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20
Research shows that when people hold a negative stereotype about a group and meet someone from that group, they often
treat that person differently and honestly don’t even realize it.
57
Substantial attention has been paid in recent years to the possibility that unconscious bias among healthcare professionals
contributes to health disparities.
58, 59, 60
In its 2003 report,
Unequal Treatment,
the Institute of Medicine concluded that
unrecognized bias against members of a social group, such as racial or ethnic minorities, may affect communication or the
care offered to those individuals.
58
In
Studies of Unconscious Bias
, Dr. Lyubansky uses the following to illustrate how unconscious bias may affect the patient-
clinician relationship and related processes, “Consider a white male clinician whose implicit bias has been activated by a
clinic visit with an elderly African-American patient who is receiving antihypertensive medications but whose blood pressure
is uncontrolled. Without realizing that he is being unduly influenced, the clinician perceives the patient as uncooperative and
unlikely to adhere to a more intensive drug regimen. The clinician may even erroneously “remember” that this patient can’t
afford the pharmacy copay. Consequently, although the patient’s hypertension is not under control, the clinician decides not
to intensify the treatment regimen. This clinician believes that he made the best decision given the situation, unaware that
his perceptions were distorted by implicit bias.”
57
Implicit bias cannot be measured accurately with a self-reporting survey tool. Sophisticated computer-based instruments
have been developed that rely on differences in response latency to reveal implicit bias. The most commonly used
instrument is the Implicit Association Test (IAT) that has been used in hundreds of studies across disciplines.
61, 62, 63
The
IAT is designed to detect the strength of a person’s automatic association between mental representations of concepts.
It functions on the principle that it is easier to make the same response to concepts that are more strongly associated,
compared to concepts less strongly associated. Studies have measured implicit bias among clinicians
64, 65, 66, 67, 68, 69
using the
IAT. Five of these studies examined racial/ethnic bias, specifically against African Americans as compared to whites. Four of
the five studies found evidence for implicit race bias among clinicians.
A number of other studies have shown that people with more implicit ethnic/racial bias have worse interpersonal interactions
with minority individuals, often in very subtle ways. In Lyubansky’s implicit bias conceptual model (figure 6) he uses the
scenario of hypertension control to illustrate the possibility that unconscious bias may affect treatment through its effects on
interpersonal communication, as well as affecting clinical decisions directly.
Figure 6: Conceptual model of the influence of implicit bias on hypertension control.