Introduction
Implicit biases are subconscious associations between two disparate attributes that can result in inequitable decisions. They operationalize throughout the healthcare ecosystem, impacting patients, clinicians, administrators, faculty, and staff. No individual is immune from the harmful effects of implicit biases. Unconscious bias-based discriminatory practices negatively impact patient care, medical training programs, hiring decisions, and financial award decisions and also limit workforce diversity, lead to inequitable distribution of research funding, and can impede career advancement.[1]
When implicit biases are ignored, they jeopardize delivering high-quality healthcare services.[2] A simple analogy can exemplify implicit bias in healthcare in action. Several physicians are reviewing the chest x-ray of a black man with a productive cough to determine a possible diagnosis. Another physician, not privy to the patient's demographics, joins the discussion later and quickly states that his condition most likely is cystic fibrosis. The clinicians were initially influenced by the patient's demographics and then realized the chest X-ray findings were diagnostic for late-stage cystic fibrosis, a condition more common in White populations than other races.
Explicit versus Implicit Bias
With explicit bias, individuals are aware of their negative attitudes or prejudices toward groups of people and may allow those attitudes to affect their behavior. The preference for a particular group is conscious. For example, a hospital CEO may seek a male physician to head a department due to his explicit belief that men make better leaders than women. This type of bias is fully conscious.
Implicit bias includes the subconscious feelings, attitudes, prejudices, and stereotypes an individual has developed due to prior influences and imprints throughout their lives. Individuals are unaware that subconscious perceptions, instead of facts and observations, affect their decision-making. Implicit bias and explicit bias are both problematic because they lead to discriminatory behavior and potentially suboptimal healthcare delivery.
We all hold implicit biases. Implicit bias is challenging to recognize in oneself; awareness of bias is one step toward changing one's behavior.[1] Cultural safety refers to the need for healthcare professionals to examine themselves and the potential impact of their culture, power, privilege, and personal biases on clinical interactions and healthcare delivery. This requires health providers to question their own attitudes, assumptions, stereotypes, and prejudices that may contribute to a lower quality of healthcare for some patients. Cultural safety compels healthcare professionals and organizations to engage in ongoing self-reflection and self-awareness and hold themselves accountable to provide culturally safe care, which the patients and their communities define.[3] Healthcare professionals and their healthcare organizations should work together to develop strategies to mitigate the harmful effects of bias and reduce bias-based decisions that contribute to barriers to healthcare access, healthcare disparities in patient care delivery, and lack of workforce diversity.
Stigmatized Groups and the Implicit Association Test (IAT)
Although we may consciously reject negative associations with stigmatized groups, it is virtually impossible to dissociate from a culture impregnated with such stereotypes. Patients from stigmatized groups may have one or more of these characteristics or conditions: advanced age, non-White race, HIV, disabilities, and substance or alcohol use disorders.[4][5][6] Other factors include low socioeconomic status, mental illness, non-English speaking, non-heterosexual, and obesity.[7][8][9][10] Implicit biases, by definition, occur in the absence of salient understanding or conscious awareness.[11][12] However, we can apply harm mitigation strategies to avoid the destructive implications of implicit bias. To this end, recognition is the first step.
Implicit biases in healthcare are well-characterized by studies that use Implicit Association Tests (IAT) to evaluate medical decision-making toward stigmatized groups. The IAT measures the strength of associations between concepts and evaluations or stereotypes to reveal an individual's hidden or subconscious biases (Project Implicit - implicit.harvard.edu). The IAT is a highly validated measure for implicit biases; although vulnerable to voluntary control, the tool remains a gold standard in implicit bias research.[13][14] Studies have shown that strong implicit biases hinder communication.[15] Effective patient-healthcare provider (HCP) communication is associated with reduced patient morbidity and mortality, lower healthcare costs, and decreased rates of HCP burnout.[16][17][18][16]
Implicit biases become destructive when they translate into microaggressions, defined as verbal or nonverbal cues that communicate hostile attitudes towards those from stigmatized groups.[19][20] Although often unintentional, microaggressions maintain power structures and threaten the psychological safety of patients, resulting in adverse public health implications.[21] Reducing microaggressions has been shown to reduce HCP burnout and depression.[22][23]
Implicit Bias Awareness and Training
Comprehensive implicit bias training enhances the healthcare workforce's financial value, productivity, and longevity. The recognition of implicit bias is the first step in mitigating its effects. Many states in the US require implicit bias training for employment and licensure in the healthcare profession. The ongoing engagement of implicit biases among HCPs promotes cultural safety in healthcare organizations, representing a critical consciousness that welcomes accountability in the collaborative effort to provide culturally safe healthcare as defined by patients and their communities. HCPs should be aware of their implicit biases but not blame themselves when situations out of their control arise—respect for themselves, peers, and patients is the utmost priority. Progress toward reducing implicit bias is limited without personal discomfort and vulnerability.
