Implicit Bias in Health Care ___________________________________________________________________
implicit preference for their own group. For biracial White/ Black adults, 23% were neutral. In addition, 22% of biracial White/Asian participants had no or minimal implicit racial biases. However, 42% of the White/Black biracial adults leaned toward a pro-White bias. In another interesting field experiment, although not specifi- cally examining implicit bias, resumes with names commonly associated with African American or White candidates were submitted to hiring officers [41]. Researchers found that resumes with White-sounding names were 50% more likely to receive callbacks than resumes with African American- sounding names [41]. The underlying causes of this gap were not explored. Implicit bias related to sex and gender is also significant. A survey of emergency medicine and obstetrics/gynecology residency programs in the United States sought to examine the relationship between biases related to perceptions of leader- ship and gender [42]. In general, residents in both programs (regardless of gender) tended to favor men as leaders. Male resi- dents had greater implicit biases compared with their female counterparts. In a scoping review of studies around the world, researchers identified 87 studies that assessed unconscious biases among healthcare professionals [109]. Racial implicit biases were most frequently studied. Physicians and nurses were included in the majority of the studies. Analysis of the included studies indicates that implicit biases remain prevalent among healthcare providers. Other forms of implicit bias can affect the provision of health and mental health care. One online survey examining anti-fat biases was provided to 4,732 first-year medical students [43]. Respondents completed the IAT, two measures of explicit bias, and an anti-fat attitudes instrument. Nearly 75% of the respondents were found to hold implicit anti-fat biases. Interestingly, these biases were comparable to the scope of implicit racial biases. Male sex, non-Black race, and lower BMI predicted holding these implicit biases. Certain conditions or environmental risk factors are associated with an increased risk for certain implicit biases, including [44; 45; 106]: • Stressful emotional states (e.g., anger, frustration) • Uncertainty • Low-effort cognitive processing • Time pressure • Lack of feedback • Feeling behind with work • High patient caseload • Lack of guidance • Long hours • Patient overcrowding
• High-crises environments • Mentally taxing tasks • High cognitive load • Juggling competing tasks
THEORETIC EXPLANATIONS AND CONTROVERSIES
A variety of theoretical frameworks have been used to explore the causes, nature, and dynamics of implicit biases. Each of the theories is described in depth, with space given to explore controversies and debates about the etiology of implicit bias. SOCIAL PSYCHOLOGICAL AND COGNITIVE THEORETICAL FRAMEWORKS One of the main goals of social psychology is to understand how attitudes and belief structures influence behaviors. Based on frameworks from both social and cognitive psychology, many theoretical frameworks used to explain implicit bias revolve around the concept of social cognition. One branch of cognitive theory focuses on the role of implicit or nondeclara- tive memory. Experts believe that this type of memory allows certain behaviors to be performed with very little conscious awareness or active thought. Examples include tooth brush- ing, tying shoelaces, and even driving. To take this concept one step farther, implicit memories may also underlie social attitudes and stereotype attributions [46]. This is referred to as implicit social cognition. From this perspective, implicit biases are automatic expressions based on belonging to certain social groups [47]. The IAT is premised on the role of implicit memory and past experiences in predicting behavior without explicit memory triggering [48]. Another branch of cognitive theory used to describe implicit biases involves heuristics. When quick decisions are required under conditions of uncertainty or fatigue, and/or when there is a tremendous amount of information to assimilate without sufficient time to process, decision-makers resort to heuristics [49]. Heuristics are essentially mental short cuts that facilitate (usually unconscious) rules that promote automatic processing [50]. However, these rules can also be influenced by socialization factors, which could then affect any unconscious or latent cognitive associations about power, advantage, and privilege. Family, friends, media, school, religion, and other social institutions all play a role in developing and perpetuating implicit and explicit stereotypes, and cognitive evaluations can be primed or triggered by an environmental cue or experience [51]. When a heuristic is activated, an implicit memory or bias may be triggered simultaneously [47]. This is also known as the dual-process model of information processing [50].
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