If you have seen the show “Avenue Q”, the hilariously funny spoof of Sesame Street, you may remember the song, “Everyone’s a little bit racist”. The characters sing about the idea that we all have implicit bias that can affect what we do in our everyday lives. This doesn’t mean we are bad people but the recognition of these biases could actually help us all get along better.
The phenomenon of implicit bias has been well described and studied at Harvard University by Mahzarin Banaji and Anthony Greenwald (their book “Blindspot” is worth reading). Through the use of the Implicit Association Test (IAT) they have been able to prove that it is “unconscious cognition,” rather than conscious thought that drives human judgment and behavior. The test has been available online for 20 years. It takes about 10 minutes to complete and after the users make a series of rapid associations, it can measure their attitudes about different groups of people that they may be wholly unaware of and may even soundly disagree with in their conscious mind. One of the first IATs that I took was about gender and work. Despite considering myself an ardent feminist with a 25-year career as a physician and medical educator, I demonstrated a positive association between men and work and between women and home. My initial reaction was disbelief and mortification. Then in a faculty development workshop on implicit bias, I was able to reflect with my colleagues that we are all victims of socialization that has firmly planted itself in our unconscious mind.
Through the use of functional MRI (fMRI), researchers have been able to show that we not only have difficulty being empathic with those who our brain recognizes as different than ourselves, but these differences vary with the individuals’ IAT scores. In a study by Chiao, black and white participants watch a needle penetrating a black, white or purple (race neutral) hand. The researchers observed that the muscle specific motor-evoked potentials (MEPs) which are usually inhibited when participants observe the physical suffering of another were only inhibited when participants observed injury to a hand which matched their race. Participants who had greater unconscious racial bias on the IAT showed more in-group bias as measured by lack of MEP inhibition. [Chiao 2010]
There is extensive literature showing disparities in healthcare based on race and socioeconomic status. The degree to which these disparities are linked to providers’ implicit bias has not yet been established. However, it is clear that many non-white patients have a distinct distrust for the health care system in general and that is associated with a stronger preference for having a race-matched physician. [Chen 2004]
Recognizing how unconscious bias and the lack of diversity affects patient care and medical education at academic medical institutions, the AAMC worked with the Kirwan Institute for the Study of Race and Ethnicity to convene the Diversity and Inclusion Innovation Forum in 2014. Invitees were unconscious bias researchers and people who have been developing unconscious bias interventions at their academic medicine institutions. They have published an extensive review of the conversations and the interventions identified by the participants. [Lewis 2017]
Efforts to develop educational programs for faculty and students on implicit bias center around helping learners to identify their own biases and manage them. At Harvard Medical School, educators developed and taught a 14-session course on culture, self-reflection and medicine to first, second and fourth-year medical students. After completing the course, students reported an increased awareness of their blind spots and that providing equitable care and treatment would require lifelong reflection and attention to these biases. [White 2018]
There are other descriptions of interventions in identifying implicit bias in academic medicine and nursing literature. However, what is needed now are evidence-based strategies that show how these interventions can make an actual impact on behavior and improve patient outcomes. How can implicit bias awareness and training translate to better patient care and advance health equity among our patient population? It is clear that this is an area of medical education that is growing rapidly with a great focus on making a difference. The entire continuum of health professions education – undergraduate, graduate and faculty development – need to be trained in order to ensure sustained impact for our patients. As Martin Luther King Jr. once said, “Let us realize the arc of the moral universe is long, but it bends toward justice.”
-Felise Milan, MD Community of Practice Member
Felise Milan, MD is a professor of medicine at the Albert Einstein College of Medicine in Bronx, NY where she is the director of the Clinical Skills Center and the pre-clerkship clinical skills curriculum. She is one of the founders of and recent past president of the Directors of Clinical Skills Courses (DOCs).
“Everyone’s a little bit racist” by Avenue Q: https://www.youtube.com/watch?v=RovF1zsDoeM
Implicit Association Test: https://implicit.harvard.edu/implicit/
Chiao JY Racial Bias Reduces Empathic Sensorimotor Resonance with Other-Race Pain. Current Biology June 2010; 20(11):1018-1022.
Chen FM, Fryer GE, Phillips RL, Wilson E, Pathman DE. Patients’ Beliefs About Racism, Preferences for Physician Race, and Satisfaction With Care. Annals of Family Medicine 2004
White AA 3rd, Logghe HJ, Goodenough DA, Barnes LL, Hallward A, Allen IM, Green DW, Krupat E, Llerena-Quinn R. Self-Awareness and Cultural Identity as an Effort to Reduce Bias in Medicine. J Racial Ethn Health Disparities. 2018 Feb;5(1):34-49
Glicksman E Unconscious Bias in Academic Medicine: Overcoming the Prejudices We Don’t Know We Have. AAMC News September 27, 2016. https://news.aamc.org/diversity/article/unconscious-bias/
AAMC publication 2017: Proceedings of the Diversity and Inclusion Innovation Forum: Unconscious Bias in Academic Medicine How the Prejudices We Don’t Know We Have Affect Medical Education, Medical Careers, and Patient Health. The Kirwan Institute for the Study of Race and Ethnicity Columbus, Ohio. Eds: Darcy Lewis and Emily Paulsen (available for free at: https://store.aamc.org/proceedings-of-the-diversity-and-inclusion-innovation-forum-unconscious-bias-in-academic-medicine.html)