Could Your Implicit Racial Bias Be Harming Your Patients?
How racism and bias impair healthcare delivery and lead to poor health outcomes.
This article provides an overview of the existence and role of racism in healthcare, how it manifests, and its negative impact on the healthcare of people in racial and ethnic groups resulting in health disparities. It includes a focus on provider-patient relationships and delves into how unconscious healthcare professional bias contributes to health disparities or inequities and offers strategies to address at the individual healthcare professional and organization level.
Racism is a serious threat to public health
Reviewed by Dr. Regina Hampton and Dr. Leanne Burnham
A groundswell of published research from leading organizations has revealed that racism, on its own, negatively affects the health outcomes of millions of Americans. These studies have shown that racial and ethnic minorities experience a lower quality of health service, higher rates of illness and death and are less likely to receive even routine medical procedures than are white Americans. Further, the impact of the COVID-19 pandemic revealed the severe effects on communities of color resulting in disproportionate case counts and deaths.
As the nations’ leading public health entity, the Centers for Disease Control and Prevention (CDC) declared racism to be a serious threat to public health on April 8, 2021, with this statement:
“Racism is not just the discrimination against one group based on the color of their skin or their race or ethnicity, but the structural barriers that impact racial and ethnic groups differently to influence where a person lives, where they work, where their children play, and where they worship and gather in community. These social determinants of health have life-long negative effects on the mental and physical health of individuals in communities of color… Over generations, these structural inequities have resulted in stark racial and ethnic health disparities that are severe, far-reaching and unacceptable.”
A comprehensive 2003 report requested by Congress, from the U.S. committee of the Institute of Medicine (now the National Academy of Science) titled: Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare brought to light the many racial and ethnic disparities in healthcare that were consistently evident across a range of illnesses and healthcare services.
The data from Unequal Treatment and other sources finds that Black, Indigenous, and People of Color (BIPOC), experience higher rates of illness and death across a wide range of health conditions, when compared to whites and the life expectancy of non-Hispanic/Black Americans is four years lower than that of white Americans.
BIPOC populations face a myriad of barriers and consequences connected to systemic racism, that negatively impact access to screening and prevention, access to timely treatment or overtreatment, access to clinical trials and centers of excellence and may experience higher rates of exposure to pollution and environmental toxins.
This occurs even when adjusting for socioeconomic differences and other health access related factors. The report found that racial and ethnic disparities in healthcare occur in the context of broader historic and current day social and economic inequality and found evidence of persistent discrimination in many sectors of American life.
Diminishing the impact of racism on health is even more critical as our nation becomes more diverse and multiracial. BIPOC or Hispanic/Latinx, Asian, Native American, or Alaska Native, Native Hawaiian or Pacific Islanders make up 43% of the U.S. population, an increase from 34% in 2010. (CNN, 2021)
The CDC and other medical professional and health organizations including the American Medical Association (AMA), the American Public Health Association (APHA) and the Harvard T.H. Chan School of Public Health have recognized the impact of racism on public health and announced their commitment to reducing racism in healthcare, along with plans of action and policies to advance health equity and reduce barriers to appropriate medical care.
A closer look: Health disparities associated with systemic inequality and racism
IOM’s Unequal Treatment report found some of the strongest evidence for healthcare disparities in cardiovascular disease for African Americans and Hispanics relative to whites, noting differences in treatment were not due to clinical factors and resulted in underuse of services by Blacks and overuse of services by whites.
Consider additional examples below:
Striking maternal-child health disparities exist for BIPOC women
Black, Alaska Native, and Native American women are two to three times more likely to die from pregnancy-related causes compared to white women. And for these same BIPOC groups over the age of 30, the pregnancy-related mortality rate increased to four to five times more likely than for white women.
In a comparison of educated women, Black women with at least a college degree had a pregnancy-related mortality rate 5.2 times that of white women with a college degree.
Clinical trial enrollment of racial/ethnic groups have decreased over the past two decades even in diseases in which minority populations are more likely to suffer worse outcomes. A 2020 review on reaching underrepresented populations in clinical trials revealed:
Black/African Americans make up 13.4% of the U.S. population, but only 5% of trial participants.
Hispanic/Latinx represent 18.1% of the U.S. population, but less than 1% of trial participants.
