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Implicit Bias In Healthcare

writtenByWritten by: Riley McCabe
Riley McCabe

Riley McCabe

Riley has a background in international affairs and enjoys writing about health and public policy subjects. He hopes his work will provide readers with the tools to live happily.

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July 21, 2020 Read Time - 9 minutes

Implicit Bias In Healthcare

Implicit bias refers to subconscious associations that can lead to negative evaluations of a person based on characteristics such as race or gender. Such implicit associations between individuals and categorical attributes may influence our judgment, regardless of intentions. Hidden biases can help explain the gap between what a person wants to do (eg. treat everyone equally) and the way they act.

We commonly think of such patterns as stereotypes and prejudices held against people of a certain race, ethnicity, gender, sexual orientation, or ability. In addition to affecting our judgment of people, implicit biases manifest in non-verbal behaviors towards others. Someone may avoid eye contact or keep physical distance based upon implicit biases

In healthcare, we need to carefully consider the impact of implicit biases. After all, our industry is founded on the idea that all people are deserving of proper and equal treatment. In order to fulfill this goal, we have an obligation to examine the implicit biases that result in negative evaluations of our patients and inequity in patient outcomes.

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Implicit Bias in Patient Care

Numerous studies have demonstrated the influence of implicit biases against categorical groups of people that usually go unreported or unrecognized.

For example, a study published in the American Economic review found that simply changing white-sounding names to black-sounding names on identical resumes in the United States has a negative effect on the number of callbacks. Such implicit biases are a reflection of a greater problem in America. Unsurprisingly, these prejudices are not left at the door when healthcare professionals enter their workplace.

Studies have also demonstrated the effect of implicit biases in patient care. Extensive research has repeatedly found that people of color face disparities in access to health care, the quality of care received, and health outcomes in the United States. The attitudes and behaviors of healthcare providers are identified as a factor contributing to these disparities, and such attitudes are often informed by implicit biases.

For example, black women are three to four times more likely to die from pregnancy-related causes than white women, according to the Center for Disease Control and Prevention. This is a big reason why the overall rate of pregnancy-related deaths has increased in the last 20 years, making the United States’ maternal mortality rate the highest in the industrialized world.

Implicit biases have a role to play in these figures according to an interview for the American Heart Association with Dr. Ana Langer, director of the Women and Health Initiative at the Harvard T.H. Chan School of Public Health in Boston. “Basically, black women are undervalued. They are not monitored as carefully as white women are. When they do present with symptoms, they are often dismissed.”

In 2017, when Serena Williams reported that she was experiencing a pulmonary embolism to nurses a day after giving birth to her daughter, her concerns were initially dismissed. Even successful, affluent black women are subject to the implicit bias of healthcare professionals which jeopardizes their safety and ultimately many lives.


Read: COVID-19 Impact on Black Communities


In 1999, a study published in the New England Journal of Medicine demonstrated the role of implicit bias in general physician care. Researchers hired actors to portray patients with particular characteristics and symptoms in scripted interviews with 720 physicians. Controlling for factors that would influence the likelihood of coronary artery disease, the study found that the race and sex of the patient independently influenced how physicians manage chest pain.

When patients were portrayed with identical medical histories and symptoms, non-white women were far less likely to receive recommendations for cardiac catheterization than their white counterparts.

To control for the possibility that the recommendations of the doctors could have reflected perceptions of personalities rather than race or sex, researchers surveyed physicians about each patient after their interview. Incorporating these assessments into the study did not change the central findings that non-white women received worse quality of care on account of their race and gender.

Today, this problem still exists. In 2015, a comprehensive review of 15 studies in the American Journal of Public Health found that implicit biases in healthcare professionals were similar to that of the general population. Most healthcare providers were found to have an implicit bias of positive attitudes towards white patients and negative attitudes towards patients of color.

From the 2015 report, “Although some associations between implicit bias and health care outcomes were nonsignificant, results also showed that implicit bias was significantly related to patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes.” Such biases not only leave people of color generally less satisfied with their interactions in healthcare but also at greater risk of illness due to inadequate treatment.

On the whole, people of color experience disparities of morbidity, mortality, and health status. According to that same 2015 study, “Black Americans, Hispanic Americans, and American Indians have higher infant mortality rates than White and Asian Americans.”

Further, black Americans suffer from the highest rates of premature deaths related to heart disease and stroke. “In addition, numerous disparities in health conditions and risk behaviors exist among people of color, including asthma, cigarette smoking, diabetes, early childbearing, HIV/AIDS, hypertension, low birth weight, obesity, periodontitis, preterm births, and tuberculosis.” Despite the steady advancement of treatments and healthcare practices over time, the outcomes of patients are still defined by racial and gender disparities.

