Mitigating Implicit Racial Bias in Health/Healthcare

As discussed in the previous sections, the influence of implicit bias is evident in both medical education and everyday healthcare practices, thereby subtly shaping the learning experiences of students and the development trajectories of healthcare professionals. Without recognition of and adequate intervention for implicit bias, individuals immersed in these systems may inadvertently promote inequitable practices. In this section, we present a compilation of articles published between 2018 and 2020 that explored strategies aimed at mitigating implicit bias within the healthcare field. A total of 30 articles were analyzed for this section; this constitutes almost half of our 61-article dataset. Table 2 lists the specialties and citations for readers seeking further specialty-specific details.    

Table 2. Implicit Bias Mitigation Strategy Research 2018-2020 by Specialty  

These interventions cover various career stages, from medical student education and residency program matching to professional development for healthcare providers and medical school faculty retention. Ranging from widely practiced awareness training to examinations of the medical school environment, these strategies address individual, institutional, and systemic factors. Consistent with our other 2018-2020 State of the Science Reports, we define individual-level factors as those factors that influence individuals’ likelihood to cognitively but unconsciously rely on implicit racial bias – including but not limited to previously established influences as cognitive load (fatigue, stress, burnout) and ambiguous decision / decision complexity. While these factors are influenced by the situation, individuals experience them individually. We define institutional factors as factors that shape the context at the meso-level, like at the level of the entire medical or nursing school, or across an entire specialty nationally. Finally, we define systemic factors as the set of factors that transcend or intersect with healthcare. For example, cultural and historical stereotypes are not usually unique to the healthcare system. Similarly, while the child welfare or criminal justice system intersects with the U.S. healthcare system, they are not synonymous with the healthcare system. We organize this section accordingly. Table 3 presents a summary of the mitigation strategies derived from our review of healthcare-specific strategies discussed among the articles we analyzed. Each strategy is hyperlinked to facilitate easier navigation for readers.   

Table 3. Mitigation Strategies Discussed in Healthcare Implicit Racial Bias Research, 2018-2020  

Echoing ​van Ryn et al., (2015)​, Hernandez (2018), Burgess et al. (2019) and Motzkus et al. (2019) all found that medical students enter medical school and become habituated to norms and practices that can often reinforce rather than mitigate implicit racial bias, with serious implications for patient care. For example, Burgess and colleagues (2019) found lower levels of patient empathy among their strongly conservative respondents at the 4th year versus the 1st year of medical school, suggesting a role for medical school norms beyond individuals’ ideologies.  Hernandez suggested leaders harness the opportunity to change institutional norms to mitigate implicit bias among students by assessing the formal and informal curricula, and the so called  “hidden curriculum,” which are transmitted through structural and cultural factors such as methods of evaluation and colloquialisms.   

Several studies focus attention on practices providers should engage in consciously to thwart unconscious racial bias. Bermudez (2018) applied social dreaming theory and the social dreaming matrix in sessions with students, faculty, and staff. In documenting his experiments from these psychotherapy workshops Bermudez concluded that the social dreaming matrix offered a distinctive chance for participants to perceive the struggles of others with implicit bias and racial trauma as if they were their own. Through this reflection and meaning creation process, a collective psychoanalytic path is formed, leading to an improved and proactive social and moral imagination that may intervene against the negative effects of implicit racial bias.  

In a similar vein multiple studies ​(Burgess et al., 2019; Fadus et al., 2019; Stone et al., 2020)​ provided evidence that a tailored approach beyond the standard approach to race in curriculum and course design is important. In light of their findings, Burgess et al. (2019) suggests designing course content that resonates with more conservative individuals within curricula that might focus on values such as respect for authority and in-group loyalty and using influential figures in the medical profession as the source of communication. Fadus et al. (2019) suggests a nuanced approach that doesn’t rely solely on a patient’s appearance to infer racial or cultural identity but strives to obtain additional relevant information like cultural or immigrant backgrounds that help providers develop a comprehensive understanding of the factors that shape the values, attitudes and symptomatology among patients from diverse backgrounds. Specifically, the educational experience can raise awareness regarding common disparities by race that exist in healthcare settings, such as the disproportionate administration of higher doses of anti-psychotics to Black men that cannot be solely explained by clinical severity ​(Walkup et al., 2000)​. These curricular innovations aim to help medical students to grasp the implications of cognitive errors such as confirmation bias and framing, which may perpetuate misunderstanding of racial and ethnic minority patients. 