Healthcare professional bias is cited as a factor. As a result, healthcare professionals may withhold treatment based on preconceived notions about protocol adherence or neglect to share information about clinical trial options due to their own bias. This occurs even while the FDA has acknowledged there may be meaningful differences in responses to medications and incidence of adverse events.
Source: Representation in Clinical Trials: A Review on Reaching Underrepresented Populations in Research
Pronounced disparities in cancer morbidity and mortality exist in BIPOC populations in particular, with late-stage diagnosis of unscreened cancer and in disproportionately higher cases in Black and Brown communities.
| Pronounced Disparities | Research Highlights From Pro Hub, Health Equity-Focused Health Professionals | |
| Colorectal cancer |
|
What Disparities Are Seen in Colorectal Cancer? – Folasade May, MD, PhD |
| Prostate cancer |
|
Screening Strategies Could Reduce Prostate Cancer Mortality, Overdiagnosis Among Black Men - Yaw Nyame MD, MS, MBA, MHSA |
| Breast cancer |
|
Breast Cancer in Men and Clinical Trial Disparities - Wendy Woodard MD, PhD |
| Multiple myeloma |
|
Joseph Mikhael, MD, MEd, FRCPC, FACP |
Digging Deeper: Racism is an obstacle to achieving health equity
Racism is a system, and it can’t be undone unless we recognize its existence, how it functions and is perpetuated. The CDC describes racism as “a system of structures, policies, practices, and norms, that assign value and determine opportunity based on the way people look or the color of their skin. Racism is both interpersonal and structural, negatively affecting the mental and physical health of millions of people, preventing them from attaining their highest level of health.
As in many areas of American life, racism exists in healthcare and creates differences that affect the quality of healthcare beyond access-related factors. The operation of the healthcare system and discrimination at the individual, patient-healthcare professional level results in biases, prejudices, stereotyping, and variability in clinical communication and decision-making that can lead to disparities or inequities in healthcare and poorer outcomes for BIPOC people.
The goals of Healthy People 2030, a federal initiative measuring improvements in the health of the U.S. population incorporate the five domains of the Social Determinants of Health (SDOH) as key drivers of health equity: economic stability, education access and quality, healthcare access and quality, neighborhood environment and infrastructure, and social and community context. The SDOH contributes to and affects an individual’s ability to experience health and well-being. Racism, discrimination, and violence are interconnected components of the social determinants of health that can increase risk for poor health outcomes.
Racial bias in clinical practice is a persistent cause of healthcare disparities. We can’t have a conversation about health disparities without addressing bias. While race is not a meaningful scientific construct or a biologic category, it is a relevant socio-cultural concept. In the context of medicine, genetic variations within populations are relevant to clinical decision-making, treatment response and survival. A racial identity does not reflect innate differences that produce unequal health outcomes. Yet medical education continues to use race as a meaningful, inherent biological factor. As a result, physicians are trained in ways that inadvertently pathologize race in medicine, are exposed to highlighted racial differences without context, and epidemiologic data that misrepresents and misinterprets race-based data, ultimately encouraging forms of explicit and implicit or unconscious bias and affecting the delivery of medical care. For example, a study examining over 880 lectures from 21 courses in one institution’s preclinical medical curriculum as well as in the authors’ institutions found misrepresentation of race across five key domains:
Semantics – using imprecise and non-biologic labels that mix or confused race and ancestry
Prevalence without context – discussing racial and ethnic differences in prevalence for a disease without context, history, or social determinant causes
Race-based diagnosed bias – linking racial groups and particular diseases priming students to associate the disease with race instead of relevant factors
Pathologizing race – a tendency to link or associate BIPOC groups with increased disease burden
Race-based clinical guidelines - biased data on race in diagnostic and clinical calculators and guidelines can lead to differences in treatment that are not evidence-based. For example:
The eGFR (estimated glomerular filtration rate) relies on false assumptions about race and muscle mass distorting the assessment of kidney function in Black patients. Anyone identified as Black receives a higher eGFR suggesting better kidney function.
This and 20 widely used clinical algorithms embed “outdated, suspect racial science or biased data” according to an analysis published in August 2020 in the New England Journal of Medicine (NEJM), Hidden in Plain Sight – Reconsidering the Use of Race Correction in Clinical Algorithms. The analysis suggested that many race-based algorithms have the effect of directing more attention and resources to white patients than BIPOC patients.
