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An Evaluation of Implicit Bias Training in Graduate Medical Education
... These discussions should be led by an experienced bias mitigation workshop leader. While data are lacking that cardiovascular outcomes are improved by bias mitigation training of healthcare teams 63,66,67 , there is evidence that to educate clinicians and healthcare workers in strategies to override racial and other biases may enhance the atmosphere of inclusion perceived by patients and colleagues alike, and enhance patient trust 79 . ...
Racism and racial bias influence the lives and cardiovascular health of minority individuals. That minority groups tend to have a higher burden of cardiovascular disease risk factors is often a result of racist policies that restrict opportunities to live in healthy neighbourhoods and have access to high quality education and healthcare. That minorities tend to have the worst outcomes when cardiovascular disease develops is often a result of institutional or individual racial bias encountered when they interact with the healthcare system. In this review we discuss bias, discrimination, and structural racism from the viewpoints of cardiologists in Canada, the UK and USA, and how racial bias impacts cardiovascular care. Finally, we discuss proposals to mitigate the impact of racism in our specialty.
Background:
Physicians are on the front lines of the U.S. opioid epidemic, providing care in multiple treatment settings. Very little is known, however, about whether this experience has contributed to physician burnout. This information is critical for guiding efforts to expand the relatively low level of training on opioid misuse currently available in medical education.
Methods:
We surveyed 408 board-certified physicians practicing in Ohio about their experiences working with patients who misuse opioids. We also collected quantitative measures of physicians' burnout and their level of contact with this patient population. We coded and analyzed open-ended responses and calculated a partial correlation between contact and burnout, controlling for relevant factors.
Results:
Physicians experienced three primary barriers when working with patients who misuse opioids: inadequate knowledge and training, limited external resources and partnerships in their communities, and an incomplete context for understanding problematic patient behaviors. 70% of physicians experienced negative emotions when working with this patient population and 19% mentioned experiencing burnout specifically. Contact with patients who misuse opioids was significantly and positively associated with burnout scores.
Conclusions:
Our findings underscore the need for medical educators to take a proactive approach to equipping physicians with the knowledge, skills, and resources needed to effectively work with patients who misuse opioids.
Introduction:
Discrimination based on race is a known source of stress in individuals and is a contributor to poor health outcomes in patients. However, less is known about how the experiences of racism impact the stress levels of emergency health care workers (EHCWs).
Objectives:
The goal of this study was to assess the impact that racism has on the stress of EHCWs.
Methods:
An anonymous electronic cross-sectional survey of EHCWs including attending physicians, resident physicians, advanced practice providers, nurses, and staff at three large metropolitan hospitals was administered in the summer of 2020. The survey evaluated the stress related to systemic racism and the COVID-19 pandemic in addition to the wellness measures utilized to cope with these stressors. The focus of this article is the impact of systemic racism on EHCWs.
Results:
Of the 576 eligible participants, the total number of respondents utilized for analysis was 260. Overall, 64% of participants were very concerned about the state of racism in the United States, and 30% reported moderate-high or high stress resulting from racism. When stratified by race, 46% of Black participants reported moderate-high or high stress resulting from racism, compared to 31% of other participants of color and 23% of White participants (p = 0.002).
Conclusion:
Systemic racism is a significant concern and source of stress for EHCWs. Additional research about systemic racism, its impact on medical providers, and more importantly, active strategies to reduce and ultimately eliminate it in health care is needed.
Background:
In the United States, people of color face disparities in access to health care, the quality of care received, and health outcomes. The attitudes and behaviors of health care providers have been identified as one of many factors that contribute to health disparities. Implicit attitudes are thoughts and feelings that often exist outside of conscious awareness, and thus are difficult to consciously acknowledge and control. These attitudes are often automatically activated and can influence human behavior without conscious volition.
Objectives:
We investigated the extent to which implicit racial/ethnic bias exists among health care professionals and examined the relationships between health care professionals' implicit attitudes about racial/ethnic groups and health care outcomes.
Search methods:
To identify relevant studies, we searched 10 computerized bibliographic databases and used a reference harvesting technique.
Selection criteria:
We assessed eligibility using double independent screening based on a priori inclusion criteria. We included studies if they sampled existing health care providers or those in training to become health care providers, measured and reported results on implicit racial/ethnic bias, and were written in English.
