Implicit Bias in Health Care

Course #57000 • 3 Hours/Credits

Study Points

  1. Define implicit and explicit biases and related terminology.
  2. Evaluate the strengths and limitations of the Implicit Association Test.
  3. Describe how different theories explain the nature of implicit biases, and outline the consequences of implicit biases.
  4. Discuss strategies to raise awareness of and mitigate or eliminate one's implicit biases.

    1 . Dr. X, a physician, acknowledges that she still has a lot to learn about different racial and ethnic minority groups. She is willing to learn from her patients and assume the role of learner. Dr. X is demonstrating
    A) diversity.
    B) reflexivity.
    C) explicit bias.
    D) cultural humility.


    Cultural humility refers to an attitude of humbleness, acknowledging one's limitations in the cultural knowledge of groups. Practitioners who apply cultural humility readily concede that they are not experts in others' cultures and that there are aspects of culture and social experiences that they do not know. From this perspective, patients are considered teachers of the cultural norms, beliefs, and value systems of their group, while practitioners are the learners [15]. Cultural humility is a lifelong process involving reflexivity, self-evaluation, and self-critique [16].

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    2 . What tool is used to quantitatively measure implicit bias?
    A) IAT
    B) SOAP
    C) STOP
    D) fMRI


    Project Implicit is a research project sponsored by Harvard University and devoted to the study and monitoring of implicit biases. It houses the Implicit Association Test (IAT), which is one of the most widely utilized standardized instruments to measure implicit biases. The IAT is based on the premise that implicit bias is an objective and discreet phenomenon that can be measured in a quantitative manner. Developed and first introduced in 1998, it is an online test that assesses implicit bias by measuring how quickly people make associations between targeted categories with a list of adjectives [33]. For example, research participants might be assessed for their implicit biases by seeing how rapidly they make evaluations among the two groups/categories career/family and male/female. Participants tend to more easily affiliate terms for which they hold implicit or explicit biases. So, unconscious biases are measured by how quickly research participants respond to stereotypical pairings (e.g., career/male and family/female). The larger the difference between the individual's performance between the two groups, the stronger the degree of bias [34,35]. Since 2006, more than 4.6 million individuals have taken the IAT, and results indicate that the general population holds implicit biases [3].

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    3 . Which of the following is NOT a risk factor in triggering implicit biases for health professionals?
    A) Uncertainty
    B) Cognitive dissonance
    C) Time pressure to make a rapid decision
    D) Heavy workload and feeling behind schedule


    Certain conditions or environmental risk factors are associated with an increased risk for certain implicit biases, including [44,45]:

    • Stressful emotional states (e.g., anger, frustration)

    • Uncertainty

    • Low-effort cognitive processing

    • Time pressure

    • Lack of feedback

    • Feeling behind with work

    • Lack of guidance

    • Long hours

    • Overcrowding

    • High-crises environments

    • Mentally taxing tasks

    • Juggling competing tasks

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    4 . How might critical theory or a structural perspective be integrated into the values and ethics of interprofessional collaboration and practice?
    A) Advocate for more neurologic imaging studies to examine how implicit bias affects the brain.
    B) Analyze how communications should reflect autonomous decision-making in its role in racism.
    C) The ethical responsibility is to advocate for policies that perpetuate and reinforce implicit biases.
    D) The role of health professionals is to focus less on the unconscious and instead emphasize explicit bias as the behaviors.


    Many scholars and policymakers are concerned about the narrow theoretical views that researchers of implicit bias have taken. By focusing on unconscious cognitive structures, social cognition and neuroscientific theories miss the opportunity to also address the role of macro or systemic factors in contributing to health inequities [9,57]. By focusing on the neurobiology of implicit bias, for example, racism and bias is attributed to central nervous system function, releasing the individual from any control or responsibility. However, the historical legacy of prejudice and bias has roots in economic and structural issues that produce inequities [58]. Larger organizational, institutional, societal, and cultural forces contribute, perpetuate, and reinforce implicit and explicit biases, racism, and discrimination. Psychological and neuroscientific approaches ultimately decontextualize racism [9,57].

    In response to this conflict, a systems-based practice has been proposed [59]. This type of practice emphasizes the role of sociocultural determinants of health outcome and the fact that health inequities stem from larger systemic forces. As a result, medical and health education and training should focus on how patients' health and well-being may reflect structural vulnerabilities driven in large part by social, cultural, economic, and institutional forces. Health and mental health professionals also require social change and advocacy skills to ensure that they can effect change at the organizational and institutional levels [59].

    Implicit bias is not a new topic; it has been discussed and studied for decades in the empirical literature. Because implicit bias is a complex and multifaceted phenomenon, it is important to recognize that there may be no one single theory that can fully explain its etiology.

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    5 . Which of the following statements regarding health disparities is FALSE?
    A) Health disparities are linked to disadvantaged groups.
    B) Health disparities refer to differences in health status and disease that are tied to structural inequities.
    C) There are no differences in life expectancies among African Americans and White Americans.
    D) The Institute of Medicine has implicated implicit bias in the development and continuance of health disparities.


    Implicit bias has been linked to a variety of health disparities [1]. Health disparities are differences in health status or disease that systematically and adversely affect less advantaged groups [60]. These inequities are often linked to historical and current unequal distribution of resources due to poverty, structural inequities, insufficient access to health care, and/or environmental barriers and threats [61]. Healthy People 2030 defines a health disparity as [62]:

    …a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.