Find the list of race-based algorithms that may perpetuate race-based health inequalities in the Learn More, Take Action section.
Healthcare professionals’ implicit bias is a contributing cause of healthcare disparities
Unconscious or implicit bias involves associations or attitudes toward a group that unknowingly alter the individual’s perceptions. Even people who endorse equality and impartiality and are well-meaning may demonstrate unconscious negative racial attitudes and stereotypes. Healthcare professionals’ unconscious bias towards racial and ethnic groups can unwittingly influence their medical decisions, provider-patient relationships and the quality of care received by BIPOC patients. The article “Why the Color of Your Skin Can Affect the Quality of Your Diagnosis” from the Society to Improve Diagnosis in Medicine, explores how physicians are reluctant to acknowledge that their biases affect their diagnostic decisions and that racial implicit bias most often leads to dismissing the patient’s information and minimizing degree and significance of pain.
There is strong evidence of unconscious bias among healthcare professionals.
While studies have not determined the degree to which unconscious bias affects clinical decision-making, there is strong evidence confirming unconscious bias among healthcare professionals does affect behavior and judgment. This dynamic is compounded by the time and resource constraints that exist in the healthcare setting, reliance on automatic associations, stereotypes and medical mnemonics based on disease prevalence data alone. Unconscious bias towards patients may occur related to the individuals’: race/ethnicity, gender, gender identity, sexual orientation, socioeconomic status, age, language spoken, weight, HIV status, injection drug use, and disability.
Consider some of the data on healthcare professional bias:
A systemic review of research between 2015 – 2016 on implicit bias in health care disparities found 31 studies demonstrating evidence of:
Pro-white or light-skin positive bias and anti-Black, Hispanic, Native American or dark-skin negative bias among a variety of healthcare professionals across disciplines and levels of training and that correlates with poorer patient-healthcare professional interactions.
A validated tool developed by Harvard researchers for measuring healthcare professional bias, the Implicit Association Test (IAT) has been extensively studied and provides feedback on an individual’s degree of bias. Many studies on implicit bias use the IAT.
The Race IAT captures reaction time, word, and picture associations to assess preferences, attitudes, and beliefs. Automatic associations uncover deeply held beliefs the individual is unable or unwilling to acknowledge.
According to Harvard’s Project Implicit, the Race IAT has been taken over 4 million times between 2002 and 2017 and 75% of test takers demonstrate an automatic white preference, and associate white people with goodness and Black people with badness. These results can signal potential discriminatory behavior even when the individual does not outwardly or explicitly express negative racial views.
Find the link to the IAT for self-test and reflection
From the patient perspective: Patient surveys conducted by health policy and research organizations corroborate that BIPOC patients: perceive healthcare professional implicit bias and experience impaired provider-patient relationships and expressed less satisfaction with their care.
A 2013 study conducted by Kaiser Permanente and Denver Health compared 2,908 patients’ primary care assessment surveys against their 134 primary care providers completed explicit and implicit ethnic/racial bias tests.
The surveys found that primary care providers (physicians and nurses) with greater implicit bias measured by the IAT, were rated lower in patient-centered care by their Black patients as compared to a reference group of white patients.
Approximately two-thirds of the healthcare professionals IAT tests showed moderate to strong implicit bias against Blacks and Latinos, yet these healthcare professionals reported low rates of explicit bias against these groups.
The stronger the implicit bias healthcare professionals showed for whites, the lower their Black patients rated their delivery of patient-centered care.
Latino patients gave their healthcare professionals lower patient-centered ratings, but they were not found to depend on health professionals’ implicit bias. Researchers posited this could be due to the way bias is expressed and patients’ sensitivity to it.
A 2020 national Coronavirus Tracking Survey conducted by the Urban Institute’s Health Policy Center evaluated patients’ perceptions of discrimination and unfair judgement while seeking health care during the prior twelve months. The experience of discrimination or unfair judgement undermines trust, treatment adherence and care follow-through.
Overall, 5.1% of nonelderly adults report having been discriminated against or unfairly judged by healthcare professionals. Race or ethnicity was the most common reason reported for perceived discrimination or unfair judgement.