Data collection and analysis:
We included a total of 15 studies for review and then subjected them to double independent data extraction. Information extracted included the citation, purpose of the study, use of theory, study design, study site and location, sampling strategy, response rate, sample size and characteristics, measurement of relevant variables, analyses performed, and results and findings. We summarized study design characteristics, and categorized and then synthesized substantive findings.
Main results:
Almost all studies used cross-sectional designs, convenience sampling, US participants, and the Implicit Association Test to assess implicit bias. Low to moderate levels of implicit racial/ethnic bias were found among health care professionals in all but 1 study. These implicit bias scores are similar to those in the general population. Levels of implicit bias against Black, Hispanic/Latino/Latina, and dark-skinned people were relatively similar across these groups. Although some associations between implicit bias and health care outcomes were nonsignificant, results also showed that implicit bias was significantly related to patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes. Implicit attitudes were more often significantly related to patient-provider interactions and health outcomes than treatment processes.
Conclusions:
Most health care providers appear to have implicit bias in terms of positive attitudes toward Whites and negative attitudes toward people of color. Future studies need to employ more rigorous methods to examine the relationships between implicit bias and health care outcomes. Interventions targeting implicit attitudes among health care professionals are needed because implicit bias may contribute to health disparities for people of color. (Am J Public Health. Published online ahead of print October 15, 2015: e1-e17. doi:10.2105/AJPH.2015.302903).
Physician implicit (unconscious, automatic) bias has been shown to contribute to racial disparities in medical care. The impact of medical education on implicit racial bias is unknown.
To examine the association between change in student implicit racial bias towards African Americans and student reports on their experiences with 1) formal curricula related to disparities in health and health care, cultural competence, and/or minority health; 2) informal curricula including racial climate and role model behavior; and 3) the amount and favorability of interracial contact during school.
Prospective observational study involving Web-based questionnaires administered during first (2010) and last (2014) semesters of medical school.
A total of 3547 students from a stratified random sample of 49 U.S. medical schools.
Change in implicit racial attitudes as assessed by the Black-White Implicit Association Test administered during the first semester and again during the last semester of medical school.
In multivariable modeling, having completed the Black-White Implicit Association Test during medical school remained a statistically significant predictor of decreased implicit racial bias (-5.34, p ≤ 0.001: mixed effects regression with random intercept across schools). Students' self-assessed skills regarding providing care to African American patients had a borderline association with decreased implicit racial bias (-2.18, p = 0.056). Having heard negative comments from attending physicians or residents about African American patients (3.17, p = 0.026) and having had unfavorable vs. very favorable contact with African American physicians (18.79, p = 0.003) were statistically significant predictors of increased implicit racial bias.
Medical school experiences in all three domains were independently associated with change in student implicit racial attitudes. These findings are notable given that even small differences in implicit racial attitudes have been shown to affect behavior and that implicit attitudes are developed over a long period of repeated exposure and are difficult to change.
Although the medical profession strives for equal treatment of all patients, disparities in health care are prevalent. Cultural stereotypes may not be consciously endorsed, but their mere existence influences how information about an individual is processed and leads to unintended biases in decision-making, so called "implicit bias". All of society is susceptible to these biases, including physicians. Research suggests that implicit bias may contribute to health care disparities by shaping physician behavior and producing differences in medical treatment along the lines of race, ethnicity, gender or other characteristics. We review the origins of implicit bias, cite research documenting the existence of implicit bias among physicians, and describe studies that demonstrate implicit bias in clinical decision-making. We then present the bias-reducing strategies of consciously taking patients' perspectives and intentionally focusing on individual patients' information apart from their social group. We conclude that the contribution of implicit bias to health care disparities could decrease if all physicians acknowledged their susceptibility to it, and deliberately practiced perspective-taking and individuation when providing patient care. We further conclude that increasing the number of African American/Black physicians could reduce the impact of implicit bias on health care disparities because they exhibit significantly less implicit race bias.
We developed a multi-faceted prejudice habit-breaking intervention to produce long-term reductions in implicit race bias. The intervention is based on the premise that implicit bias is like a habit that can be reduced through a combination of awareness of implicit bias, concern about the effects of that bias, and the application of strategies to reduce bias. In a 12-week longitudinal study, people who received the intervention showed dramatic reductions in implicit race bias. People who were concerned about discrimination or who reported using the strategies showed the greatest reductions. The intervention also led to increases in concern about discrimination and personal awareness of bias over the duration of the study. People in the control group showed none of the above effects. Our results raise the hope of reducing persistent and unintentional forms of discrimination that arise from implicit bias.