Due to prevailing stereotypes that often characterize Hispanic/Latinx patients as medically noncompliant (Sabin et al., 2009), Jeff Stone and colleagues (2020) conducted a study comparing implicit racial bias levels of first-year medical students from different racial and ethnic backgrounds toward Hispanics before and after two active learning workshops. The workshops covered topics such as the psychological mechanisms of intergroup bias, and the effects of implicit bias on patient care. Then, the students completed a series of activities to learn how to control their implicit bias when interacting with patients. Prior to the workshops, assessment revealed that both the majority and nontarget minority groups held considerable levels of implicit stereotypes regarding Hispanics, but the target minority group did not. After completing the workshops, the majority group showed a significant decrease in implicit bias, but this change was not found in the nontarget minority group. The main findings from this study are two-fold. First, it showed that both proactive and reactive strategies are effective in mitigating implicit bias in medical students. According to Stone and colleagues (2020), activating beliefs or “stereotypes” to categorize patients can be helpful in diagnosing and treating patients using epidemiology and clinical case studies. Thus, as opposed to promoting a strategy focusing on negating automatic associations, it may be more effective to train medical students on proactive and reactive strategies to make the switch from category-based practice to individual-based processing when interacting with patients from stigmatized groups. The second contribution of this study was to demonstrate that not all ethnic and racial minority individuals respond the same way when learning to control implicit bias. This finding led to the recommendation highlighted by the authors that tailoring may be necessary in designing the materials and activities for implicit bias intervention curriculum. It involves not only customizing the context of the materials to match the scenarios and research findings to specific doctor-patient interactions, but also culturally tailoring the materials and activities for medical students of different ethnic and racial minority groups.   

Institutional Strategy #2: Pilot Novel Curricula  

Three (3) studies offered curricular interventions that can be piloted systematically at the department or school (e.g., medical school, nursing school, or pharmacy school) level.  The ability of an individual to consistently adopt and uphold a trauma-informed approach is contingent upon their own well-being. For this reason, the studies discussed here acknowledge and incorporate individual strategy insights when designing their institutional strategy.  

The Trauma-Informed Medical Education (TIME) model was proposed to foster awareness that medical students and trainees can experience trauma from an environment imbued with implicit bias and to advocate for new practices in medical education. Authors Aneesa McClinton and Cato Laurencin (2020) argued that the prevalence of implicit bias in patient-provider interactions and its impact on learners’ experiences (see, e.g., Green 2018; Backhus et al. 2018; Capers et al. 2017; Rodriguez et al. 2014) necessitates a set of curricular principles aimed at establishing a supportive environment ​(Ravi & Little, 2017)​. Since identifying individuals who have experienced trauma can be challenging in the context of institutions, trauma-informed principles can be implemented as a universal precautionary measure (see also ​Kuehn, 2020)​. In so doing, the TIME approach does not rely on individual disclosures of the specific trauma endured (therefore avoiding privacy policy issues). Instead, it operates on a set of principles aimed at establishing a supportive environment (Ravi & Little, 2017). Similar to Stone et al.’s (2020) attention to proactive and reactive strategies used in clinical settings, the TIME model proposes four Rs for medical student training in implicit bias mitigation at both the individual and institutional levels: realize, recognize, respond and resist ​(McClinton & Laurencin, 2020)​.  

