Implicit Bias in Health Care ___________________________________________________________________
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. One of the most salient statistics that highlights racial health disparities is in maternal morbidity and mortality rates. In the United States, Black patients are 212% more likely than White patients to die from pregnancy- or childbirth-related causes [110]. In addition, during the COVID-19 pandemic, evidence of racial health disparities was widespread. People of color were hospitalized for COVID at 4.7 to 5.3 times the rate of White Americans [110]. Gender health disparities have also been demonstrated. Gener- ally, self-rated physical health (considered one of the best prox- ies to health) is poorer among women than men. Depression is also more common among women than men [66]. Lesbian and bisexual women report higher rates of depression and are more likely than non-gay women to engage risk behaviors such as smoking and binge drinking, perhaps as a result of LGBTQ+-related stressors. They are also less likely to access healthcare services [67]. Socioeconomic status also affects health care engagement and quality. In a study of patients seeking treatment for thoracic trauma, those without insurance were 1.9 times more likely to die compared with those with private insurance [68].
• Communication • Relationship • Patient satisfaction and patient’s view toward provider’s patient-centeredness • Treatment adherence and practitioners’ views of patient’s likelihood to adhere to treatment • Practitioners’ clinical decision-making
In a landmark 2007 study, a total of 287 internal medicine physicians and medical residents were randomized to receive a case vignette of an either Black or White patient with coronary artery disease [70]. All participants were also administered the IAT. When asked about perceived level of cooperativeness of the White or Black patient from the vignette, there were no dif- ferences in their explicit statements regarding cooperativeness. Yet, the IAT scores did show differences, with scores showing that physicians and residents had implicit preferences for the White patients. Participants with greater implicit preference for White patients (as reflected by IAT score) were more likely to select thrombolysis to treat the White patient than the Black patient [70]. This led to the possible conclusion that implicit racial bias can influence clinical decisions regarding treatment and may contribute to racial health disparities. However, some argue that using vignettes depicting hypothetical situations does not accurately reflect real-life conditions that require rapid decision-making under stress and uncertainty. PATIENTS’ PERCEPTIONS OF CARE It has been hypothesized that providers’ levels of bias affect the ratings of patient-centered care [34]. Patient-centered care has been defined as patients’ positive ratings in the areas of perception of provider concern, provider answering patients’ questions, provider integrity, and provider knowledge of the patient. Using data from 134 health providers who completed the IAT, a total of 2,908 diverse racial and ethnic minority patients participated in a telephone survey. Researchers found that for providers who scored high on levels of implicit bias, African American patients’ ratings for all dimensions of patient-centered care were low compared with their White patient counterparts. Latinx patient ratings were low regardless of level of implicit bias. A 2013 study recorded clinical interactions between 112 low-income African American patients and their 14 non- African American physicians for approximately two years [71]. Providers’ implicit biases were also assessed using the IAT. In general, the physicians talked more than the patients; however, physicians with higher implicit bias scores also had a higher ratio of physician-to-patient talk time. Patients with higher levels of perceived discrimination had a lower ratio of physician-to-patient talk time (i.e., spoke more than those with lower reported perceived discrimination). A lower ratio of physician-patient talk time correlated to decreased likelihood of adherence.
CLINICAL DECISIONS AND PROVIDER-PATIENT INTERACTIONS
In an ideal situation, health professionals would be explicitly and implicitly objective and clinical decisions would be com- pletely free of bias. However, healthcare providers have implicit (and explicit) biases at a rate comparable to that of the general population [6; 69]. It is possible that these implicit biases shape healthcare professionals’ behaviors, communications, and interactions, which may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions [69]. For example, physicians have been shown to minimize Black patients’ pain, ignore their complaints, and spend less time in examination rooms with them [111]. In a 2021 study, physicians were more likely to expect Black patients would not adhere to an HIV pre-exposure prophylaxis medication compared with White patients [112]. As a result, physicians were less likely to discuss available regimens with Black patients. They may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients’ trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up [7]. The adverse consequences of implicit biases between patients and practitioners emerge in the following areas [106]:
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