Unconscious Bias: What It Is, How It Influences Health Care, and What You Can Do About It

From the University of California, San Francisco (UCSF) Office of Diversity and Outreach website

Bias is a prejudice in favor of or against one thing, person, or group compared with another, usually in a way that’s considered to be unfair. Biases may be held by an individual, group, or institution and can have negative or positive consequences.

There are two types of biases:

1. Conscious bias (also known as explicit bias)
2. Unconscious bias (also known as implicit bias)

It is important to note that biases, conscious or unconscious, are not limited to ethnicity and race. Though racial bias and discrimination are well documented, biases may exist toward any social group. Age, gender, gender identity, physical/cognitive abilities, religion, sexual orientation, weight, and many other characteristics are subject to bias.

Unconscious biases are social stereotypes formed outside conscious awareness. Everyone holds unconscious beliefs about various social and identity groups, and these biases stem from the universal human tendency to organize the outside world (identify threats, assess safety) using category shortcuts.

Unconscious bias is far more prevalent than conscious prejudice and often does not match our conscious values and beliefs. Biases may be more likely to influence behavior when we are multi-tasking or working under stress and time pressure.

A growing body of evidence supports the role of unconscious bias on disparities in access to, and outcomes, of health care.

• Unconscious biases develop at an early age: biases are measurable during middle childhood and appear to develop across childhood. [1]
• Unconscious biases have real world effects on behavior. [2]
• Unconscious biases are malleable; the impact of unconscious bias can be reduced through training. [3]

A substantial amount of research demonstrates the adverse impact of unconscious bias in the criminal justice system, education, as well as health/health care. [4]

Conscious and unconscious bias has an impact on hiring, promotion, and mentoring, and contributes to health care disparities.

For example:

• Fictitious resumes with White-sounding names sent to help-wanted ads were more likely to receive callbacks for interviews compared to resumes with African-American sounding names. Resumes with White-sounding names received 50% more callbacks for interviews. [5]
• Science faculty rated male applicants for a laboratory manager position as significantly more competent and hirable than female applicants. Faculty also selected a higher starting salary and offered more career mentoring to the male applicants. [6]
• Implicit bias among health care professionals can influence their behaviors and judgments. [7]

Of the tools available, the Implicit Association Test (IAT) is most well-studied. The IAT was developed to detect unconscious bias in race, gender, sexual orientation, and national origin.

How does the IAT work?

The IAT measures the relative strength of associations between pairs of concepts. It is designed as a sorting task in which individuals are asked to sort images or words that appear on a computer screen into one of two categories. The basic premise is that when two concepts are highly correlated in the unconscious (e.g., Asian people are smart), people are able to pair those concepts faster than two concepts that are not strongly associated (e.g., Asian people are lazy). The IAT is relatively resistant to social desirability concern, and the reliability and validity have been rigorously tested.

What does the IAT tell us about bias in health care?

The IAT has been used to explore the impact of unconscious bias on clinician behavior.

• A greater pro-White unconscious bias among physicians is associated with greater likelihood of prescribing thrombolytics for White patients compared to Black patients presenting with the same acute coronary syndrome. [8]
• A greater pro-White unconscious bias was associated with a greater willingness to prescribe pain medications for White versus Black children presenting with the same painful syndromes. [9]
• Greater pro-White unconscious bias was associated with poorer ratings of the quality of interpersonal care among Black patients as compared to White patients. [10]

Individual strategies to address unconscious bias include:

• Promoting self-awareness: recognizing one’s biases using the Implicit Association Test (or other instruments to assess bias) is the first step. During patient care, ask yourself “Would I treat this patient any differently if he or she were White?”.
• Understanding the universal nature of unconscious bias is essential. The categorization process that gives rise to unconscious bias is a normal and universal aspect of human cognition. Understanding this concept can help individuals gain conscious awareness of how unconscious biases influence our behaviors, and conscious awareness gives us the choice and ability to reduce its adverse impacts. [11]
• Opportunities to interact with others (especially those from socially dissimilar groups) can be helpful in reducing stereotyping.
• Facilitated discussions and training sessions promoting bias literacy utilizing the concepts and techniques above have been effective in minimizing bias. Evidence suggests that providing unconscious bias training for faculty members reduces the impact of bias in the health system workplace. [12]

Team Strategies [13]

• Remember that bias is universal, but teams should normalize attempts to label and uncover bias. Design processes for bias mitigation in advance.
• Create a team culture where “pausing” and checking for bias is the norm.
• Hold yourself accountable before others, and engage in challenging team conversations regularly.

Institutional Strategies

Changes in individual behavior require a supportive work context through organizational structures and processes that recognize the reality and the power of unconscious bias and take steps to reduce it. This includes standardizing and routinizing equity and inclusion in staff and leadership recruitment, hiring, retention, performance rating, and promotion; to assess and work to improve the experience of diverse patient groups; and to train all staff in awareness of and steps to reduce the impact of unconscious bias on the care they provide. Examples include:

• Developing concrete, objective, and standardized indicators and outcomes for hiring, evaluation, and promotion to reduce the influence of unconscious bias and stereotypes [14-16]
• Developing standardized criteria for performance evaluations [17]
• Developing and utilizing structured interviews, and developing objective evaluation criteria for hiring [18-19]
• Providing unconscious bias training workshops for all staff and leadership

• E-Learning Seminar: What You Don’t Know: The Science of Unconscious Bias and What to do About It in the Search and Recruitment Process, Association of American Medical Colleges (AAMC)
• Exploring Unconscious Bias in Academic Medicine, Association of American Medical Colleges (AAMC)
• Project Implicit
• Proven Strategies for Addressing Unconscious Bias in the Workplace, Diversity Best Practices, Cook Ross, Inc.
• State of the Science: Implicit Bias Review 2014, Kirwan Institute for the Study of Race and Ethnicity
• The New Science of Unconscious Bias: Workforce & Patient Care Implications, CM Elearning, The University of Minnesota
• The Science of Equality, Volume 1: Addressing Implicit Bias, Racial Anxiety, and Stereotype Threat in Education and Health Care, Perception Institute
• Unconscious Bias, Cook Ross, Inc.
• Unconscious Bias Training for the Health Professions, Association of American Medical Colleges (AAMC)
• Women in Science, Nature.com
• The Neuroscience of Unconscious Bias, The American Bar Association Litigation Section
• Unconscious Bias in Academic Medicine, Proceedings of the 2017 AAMC Diversity and Inclusion Innovation Forum