Implicit Bias: Evolution of a Powerful Idea.

PurposeImplicit bias is the application of an unconscious attitude or belief; in the clinical setting, a provider’s perception of a patient, based upon perceived race or ethnicity, is hypothesized to affect clinical decisions, provider-patient interactions and patient health. The purpose of this paper is to provide a brief synopsis of and critique the relevant works over the past 15 years while highlighting the strengths of this body of literature.Design/methodology/approachA MEDLINE search, from 2000 to 2015, using the terms “implicit bias,” “unconscious bias” and “aversive racism” was performed. US-based studies investigating the effect of racial or ethnic implicit bias on the clinical encounter or patient outcomes were assessed. In total, 15 articles were eligible for review.FindingsDespite well-reasoned hypotheses that racial/ethnic bias negatively affects patient care, this review found mixed results. Largely, studies showed that US-providers hold an anti-black implicit bias negatively affecting patient-provider communication and patient satisfaction. But studies have not shown that this bias consistently negatively affects diagnosis and treatment regimens of black patients in comparison to white patients. There is a significant dearth of implicit bias literature addressing the care of other patient groups of color.Originality/valueThis review of the recent literature challenges the black-white dichotomy of most implicit bias research in the USA and highlights the lack of patient-oriented outcome research in this field. Furthermore, it demonstrates that regardless of the effect of implicit bias on patient outcomes, focus on eliminating implicit bias is insufficient to improve the health of people of color.

ContextStudies 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.ObjectiveTo 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.Design, Setting, and ParticipantsAn 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.Main Outcome MeasuresIAT 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.ResultsPhysicians 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).ConclusionsThis 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.

When people hold implicit biases against a group they typically engage in discriminatory behaviour against group members. In the context of the implicit racial bias of ‘White' against ‘Black' people, it has been shown several times that implicit bias is reduced after a short exposure of embodiment in a dark-skinned body in virtual reality. Embodiment usually leads to the illusion of ownership over the virtual body, irrespective of its skin colour. Previous studies have been carried out in virtual scenarios that are affectively neutral or positive. Here, we show that when the scenario is affectively negative the illusion of body ownership of White participants over a White body is lessened, and implicit bias is higher for White participants in a Black virtual body. The study was carried out with 92 White female participants, in a between-groups design with two factors: BodyType (their virtual body was White or Black) and a surrounding Crowd was Negative, Neutral or Positive towards the participant. We argue that negative affect prevents the formation of new positive associations with Black and distress leads to disownership of the virtual body. Although virtual reality is often thought of as an ‘empathy machine' our results suggest caution, that this may not be universally the case.

A call for grounding implicit bias training in clinical and translational frameworks

BackgroundCognitive and implicit biases negatively impact clinicians’ decision-making capacity and can have devastating consequences for safe, effective, and equitable healthcare provision. Internationally, health care clinicians play a critical role in identifying and overcoming these biases. To be workforce ready, it is important that educators proactively prepare all pre-registration healthcare students for real world practice. However, it is unknown how and to what extent health professional educators incorporate bias training into curricula. To address this gap, this scoping review aims to explore what approaches to teaching cognitive and implicit bias, for entry to practice students, have been studied, and what are the evidence gaps that remain.MethodsThis scoping review was guided by the Joanna Briggs Institute (JBI) methodology. Databases were searched in May 2022 and included CINAHL, Cochrane, JBI, Medline, ERIC, Embase, and PsycINFO. The Population, Concept and Context framework was used to guide keyword and index terms used for search criteria and data extraction by two independent reviewers. Quantitative and qualitative studies published in English exploring pedagogical approaches and/or educational techniques, strategies, teaching tools to reduce the influence of bias in health clinicians' decision making were sought to be included in this review. Results are presented numerically and thematically in a table accompanied by a narrative summary.ResultsOf the 732 articles identified, 13 met the aim of this study. Most publications originated from the United States (n=9). Educational practice in medicine accounted for most studies (n=8), followed by nursing and midwifery (n=2). A guiding philosophy or conceptual framework for content development was not indicated in most papers. Educational content was mainly provided via face-to-face (lecture/tutorial) delivery (n=10). Reflection was the most common strategy used for assessment of learning (n=6). Cognitive biases were mainly taught in a single session (n=5); implicit biases were taught via a mix of single (n=4) and multiple sessions (n=4).ConclusionsA range of pedagogical strategies were employed; most commonly, these were face-to-face, class-based activities such as lectures and tutorials. Assessments of student learning were primarily based on tests and personal reflection. There was limited use of real-world settings to educate students about or build skills in biases and their mitigation. There may be a valuable opportunity in exploring approaches to building these skills in the real-world settings that will be the workplaces of our future healthcare workers.