Currently, very limited knowledge exists on how to conduct effective implicit bias training. However, studies show that incorporating mindfulness, coalition-building, and personal retrospection alongside broader structural changes is integral in reducing the harmful effects of implicit bias in the clinical environment.[2][24][25] This article provides strategies to mitigate the impact of implicit biases among physicians, residents, physician assistants, pharmacists, registered nurses, nurse practitioners, medical assistants, medical scribes, certified registered nurse anesthetists, physical and occupational therapists, chiropractors, dentists, hygienists, licensed nutritionists, dieticians, social workers, counselors, psychologists, other allied health professionals, and healthcare trainees. Implicit bias in continuing education is required in many states.
Implicit Bias Training: State Legislation and Requirements for Healthcare Providers
California - AB241 (legislation)
Illinois - Sec. 2105-15.7 (legislation)
Michigan - R 338.7001 (legislation)
Maryland - HB28. Sec. 1-225 (legislation)
(HB28)
Minnesota - Sec. 144.1461 (legislation)
Washington - Sec. 43.70.613 (legislation)
Massachusetts - 243 CMR 2.06(a)3 (legislation)
New York - S3077 (legislation)
Pennsylvania - HB 2110. Title 63. Sec. 2102a (legislation)
Indiana - HB 1178 (legislation)
Oklahoma - HB 2730 (legislation)
South Carolina - H 4712. Session 123 (legislation)
Tennessee - SB0956 and HB0642 (legislation)
Issues of Concern
Harm-Reduction Strategies for Stigmatized Groups
Studies show that implicit bias training has little to no benefit without disaggregating the experiences of stigmatized groups and providing actionable recommendations. Here, we outline harm-reduction strategies, disaggregated based on the previously stigmatized groups (advanced age, nonwhite race, HIV positive, disabilities, substance use disorder, alcohol use disorder, low socioeconomic status, mental illness, non-English speaking, non-heterosexual, and obesity). Patients often belong to more than one group, given the intersectionality of historically disadvantaged populations in the US (e.g., being black with low socioeconomic status).
Persons of Advanced Age
Older adults are often associated with a cultural fear of death and dying.[26][27] This fear is so pervasive that older adults may even internalize that they're a burden to others.[28][21] HCPs may perceive older adults as less independent (regardless of decision-making capacity), attention-seeking, unrewarding to care for, and visually unpleasant.[29] From a mental health standpoint, physicians are less willing to treat older adults with suicidal ideation than young adults with suicidal ideation. Healthcare trainees are more comfortable interacting with older adults (compared to younger adults) with suicidal ideation.[30] Nurses with negative perceptions towards older adults provide less health education and have shorter patient interactions with older adults.[30]
Implicit bias can result in less mental health treatment for individuals of advanced age. Strategies to reduce implicit bias are created to educate clinicians that older adults deserve mental health treatment and should not be overlooked due to unconscious prejudicial negative feelings that clinicians may hold. HCPs should aim to schedule multiple health appointments in the same location and allot extra time for care for older adults. A healthcare team must ask for written permission before speaking with family members and caregivers. Healthcare teams should talk directly to patients even if a caregiver is present. Studies have shown that peer mentor support among older adults and support from those who have experienced illness facilitates patient empowerment.[31] Providing multiple forms of accessible communication ensures a complete understanding of care.[32]
Persons of Nonwhite Race
In 2021, the Center for Disease Control and Prevention (CDC) cited racism as a serious public health threat (CDC, 2021). Indeed, numerous studies have shown specific examples of race-based discrimination in healthcare settings. For example, implicit racial biases impact clinical decision-making for pain management, noninvasive cardiac testing, thrombolysis, cardiac catheterization, and cancer screening.[33][21] Pediatric nonwhite patients also face implicit racial biases from HCPs.[34][35][36] Black, Latinx, and indigenous patients are frequently met with verbal dominance from HCPs and negative experiences in the medical setting, compromising trust in HCPs and patient care quality.[37][38][39] HCPs who score highly on the IAT for black-white implicit bias are often rated poorly by black patients regarding patient-centered care.[37] Implicit biases against those of nonwhite race are particularly salient when the clinician perceives increased time pressure and ambiguity, such as in acute care or emergencies.[40][41][42] The COVID-19 pandemic exacerbated discriminatory attitudes towards HCPs of Asian and Pacific Islander descent.[43][44]
