Implicit Bias

Implicit bias is unconscious bias that all of us carry. Sally Kohn in a TED talk talks about hate and bullying. She talks about how we need to get away from the idea that hate exists in “them” and realize that we all have hate. We are not born with hate but it is the product of our culture and that we can challenge it’s expression in ourselves and shape our culture to change.

Naturally, implicit bias exists in healthcare as it exists in the rest of the world. A video by Mahzarin Banaji, Ph.D., professor, Harvard University, and chair of human dynamics, Santa Fe Institute discusses diversity and describes bias as a “blindspot”. She wants to get away from the idea that bias is from people meaning harm. True, there are bigots. But even people with no overt conscious bias can make decisions or judgements that are biased. She describes bias as a multi-layered onion which needs to be unpeeled in a ongoing process. A study titled “Implicit bias in healthcare professionals: a systematic review” reviewed papers from 2003-2013 and found numerous studies confirming implicit bias among healthcare professionals. Most studies focus on the implicit association test described by Irene Blair and co-authors as:

“ Implicit bias cannot be measured with standard (self-report) survey questions. Instead, sophisticated instruments have been developed for this purpose, the most commonly used being the Implicit Association Test (IAT).11,12 The IAT is a computer-based measure that relies on differences in response latency to reveal implicit bias. The IAT has been used in hundreds of studies across a wide array of disciplines, including psychology, health, political science, and market research.8,9,12 The IAT operates on the principle that it is easier to make the same response (eg, a key press) to concepts that are more strongly associated, compared to concepts less strongly associated. Respondents are thus asked to sort words or pictures into one of four superordinate groups, representing two concept dimensions (eg, race: black vs white; and evaluation: good vs bad). The strength of association between concepts is determined by the respondents’ speed in sorting the items under two different conditions, with faster responses in one condition indicating a stronger association. Most white respondents, for example, are significantly faster when the “black” and “bad” items require the same response and the “white” and “good” items require another response, compared to when “black” and “good” responses are the same and “white” and “bad” responses are the same.8,9,12 The larger the performance difference, the stronger the implicit association or bias for a particular person.”

A fun exercise from Project Implicit lets you participate in studies using the IAT relating to bias and gives you feedback on if you are biased. The study I did was on bias about breastfeeding versus bottle feeding but different studies are on gender, race, and other areas. I suggest taking the race test and at least one other.

There is a great 30 minute video on Implicit Bias from the AAMC. It focuses on academic medicine but presents points that can be generalized.

The Institute for Health Improvement presents several strategies for combating implicit bias quoted below:

 

  • Stereotype replacement — Recognizing that a response is based on stereotype and consciously adjusting the response
  • Counter-stereotypic imaging — Imagining the individual as the opposite of the stereotype
  • Individuation — Seeing the person as an individual rather than a stereotype (e.g., learning about their personal history and the context that brought them to the doctor’s office or health center)
  • Perspective taking — “Putting yourself in the other person’s shoes”
  • Increasing opportunities for contact with individuals from different groups — Expanding one’s network of friends and colleagues or attending events where people of other racial and ethnic groups, gender identities, sexual orientation, and other groups may be present
  • Partnership building — Reframing the interaction with the patient as one between collaborating equals, rather than between a high-status person and a low-status person

Similarly, in Seeing Patients: Unconscious Bias in Health Care, Dr. Augustus White offers these practical tips to combat implicit bias in health care:

  • Have a basic understanding of the cultures your patients come from.
  • Don’t stereotype your patients; individuate them.
  • Understand and respect the tremendous power of unconscious bias.
  • Recognize situations that magnify stereotyping and bias.
  • Know the National Culturally and Linguistically Appropriate Services (CLAS) Standards.
  • Do a “Teach Back.” Teach Back is a method to confirm patient understanding of health care instructions that is associated with improved adherence, quality, and patient safety.95
  • Assiduously practice evidence-based medicine.

 

So although implicit bias is present in all of us, there are clear steps we can take to minimize its impact.

 

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