Black adults reported being discriminated against or unfairly judged by healthcare professionals and their staff at a rate almost three times higher than that of white adults and twice as high as Latino/Hispanic Adults.
Black women (13.1%) and Black adults of low incomes (14.6%) reported the highest levels of discrimination or unfair judgment.
To hear patients, tell their stories of unequal treatment in their own words, visit Our Stories.
What you and your institution can do to diminish implicit bias in healthcare
We can agree all patients have a right to receive consistent, evidence-based, high-quality, and culturally effective health care. However, when patients experience a clinical encounter as negative due to healthcare professional bias, a host of inter-related undesired circumstances may occur i.e., mistrust, and/or treatment refusal, ultimately leading to disparities and poorer outcomes. It is therefore incumbent upon healthcare professionals to manage their own expectations, beliefs, attitudes, and behaviors that influence the provider-patient relationship.
These categories of evidence-based interventions have demonstrated results in reducing healthcare professionals’ racial and ethnic biases: diversity training, patient simulations, feedback-based learning, peer clinical networks; and diversifying healthcare teams including to increase representation, mentorship, and mentorship training workshops.
Healthcare professionals’ strategies to address implicit bias and improve health equity:
Consider these steps you can take now to recognize and reduce your own bias:
Bias awareness: As an individual, Identify and self-reflect on your own implicit bias
Consider taking the IAT to identify and reduce your biases, then actively or consciously challenge your assumptions. Keep in mind the impact of your interactions with patients are what they will experience and not your intentions.
Develop a mindset of cultural humility a key aspect of a successful patient-provider relationship, which involves continuous learning, openness and sensitivity to others experiences and cultures. This approach means you respect patients and their cultures and try to understand them as learners not experts as you deliver health care.
Retrain your brain: Make small behavior changes that help retrain your brain, diversify professional and personal contacts, seek out books, articles etc. by authors of diverse ethnic and cultural backgrounds to enhance your exposure and understanding of other cultures.
Continue to build on and advance your understanding and recognition of your own implicit bias, and the role of individual and systemic or structural racism in healthcare via continuing education and other webinars programs on advancing health equity, diversity, and inclusion offered by a range of health professional and non-profit organizations.
Make a commitment to health equity by joining Diverse Health Hub’s Pro Hub, a group of health equity focused health professionals who have signed an affirmation of commitment to patient education, advancing inclusive research and providing the highest quality care to patients. https://www.diversehealthhub.org/provider-portal/pro-hub. DHH collaborates with the experts to break down their publications for patients.
Healthcare organizations’ strategies for mitigating implicit bias and improve health equity:
Increase institutional awareness of disparities in BIPOC healthcare
Foster institutional cultural and behavior change by:
Leadership demonstrating a long-term commitment to a culture of change
Identifying areas for improvement, change cultural communication, bring in expertise, provide resources to commit to antiracism learning, create multi-level long term accountability and change
Intentional group diversification of healthcare professional staffing
Utilizing data collection and monitoring by racial and ethnic group to assess progress in reducing healthcare disparities
Offer ongoing healthcare professional and allied healthcare professional trainings on unconscious bias and promotion of cultural humility
Update medical training for current and future healthcare professionals:
Include evidence-based bias reduction strategies into training programs and memberships
Evaluate and revise medical school curriculum along the five domains outlined that foster race-based biases among medical professionals.
Consider engaging the expertise of Diverse Health Hub’s Health Equity Emissary Team (HEET) to help your organization. HEET works with healthcare advocacy organizations to address health disparities, improve health outcomes, and spotlight the needs of diverse health communities. https://www.diversehealthhub.org/health-equity-initiatives
Learn More, Take Action
AMA – Center for Health Equity and Health Equity Education Center
https://edhub.ama-assn.org/ama-center-health-equity
https://edhub.ama-assn.org/health-equity-ed-center
CDC: Racism and Health
https://www.cdc.gov/healthequity/racism-disparities/index.html
Diverse Health Hub: Health and Equity Disparities Hub
https://www.diversehealthhub.org/provider-portal/topic-hubs/health-and-equity-disparities
Misrepresenting Race — The Role of Medical Schools in Propagating Physician Bias
https://www.nejm.org/doi/full/10.1056/NEJMms2025768
Project Implicit - Online Implicit Association Test (IAT)