Strategies to reduce harm from implicit racial bias include finding things in common such as a shared group membership, which has been associated with a decrease in implicit racial bias.[25] Counter-stereotypical examples, such as a 36-year-old black male CEO of a Fortune 500 company, may also result in unconscious prejudice or stereotyping.[45] Expanding one's network and forming friendships with people of different healthcare professions further reduces the effect of implicit bias in the healthcare setting.[45] One may learn to recognize personal changes in non-verbal (e.g., gestures, eye contact, body distance) and paraverbal (e.g., tone, pitch, volume) communication behaviors.[46][45][21] Racialized experiences are valuable in a patient's health history; rather than ignoring these experiences, one can recognize their impact on health outcomes. HCPs may ask clinical questions to ascertain a patient's experiences with racism.[47] Examples of questions to determine racialized experiences are as follows:
"Many of our patients face racism in healthcare; is this something you've experienced before?"
"Are there any important life events that you've experienced or are currently experiencing that affect your health?"
Finally, it is essential to thank patients for sharing their stories, validate them, and acknowledge the trauma that those experiences may have caused. Knowledge of these experiences gives context to patients who lost trust in the healthcare system or may appear "non-compliant." Incorporating this practice into healthcare workflows enhances value-based care.[48]
Persons with Limited English Proficiency
The nature of implicit bias toward those with limited English proficiency stems from an inherent miscommunication in health care. For English speakers, speaking English in the work setting is comfortable; when HCPs are displaced from their comfort zone, study findings reveal that healthcare quality declines. The widespread use of medical interpreters has reduced many patient barriers, but interpreters are usually only available in large healthcare systems and are not often used during outpatient care. As a result, HCPs often translate to the best of their ability when communicating with a patient with limited English proficiency. Although faster, this method leaves wide gaps in the exchange of health information and treatment compliance.[49][50][51] As mentioned previously, patient unfamiliarity and HCP time constraints are two competing factors that widen disparities in healthcare delivery.[15]
Strategies to reduce harm due to implicit bias against those with limited English proficiency include consistently using professional medical translators in outpatient and inpatient settings. Before patient care visits, it is more effective if HCPs and staff can ensure the professional translator is available for the entire appointment.[15] Caution must be taken when caregivers or family members offer to translate for older adults, as studies show this approach compromises patient autonomy over their care.
Persons Living with HIV (PLWH)
The nature of implicit bias against persons living with HIV (PLWH) has deep roots in AIDS exceptionalism, a Western response to a lethal virus that initially disproportionately affected men who had sex with men (MSM). Fear and stigma in the early 1980s drove a public health response that worsened the alienation of PLWH. The long-term impact of this public health response is a deeply held, false narrative that PLWH are dangerous. This narrative continues to dampen opportunities for well-studied public health measures to expand prophylaxis, diagnosis, and treatment of HIV.[52]
Implicit biases and stigma associated with HIV are independent barriers to testing, adherence, and retention.[53][54] HCPs are responsible for understanding their implicit biases against PLWH and reducing their influence on providing equitable, timely HIV treatment. Unlike other groups, greater exposure to PLWH and training to reduce the stigma associated with HIV is associated with more positive experiences among patients and HCPs.[55] Examples of implicit biases or perceptions held by HCPs are as follows: PLWH are poor, have many sexual partners, could have avoided HIV if they wanted to, and are affected due to risky or irresponsible behavior.[56][57] Some studies have shown that HCPs would themselves feel ashamed if they were infected with HIV, contributing to a fear of occupational exposure to HIV.[55][58][59]
Strategies to reduce harm due to implicit biases against PLWH include actively countering the belief that HIV is avoidable without irresponsible behavior. Decades of studies have shown that PLWH is not the problem; a nationwide response that fails to protect its vulnerable population(s) has a more catastrophic outcome than the role of any individual group.[59] Furthermore, one must actively avoid the assumption that HIV runs in specific circles or neighborhoods; public health efforts to target at-risk groups do not necessarily equate to deeming which are high-risk communities.