Healthcare Reform to Address Implicit Bias

Implicit biases can be especially hard to address because of their covert nature. However, the healthcare industry must tackle its contributions to inequity head-on. Here, we’re going to discuss some of the ways we can begin taking on the challenge.

Bias Training

Implementing bias training programs into medical, nursing, and other health schools is the first step to raise awareness of this issue and begin challenging healthcare professionals to address their own biases. All clinicians and personnel interacting with patients need not only to be made aware of this issue but equipped to handle it.

Diversify the Pipeline

If we want to create a healthcare industry that reflects and supports the diversity of our patients, expanding the career pipeline must be a long-term goal. If medical schools are interested in increasing the number of black, Latinx, and other racial minorities at their institutions, they need to create relationships with colleges and high schools to identify and mentor prospective students.

Further, the cost of a medical education is too great a barrier for many students who have no relationship with the medical community. Providing mentors and outreach that can help students understand the process of receiving and paying off student loans is just the first step. The greater challenge will be generating investments to lessen the burden of medical school costs, especially for marginalized communities who do not have a family member working in medicine.

Using Data

The healthcare industry can utilize data to combat inequity like never before. Surveying and tracking performance outcomes are critical for addressing these issues comprehensively. Delivery systems must use all available data to continuously conduct subgroup analyses of their patients. Such information can reveal whether individuals across demographic characteristics are receiving the equitable care they deserve.

  • Book on our free mobile app or website.

    Our doctors operate in all 50 states and same day appointments are available every 15 minutes.

  • See a doctor, get treatment and a prescription at your local pharmacy.

  • Use your health insurance just like you normally would to see your doctor.

Book an appointment PlushCare-App-Steps

This Problem is Bigger Than Just Doctors

Doctors show similar rates of implicit biases as the average person. If we want to change the way biases influence healthcare, we have to acknowledge that such biases are not limited to the walls of a hospital room. Rather, a more holistic view of the entire healthcare industry, and indeed society, is necessary. A true, comprehensive approach to health equity demands reform of the social and economic factors that are responsible for creating marginalized people who in turn become marginalized patients.

In healthcare, the reasons for racial disparities are complicated. However, the two biggest factors are a lack of access and poor quality of care. In this article we have considered just a few of the ways implicit biases influence quality of care. Our mission must also be to understand how marginalized communities in America have less access to care.

In short, improving the attitudes of doctors can only do so much when specific communities around the country have less access to necessary treatment, education, and wealth. While outcomes in health need to be improved by reducing the negative implicit biases associated with race, sex, gender, and ethnicity, the work does not end there.

That’s why PlushCare is working to provide telehealth services at affordable costs to all who need it. Telehealth is built on the idea of expanding access to care: anywhere you can get online, you can consult a doctor. We’re working every day to reach communities that are deprived of proper treatment by making it simpler and less expensive to speak with medical professionals.


Read: Doctors For Patients Without Insurance


By empowering patients with better access to care, telehealth also improves patient outcomes. For example, data shows medication adherence rates of 90% for those enrolled in PlushCare’s online PrEP program. That means marginalized LGBTQ+ and black communities who are most at risk of HIV/AIDS have improved patient outcomes when using telehealth services.

We are only just beginning to realize telehealth’s potential to combat health inequity. Acknowledging the role of implicit biases is the first stop on a very long road for the health industry. Implementing adequate training, tracking patient outcomes, and increasing access to care must be our mission today and always.


Read More About Implicit Bias in Healthcare


Sources

ncbi.nlm.nih.gov. Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. Accessed on July 11, 2020. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5333436/#CR8

healthaffairs.org. It’s Time To Address The Role Of Implicit Bias Within Health Care Delivery. Accessed on July 11, 2020. https://www.healthaffairs.org/do/10.1377/hblog20200108.34515/full/

nejm.org. The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization. Accessed on July 11, 2020. https://www.nejm.org/doi/10.1056/NEJM199902253400806?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dwww.ncbi.nlm.nih.gov

heart.org. Why are black women at such high risk of dying from pregnancy complications? Accessed on July 11, 2020. https://www.heart.org/en/news/2019/02/20/why-are-black-women-at-such-high-risk-of-dying-from-pregnancy-complications

Most PlushCare articles are reviewed by M.D.s, Ph.Ds, N.P.s, nutritionists and other healthcare professionals. Click here to learn more and meet some of the professionals behind our blog. The PlushCare blog, or any linked materials are not intended and should not be construed as medical advice, nor is the information a substitute for professional medical expertise or treatment. For more information click here.

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