___________________________________________________________________ Implicit Bias in Health Care
• Treatment adherence and practitioners’ views of patient’s likelihood to adhere to treatment • Practitioners’ clinical decision-making
the part of the physicians in the visits with Black patients and 11% greater in interactions with White patients. Physicians with higher implicit bias scores and lower verbal dominance also received lower scores on patient ratings on interpersonal care, particularly from Black patients [72]. In focus groups with racially and ethnically diverse patients who sought medical care for themselves or their children in New York City, participants reported perceptions of discrimi- nation in health care [73]. They reported that healthcare pro- fessionals often made them feel less than human, with varying amounts of respect and courtesy. Some observed differences in treatment compared with White patients. One Black woman reported [73]: When the doctor came in [after a surgery], she pro- ceeded to show me how I had to get up because I’m being released that day “whether I like it or not”… She yanked the first snap on the left leg…So I’m thinking, ‘I’m human!’ And she was courteous to the White lady [in the next bed], and I’ve got just as much age as her. I qualify on the level and scale of human being as her, but I didn’t feel that from the doctor. Another participant was a Latino physician who presented to the emergency department. He described the following [73]: They put me sort of in the corner [in the emergency department] and I can’t talk very well because I can’t breathe so well. The nurse comes over to me and actually says, “Tu tiene tu Medicaid?” I whispered out, “I’m a doctor…and I have insurance.” I said it in perfect English. Literally, the color on her face went completely white…Within two minutes there was an orthopedic team around me…I kept wonder- ing about what if I hadn’t been a doctor, you know? Pretty eye opening and very sad. These reports are illustrative of many minority patients’ expe- riences with implicit and explicit racial/ethnic biases. Not surprisingly, these biases adversely affect patients’ views of their clinical interactions with providers and ultimately contribute to their mistrust of the healthcare system.
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. Another study assessed 40 primary care physicians and 269 patients [72]. The IAT was administered to both groups, and their interactions were recorded and observed for verbal domi- nance (defined as the time of physician participation relative to patient participation). When physicians scored higher on mea- sures of implicit bias, there was 9% more verbal dominance on
DEVELOPMENTAL MODEL TO RECOGNIZING AND REDUCING IMPLICIT BIAS
There are no easy answers to raising awareness and reducing health providers’ implicit bias. Each provider may be in a differ- ent 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
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