Although implicit bias and unconscious associations can be a subtle influence on cognition and behavior, their impact on decisions can be significant. 8,9 Recently, an increasing number of states have enacted legislation recognizing the criticality of implicit bias in healthcare. The following is an example from California. 10
(e) Implicit gender bias also impacts treatment decisions and outcomes. Women are less likely to survive a heart attack when they are treated by a male physician and surgeon. LGBTQ and gender-nonconforming patients are less likely to seek timely medical care because they experience disrespect and discrimination from healthcare staff, with one out of five transgender patients nationwide reporting that they were outright denied medical care due to bias. (f) The Legislature intends to provide specified healing arts licensees with strategies for understanding and reducing the impact of their biases in order to reduce disparate outcomes and ensure that all patients receive fair treatment and quality healthcare. The process of implicit bias in no way diminishes the importance of conscious, deliberate behavior. Physicians’ conscious endorsements of the values of equity and fairness can be an important element of their service to patients. In addition to deeply held values, creating equitable healthcare environments requires physicians’ conscious actions to build systems and processes that move them towards the elimination of disparities. It is not only the responsibility of those with particular titles, like a chief diversity officer, but all healthcare providers must be “activists” in their own areas of work: in the treatment room, in the laboratory, or in the administrative suite. The focus on implicit bias does not absolve providers of conscious, focused, deliberate action, it simply highlights an important parallel process.
As toddlers and older children begin to spend time online, watch television, and read books, they sense the race or gender of the people who tend to be in leadership roles, those who appear dangerous, those who are police and fire people, those who are doctors, etc. Inequities and biases in the broader society get incorporated into media, which get consumed by children, whether intentionally or not. These portrayals then influence and shape unconscious associations in children of all ages. 13 Children are also influenced by the behavior of parents, caregivers, and other significant adults in their life, noticing the complexion and gender of their close friends, as well as comments and jokes. It’s not only the things that parents and caregivers say to convey fairness and kindness for all people, but it’s also what children observe day-to-day in the behavior of those adult models. 14 The process of unconscious associations can also be seen in the way adults begin to view and interact with children. In a study at the Yale Child Study Center in 2016, preschool teachers viewed videos of African American and White children walking around a classroom, talking, and interacting with each other 15 . The viewing device also recorded who and what the teachers were looking at during the study. When teachers then were told that there might be challenging behavior, the device revealed that they began to look at and track the African American children. Further, their eyes tracked the African American boys more than the other children. The teachers did not have any conscious idea of their viewing behavior. Adult Research Within the racial history of America, the complexion of African American people has always been a complex dynamic. The One Drop Rule, in practice and then in law, has existed since Africans were forcibly brought to this country. Interracial relationships, both forced and voluntary, resulted in bi-racial children and adults. Essentially, any African ancestry (“one drop of African American blood”) classified an individual as African American. 16 In addition, lighter-skinned African Americans were sometimes viewed as slightly higher in status than darker-skinned African Americans. Darker-skinned African Americans often had fewer employment opportunities and were treated more harshly. Although the deliberate disparate treatment of light-skinned and darker-skinned African Americans has significantly diminished, unconscious bias related to the complexion of people still exists in many sectors of American society. Hiring and promotions of African Americans can sometimes be significantly influenced by implicit racial bias related to complexion. 17,18 In one experiment, subjects were sent to one of two rooms. In one room subjects saw the subliminal presentation of the word “ignorant” on a screen, followed by the subliminal presentation of the face of an African American male. In the other room, subjects saw the subliminal presentation of the word “educated” and the subliminal presentation of the face of the same man.
Assembly Bill No. 241 Chapter 417
An act to amend Sections 2190.1 and 3524.5 of, and to add Section 2736.5 to, the Business and Professions Code, relating to healing arts. [Approved by Governor October 02, 2019. Filed with Secretary of State October 02, 2019.] LEGISLATIVE COUNSEL’S DIGEST This bill would require the Board of Registered Nursing, by January 1, 2022, to adopt regulations requiring all continuing education courses for its licensees to contain curriculum that includes specified instruction in the understanding of implicit bias in treatment. Beginning January 1, 2023, the bill would require continuing education providers to comply with these provisions and would require the board to audit education providers for compliance with these provisions, as specified.
THE PEOPLE OF THE STATE OF CALIFORNIA DO ENACT AS FOLLOWS:
SECTION 1. The Legislature finds and declares all of the following: (a) Implicit bias, meaning the attitudes or internalized stereotypes that affect our perceptions, actions, and decisions in an unconscious manner, exists, and often contributes to unequal treatment of people based on race, ethnicity, gender identity, sexual orientation, age, disability, and other characteristics. (b) Implicit bias contributes to health disparities by affecting the behavior of physicians and surgeons, nurses, physician assistants, and other healing arts licensees. (c) Evidence of racial and ethnic disparities in healthcare is remarkably consistent across a range of illnesses and healthcare services. Racial and ethnic disparities remain even after adjusting for socioeconomic differences, insurance status, and other factors influencing access to healthcare. (d) African American women are three to four times more likely than White women to die from pregnancy-related causes nationwide. African American patients often are prescribed less pain medication than White patients who present the same complaints, and African American patients with signs of heart problems are not referred for advanced cardiovascular procedures as often as White patients with the same symptoms.
Early Childhood Research
One of the important areas of implicit bias research focuses on the question, how early in one’s development does implicit bias begin to show up? Recent research suggests that the foundation for what later shows up as implicit bias occurs in infancy. For example, if we track the eyes of infants, at about four weeks of age they will stare longer and more frequently at female faces if a woman has been the primary caregiver. This is clearly not implicit bias, but it appears to reflect a differential association or a preference. This process of differential response in terms of what types of faces infants tend to stare at continues to evolve. 11,12 Although care has to be taken to not infer bias from infant behavior, it appears that responsiveness to faces that are similar to the infant or the individual who provides nurturing/food may be a precursor to preferences later in development. Did you Know? Much of the research on implicit bias has only occurred in the last 40 years. It has provided increasing support for theories related to the development of implicit biases and ways in which unconscious biases impact decision making.
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