Studies involving physicians suggest that unconscious bias may be related to clinical decision making and may predict poor patient-physician interaction. The presence of unconscious race and social class bias and its association with clinical assessments or decision making among medical students is unknown.
To estimate unconscious race and social class bias among first-year medical students and investigate its relationship with assessments made during clinical vignettes.
A secure Web-based survey was administered to 211 medical students entering classes at Johns Hopkins School of Medicine, Baltimore, Maryland, in August 2009 and August 2010. The survey included the Implicit Association Test (IAT) to assess unconscious preferences, direct questions regarding students' explicit race and social class preferences, and 8 clinical assessment vignettes focused on pain assessment, informed consent, patient reliability, and patient trust. Adjusting for student demographics, multiple logistic regression was used to determine whether responses to the vignettes were associated with unconscious race or social class preferences.
Association of scores on an established IAT for race and a novel IAT for social class with vignette responses.
Among the 202 students who completed the survey, IAT responses were consistent with an implicit preference toward white persons among 140 students (69%, 95% CI, 61%-75%). Responses were consistent with a preference toward those in the upper class among 174 students (86%, 95% CI, 80%-90%). Assessments generally did not vary by patient race or occupation, and multivariable analyses for all vignettes found no significant relationship between implicit biases and clinical assessments. Regression coefficient for the association between pain assessment and race IAT scores was -0.49 (95% CI, -1.00 to 0.03) and for social class, the coefficient was -0.04 (95% CI, -0.50 to 0.41). Adjusted odds ratios for other vignettes ranged from 0.69 to 3.03 per unit change in IAT score, but none were statistically significant. Analysis stratified by vignette patient race or class status yielded similarly negative results. Tests for interactions between patient race or class status and student IAT D scores in predicting clinical assessments were not statistically significant.
The majority of first-year medical students at a single school had IAT scores consistent with implicit preference for white persons and possibly for those in the upper class. However, overall vignette-based clinical assessments were not associated with patient race or occupation, and no association existed between implicit preferences and the assessments.
Implicit bias can impact physician-patient interactions, alter treatment recommendations, and perpetuate health disparities. Medical educators need methods for raising student awareness about the impact of bias on medical care.
Seventy-two third-year medical student volunteers participated in facilitated small group discussions about bias.
We tested an educational intervention to promote group-based reflection among medical students about implicit bias.
We assessed how the reflective discussion influenced students' identification of strategies for identifying and managing their potential biases regarding patients. 67% of the students (n = 48) identified alternate strategies at post-session. A chi-square analysis demonstrated that the distribution of these strategies changed significantly from pre-session to post-session (chi(2)(11) = 27.93, p < 0.01), including reductions in the use of internal feedback and humanism and corresponding increases in the use of reflection, debriefing and other strategies.
Group-based reflection sessions, with a provocative trigger to foster engagement, may be effective educational tools for fostering shifts in student reflection about bias in encounters and willingness to discuss potential biases with colleagues, with implications for reducing health disparities.
Studies documenting racial/ethnic disparities in health care frequently implicate physicians' unconscious biases. No study to date has measured physicians' unconscious racial bias to test whether this predicts physicians' clinical decisions.
To test whether physicians show implicit race bias and whether the magnitude of such bias predicts thrombolysis recommendations for black and white patients with acute coronary syndromes.
An internet-based tool comprising a clinical vignette of a patient presenting to the emergency department with an acute coronary syndrome, followed by a questionnaire and three Implicit Association Tests (IATs). Study invitations were e-mailed to all internal medicine and emergency medicine residents at four academic medical centers in Atlanta and Boston; 287 completed the study, met inclusion criteria, and were randomized to either a black or white vignette patient.
IAT scores (normal continuous variable) measuring physicians' implicit race preference and perceptions of cooperativeness. Physicians' attribution of symptoms to coronary artery disease for vignette patients with randomly assigned race, and their decisions about thrombolysis. Assessment of physicians' explicit racial biases by questionnaire.
Physicians reported no explicit preference for white versus black patients or differences in perceived cooperativeness. In contrast, IATs revealed implicit preference favoring white Americans (mean IAT score = 0.36, P < .001, one-sample t test) and implicit stereotypes of black Americans as less cooperative with medical procedures (mean IAT score 0.22, P < .001), and less cooperative generally (mean IAT score 0.30, P < .001). As physicians' prowhite implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis (P = .009).