While the TIME model has focused on medical students and trainees, the Health Equity Rounds (HER) model is aimed at faculty and practitioners across various training levels and disciplines engaging in conversations about how racism and implicit bias directly affect patient care.  Joanna Perdomo and colleagues (​2019)​ developed HER in a pediatrics department and empowered medical residents to design and later advise on curriculum development. Participants in this longitudinal, case-based curriculum included attending physicians, fellows, residents, and medical students from departments such as pediatrics and family medicine. HER sessions were held quarterly during dedicated time for departmental case conferences. Incorporating the curriculum into regularly offered case conferences can address a concern about fitting implicit racial bias into a crowded curriculum (Tsai & Michaelson 2020). The cases used in HER sessions were selected from real provider-patient interaction scenarios submitted by residents and faculty. In addition to a wide coverage of topics spanning from contraceptive counseling to Williams syndrome, these cases were also curated to focus on issues connected to implicit bias and racism to foster interdisciplinary, cross-rank conversations instead of complex medical details that might create barriers to understanding. The authors employed a variety of evidence based individual strategy techniques to enhance case presentation, including perspective taking and individuation practice based on imagery exercises. Moreover, the curriculum incorporated different methods, including reflection essays, share out loud, and think-pair-share, to encourage the participants to practice the learned techniques. Survey feedback about HER sessions indicated that HER helped them gain awareness, motivation, and tools to reflect on their implicit biases, which subsequently benefited their clinical practices. Their findings also echoed some findings we discussed at the individual level, suggesting that tailored approaches could be combined with HER curriculum for maximal impact. 

Third and finally, Billy Thomas and Amber Booth-McCoy (​2020)​ proposed a theoretical model for reducing the impact of implicit bias with descriptions of eight longitudinal stages. The first six stages include: 1) awareness of implicit biases, 2) an increase in knowledge about the science of implicit bias, 3) acknowledgement and acceptance of implicit biases and their effect on behavior and patient outcomes, 4) intentional behavioral change by self-reflection and perspective taking, 5) direct application of strategies promoting behavioral changes, 6) affirmation of behavioral change through positive feedback. These six process stages are thought to lead to a pair of final result stages: 7) actual mitigation of implicit biases through behavioral change and 8) improved patient-provider relationships and better health outcomes and equity. Along with this theoretical model, Thomas and Booth-McCoy (2020) also reviewed four intervention strategies and their outcomes. They suggested that medical schools should adopt mandatory implicit association tests and provide cultural humility training as a curriculum change. In this way, medical students can learn to care for minority and underserved communities through experience.  

Institutional Strategy 3: Adopt a Nuanced Institutional Approach to Structural Racism  

Just as patients should not be treated as if race is a one-size-fits-all shaper of health outcomes, neither should providers or students be assumed to benefit from one-size-fits-all training (see also Burgess et al. 2019). Similarly, while structural racism is pervasive it does not operate uniformly or identically in all contexts.  

Several articles acknowledged small but persistent effects among factors that could be assumed to play a bigger role. Moving protocols away from emphasizing implicit bias training in isolation can provide additional impact on reducing racial disparities. An equitable and effective healthcare environment can be constructed at multiple layers, including incorporating counter stereotypical examples in educational materials, enhancing interracial contact in the physical environment through diversifying the rank of faculty and tapping into the racial and socioeconomic diversity of the city where the medical institute is embedded.    

Acculturation should also be a part of medical curricular design (including additional education and training in interview skills) to ensure that students and trainees are using unbiased instruments in an unbiased way, ultimately contributing to a more equitable and effective treatment. For example, Fadus et al. (2019) suggested that psychiatric providers enhance their culturally informed interview techniques, utilize existing tools with cultural sensitivity (see also ​Lewis-Fernández et al., 2020)​ and improve their structural competency to better recognize the implications of socioeconomic factors on psychiatric disorder symptoms. In a similar vein, Quinn Capers and colleagues (2020) also emphasized the importance of real patient interactions in medical education. They proposed that teaching hospitals should encourage regularly recurring gatherings of health providers to review incidents in which bias or racism is suspected to have occurred.     

Residency interviews are another hurdle where implicit racial bias can manifest itself (Backhus et al., 2019). This analysis referenced a study indicating that a large proportion of medical students encounter potentially discriminatory questions during their residency match interviews ​(Santen et al., 2010)​. Backhus et al. (2019) suggested that one way to mitigate this issue is to design standardized interview questions tailored to what trainees may experience at the residency program, rather than utilizing unstructured interview formats. The authors also noted that implementing a scoring system to evaluate the interviewee's responses to these questions could further enhance the standardized interview process's effectiveness. The collective evidence presented by Backhus and colleagues (2019) emphasized the need for establishing initiatives at the institutional level to address implicit racial bias in admission and enhancing support for minority faculty members in academic medicine, thereby fostering the growth of minority medical students.  

