that the disparities experienced by blacks and Latinos are also consistently observed in Asian populations, and that unequal provisions of information and in-adequate caregiver support based on the patient’s racial background persist in…”
Facilitators and Barriers to Implementing SBIRT in Primary Care in Integrated Health Care Settings
Kulchak, A., Martín, C. F., Price, D. W., Beck, A. L., Backer, T. E., & Dearing, J. W. (2014) · Cited by 12
Self-citationLoomba, L. A., Bonanno, S., Arellano, D., Crossen, S. S., & Glaser, N. S. (2023) · JMIR Diabetes · doi:10.2196/45890 · Cited by 12
“Additional barriers faced by historically marginalized racial and ethnic groups can include difficulties with access to care, provider bias, and socioeconomic disparities [14-16].”
BackgroundHagiwara, N., Mezuk, B. R., Lafata, J. E., Vrana, S. R., & Fetters, M. D. (2018) · BMJ Open · doi:10.1136/bmjopen-2018-022623 · Cited by 13
Recent patterns of vagal nerve stimulator use in the United States: Is there a racial disparity?
Fox, J., Lekoubou, A., Bishu, K. G., & Ovbiagele, B. (2019) · Epilepsia · doi:10.1111/epi.14695 · Cited by 10
Khidir, H., McWilliams, J. M., O’Malley, A. J., Zaborski, L. B., Landon, B. E., & Smulowitz, P. B. (2021) · JAMA Network Open · doi:10.1001/jamanetworkopen.2021.25193 · Cited by 12
The role of stereotypical information on medical judgements for black and white patients
Madeira, F., Costa‐Lopes, R., Bú, E. A. D., & Marinho, R. T. (2022) · PLoS ONE · doi:10.1371/journal.pone.0268888 · Cited by 11
Metadata
- Authors
- Blair, I. V., Steiner, J. F., Fairclough, D. L., Hanratty, R., Price, D. W., Hirsh, H. K., Wright, L. A., Bronsert, M., Karimkhani, E., Magid, D. J., & Havranek, E. P.
- Affiliations
- University of Colorado Boulder (US)
- Kaiser Permanente (US)
- University of Colorado Denver (US)
- Denver Health Medical Center (US)
- ORCID
- Venue
- The Annals of Family Medicine
- Publisher
- Annals of Family Medicine
- Published
- 2013-01-01
- Volume
- 11
- Issue
- 1
- Pages
- 43-52
- ISSN
- 1544-1709 (ISSN-L)
- 1544-1717
- PMC
- PMC3596038
- OpenAlex
- W2137471755
- Cited by
- 409
- References
- 67
- Citations by year
- 2026: 15 · 2025: 27 · 2024: 34 · 2023: 39 · 2022: 43 · 2021: 56 · 2020: 40 · 2019: 38 · 2018: 26 · 2017: 30 · 2016: 24 · 2015: 16 · 2014: 14 · 2013: 7
- FWCI
- 36.64
- Type
- journal article
- Language
- en
- Open access
- diamond
- doi.org
- Locations
- The Annals of Family Medicine (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Kaiser Permanente
- University of Colorado Boulder
- University of Colorado Denver
- National Heart, Lung, and Blood Institute (HL088198, R01HL088198)
- Topics
- Health Sciences › Health Professions › General Health Professions › Patient-Provider Communication in Healthcare
- Social Sciences › Sociology and Political Science › Racial and Ethnic Identity Research
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Cultural Competency in Health Care
- Keywords
- implicit bias, explicit bias, patient-centered care, patient perception of care, Black patients, Hispanic patients, clinician-patient relationship, health disparities, racial disparities in health care, provider communication, clinician trust
- MeSH terms
- Adolescent, Adult, Black or African American, Colorado, Female, Hispanic or Latino, Humans, Male, Middle Aged, Physician-Patient Relations, Models, Statistical, Patient Satisfaction, Patient-Centered Care, Health Care Surveys, Cultural Competency, Healthcare Disparities, Young Adult, Physicians, Primary Care, Racism
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