This study represents the first evidence of unconscious (implicit) race bias among physicians, its dissociation from conscious (explicit) bias, and its predictive validity. Results suggest that physicians' unconscious biases may contribute to racial/ethnic disparities in use of medical procedures such as thrombolysis for myocardial infarction.
Objectives:
Disparities in diagnosis and treatment of racial minorities exist in the emergency department (ED). A better understanding of how physician implicit (unconscious) bias contributes to these disparities may help identify ways to eliminate such racial disparities. The objective of this systematic review was to examine and summarize the evidence on the association between physician implicit racial bias and clinical decision making.
Methods:
Based on PRISMA guidelines, a structured electronic literature search of PubMed, CINAHL, Scopus, and PsycINFO databases was conducted. Eligible studies were those that: 1) Included physicians; 2) Included the Implicit Association Test as a measure of implicit bias; 3) Included an assessment of physician clinical decision making; and 4) Were published in peer reviewed journals between 1998 and 2016. Articles were reviewed for inclusion by two independent investigators. Data extraction was performed by one investigator and checked for accuracy by a second investigator. Two investigators independently scored the quality of articles using a modified version of the Downs and Black Checklist.
Results:
Of the 1,154 unique articles identified in the initial search, 9 studies (n = 1,910) met inclusion criteria. Three of the 9 studies involved emergency providers including residents, attending physicians, and advanced practice providers. The majority of studies used clinical vignettes to examine clinical decision making. Studies that included EM providers had vignettes relating to treatment of acute myocardial infarction, pain, and pediatric asthma. An implicit preference favoring white people was common across providers, regardless of specialty. Two of the nine studies found evidence of a relationship between implicit bias and clinical decision making; one of these studies included EM providers. This one study found that EM and internal medicine residents who demonstrated an implicit preference for white individuals were more likely to treat white patients and not black patients with thrombolysis for myocardial infarction. Evidence from the two studies reporting a relationship between physician implicit racial bias and decision making was low in quality.
Conclusions:
The current literature indicates that although many physicians, regardless of specialty, demonstrate an implicit preference for white people, this bias does not appear to impact their clinical decision making. Further studies on the impact of implicit racial bias on racial disparities in ED treatment are needed. This article is protected by copyright. All rights reserved.
This qualitative study explored the reactions of practicing teachers when presented with an "encounter" experience that challenged them to examine their own bias in an on-line graduate course. In this case, the encounter experience was completing two Implicit Association Tests-one on race and one on skin tone. The researchers examined the discussion board entries of 302 early childhood and elementary teachers enrolled in the course and found that teacher reactions generally typified one of five categories: (a) disregard for the results, (b) disbelief in the results, (c) acceptance of the results, (d) discomfort with the results, finally, (e) distress with the results. The results are discussed in the context of helping teachers become aware of the potential impact of bias on the teaching and learning process. Pedagogical strategies to mediate the typology of reactions to the suggestion of personal bias are highlighted. The Journal of Negro Education, 2014.
: The impact of provider bias on clinical decision-making is believed to contribute to health disparities. We describe the results of an educational intervention using implicit association testing (IAT) aimed at promoting student and faculty awareness of personal bias regarding age and disability. We found that aggregate participant results trended toward a preference for young and abled people (a bias against older and disabled people). Potential strategies for handling discussion of personal bias in the educational setting are reviewed. Future research is needed regarding the impact of the physician assistant (PA) educational experience on trainees' personal biases.
This article uses two newly collected data sets to investigate the reliance by political actors on the external vetting of judicial candidates, in particular vetting conducted by the nation’s largest legal organization, the American Bar Association (ABA). Using these data, I show that minority and female nominees are more likely than whites and males to receive lower ratings, even after controlling for education, experience, and partisanship via matching. These discrepancies are important for two reasons. First, as I show, receiving poor ABA ratings is correlated with confirmation failure. Second, I demonstrate that ABA ratings do not actually predict whether judges will be “better” in terms of reversal rates. Taken together, these findings complicate the ABA’s influential role in judicial nominations, both in terms of setting up possible barriers against minority and female candidates and also in terms of its actual utility in predicting judicial performance.
