Implicit Bias in Healthcare

*this article was written by Dr. Lauren Dungy-Poythress for the Fort Wayne Medicine Quarterly

We all have biases that affect all aspects of our lives. They can also affect the lives of others with whom we interact. Not every bias is harmful or hurtful. However, implicit biases –biases that we do not recognize- may lead to decisions or practices in life and at work that can lead to harmful outcomes. Whether bad or good, justified or unjustified, our beliefs and attitudes can automatically trigger our behavior and decision-making. It can happen unintentionally, unconsciously, without effort, and in a matter of seconds. Research and media reports highlight that implicit bias can negatively affect patient medical care. For example, studies have found that medical students and nurses rate the pain of Black patients lower than that of white patients, and their treatment recommendations for Black patients reflect these biases. For centuries, physicians and scientists have promoted the false notion that Black people are biologically different from White people and utilized flawed evidence to create deeply flawed theories that lend support to biased and discriminatory health practices. One of those false notions is that Black people have altered sensory nerves or thickened skin that makes them less sensitive to pain.

Throughout history, definitions of race – a non-biological, man-made social construct - have varied. The criteria for assigning individuals to these social categories have been ill-defined, subjective, political, and ambiguous. The concept of race has been misused over time for social, political, and economic purposes. The use of race in medical algorithms perpetuates and often magnifies health inequities. For example, “race corrections” built into medical software utilized to determine lung and renal function are biologically flawed and are known to affect the healthcare and treatment of Black people negatively. The eligibility to be considered a candidate for transplants is known to be often hindered by such “race corrections". Research reveals that many people of color believe they have endured adverse treatment simply because of their race or ethnicity. Reports have indicated that marginalized patients, such as people of color or homeless persons, are often automatically presumed more likely to be non-compliant with their medications, to be drug-seeking, or to have ulterior motives when seeking care. Similarly, many people of color report that they are often presumed to lack medical insurance and treated as if they cannot afford medical care when seen for emergent care. As a consequence, these patient populations are often not offered optimal treatment regimens when seeking care. Additionally, reports have shown that many Black women report feelings of being devalued and disrespected by medical providers related to their race. A 2017 survey published by NPR, Harvard, and the Robert Wood Foundation highlighted that 33 percent of Black women said they had been discriminated against because of their race when going to a health doctor or clinic and that 21 percent stated that they had avoided seeking health care due to concerns of racial discrimination. Other reports have identified that a significant number of Hispanic and Asian patients feel that they are treated by medical providers as if they lack intelligence or are “not smart”. These and other factors contribute to racial disparities in health outcomes which are readily apparent in all aspects of healthcare and society. Biases and disparities related to social determinants of health have also been shown to affect health outcomes. Practices, policies, and other components of social determinants of health that negatively impact opportunities and availability related to housing, transportation, employment, and education, for example, are pervasive compounding factors that further adversely affect health outcomes for marginalized populations. 

Disturbingly, the Black maternal mortality rate has remained significantly higher than that of White women for several decades. The Black infant mortality rate has an equally disturbing and longstanding history. Black women are also more likely to experience severe maternal morbidity compared to White women. Similarly, Hispanic women and women of other non-white backgrounds experience perinatal rates of morbidity and mortality greater than that of their White counterparts. Implicit biases that affect underlying health and/or lead to discriminatory practices are central factors contributing to these health disparities. Implicit biases and discriminatory practices, intentional or unintentional, may lead to poor patient relationships, incongruent health practices, and a lower quality of care for some patients. This is particularly true in settings prone to any degree of overload or high stress. Several reports identify that minoritized patients are subject to misdiagnoses, curtailed treatment options, less pain management, and poorer clinical outcomes. These factors can all contribute to stress, anxiety, and mental health concerns – factors that create or contribute to adverse health outcomes, including complications of pregnancy that contribute to maternal and infant mortality.

Health inequity studies by the U.S. Department of Health and Human Services (HHS) have found that people of color affected by racial, ethnic, and socioeconomic barriers have lower life expectancy, higher blood pressure, and a greater strain on mental health. In 2020, the American Medical Society (AMA) officially recognized bias and structural racism as a public health threat. AMA Board Member Willarda V. Edwards stated, “The AMA recognizes that racism negatively impacts and exacerbates health inequities among historically marginalized communities. Without systemic and structural-level change, health inequities will continue to exist, and the overall health of the nation will suffer”. In 2022, the American College of Obstetrics and Gynecology (ACOG) acknowledged the adverse effects of bias in maternal health stating that “racism, not race, drives health inequities and leads to adverse health outcomes”, and that “racial and ethnic inequities in obstetrics and gynecology cannot be reversed without addressing all aspects of racism and racial bias”. 

The well-publicized murder of George Floyd by a Minneapolis police officer in 2020 has been a significant impetus for research and attention addressing concerns of bias and racial discrimination in our society. While many medical professionals, administrators, and government officials acknowledge the problems of racial bias and its effect on healthcare outcomes, medical programs and society as a whole have been slow to accept and come to terms with the issues. A recent survey published in December of 2023 by the Kaiser Family Foundation (KFF) expressed that people feel that racism and discrimination negatively impact their healthcare and well-being. KFF President and CEO, Drew Altman said of the survey results, “While there have been efforts in health care for decades to document disparities and advance health equity, this survey shows the impact racism and discrimination continue to have on people’s health care experiences”.

When lecturing or leading panel discussions regarding this topic, individuals often ask what can be done to reduce racial health disparities and improve maternal and infant health outcomes. I often reflect that in order to find the appropriate solution to a problem, you must first identify and acknowledge the problem(s). The issues underlying racial disparities in maternal and infant health, particularly Black maternal and infant health, are multifactorial and begin well before a woman becomes pregnant. Acknowledging that implicit biases affect health and well-being—as well as the delivery of medical care --is an essential first step.  Recognizing the potential for implicit bias, both within and outside the medical arena, and working effectively and intentionally to overcome these barriers is crucial in improving health outcomes for all patients. Efforts to incorporate awareness of implicit bias in both medical and non-medical training programs are essential steps in providing quality care to an increasingly diverse patient population. Working intentionally and consistently with dedicated attention to these concerns, both on an individual and organizational level, is necessary to effectively impact and reduce racial disparities in maternal and infant health.

 Be sure to join us and Dr. Dungy-Poythress at our Infant and Mortality Conference on Friday, February 23rd! Register here: healthiermomsandbabies.org/conference

 This article can be found in the Fort Wayne Medicine Quarterly: https://www.fwms.org/fortwaynemedicinequarterly