What is unconscious bias in health care?

‍A bias is a form of positive or negative prejudice towards a group of people. Bias can be conscious, or explicit, meaning that we are aware of it. Or it can be implicit, or unconscious, and we may not be aware of how it can influence our judgment—even if we think we treat all people equally.

‍As a health care provider, it’s especially important to be aware of the implicit biases you may hold, because they can have serious, albeit unintended, consequences.

‍‍What is implicit bias?

‍Biases result from the way that we store and organize information internally. They’re a reflection of our experiences, our perspective, and our social circles.

‍Implicit bias develops at an early age and it’s likely to have affected our behavior at one point or another. However, an implicit bias does not necessarily come from a bad place, it comes from oversaturation in a society that prioritizes generalizations over nuance.

One example is a parent who unconsciously associates their daughter with pink. On its face, this bias doesn’t seem harmful. But these kinds of internalized attitudes can become a problem when they perpetuate stereotypes: girls wear pink, they should be feminine and soft; boys do not wear pink because they should be strong and masculine.

The parent may even discourage their daughter from traditionally “masculine” career paths, or push superficial beauty standards.

BIPOC, LGBQ, and TGNC communities are most widely affected by implicit bias within the health care system.

This form of unconscious discrimination also impacts:  

• Women
• People over 65
• Immigrants
• People with mental health and/or substance use issues
• People who are overweight
• People with disabilities
• People who live below the Federal Poverty Level and/or use Medicaid
• People who do not speak English as their primary language
• People who lack health literacy
• The many intersections of these identities

‍How implicit bias contributes to health disparities.

‍Our individual biases operate within larger social, cultural, and economic structures whose biased policies and practices perpetuate systemic racism, sexism, and other forms of discrimination. Explicit bias contributes to health disparities in the U.S., but implicit bias plays a role, too.

However, it’s important to note that we believe that the majority of health care providers strive to deliver quality, respectful care, but that doesn’t always translate to actually providing unbiased care.

‍Biases can cause automatic reactions, especially when we’re busy, overworked, or tired.

Read below for a few examples of health disparities linked to implicit bias:

‍Unequal treatment.

• One study showed that Black patients with heart disease received lower quality and more conservative treatments, and were less likely to undergo coronary bypass operations than white patients. They were also discharged too early from the hospital following surgery.
• Clinicians are less likely to distribute pain medication to Black and Latine/x adults than to white patients for acute and chronic pain.
• Women are more likely to experience medical gaslighting, and less likely to be diagnosed with COPD than men, based on medical histories and examinations.
• Ederly patients are less likely to be treated for depression and suicidal thoughts, despite the high rates of suicide among people age 85 and over.

‍Reduced retention rates.

• Medical students and health care providers are likely to underestimate their implicit biases towards LGBTQ+ patients, especially when tired or rushed, causing their decisions to be influenced by stereotypes or internalized discriminatory attitudes.
• LGBTQ+ people who fear stigma because of past experiences will avoid seeking care. With issues like depression, suicide, and substance-use already disproportionately affecting LGBTQ+ communities, forgoing treatment compounds these health disparities.

Negative emotional impact.

• Patients can internalize a provider’s racial bias and lose confidence in their doctor-patient relationship, which can in turn affect their treatment adherence, attendance to follow-up appointments, and overall communication.

How implicit bias affects clinicians.

‍Bias-driven discriminatory practices and policies don’t just affect patients—they have widespread effects on health care providers, including:

• Lack of diversity among the health care workforce and medical students.
• An overrepresentation of female doctors in certain fields like dermatology, and an underrepresentation in other fields like cardiology.
• Inequitable distribution of research funding, and lack of diversity in clinical trials, which leads to research that focuses on and benefits white, cisgender, heterosexual, male patients.

Implicit bias is not an excuse for continued discrimination.

While it’s true that we all have implicit biases, it doesn’t mean that these internalized attitudes should be allowed to perpetuate stereotypes.

The first step is acknowledging that each one of us has bias and therefore can do better.

And those of us who are in positions of power, like clinicians, have a unique responsibility to constantly question whether they're empowering or disempowering people in their charge because of bias.

And yet, physicians more often write that Black patients are “noncompliant” in their medical notes, and clinicians have been reported to change their behaviors and body language depending on their patient.

To stop the cycle of biases informing health outcomes, it requires systemic and individual changes. As a clinician, here are a few things you can do to mitigate bias at work:

• Speak out if you witness bias. Be an active bystander. If you see discrimination occuring in a clinical setting, it’s important to flag it.
• Use person-first language. These are phrases that put the individual before their condition and prevent them from losing their identity. For example, say “person with a substance use disorder” instead of “addict.”
• Advocate for recruiting and hiring diverse health care staff. If you are in position to mentor, sponsor, or recommend new hires, providing this kind of support can make a huge difference to individuals from underrepresented backgrounds receiving care at your organization.

How to begin addressing your own unconscious biases.

Last, but not least, it’s crucial to examine and unpack your own implicit biases. This is a process of self-reflection that you can engage in before, during, and after patient interactions.

• Think about your own biases. What are they? Who are they focused on? When are they most likely to influence your decisions (when you’re tired, overworked, etc.)?
• Become an ally. For clinicians exploring power, privilege, health equity, and community-centered allyship, download Violet’s Allyship Toolkit.
• Look at things from the patient’s perspective. What is their day like, beyond the symptoms they may be experiencing? What did it take for them to get to your practice today—did they drive or take public transportation? What is their support system like?
• Broaden your social circle. Make a mindful choice to talk to people who have backgrounds that are different from your own, both professionally within the health care system and in your day-to-day life outside of work.

Addressing implicit bias is a key part of creating a more equitable health care system. To learn more about Violet and our cultural competence upskilling platform, request a demo today.