Implicit Bias and the Racial Divide in Health

“Of all the forms of inequality, injustice in health is the most shocking and inhumane,” wrote Martin Luther King, Jr. in 1966. Almost 55 years later, the recent Black Lives Matter protests have brought a renewed focus on racial inequality, including the inequities in our healthcare system.

Racism is a systemic problem in the U.S. and elsewhere; it has been woven into the fabric of our society. Systemic racism and implicit bias play a part in why, compared to whites, black Americans are 3.5% more likely to die of COVID-19 and have the highest all-cause mortality rate of any racial or ethnic group.

What is Implicit Bias?

Implicit bias describes a set of unconscious, often unintended assumptions humans tend to hold regarding people they perceive to be different than themselves. These assumptions can be negative or positive, and they reflect our brain’s natural tendency to see patterns in the information it takes in regarding people.

Many of us, regardless of race, have experienced this implicit bias firsthand. Obese patients are sometimes assumed to be sedentary or addicted to junk food. Elderly people sometimes have health complaints dismissed as just stemming “from old age.” For decades, the prevailing medical theory around PMS (premenstrual syndrome) was that it was a psychological problem, rather than a biological one.  

As healthcare professionals, we need to recognize and renounce our own implicit bias. In a January of 2020 op-ed in Health Affairs, Shantanu Agrawal and Adaeze Enekwechi stated, “Our health care system must take ownership of our contributions to the problem. Bias and prejudice are as much a part of healthcare workers as in the general population.”

It’s important to realize that we’re hardwired to resort to stereotypes, despite our best intentions. This is especially true when we’re stressed, distracted, or have little time to spend with each patient.

How Implicit Bias Impacts Medical Care

Implicit biases are destructive. Certain myths, which arose during the slavery era, still exist, and they impact the kind of care non-white populations receive.

For example, black children are less likely than other children to receive topical anesthetics, likely due to a persistent assumption that black skin is less sensitive to pain. (A 2016 study showed that 40% of medical students and residents endorsed this belief.) In addition, black parents are more likely to get reported to child protective services than non-black parents. Pregnancy-related deaths are 3.3 higher among black women than their white counterparts.

These examples are just the tip of the iceberg.

In 2019, a now-famous study detected racial bias present in a common algorithm used to determine patient eligibility for care management programs. The bias was not intentional, researchers claim, but its impact was huge, reducing black patients’ care eligibility by more than half. (Read more here.)

Breaking the Bias Habit

How do we overcome this bias? Many medical and nursing schools have incorporated implicit bias training into their curricula, as have hospitals. However, this training needs to be ongoing and extended beyond the bedside.

Many individuals and organizations have called for a comprehensive approach to the many factors driving racial inequity in healthcare. Just as Agrawal and Enekwechi stated in their Health Affairs piece, each one of us needs to address our role in perpetuating this, even if our bias is unintentional.

“Health care cannot be an observer of these issues or continue to suggest that inequity is produced by broader social forces alone,” they write. “Our response must have the urgency this issue deserves.”

According to Psychology Today, it’s not enough for people to simply be aware that they have the potential to be implicitly biased. Patricia Devine and her colleagues suggest some practices to “break the prejudice habit”. These practices include:

  • Consciously contrasting negative stereotypes with specific counter-examples
  • Exposing people to these counter-examples
  • “Individuating” people by looking for specific information about members of other racial groups, so you can recognize people based on their own personal attributes, rather than stereotypes
  • Seeking out the perspectives of outgroup members, so you can view situations through their lens and worldview
  • Making more effort to engage in positive interactions with members of other ethnic and racial groups

Changing Subconscious Bias Requires Conscious Effort

Public institutions, including health care facilities, are starting to implement explicit policies in the pursuit of abolishing implicit bias. When it comes to racism, stereotyping, and assumptions, most people out there really do want to “do the right thing”. The challenge, however, lies in consciously working to change our biases, using tools like those outlined above.

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