At the institutional level of implicit bias mitigation, Ivuoma Onyeador and colleagues (2020) examined the influence of three medical school factors, including interracial contact, medical school environment, and diversity training (for both implicit and explicit racial bias) during medical residency. Using a 6-year longitudinal dataset, they found that the quality of contact predicted a very small but consistent reduction in implicit bias. However, racial climate, modeling of bias, and length of diversity training did not consistently lower implicit bias. These results provided valuable insight into the long-term effects of implicit bias mitigation trainings in medical education and highlighted the importance of encouraging interracial contact at the institutional level.  

Healthcare continues to present unique opportunities for evidence-based research to mitigate implicit racial biases. For example, implicit bias can influence how medical practitioners allocate healthcare resources, potentially contributing to disparities among patients of different racial and ethnic backgrounds. Evan Graboyes and colleagues ​(2020)​ discussed strategies to address this issue in head and neck cancer care delivery, specifically in how surgical cases are prioritized. Previously, it has been suggested that a "color-blind" decision-aid prioritization system, which excludes race information from the decision-making process, could help rectify unequal treatment of racial and ethnic minority patients. Graboyes et al. (2020) cautioned against this simplistic approach because, even after removing race/ethnicity data, clinical stage and comorbidity severity would still have a role in this prioritization scheme. As African American and Hispanic/Latino patients are more likely to have comorbidities and present with advanced stages of diseases, implementing a decision-aid prioritization system solely focused on maximizing benefits based on comorbidity and disease stage could inadvertently perpetuate bias against these patients. Therefore, a comprehensive approach is necessary to mitigate bias and ensure equitable treatment for all patients. Graboyes and colleagues suggested a possible solution to this problem, which is developing a prioritization scheme that incorporates evidence-based, data-driven weights based on patient populations and local or regional prevalence of the relevant diseases. Another solution could be to develop a framework that prioritizes racial and ethnic minorities based on ethical principles, such as giving priority to those who are worse off (Graboyes et al., 2020). Although the optimal solution has yet to be determined, Graboyes and colleagues’ discussion emphasized the need for objective and metric-based decision aid/intervention tools to address disparities associated with implicit racial biases. Graboyes and colleagues’ recommendation for such tools concurs with findings in the 2018 Sate of the Science. Hymel et al. (2018) recommended that future attention needs to be devoted to developing validated and evidence based AHT screening tools in order to reduce the potential negative impact of implicit racial and ethnic bias in AHT diagnosis and evaluation.  

While many authors in our three-year dataset focused on infant and pediatric contexts, one publication stood out for its development of a novel end-of-life tool.  Elizabeth Chuang and colleagues (2020) developed a novel tool on the basis of the Race IAT to measure provider’s implicit bias in end-of-life (EOL) care. Through literature review, the researchers identified an initial pool of words used in EOL care that fit under two categories: comfort-oriented or aggressive. Clinicians in the specialties that treat serious illness were invited to rate and rank the words included in the initial pool. Words that were consistently sorted and ranked as representative of the two target categories were chosen as attributes in the novel EOL-IAT. Participants were instructed to categorize these words with two response keys, representing counterbalanced pairings of race (Black/White) and attributes (comfort/aggressive). This tool was piloted online through ProjectImplicit® and yielded promising results for practical application. This study represented an effort in customizing tools for accessing implicit biases held by providers of different specialties. It serves as a reminder for us that providers' implicit bias may not be as straightforward as associating White people with the attribute of "good" and  

Black people with “bad”. Instead, it can manifest in ways specific to the care of the specialty. For example, in EOL care, it may be more critical to determine if providers tend to associate White patients with the attribute of “comfort”, while exhibiting a stronger tendency to associate “aggressive” with Black patients.