Persons of the LGBTQIA+ Community
The stigma surrounding PLWH and its misconstrued association with the lesbian, gay, bisexual, transgender, or queer/questioning (LGBTQ) community is exacerbated by heteronormative microaggressions when receiving healthcare, conveying the message that non-heterosexual identities are abnormal, different, or inferior to the heterosexual majority.[60] Unsurprisingly, HCPs identifying as heterosexual tend to harbor these implicit associations.[61][62] Among HCPs, mental health providers are least likely, and nurses are most likely to hold implicit preferences for heterosexual patients.[61] When caring for sexual minority patients, HCPs with implicit biases express discomfort while taking patient sexual histories and advising about safe sex behaviors, compromising the quality of care for sexual minority patients.[61]
To reduce harm from implicit biases against those identifying with the LGBTQ community, it is essential to do one's diligence in understanding the terminology and how patients define themselves.[63] For example, a person whose gender differs from that assigned at birth may refer to themselves as transsexual in formal settings but may also use self-descriptors such as trans, gender non-conforming, they/them/theirs, or nonbinary. HCPs should discuss and use patient self-descriptors both in communication and medical documentation. The more HCPs deliberately create safe spaces for patients of the LGBTQ community, the easier it will be to use patient self-descriptors in HCP workflows.[64]
Although not enough to produce culturally competent care, small changes such as supporting the observance of LGBTQ Pride Day or encouraging employees to use their descriptor pronouns can have a positive impact.[65] Lastly, HCPs should be aware of this population's relevant social and health needs and provide appropriate screenings and treatment without isolating patients.[66] Examples of these needs include violence prevention, comprehensive mental health treatment, discussions on substance and alcohol use, HPV screening, food insecurity, transgender transitional care, and hormonal therapy.[67][68][69][70][71]
Persons with Substance Use Disorder, Alcohol Use Disorder, History of Incarceration, or Exposure to Police Violence
Individuals with substance and alcohol use disorders, a history of incarceration, or exposure to police violence represent a population with significant unmet social and health needs. These unmet needs are exacerbated when HCPs hold negative implicit attitudes that individuals belonging to these groups are poorly motivated, manipulative, noncompliant, and violent.[72][73][74] HCPs have been shown to unfairly judge patient "treatability" before admission to rehabilitation programs, provide lower-quality palliative care for late-stage patients with cancer and substance use disorders and display microaggressions towards pregnant patients with substance use disorders during prenatal visits.[75][76][75][77]
Studies findings reveal that medical, nursing, and pharmacy trainees rarely receive training in healthcare delivery for persons with histories of criminal legal system exposure, characterized as those with frequent police stops, arrests, and incarceration, despite this group representing 57% of men and 31% of women in the US population.[78][79][80] As more individuals are released from jails and prisons into the community, HCPs unaware of their prejudicial negative feelings toward persons with criminal legal system involvement may threaten the psychological safety of an already vulnerable, community-dwelling population.[81]
One goal of implicit bias awareness and training is to reduce the harmful effects of implicit biases toward community-dwelling persons with a history of criminal legal system involvement. To do this, we must first dismantle the idea that a person with a history of incarceration must be a bad person; some groups are more likely to be incarcerated due to race alone.[82][83] Nearly 1 in 3 black men will be imprisoned in the US.[83] Furthermore, sentence length, police brutality, and delayed parole are features encumbered by implicit bias.[84][85][86][87] Prevalent comorbidities such as severe mental illness make it virtually impossible to re-integrate into one's community without the assistance of a strong family network, healing environments, and financial resources.[88][89][90] Trauma-informed healthcare is messy, difficult, and time-consuming, but essential, given the complex health needs of this population. Individuals with a history of incarceration may present anywhere in the healthcare system. HCPs, when able, must carefully document these experiences in a protected health record to inform other HCPs and avoid re-traumatizing patients.