Medical Education 2011: 45: 768–776
Context Non-conscious stereotyping and prejudice contribute to racial and ethnic disparities in health care. Contemporary training in cultural competence is insufficient to reduce these problems because even educated, culturally sensitive, egalitarian individuals can activate and use their biases without being aware they are doing so. However, these problems can be reduced by workshops and learning modules that focus on the psychology of non-conscious bias.
The Psychology of NON-Conscious Bias Research in social psychology shows that over time stereotypes and prejudices become invisible to those who rely on them. Automatic categorisation of an individual as a member of a social group can unconsciously trigger the thoughts (stereotypes) and feelings (prejudices) associated with that group, even if these reactions are explicitly denied and rejected. This implies that, when activated, implicit negative attitudes and stereotypes shape how medical professionals evaluate and interact with minority group patients. This creates differential diagnosis and treatment, makes minority group patients uncomfortable and discourages them from seeking or complying with treatment.
Pitfalls in Cultural Competence Training Cultural competence training involves teaching students to use race and ethnicity to diagnose and treat minority group patients, but to avoid stereotyping them by over-generalising cultural knowledge to individuals. However, the Culturally and Linguistically Appropriate Services (CLAS) standards do not specify how these goals should be accomplished and psychological research shows that common approaches like stereotype suppression are ineffective for reducing non-conscious bias. To effectively address bias in health care, training in cultural competence should incorporate research on the psychology of non-conscious stereotyping and prejudice.
Training in Implicit Bias Enhances Cultural Competence Workshops or other learning modules that help medical professionals learn about non-conscious processes can provide them with skills that reduce bias when they interact with minority group patients. Examples of such skills in action include automatically activating egalitarian goals, looking for common identities and counter-stereotypical information, and taking the perspective of the minority group patient.
This paper explores the role of racial bias toward Blacks in interracial relations, and in racial disparities in health care in the United States. Our analyses of these issues focuses primarily on studies of prejudice published in the past 10 years and on health disparity research published since the report of the US Institute of Medicine (IOM) Panel on Racial and Ethnic Disparities in Health Care in 2003. Recent social psychological research reveals that racial biases occur implicitly, without intention or awareness, as well as explicitly, and these implicit biases have implications for understanding how interracial interactions frequently produce mistrust. We further illustrate how this perspective can illuminate and integrate findings from research on disparities and biases in health care, addressing the orientations of both providers and patients. We conclude by considering future directions for research and intervention.
Recent reports speculate that provider implicit attitudes about race may contribute to racial/ethnic health care disparities.
We hypothesized that implicit racial bias exists among pediatricians, implicit and explicit measures would differ and implicit measures may be related to quality of care.
A single-session, Web survey of academic pediatricians in an urban university measured implicit racial attitudes and stereotypes using a measure of implicit social cognition, the Implicit Association Test (IAT). Explicit (overt) attitudes were measured by self-report. Case vignettes were used to assess quality of care.
We found an implicit preference for European Americans relative to African Americans, which was weaker than implicit measures for others in society (mean IAT score = 0.18; P = 0.01; Cohen's d = 0.41). Physicians held an implicit association between European Americans relative to African Americans and the concept of "compliant patient" (mean IAT score = 0.25; P = 0.001; Cohen's d = 0.60) and for African Americans relative to European Americans and the concept of "preferred medical care" (mean IAT score =-0.21; P = 0.001; Cohen's d = 0.64). Medical care differed by patient race in 1 of 4 case vignettes. No significant relationship was found between implicit and explicit measures, or implicit measures and treatment recommendations.
Pediatricians held less implicit race bias compared with other MDs and others in society. Among pediatricians we found evidence of a moderate implicit "perceived patient compliance and race" stereotype. Further research is needed to explore whether physician implicit attitudes and stereotypes about race predict quality of care.
What the NBA can teach us about eliminating racial bias, The Washington Post
- C Ingraham
Ingraham, C. (2014). What the NBA can teach us about eliminating racial bias, The Washington Post. Available at:
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as/?noredirect=on&utm_term=.d1d5656ce880. (Accessed: January 31, 2019).
Written in Black & White: Exploring Confirmation Bias in Racialized Perceptions of Writing Skills
- A N Reeves
Reeves, A.N. (2014). Written in Black & White: Exploring Confirmation Bias in Racialized Perceptions of Writing
Skills', Yellow Paper Series.