Implicit Bias in Health/Health Care: 2019  

Impact of Healthcare Providers’ Implicit Racial Bias  

Medical Education  

No matter the industry – healthcare, education, or criminal justice – implicit racial and ethnic bias has been found to play a heightened role in cognitive functions whenever there are high stress / high cognitive load or ambiguous environments, to the point of being settled science. While many healthcare providers chide television and film representations of healthcare, there is one thing they do not contest: working as a healthcare provider is stressful and so is the training. In other words, medical trainees (e.g., medical or nursing students, interns, residents) are experiencing high cognitive loads in learning contexts which are uncertain ​(Johnson et al., 2016)​ and high stakes (medical care). So it is not surprising to learn that medical students and residents are more likely to have their preexisting implicit biases translated into explicit patient-care-related outcomes. Two longitudinal quantitative studies – one of 3,756 medical students across 49 different medical schools (Burgess et al. 2019) and one of 3,392 medical residents across various specialties – document this phenomenon. Liselotte Dyrbye and colleagues ​(2019)​ conducted a study to investigate medical residents’ implicit bias and their symptoms of burnout. A total of 3,392 non-Black participants across various specialties completed three point-in-time questionnaires: during their fourth year of medical school, as well as at the second and third years of residency. The findings showed that 45.2% and 41.3% of the sample experienced symptoms of burnout and depression, respectively. Moreover, after controlling for confounding variables such as demographics and specialty, burnout symptoms in the second year of residency were found to be positively associated with implicit racial biases a year later. Considering the widespread occurrence of burnout symptoms among medical residents and the adverse link between implicit racial bias and suboptimal care, Dyrbye et al. argued that signs of burnout could contribute to inequalities in healthcare delivery. Both medical residents and medical students form part of the essential pipeline for future healthcare providers.    

Medical education research published in 2019 took two directions; exploring trainees’ existing implicit racial biases and the potential impact of such implicit biases on patient care and diversity of the pipeline, which is a critical pathway for improving the provision of culturally competent care. Both medical residents and medical students form part of the essential pipeline for future healthcare providers. Two articles looked at implicit racial bias among medical students, concluding that medical students’ implicit racial bias can have an impact on patient care. 

Diana Burgess et al. (2019) collected data on political ideology and implicit bias from a sample of medical students. Using a stratified random sampling strategy, they recruited a total of 3,756 students in their first and fourth years of study from 49 medical schools. The researchers found that first-year students’ political ideology was associated with their implicit bias in year four. Specifically, a greater conservative political orientation in year one was linked to higher implicit racial bias against Black individuals in their final year of medical school. Over the duration of the study, a stronger initial conservative political ideology also predicted increased explicit attitudes toward stigmatized groups, reduced internal motivation to regulate racial prejudice, diminished levels of empathy toward patients, and decreased levels of patient-centered attitudes at a later time point. These correlations remained consistent across different medical schools and were not influenced by students' race or geographic location. Burgess and colleagues also noted that conservative ideology may align with characteristics like conscientiousness, self-control, and a sense of duty, which could potentially be utilized to improve care for marginalized populations. They did not, however, test any mitigation strategies, suggesting instead that further investigation is necessary. Second, Christine Motzkus and colleagues ​(2019)​ examined two cohorts of pre-clinical medical students enrolled in a determinants of health course, analyzing 250 deidentified essays from the course itself. More about Motzkus et al.’s findings can be found in the mitigation strategies section.   

The second thread of medical education research in 2019 focused on the pipeline into medical school. Building on Abelson et al.’s 2018 study of the lack of diversity in the surgical specialty, Leah Backhus and colleagues (2019) assess problems presented by implicit racial bias and implicit gender bias. Backhus et al. found that the representation of African American surgeons at all levels of the academic hierarchy, including tenure, either remained stagnant or declined between 2003 and 2006. Additionally, retention rates were significantly higher for White assistant professors, whereas Black assistant professors had the lowest promotion rates across all specialties. Backhus et al.’s 2019 study recognized the pervasive nature of implicit racial bias throughout the recruitment and training processes for future physicians. The authors pointed out that racial and ethnic minorities in both medicine and medical education are significantly underrepresented. According to the data collected between 2014 and 2015, Black individuals comprised only 5.7% of medical students and 6.2% of general surgery residents. These figures starkly contrast with the 12.4% representation of Black individuals in the U.S. population. Similarly, despite Hispanics constituting 17.4% of the U.S. population, only 4.5% of medical students and 8.5% of general surgery residents represent this demographic (Abelson et al., 2018). Backhus and colleagues (2019) suggested such racial disparities in medical education could be partially due to implicit racial biases held by influential individuals in the system. The authors referenced a study that examined the implicit biases of 140 members of medical school admissions committees at a Midwestern university. Using the Black-White IAT, the study found that all groups of the committee exhibited levels of implicit preference for White males and faculty were shown to have the highest implicit bias scores ​(Capers et al., 2017)​. Moreover, underrepresentation of minorities in medical education at the faculty level could directly influence the recruitment, mentoring, and retention of minority students ​(Rodriguez et al., 2014)​.   