Persons with Low Socioeconomic Status or a History of Homelessness
It is well-documented that HCPs working in safety-net hospitals and emergency departments express disdain towards individuals with low socioeconomic status and homelessness, colloquially known as the "revolving door" of acute care utilization in this population.[91][92] HCPs may perceive hospital admissions of patients with a history of homelessness as an unnecessary use of resources that may otherwise be used for those who need them.[93][94][95] Discriminatory behavior towards those experiencing homelessness is associated with suboptimal healthcare delivery and increased hospitalizations, exacerbating the "revolving door" problem.[54][96][97][98][99][100] An explanation for discriminatory behavior among HCPs is relative exhaustion from large patient loads, administrative pushback, and competing demands in acute care environments, which tend to amplify implicit biases.[42][41]
Strategies to reduce harm from implicit biases towards individuals from this group are twofold: 1) countering burnout with mindfulness and positive coping mechanisms and 2) eliminating the belief that low socioeconomic status and/or homelessness is earned.[101][102][103][104] On the contrary, decades of research suggest that homelessness is neither incidental nor self-directed. Adverse childhood experiences and "poverty traps"—systems designed to siphon wealth from the poor to the wealthy—make it virtually impossible for those in poverty to gain enough social capital to access outpatient preventive healthcare.[105][106][107] Indeed, it may be easy to blame patients experiencing homelessness for their unmet health needs, but the habit of doing so perpetuates negative behaviors, worsens burnout, and decreases job satisfaction among HCPs.[108][109][110][111]
Persons with a Disability
Evidence exists for the presence of implicit bias toward persons with a disability (PWD) from OT/PT specialists,[112] genetic counselors,[113] healthcare researchers, and other HCPs[114][115] In the US, PWD receive suboptimal preventive care and have overall poorer health statuses compared to those without a disability, partly due to negative implicit attitudes from HCPs.[116][117][118][119] When asked about their willingness to treat PWD, HCPs feel largely unprepared to care for PWD and prefer not to treat them due to limited education on PWD's unique health needs.[120] Interestingly, studies show that current healthcare education paradoxically promotes ableist viewpoints.[121][120][122]
To reduce harm from HCP implicit biases toward PWD, HCPs should involve PWD in redesigning clinic spaces to improve accessibility. Many US outpatient clinics have incorporated features such as wheelchair-accessible doors, touchscreens, height-adjustable exam tables, and scales with handrails, but the lack of national standardization remains a limitation.[123][124][125] Additionally, not including PWD in clinic redesign has led to mediocre improvements in accessibility.[125][123] To address this issue, focus groups with PWD as team members could develop patient-centered questions to identify patients needing healthcare accommodations.[126] Long-term changes include increasing the representation of HCPs with disabilities.[127]
Persons with Mental Illness
The prevalence of mental illness is rising due to increased recognition and treatment (National Institute of Mental Health, 2022). Unfortunately, the negative stigma of having a mental illness prohibits many from seeking treatment.[21][128] The stigma surrounding mental illness has deep roots in US history; in the 19th and early 20th centuries, those with severe mental illness were held in asylums with limited access to the outside world. Deinstitutionalization, or the release of patients with serious mental illness into the community, began in the 1950s and was largely driven by financial burdens for the rising welfare state in maintaining asylums.[129][130] Unfortunately, closing asylums was not met with increased community-based mental health services, leading to the systematic stigmatization and criminalization of patients with serious mental illness.[129] This history reflects a broader message that forms implicit biases among HCPs today: that having a mental illness is shameful.[128][131][132][21]
Strategies to reduce harm due to implicit biases toward those with mental illness include speaking up when HCP colleagues dismiss a patient's mental illness or use it as a reason for lower-quality medical treatment.[133][134][135] HCPs should avoid the assumption that patients with mental illness seek to take advantage of the healthcare system.[135] Indeed, numerous studies suggest that those with mental illness are quickly labeled as "frequent flyers" in acute care settings, more likely to be dismissed when complaining of pain, despite having more complex health needs.[136]
Persons with Obesity
Those with obesity are too often misrepresented as lazy, irresponsible, and lacking self-discipline; however, ample evidence suggests that genetic factors, socioeconomic status, and environment can change a person's obesity risk.[137] The idea that individuals with obesity are inferior is perpetuated in social media, colleges, and health care.[138]
Strategies to reduce harm to those with obesity starts with using appropriate terminology. For example, HCPs must use the word obesity as a noun describing an illness and not use the word obese as an adjective to describe a patient. The proper terminology is a patient with obesity and not an obese patient. This concept also applies to electronic health documentation; for example, the HCP should record a patient's information as a "31-year-old patient with obesity" and not a "31-year-old obese patient." [139] While HCPs must provide optimal health recommendations for patients, they must recognize the genetic, environmental, and ethnic factors influencing body fat distribution. The best outcomes for weight management occur in collaboration with an interdisciplinary team of dieticians, primary care providers, and bariatric services.[140]
