A group of researchers at an academic medical center are conducting research on implicit bias in 200 emergency medicine trainees. A survey is administered, asking respondents to agree or disagree with the following statements: "I believe in offering equitable care to patients regardless of ethnicity"; "My patients' ethnicity does not influence my quality of care." One hundred percent of respondents agree with both statements. Subsequently, a computerized implicit bias test is administered. The test displays images of faces from either a minority or nonminority ethnic group, alongside a list of positive or negative words, such as "cooperative," "noncompliant," or "drug-seeking." Respondents are asked to quickly match one word to each face, and differences in response times for positive or negative associations by ethnicity are measured. Results show 76% of respondents more rapidly associate the minority ethnicity with "noncompliant" and "drug-seeking." Which of the following is the best next step?
Implicit bias | |
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*Examples include computerized, image-based sequential priming tests. | |
Implicit bias describes subconscious alterations in thoughts and attitudes toward specific groups (eg, ethnicity, socioeconomic status, age). As seen in this study, implicit bias contrasts with explicit discrimination: All respondents (100%) consciously expressed commitment to equity, but 76% demonstrated unconscious, implicit bias by more rapidly associating faces belonging to the ethnic minority group with negative words (eg, "drug-seeking"). Implicit bias perpetuates health disparities by subtly but systematically altering provider-patient interactions (eg, communication style, diagnostic workup); therefore, organizational action addressing implicit bias is indicated (Choice C).
According to the Joint Commission, implicit bias can be addressed by the following measures:
Assess for bias: Implicit bias uses heuristics (eg, fast thinking or mental shortcuts); therefore, it is frequently measured using rapid image association tests (eg, Implicit Association Test), as described in this study.
Encourage awareness and collaborative discussion of implicit biases: In this case, group debriefing on the study results is the best next step.
Train clinicians in metacognition (ie, self-monitoring cognitive patterns): This process can reduce automatic, unconscious reliance on stereotypes and flawed patterns (common in complex, busy settings).
(Choice A) Anonymous error-reporting portals are important but address only visible, overt discrimination, which is not evident in this study. Portals are less likely to detect or address implicit bias, which exerts subtle, less visible influences on provider-patient interactions (eg, spending less time with a patient of a group perceived to be noncompliant).
(Choice B) Organizational guidelines can promote a culture of health equity; however, as seen in this study, providers often believe they already offer equitable care (despite having implicit bias). Moreover, providers are often unaware of how their unconscious attitudes influence care outcomes. Therefore, small group debriefing is a superior next step in promoting awareness and discussion of implicit bias.
(Choice E) Providers are often unaware of their implicit biases and can experience distress upon discovery. Therefore, organizations should avoid punitive actions and focus on increasing collaborative (eg, small group) discussion and awareness.
Educational objective:
Implicit bias, or subconscious attitudes toward specific groups (eg, ethnicity), is highly prevalent and can perpetuate health disparities. Organizations can address implicit bias by assessing for its presence, encouraging individual and group awareness (eg, small group debriefing), and promoting metacognition (ie, self-monitoring thought processes).