Confronting Implicit Bias in Healthcare: Strategies for Clinicians

Laura M. Cascella, MA, CPHRM

Efforts to reduce bias in healthcare have received increasing attention in recent years as the industry confronts issues associated with health equity, diversity, inclusivity, and health disparities. Bias is recognized as a significant barrier to achieving equitable and culturally competent care; yet, identifying and remediating this problem is complex.

Although incidents of explicit bias might be easily rooted out, research suggests that much of the bias in healthcare is implicit,¹ “thereby unintentionally affecting behavior, interactions, and decision-making.”² As a result, these issues may go undetected, or they might be difficult to confront because of (a) their imprecise nature, (b) the discomfort associated with tackling complicated, emotionally charged topics, and/or (c) lack of awareness or denial that a problem exists.

Unfortunately, maintaining the status quo and avoiding the reality of implicit bias can have detrimental consequences, including medical and treatment errors, poor patient outcomes, mistrust in the healthcare system, a toxic workplace culture, and increased liability exposure.

Research to identify best practices for reducing implicit bias is ongoing, and much work is still needed to determine practical, effective strategies. However, researchers have proposed a number of ways that clinicians, on an individual level, can take steps to recognize and resist biased behavior, including:

• Being aware of health disparities and discrimination affecting various populations, as well as common types of implicit and explicit bias that can affect clinical reasoning and decision-making.
• Completing self-assessments to help identify subconscious feelings, attitudes, and thoughts that may contribute to stereotypes and bias. The Implicit Association Test (IAT) is a commonly used self-assessment. Although this test isn’t infallible, UpToDate notes that “IAT remains widely accepted as a good approximation of unconscious biases.”³
• Playing an active role in advocating for and upholding a culture that supports psychological safety and encourages collaboration, teamwork, diversity, and inclusion.
• Participating in training to improve situational awareness and better understand metacognition. This type of training may help providers think critically about their thought processes and how bias can affect thinking and reasoning.
• Using techniques such as cognitive forcing functions, which are strategies designed to help practitioners self-monitor their decisions and avoid potential lapses in clinical judgment.
• Learning and implementing skills such as stereotype replacement, counter-stereotype imagining, perspective-taking, emotional regulation, and partnership-building to reduce bias and promote empathy, positive feelings, and patient-centered care.
• Working toward a better understanding of cultural beliefs, attitudes, and values that affect various patient populations. The U.S. Department of Health and Human Services’ Think Cultural Health website offers numerous educational resources for different provider types and care settings.
• Consciously making an effort to see each patient as a unique individual (rather than applying stereotypical characteristics), and respecting their personal values, experiences, preferences, and expressed needs.
• Using techniques and methods to assist in cross-cultural communication, break down health literacy barriers, and improve provider–patient communication. Examples of such techniques and methods include motivational interviewing, the LEARN model, the explanatory model, the RESPECT model, and the teach-back method.
• Identifying situations that might increase the likelihood of stereotyping or making biased decisions. Acknowledging these situations can help improve overall awareness and understanding.
• Asking patients about their experiences with bias and discrimination in the healthcare system to better understand their perceptions and as a possible trigger to purposefully use debiasing techniques.
• Using clinical pathways, adhering to established standards of care, and practicing evidence-based medicine.
• Evaluating how evolving technologies — such as clinical decision support and artificial intelligence — can help reduce bias in diagnostic and treatment decision-making. Being aware of how flawed technology can reinforce bias also is important.
• Working with other providers and staff members to address issues related to bias, to discuss challenges and frustrations, and to work toward solutions that support the delivery of high-quality, equitable care.⁴

In Summary

Implicit bias is a serious problem in healthcare that can result in numerous negative outcomes, including physical and emotional harm. Further, failure to confront bias runs counter to the ethical principles of beneficence, nonmaleficence, and justice, which guide the practice of medicine. Healthcare leaders, providers, and staff members can make strides in reducing bias by acknowledging its existence and taking deliberate steps to prevent it from occurring.

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¹ Drwecki, B. B. (2015, March). Education to identify and combat racial bias in pain treatment. AMA Journal of Ethics, 17(3), 221–228.

² Trainer, B. (2022, February 28). Acknowledging and mitigating unconscious bias in health care. KevinMD.com. Retrieved from www.kevinmd.com/2022/02/acknowledging-and-mitigating-unconscious-bias-in-health-care.html

³ Bryant, A. (2022, January 28). Racial and ethnic disparities in obstetric and gynecologic care and role of implicit biases. UpToDate. Retrieved from www.uptodate.com/contents/racial-and-ethnic-disparities-in-obstetric-and-gynecologic-care-and-role-of-implicit-biases

⁴ Edgoose, J., Quiogue, M., & Sidhar, K. (2019, July/August). How to identify, understand, and unlearn implicit bias in patient care. Family Practice Management, 26(4), 29-33. Retrieved from www.aafp.org/fpm/2019/0700/p29.html; Heath, S. (2020, October 16). What is implicit bias, how does it affect healthcare? Patient Engagement HIT. Retrieved from https://patientengagementhit.com/news/what-is-implicit-bias-how-does-it-affect-healthcare; The Joint Commission. (2016, April 11). Quick Safety Issue 23: Implicit bias in health care. Retrieved from www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-23-implicit-bias-in-health-care/; Drwecki, Education to identify and combat racial bias in pain treatment; Tropp, L. R., & Godsil, R. D. (2015, January 23). Overcoming implicit bias and racial anxiety. Psychology Today. Retrieved from www.psychologytoday.com/blog/sound-science-sound-policy/201501/overcoming-implicit-bias-and-racial-anxiety; Croskerry, P., Singhal, G., & Mamede, S. (2013). Cognitive debiasing 2: Impediments to and strategies for change. BMJ Quality & Safety, 22(Suppl 2), ii65–72.

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