Provider Implicit Bias: Bringing Awareness to Clinical Practice

Black Americans are at greater risk for early mortality and morbidity from a range of health conditions, such as diabetes, hypertension, obesity, asthma, heart disease, and certain cancers, compared with White Americans.^1,2

Evidence suggests these health disparities stem from structural racism, as well as provider implicit bias or unconscious bias, that factors into judgments and influences clinical decision-making.¹

Moreover, these health disparities cannot be accounted for by socioeconomic factors alone. The COVID-19 pandemic further underscored these health disparities, as minority populations were disproportionately affected by the illness in the first 2 years of the pandemic.¹

Health Disparity: Part of American History

Prior to the Civil War, physicians, scientists, and slave owners perpetuated beliefs in the physical dissimilarities between Black and White populations as a way to justify slavery.³ These beliefs are still held today. A 2016 survey found that almost 50% of White medical students and residents admitted to false beliefs regarding biologic variances between White and Black patients.⁴

It is crucial to understand racial inequalities in medical treatment. The term “racism” refers to a system based on a discriminative mentality that classifies and ranks the human population in stereotypical ways and allocates societal resources accordingly (Table 1).^5,6 At the individual level, this may or may not be accompanied by bias, whether conscious or unconscious. These untrue opinions may influence medical decisions and contribute to racial disparities in health-related outcomes.^3-4

Table 1. Definitions^5,6

Race	Any one of the groups that humans are often divided into based on physical traits regarded as common among people of shared ancestry
Racial disparity	The imbalances and incongruities between the treatment of racial groups including economic status, income, housing options, societal treatment, safety, and other aspects of life and society
Racism	A system based on a discriminative mentality that classifies and ranks the human population in stereotypical ways and allocates societal resources accordingly
Implicit bias	A bias of prejudice that is present but not consciously held or recognized

Distrust of the medical profession by Black patients can be traced back to when Black individuals were used for experimental procedures, surgeries, and dissections. For example, in the 1800s, James Marion Sims, MD, known as the “father of modern gynecology,” performed gynecologic surgical procedures on unanesthetized Black women.⁵ More recently, the Tuskegee Syphilis Study has contributed to fear and mistrust among patients and vestiges of the belief that Black people are less than human, which is still rooted in America today.⁷

Distrust of medical professionals, false beliefs, social disadvantages, clinician bias, and a discriminative health care system all contribute to ethnic and racial disparities. According to Fiscella and Sanders, “Separate and unequal systems of health care between states, between health care systems, and between clinicians constrain the resources that are available to meet the needs of disadvantaged groups, contribute to unequal outcomes, and reinforce implicit bias.”⁸

To counter implicit and unconscious bias, initiatives beyond diversity and cultural competency training are needed. Health care providers can positively impact disparities by building trust and respect while promoting equity and justice in the health care system. Medical students should be offered courses that promote cultural awareness in patient care and help to develop vital communication and clinical skills related to reducing negative associations, which can affect judgment and behavior.⁹

Health Disparities Related to Implicit Bias

Implicit bias refers to an individual’s unconscious or conscious perceptions, stereotypes, and beliefs of others. Subconscious beliefs can cause one to speak or act in ways contrary to their conscious principles. These biases can be positive or negative and may raise serious concerns in health care. The implicit bias of health care providers can adversely affect their medical decision-making, severely impacting an already underprivileged population.¹⁰

Maina et al found that 8 of 14 studies (57%) that explored the relationship between implicit bias and health care outcomes using clinical scenarios or simulated patients found no statistically significant relationship between implicit bias and patient care.¹⁰ However, 6 studies found that higher implicit bias was correlated with disparities in treatment recommendations, expectations of therapeutic bonds, pain management, and empathy. Half of the studies examined the impact of implicit provider bias on real-world, patient-provider interaction and found that providers with more pronounced implicit bias demonstrated worse patient-provider communication.¹⁰

A provider’s ability to empathize with a patient can enhance their ability to deliver high-quality and competent care. A positive interaction between clinicians and patients can influence the likelihood of a patient adhering to medical treatments. It also helps these patients understand and participate in their care. However, Roberts et al found that patients with low socioeconomic status rated their clinicians’ empathy scores lower than did patients who did not have low socioeconomic status (mean difference, -0.87 [95% CI, -1.72 to -0.02]).¹¹

Moreover, race or ethnicity is also factored into some of the strategies and calculations applied by practitioners when administering treatment and medications. As a result of this implicit bias, Black patients may be less likely to receive specific medicines, transplants, and specialist referrals. For example, study findings show that minorities are less likely to be prescribed pain relief medications. Specifically, an analysis of data from 350 emergency departments in the US found that non-White patients were 22% to 30% less likely to receive analgesic medication and 17% to 30% less likely to receive opioids compared to their White counterparts.¹²

Another trickle-down effect of implicit bias is that a health care provider might not issue a referral for an uninsured patient to a specialty clinic if there is no system of care for uninsured patients in the local community. In addition, a patient may not visit a specialist if the clinic is too far away from their home or if the out-of-pocket costs are too high. Also, minority populations often have limited access to health care, particularly preventative care, early intervention, and effective management of chronic illness, which play a fundamental role in optimal health-related outcomes. As a result, disparities in the quality and quantity of treatment among different racial and ethnic groups contribute to racial health disparities.

Even among minority patients who do have access to health care, the quality of that care is decreased compared with that among White patients. The 2021 National Healthcare Quality and Disparities Report found worse quality of care among Black vs White patients for 11 out of 29 (38%) patient safety measures, 18 out of 43 (42%) effectiveness of care measures, and 32 out of 72 (44%) healthy living measures (Table 2).¹³

This article originally appeared on Clinical Advisor