Healthcare Providers  

Four (4) studies, each in a different specialty (trauma care, otolaryngology, nursing, and dentistry), continued to use a broad definition of healthcare provider beyond the narrow focus on MDs ​(Narayan, 2019; Tajeu et al., 2018; Zebib et al., 2019)​. While some 2019 medical education studies emphasized the stress and ambiguity aspects of the healthcare context, another study emphasized the population context to evaluate whether racial and socioeconomic diversity would mitigate the existence of implicit racial bias in trauma care. Laura Zebib and colleagues (2019) recruited 91 participants from ten (10) healthcare professions in Miami, Florida. Their study found that trauma healthcare professionals in a multicultural city exhibited reduced levels of implicit racial and socioeconomic bias compared to the average implicit bias amount White surgeons in the U.S.  

In a summary of the associations among implicit bias and patient safety as well as the quality of care, Karthik Balakrishnan & Ellis Arjmand ​(2019)​ underscored that professional healthcare providers are as susceptible as the general population to implicit social and cultural biases ​(Zestcott et al., 2016)​. Drawing on studies conducted by Plaisime et al. ​(2017)​ ​and Penner et al., (2016)​, Balakrishnan and Arjmand suggested that the implicit biases not only influence assessment made by clinicians and providers’ decision-making processes in treatment, but also affect how patients perceive their encounters with healthcare professionals, which impacts patient satisfaction and their confidence in the care received.  

Mary Narayan (2019) also discussed the presence of implicit bias, suggesting that such bias influences the relationships between providers and patients, the quality of care delivered, and the psychosocial well-being of patients. Regarding the provider-patient relationship, biases may lead to perceiving Black patients as having inferior communication skills and being less warm, friendly, and team-oriented. This perception can result in decreased patient adherence, fewer return visits, and diminished trust in healthcare providers ​(Chapman et al., 2013)​. Furthermore, implicit biases may manifest as spending less time listening to Black patients and assuming that Black and Hispanic patients are less likely to adhere to treatment and cooperate compared to White patients (Zestcott et al., 2016). In terms of the quality of care, studies have shown that implicit bias influences diagnoses, treatment recommendations, the thoroughness of patient histories, and the frequency of tests ordered ​(FitzGerald & Hurst, 2017)​. Lastly, implicit biases can also affect patients' health outcomes, impacting factors such as social integration, levels of depression, and overall life satisfaction ​(Hall et al., 2015)​. 

Neha Patel et al. ​(2019)​ implemented a cross-sectional survey at the University of Cagliari, Italy. Fifty-seven qualified dentists working in the endodontic department of one hospital participated in the survey. These examiner respondents were randomly assigned to review a clinical vignette featuring either a Black or White patient presenting a decayed tooth and related symptoms of irreversible pulpitis, which signals that the innermost layer of a tooth is no longer able to heal itself. Both canal treatment and extraction were viable treatment options. However, the loss of a tooth can result in compromised aesthetics, lower biting stability, and replacement options (such as fixed partial dentures or implants) may result in damage of adjacent teeth ​(Al-Quran et al., 2011; Saunders & Saunders, 1998)​. The examiner participants were tasked with assessing the likelihood that the patient’s symptoms were due to irreversible pulpits, providing their treatment recommendation, and indicating the strength of this recommendation.  

Implicit racial bias held by respondents was measured using the Brief Implicit Association Test (BIAT) ​(Nosek et al., 2014)​. Across both conditions, 91.23% of the examiners participating in the study exhibited a pro-White implicit bias. Additionally, they were significantly more inclined to recommend root canal treatment for White patients and extraction for Black patients. Patel and colleagues suggested that the preference to recommend tooth extraction to Black patients might stem from assumptions about their socioeconomic status, which leads the examiners to believe that Black patients may not be able to afford root canal treatment. While this might be perceived as an empathetic gesture to avoid causing financial strain, the authors highlighted that it still reflects bias.  

Conclusion  

In sum these 2019 articles continue to articulate the harms that can ensue with failure to address implicit racial bias in healthcare. They complement those published in 2018 in terms of a focus on expanding scholars’ and clinical practitioners’ attention to broadening the types of healthcare providers studied, providing empirical and meta-analytical evidence of an existing problem that requires mitigation.