What is clinician implicit bias?

What is Clinician Implicit Bias

Clinician implicit bias refers to unconscious attitudes and stereotypes that operate outside of conscious awareness and can directly contradict a clinician's stated beliefs and values, yet automatically influence clinical decision-making, patient interactions, and treatment recommendations. 1

Core Definition and Mechanism

Implicit bias operates at an unconscious level of awareness and can be in direct contradiction to espoused beliefs and values. 1 Unlike explicit racial biases, which are deliberative attitudes expressed consciously through physical and verbal interaction, implicit bias is automatically activated without conscious volition and influences behavior in ways clinicians may not recognize. 1, 2

• Cultural stereotypes may not be consciously endorsed, but their mere existence influences how information about individual patients is processed, leading to unintended biases in clinical decision-making. 2
• Physicians exhibit low levels of explicit bias, but implicit racial bias is automatically activated across healthcare settings. 1
• These biases are insidious, occur across the healthcare spectrum, and likely play an important role in determining participant eligibility for treatments and whether certain therapeutic options are presented at all. 1

Clinical Impact on Patient Care

Healthcare providers' implicit racial bias has been associated with negative ratings of clinical treatments, less patient-centered communication, under-treatment of pain, poor provider communication, and views of minority patients as less medically adherent than White patients. 1

Specific Clinical Manifestations:

• Treatment decisions: One common implicit bias is that African American patients will be less compliant with complex treatment regimens or clinical trials, potentially leading to differential patient referral and limiting opportunities for these populations. 1
• Patient-provider interactions: African American patients perceived communication as less patient-centered and supportive among oncologists who had higher levels of implicit bias. 1
• Pain management: Physician-level bias has been associated with false beliefs that African American patients have greater pain tolerance, thicker skin, and feel less pain than White patients. 1
• Research enrollment: Clinicians failed to present active research opportunities to their African American patients 24% of the time compared with 8% of the time for all other groups. 1
• Prenatal drug testing: Despite similar rates of substance use among Black and White women, Black women were reported to social services at approximately 10 times the rate of White women, with Black race remaining independently associated with drug screening even when controlling for standard screening criteria. 1

Prevalence Among Healthcare Professionals

Low to moderate levels of implicit racial/ethnic bias were found among healthcare professionals in all but one study, with these implicit bias scores similar to those in the general population. 3 All of society is susceptible to these biases, including physicians, and research demonstrates that implicit bias exists across racial, ethnic, gender, and other demographic characteristics. 2, 3

Relationship to Health Disparities

Implicit bias was significantly related to patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes, contributing to systemic health disparities. 3

• In healthcare, bias has significant impact on who receives guideline-based care; sex and race were found to be independent factors in determining provider recommendations for cardiac catheterization in patients presenting with chest pain. 1
• Implicit bias likely has led to systemic underenrollment of minorities in research and differential access to evidence-based treatments. 1
• The contribution of implicit bias to healthcare disparities could decrease if all physicians acknowledged their susceptibility to it and deliberately practiced perspective-taking and individuation when providing patient care. 2

Critical Caveats

Building awareness alone through implicit bias training may be motivating to providers but not lead to behavior change; it may also be counterproductive if the process incites defensiveness or avoidance among providers. 1

• Limited empirical evidence demonstrates the effectiveness of implicit bias training for long-term change in implicit preferences or measuring impact on patient-level outcomes. 1
• More promising approaches include actions aimed at changing behavior and engaging actively with the process of reducing bias, including stereotype replacement, seeking common identity information with groups outside one's own, and perspective taking. 1
• To combat implicit bias, those involved in clinical care must first understand their own biases through mechanisms such as the Implicit Association Test. 1
• The American College of Cardiology recommends that anesthesiologists undergo formal cultural competency training coupled with systematic strategies to prevent stereotyping and bias, while implementing patient-centered communication approaches. 4