Implicit bias is often viewed as a hidden force inside people that makes them perform inappropriate actions. This perspective can induce resistance against the idea that people are implicitly biased and complicates research on implicit bias. I put forward an alternative perspective that views implicit bias as a behavioral phenomenon. more specifically, it is seen as behavior that is automatically influenced by cues indicative of the social group to which others belong. This behavioral perspective is less likely to evoke resistance because implicit bias is seen as something that people do rather than possess and because it clearly separates the behavioral phenomenon from its normative implications. Moreover, performance on experimental tasks such as the Implicit Association Test is seen an instance of implicitly biased behavior rather than a proxy of hidden mental biases. Because these tasks allow for experimental control, they provide ideal tools for studying the automatic impact of social cues on behavior, for predicting other instances of biased behavior, and for educating people about implicitly biased behavior. The behavioral perspective not only changes the way we think about implicit bias but also shifts the aims of research on implicit bias and reveals links with other behavioral approaches such as network modeling.

In this brief report, an unanswered question in implicit weight bias research is addressed: Is weight bias stronger when obese and thin people are pictured engaging in stereotype consistent behaviors (e.g., obese-watching TV/eating junk food; thin-exercising/eating healthy) as opposed to the converse? Implicit Associations Test (IAT) data were collected from two samples of overweight/obese adults participating in weight loss treatment. Both samples completed two IATs. In one IAT, obese and thin people were pictured engaging in stereotype consistent behaviors (e.g., obese-watching TV/eating junk food; thin-exercising/eating healthy). In the second IAT, obese and thin people were pictured engaging in stereotype inconsistent behaviors (e.g., obese-exercising/eating healthy; thin-watching TV/eating junk food). Implicit weight bias was evident regardless of whether participants viewed stereotype consistent or inconsistent pictures. However, implicit bias was significantly stronger for stereotype consistent compared to stereotype inconsistent images. Implicit anti-fat attitudes may be connected to the way in which people with obesity are portrayed.

Learning Together About Racism

The centrality of race to our history and the substantial racial inequalities that continue to pervade society ensure that "race" remains an extraordinarily salient and meaningful social category. Explicit racial prejudice, however, is only part of the problem. Equally important - and likely more pervasive - is the phenomenon of implicit racial prejudice: the cognitive processes whereby, despite even our best intentions, the human mind automatically classifies information in racial categories and against disfavoured social groups. Empirical research shows convincingly that these biases against socially disfavoured groups are (i) pervasive; (ii) often diverge from consciously reported attitudes and beliefs; and (iii) influence consequential behaviour towards the subjects of these biases. The existence of implicit racial prejudices poses a challenge to legal theory and practice. From the standpoint of a legal system that seeks to forbid differential treatment based upon race or other protected traits, if people are in fact treated differently, and worse, because of their race or other protected trait, then the fundamental principle of anti-discrimination has been violated. It hardly matters that the source of the differential treatment is implicit rather than conscious bias. This article investigates the relevance of this research to the law by means of an empirical account of how implicit racial bias could affect the criminal trial trajectory in the areas of policing, prosecutorial discretion and judicial decision-making. It is the author's hypothesis that this mostly American research also applies to South Africa. The empirical evidence of implicit biases in every country tested shows that people are systematically implicitly biased in favour of socially privileged groups. Even after 1994 South Africa – similar to the US – continues to be characterised by a pronounced social hierarchy in which Whites overwhelmingly have the highest social status. The author argues that the law should normatively take cognizance of this issue. After all, the mere fact that we may not be aware of, much less consciously intend, race-contingent behaviour does not magically erase the harm. The article concludes by addressing the question of the appropriate response of the law and legal role players to the problem of implicit racial bias.

The centrality of race to our history and the substantial racial inequalities that continue to pervade society ensure that "race" remains an extraordinarily salient and meaningful social category. Explicit racial prejudice, however, is only part of the problem. Equally important - and likely more pervasive - is the phenomenon of implicit racial prejudice: the cognitive processes whereby, despite even our best intentions, the human mind automatically classifies information in racial categories and against disfavoured social groups. Empirical research shows convincingly that these biases against socially disfavoured groups are (i) pervasive; (ii) often diverge from consciously reported attitudes and beliefs; and (iii) influence consequential behaviour towards the subjects of these biases. The existence of implicit racial prejudices poses a challenge to legal theory and practice. From the standpoint of a legal system that seeks to forbid differential treatment based upon race or other protected traits, if people are in fact treated differently, and worse, because of their race or other protected trait, then the fundamental principle of anti-discrimination has been violated. It hardly matters that the source of the differential treatment is implicit rather than conscious bias. This article investigates the relevance of this research to the law by means of an empirical account of how implicit racial bias could affect the criminal trial trajectory in the areas of policing, prosecutorial discretion and judicial decision-making. It is the author's hypothesis that this mostly American research also applies to South Africa. The empirical evidence of implicit biases in every country tested shows that people are systematically implicitly biased in favour of socially privileged groups. Even after 1994 South Africa – similar to the US – continues to be characterised by a pronounced social hierarchy in which Whites overwhelmingly have the highest social status. The author argues that the law should normatively take cognizance of this issue. After all, the mere fact that we may not be aware of, much less consciously intend, race-contingent behaviour does not magically erase the harm. The article concludes by addressing the question of the appropriate response of the law and legal role players to the problem of implicit racial bias.

