Clinicians are more likely to consider black patients less compliant and less cooperative in medical settings than white patients.¹

Clinicians are more likely to prescribe narcotic pain medication to white patients versus black patients with the same complaint and pain scale, even in the pediatric population.

Black women are three times more likely to die from pregnancy-related deaths compared with their white counterparts, and black and Native American infants are twice as likely to die.²

While health inequities—the differences in health that are influenced by social, economic, and environmental inequities—can exist across many dimensions such as gender, gender identity, sexual orientation, age, and disability status, it is racial health inequities that have been the most obstinate and profound.³

Both structural and interpersonal discrimination are involved in racially disparate health inequities. Unconscious bias, a type of interpersonal discrimination, on the part of health care practitioners has been implicated as one of the factors.

What Is Unconscious Bias?

Unconscious bias is a psychological process that is instinctual and necessary for human survival. However, structural racism and other systems of oppression can influence unconscious biases in detrimental ways.

Unconscious bias is a person’s tendency to associate a group or category attribute, such as being black, with a negative evaluation (unconscious prejudice) or another category attribute, such as being violent (unconscious stereotype).⁴

Clinicians have been shown to display low levels of conscious (explicit) bias but high levels of unconscious (implicit) bias toward marginalized groups—the same levels of unconscious bias as the wider population.⁵

Research suggests that unconscious bias on the part of clinicians contributes to racial health inequities by influencing communication and decision making in clinical encounters. Specifically, the unconscious biases that should be of concern to clinicians are the biases that operate to the detriment of those who are already made vulnerable due to structural racism.

In response, health care organizations have been calling for trainings in unconscious bias for their clinicians to help clinicians recognize their own biases and to equip them with practical bias mitigation strategies with the goal of mobilizing for health equity.

The current literature suggests that there are two key elements for success for unconscious bias trainings: 1) instructors need to translate the abstract, theoretical concepts and processes that support the effectiveness of the strategies into practical, concrete clinical skills; and 2) instructors need to develop active learning exercises that allow participants the opportunity to practice the skills before they use them in the clinical setting.⁶

Integrating unconscious bias training into existing health care training has been shown to be necessary to address the role that clinicians may play in creating disparate care for marginalized patients.⁷

The utility of unconscious bias trainings is that they can help the unconscious become conscious. Participants are encouraged to 1) recognize and accept that they all have bias, 2) develop the capacity to use a flashlight on themselves, 3) explore awkwardness and discomfort, and 4) get (and accept) feedback.⁸

There are more advanced bias mitigation strategies like stereotype replacement, counter-stereotype imaging, perspective taking, individuating, and increased opportunities for contact that require consistent practice and intentionality on the part of clinicians.⁹

It is critical to remember that unconscious bias trainings, especially “one-and-done” trainings, are an inadequate solution to eradicating health inequities. These trainings should be only one piece of a larger, multipronged strategy to addressing bias and racism in health care.

Health care organizations and institutions must consider how bias and discrimination may show up not only in clinical care but in their practices and policies. Effective strategies should include not only implementing structured processes in clinical care but in the hiring and retention of a diverse health care workforce that can competently care for an increasingly diverse patient population. These strategies include structured interviewing processes, structured evaluation tools, and routine analysis of disaggregated data from organizational climate and culture surveys.

While counseling and clinical interventions have the smallest impact on health outcomes and socioeconomic factors, like poverty and inequality, have the largest, it is important to be mindful that unconscious bias in the interpersonal encounter between a clinician and patient can exacerbate preexisting health inequities due mostly to structural factors.

As clinicians, we should recognize that we have power in the clinician-patient relationship—the ability to influence our patient’s actions, beliefs, and decisions. We need to use this power wisely and safely.

In the future, we will delve into many of these issues in this space, identifying ways to recognize equity issues and, as crucially, acting to address them. I look forward to a vigorous, productive, and enlightening conversation. 

“The Equity Equation” is curated by Dara Kass, MD, and Uché Blackstock, MD.

Dr. Blackstock is CEO and founder of Advancing Health Equity.

References

1. Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health. 2015;105(12):e60-e76.
2. Howell EA. Reducing disparities in severe maternal morbidity and mortality. Clin Obstet Gynecol. 2018;61(2):387-399.
3. The State of Health Disparities in the United States. In: National Academies of Sciences, Engineering, and Medicine; Weinstein J, Geller A, Negussie Y, et al, eds. Communities in Action: Pathways to Health Equity. Washington, DC: National Academies Press; 2017.
4. Holroyd J, Sweetman J. The Heterogeneity of Implicit Bias. In: Brownstein M, Saul J, eds. Implicit Bias and Philosophy, Volume 1: Metaphysics and Epistemology 1. Oxford, UK: Oxford University Press; 2016:80-103.
5. Dehon E, Weiss N, Jones J, et al. A systematic review of the impact of physician implicit racial bias on clinical decision making. Acad Emerg Med. 2017;24(8):895-904.
6. Zestcott CA, Blair IV, Stone J. Examining the presence, consequences, and reduction of implicit bias in health care: a narrative review. Group Process Intergroup Relat. 2016;19(4):528-542.
7. Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. J Gen Intern Med. 2013;28(11):1504-1510.
8. Ross H. Everyday bias: further explorations into how the unconscious mind shapes our world at work. Cook Ross web site.. Accessed Oct. 17, 2019.
9. Devine PG, Forscher PS, Austin AJ, et al. Long-term reduction in implicit race bias: a prejudice habit-breaking intervention. J Exp Soc Psychol. 2012;48(6):1267-1278.