Diversity, Equality & Inclusion: Understanding Implicit Bias

Healthcare professionals are expected to practice cultural humility and provide patient-centered care to diverse individuals who have different cultural backgrounds than their own. Culture, however, is far broader than what many of us typically think of as cultural differences due to country of origin. For example, a white male Christian provider who grew up in affluence needs to practice cultural humility when caring for women, Muslims, non-whites, or those who are impoverished. While one may not know exactly what it's like to bear characteristics that do not apply to oneself, providers must be open-minded to understand the role of "culture," whatever its source, in patient disease presentation, illness experience and recovery trajectory. A critical step in cultural humility is understanding the insidious role of implicit bias in our everyday thoughts and actions.

We all have implicit bias shaped by our personal, social and cultural experiences. These unconscious stereotypes and prejudices influence our reactions to circumstances. We are unaware of such automatic assumptions about people and situations that in turn impact our decision-making and shape our daily actions. Having an implicit bias doesn't make someone a racist or mean a person is prejudiced against individuals who are unlike oneself. It does mean our lived experiences have resulted in unavoidable subconscious conditioning that can contribute to racial and socioeconomic disparities in health outcomes and systemic barriers to health equity. One of the biggest threats to equitable patient care occurs when healthcare professionals believe they don't have implicit bias, and that they treat every patient equally.

For several generations, providers have been making clinical decisions based on automatic assumptions about patients' social, cultural or economic backgrounds. The earliest research on the impact of implicit bias on patient care centered on race, and showed that when black and white patients presented with chest pain suggestive of a potential heart attack, white patients were far more likely to receive timely access to life-saving cardiac interventions. Additional research has shown the same race-based treatment patterns existing for a number of diseases. Implicit bias isn't only about race, however. It impacts assumptions, and consequently actions, about numerous characteristics, including gender, body size, sexual preference, religion and health behaviors. While we can't rid ourselves of implicit bias, taking the time to recognize it and checking one's assumptions can go a long way in combatting the effects on health outcomes.

Most providers lack the training and skills to implement cultural humility fully in their daily practice. Making providers aware of the need to treat patients equally is a potentially more effective strategy than attempting to eliminate implicit bias. Surgical professionals need to recognize that stereotypes and prejudices occur in everyday thinking, and that acknowledgment is the first step in overcoming these unconscious barriers to cultural competence.

Leaders with implicit bias adversly impact the hiring of a diverse workforce.

The Implicit Association Test measures attitudes and beliefs people may be unwilling or unable to report (osmag.net/U4ajAT). Taking the free test could reveal implicit attitudes of which you and your colleagues might not have been aware. This test is a good way to begin implicit bias training. Continuing with educational sessions conducted at least annually will help your team recognize biases they have, and therefore make them aware of the assumptions they make about certain patient characteristics. Providers who are more aware of these assumptions can act more deliberately to ensure they provide the same processes of care to all patients.

Approaching each patient interaction with empathy, showing compassion and having a sense of the patient's perspective are effective ways to counteract the impact of implicit bias. Surgical professionals can also improve how they communicate with diverse patient groups. For example, surgeons can employ the shared decision-making model, which involves asking patients to tell their story, openly and honestly sharing the risks and benefits of surgical procedures, making recommendations for treatment, asking patients for their preferred approach and arriving at a mutual decision about the best path forward.

It's challenging to definitively link implicit bias to adverse surgical outcomes, but patient care is negatively impacted if providers don't empathize with patients of all races, ethnicities, genders, sexualities and other characteristics. Implicit bias could also negatively impact quality communication and the sharing of information among a diverse group of healthcare providers. Although this factor has not been definitively studied, it's deserving of further research.

Discussions about racial and societal disparities in communities across the country have increased awareness about implicit bias and its impact on healthcare equality. The younger generation of healthcare providers is also pushing for change in established workplace cultures with respect to addressing implicit bias in the treatment of patients with various sociocultural backgrounds and growing an emphasis on practicing cultural humility. Continuing to increase awareness of unconscious prejudices and attitudes among surgical professionals will lead to improved access to care for all patients. OSM