Introduction. Unconscious, or implicit, bias may influence physician treatment decisions and contribute to healthcare disparities. Research Questions. Is implicit bias associated with inappropriate care for claudication and 1-year major amputation? Methods: All vascular interventionists of the Society for Vascular Surgery Vascular Quality Initiative (VQI) were invited to take the race Implicit Association Test (IAT). The IAT asks participants to classify sequential images of African American (Black) and European American (White) faces to positive and negative attributes and groups them by racial preference based on reaction time. IAT results were weighted and linked to VQI peripheral revascularization data to test the association between implicit bias with patient race and performance of below-knee procedures for claudication, a measure of inappropriate care. We assessed the association of below-knee procedures and patient race with odds of 1-yr amputation, using physician implicit bias as a moderator. Results: Among the 218 physicians that completed the IAT, physicians with White preference (70%) were more likely to perform a below-knee procedure on Black patients ( Fig A ) and their Black patients had increased odds of 1-yr amputation compared to White patients (OR: 3.0, 95%CI: 1.7-5.4). Physicians with no preference (20%) had no variability in below-knee procedures by patient race and fewer 1-yr amputations. A below knee procedure for claudication (ref: above-knee) was associated with increased odds of 1-year amputation, but the effect was greater among physicians with White bias (OR: 8.2;4.7-14.5) compared to no bias (OR: 3.6;1.4-9.7) ( Fig B ). Conclusions: Implicit bias is associated with inappropriate treatment selection, especially for Black patients. These results suggest the need for system level interventions that transparently identify procedures that are not aligned with best practices to reduce the negative effect of implicit bias.

Commentary: Women congenital cardiac surgeons: Affirming the few

Implicit bias seems to be a universal primitive function of all brains. Police officers have been found to have near universal implicit bias against racial and ethnic minorities. This does not mean that discriminatory behavior (explicit bias) has to inevitably follow. Reports of police use of lethal force have found that African Americans are far more likely to be shot and killed than their numbers in the population would predict. The actual number of individuals killed by police is not certain since the reporting of lethal force by police departments is voluntary. Evidence suggests that appropriate training of police can help reduce any tendency for police officers to exhibit discriminatory lethal violence against African Americans. We recommend the following changes: required reporting of all police shootings and the circumstances surrounding the shootings, counter training for implicit bias for all police officers, organizational policy and legislative reforms for law enforcement, and more diligent prosecution of inappropriate use of lethal force by police officers.

Nationwide, more than 22% of births in France are to women who were born elsewhere. It is now well documented that overall, these women, like migrants throughout Europe, have higher perinatal and maternal risk levels than non-migrants. The mechanisms of these social inequalities in health have not yet been sufficiently and adequately explored. Access to and quality of care are likely to be intermediate factors in their explanation. This hypothesis is especially probable in view of recent work showing higher rates of inadequate prenatal and suboptimal perinatal care in some groups of migrant women compared to women born in France. This workshop aims to present and discuss a mixed-methods research program founded by the French National Research Agency (ANR). The program was designed to address and assess the role played by health professional's implicit bias (IB) in the provision of differential care that could explain disparities in maternal and perinatal health between certain groups of migrants and women born in France. The existence of these IB has been demonstrated in healthcare professionals in several specialties, mainly in North America, but never in the perinatal field nor in European settings. While this program has focused on care as diverse as cesarean section, epidural analgesia during labor, prevention and management of eclampsia, and Down syndrome screening, we propose to report on our approach through the issue of Down syndrome screening. IB has been shown to be less likely to induce differential care in highly protocolized emergency care settings. Conversely, non-emergency situations such as prenatal care, where there is nevertheless time pressure on health care professionnals, are more likely to be contexts for the existence of non-medically based differential care. Access to prenatal screening for Down's syndrome, where patient information plays a fundamental role, seemed to us to be a particularly interesting model for the study of differential care and the role played by IB. While the role of conscious and unconscious discrimination phenomena in the mechanisms of social health inequalities appears as increasingly probable, this workshop, based on data from a multidisciplinary research program, will shed additional light on these issues from the very concrete question of down syndrome screening. Researchers involved in this multidisciplinary project will present the results successively from epidemiological, qualitative sociological, and quantitative psycho-sociological approaches addressing differential care practices in Down syndrome screening. This mixed-methods approach will provide complementary insights into the research question. Our methods and results will then be discussed in an audience session led by moderators external to the project but experts in social health inequalities. Key messages Differential care between pregnant migrant women and native women has been evidenced in Down syndrome screening in France. Disparities in the use of Down syndrome screening according to women place of birth are almost partly related to differences in the opportunity of an informed choice.

This chapter reviews the extant literature regarding the existence of implicit bias in key selection, recruitment, and promotion decision-making processes. It includes an analysis of the impact of stereotyping on screening of resumes, in-group bias in interviews, the impact of stereotype threat on candidate performance, and interviewer confirmation bias. This substantial body of evidence suggests that to tackle discrimination caused by implicit bias in the modern workplace, a different approach is needed. These subtler, deeper routed forms of discrimination require subtler and deeper-routed interventions. Instead of attempting to ‘outlaw’ implicit bias, its motivational underpinning must be addressed, along with the cultural factors, which may trigger or maintain the beliefs and attitudes underpinning the bias.