    As noted, in 2003, the Institute of Medicine implicated implicit bias in the development and continued health disparities in the United States [1]. Despite progress made to lessen the gaps among different groups, health disparities continue to exist. One example is racial disparities in life expectancy among Black and White individuals in the United States. Life expectancy for Black men is 4.4 years lower than White men; for Black women, it is 2.9 years lower compared with White women [63]. Hypertension, diabetes, and obesity are more prevalent in non-Hispanic Black populations compared with non-Hispanic White groups (25%, 49%, and 59% higher, respectively) [64]. In one study, African American and Latina women were more likely to experience cesarean deliveries than their White counterparts, even after controlling for medically necessary procedures [65]. This places African American and Latina women at greater risk of infection and maternal mortality.

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    6 . An implicit bias training is offered at a hospital, and a total of 50 health professionals attend. During the breakout session, training participants are assigned to discussion groups. One nurse agrees that implicit bias is prevalent, but she is quite sure she does not hold any implicit biases. Which developmental stage might this nurse be in?
    A) Defense
    B) Minimization
    C) Structural competence
    D) Counter-stereotype acceptance


    There are no easy answers to raising awareness and reducing health providers' implicit bias. Each provider may be in a different developmental stage in terms of awareness, understanding, acceptance, and application of implicit bias to their practice. A developmental model for intercultural sensitivity training has been established to help identify where individuals may be in this developmental journey [74,75]. It is important to recognize that the process of becoming more self-aware is fluid; reaching one stage does not necessarily mean that it is "conquered" or that there will not be additional work to do in that stage. As a dynamic process, it is possible to move back and forth as stress and uncertainty triggers implicit biases [74]. This developmental model includes six stages:

    • Denial: In this stage, the individual has no awareness of the existence of cultural differences between oneself and members of other cultural groups and subgroups. Individuals in this stage have no awareness of implicit bias and cannot distinguish between explicit and implicit biases.

    • Defense: In this stage, the person may accept that implicit biases exist but does not acknowledge that implicit biases exist within themselves.

    • Minimization: An individual in this stage acknowledges that implicit biases may exist in their colleagues and possibly themselves. However, he or she is uncertain of their consequences and adverse effects. Furthermore, the person believes he or she is able to treat patients in an objective manner.

    • Acceptance: In the acceptance stage, the individual recognizes and acknowledges the role of implicit biases and how implicit biases influence interactions with patients.

    • Adaptation: Those in the adaptation stage self-reflect and acknowledge that they have unrecognized implicit biases. Not only is there an acknowledgement of the existence of implicit bias, these people begin to actively work to reduce the potential impact of implicit biases on interactions with patients.

    • Integration: At this stage, the health professional works to incorporate change in their day-to-day practice in order to mitigate the effects of their implicit biases on various levels—from the patient level to the organization level.

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    7 . If psychological safety is threatened, what might be a potential outcome in implicit bias training?
    A) Recriminations
    B) Self-confessions of guilt
    C) Health disparities increase
    D) Learning may be compromised


    Creating and fostering a sense of psychological safety in the learning environment is crucial. Psychological safety results when individuals feel that their opinions, views, thoughts, and contributions are valued despite tension, conflict, and discomfort. This allows the individual to feel that their identity is intact [76]. When psychological safety is threatened, individuals' energies are primarily expended on coping rather than learning [76]. As such, interventions should not seek to confront individuals or make them feel guilty and/or responsible [77].

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    8 . As part of an implicit bias training, participants watch a film about an African American man's experiences navigating the health system and are asked to enter the protagonist's lived reality. What type of intervention is this?
    A) Priming
    B) Attunement
    C) Control strategies
    D) Perspective taking


    Perspective taking is a strategy of taking on a first-person perspective of a person in order to control one's automatic response toward individuals with certain social characteristics that might trigger implicit biases [82]. The goal is to increase psychological closeness, empathy, and connection with members of the group [4]. Engaging with media that presents a perspective (e.g., watching documentaries, reading an autobiography) can help promote better understanding of the specific group's lives, experiences, and viewpoints. In one study, participants who adopted the first-person perspectives of African Americans had more positive automatic evaluations of the targeted group [83].

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    9 . Mr. A, a social worker, attempts to record personal information about his patients and not simply social characteristics. For example, he writes, "Patient is an elderly Hispanic woman, age 79 years. She lives with her daughter and is an avid pianist." What is this an example of?
    A) STOP
    B) Priming
    C) Power-sharing
    D) Individuation


    Individuation is an implicit bias reduction intervention that involves obtaining specific information about the individual and relying on personal characteristics instead of stereotypes of the group to which he or she belongs [4,82]. The key is to concentrate on the person's specific experiences, achievements, personality traits, qualifications, and other personal attributes rather than focusing on gender, race, ethnicity, age, ability, and other social attributes, all of which can activate implicit biases. When providers lack relevant information, they are more likely to fill in data with stereotypes, in some cases unconsciously. Time constraints and job stress increase the likelihood of this occurring [69].

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    10 . All of the following are concerns with research conducted to examine the effectiveness of implicit bias reduction interventions, EXCEPT:
    A) The studies conducted to examine implicit bias reduction interventions utilize cross-sectional and not longitudinal designs.
    B) The studies conducted to examine implicit bias reduction interventions may not be generalizable to the general population.
    C) The studies conducted to examine implicit bias reduction interventions have measured long-term but not immediate outcomes.
    D) Study samples have tended to include psychology students and it is not clear whether findings can be applied to other populations.


    In general, the sample sizes were small. It is also unclear how generalizable the findings are, given many of the research participants were college psychology students. The 30 studies included in the meta-analysis were cross-sectional (not longitudinal) and only measured short-term outcomes, and there is some concern about "one shot" interventions, given the fact that implicit biases are deeply embedded. Would simply acknowledging the existence of implicit biases be sufficient to eliminate them [95,96]? Or would such a confession act as an illusion to having self-actualized and moved beyond the bias [95]?

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