Learn More About: Managing Implicit Bias

Managing Implicit Bias

Michael Harasimowicz BS, Carrie Schuman BS, Jill Lavigne, PhD, MPH
Wegmans School of Pharmacy, St John Fisher College, Rochester, NY

Learning Objectives

  • Define implicit bias.
  • Describe the association between implicit bias and patient outcomes.
  • Enumerate the frequency of pain crises and life expectancy of patients with sickle cell anemia.
  • Based on the epidemiology of sickle cell anemia, the characteristics of Sharee’s neighborhood and the racial distribution of physicians and sickle cell anemia patients, describe the likelihood that implicit bias might occur in her health care.
  • List at least 2 of Sharee’s experiences that illustrate potential implicit bias.
  • Briefly describe what you might do to recognize and address implicit bias in your own practice.

Sickle Cell Disease in the US: Understanding the Disease Context

Sickle cell anemia is a deadly and painful disease with variable coverage in US health care professional training programs

  • Mortality
    • Average life expectancy is 42 years in males and 48 years in females
  • Pain crises
    • 2/3 of patients experience chronic pain with acute events occurring multiple times throughout a year
    • Frequency and severity of pain are variable

Platt OS, et al. New England Journal of Medicine. 1994; 330(23):1639–44
Wally R, et al. Annals of Internal Medicine. 2008; 148(2): 94-101

Sickle Cell Disease(SCD) in the US: Context for stigmatization

  • Most US healthcare providers are White. Most US Sickle Cell Disease patients are Black or Hispanic.
  • According to the CDC, about 100,000 Americans are affected with Sickle Cell Disease
    • Occurs in about 1 out of every 365 African-Americans
    • Occurs in about 1 out of every 16,300 Hispanic-Americans
  • The opioid epidemic has increased stigmatization of patients with SCD, because the pain is "invisible" and patients need pain medication urgently during crises

Castillo-Page L. Association of American Medical Colleges; 2016
Sickle Cell Disease: Data & Statistics [Internet]. Center for Disease Control and Prevention. CDC; 2016

Sharee’s Hometown Demographics

  • Median age: 31.3 years
  • Median household income: $31,684
  • Poverty rate: 32.8%
  • Non-English speakers: Spanish and African languages
  • Majority of residents are African American

Rochester, NY [Internet]. DataUSA. Deloitte; 2014

Sharee’s Hometown Provider Characteristics

  • Demographics
    • Providers mostly White
  • Academic medical center is immediately adjacent to high poverty areas of the city
    • In primary care, most patients are from minority groups and live in poverty

What is Implicit Bias?

Bias that is subconscious and is accumulated over a lifetime of experience

  • Can override conscious beliefs
  • Can lead one to unknowingly act against one’s accepted values
  • Influenced by role modeling as much as by overt “teaching”
  • Affects decisions and behavior towards others
    • Not limited to race

Steed J. Mayo Clinic News Network. Mayo Clinic; 2015

Implicit Bias: Effects on Health Care

  • Health care providers act in accordance with implicit bias every day
    • Occurs more commonly when stressed or tired
  • Can affect a provider’s body language, generating subtle cues that lead patients to:
    • lose trust
    • withhold information
    • fail to follow provider advice
  • Reduce quality of care and can lead to medical errors
    • e.g., misdiagnosis via different lines of questioning
    • failure to treat pain
  • Implicit bias rates among clinicians are same as in general population
  • May affect treatment protocols/options or pain management
  • May affect perception and decision making
  • Most commonly targets racial/ethnic minorities
    • Can cause longer wait times
    • Less time spent "seeing" provider

Steed J. Mayo Clinic News Network. Mayo Clinic; 2015

Wyatt R, et al. Achieving Health Equity: A Guide for Health Care Organizations. IHI White Paper.
Cambridge, Massachusetts: Institute for Healthcare Improvement; 2016.

Implicit Bias: Effects on Patients

  • Non-white patients receive fewer cardiovascular interventions and fewer renal transplants
  • African American women are more likely to die after being diagnosed with breast cancer
  • In the US, life expectancy is lower in African Americans than Whites

The national CLAS Standards [Internet]. U.S. Department of Health and Human Services, Office of Minority Health; 2018.

Implicit Bias in Health Care

  • Non-white patients are less likely to be prescribed pain medications (non-narcotic and narcotic)
  • Patients of color are more likely to be blamed for being too passive about their health care

The national CLAS Standards [Internet]. U.S. Department of Health and Human Services, Office of Minority Health; 2018.

Examples from Sharee’s Experiences

  • She has learned to present to the ED only after careful grooming, so providers will not regard her acute pain episodes as drug-seeking behavior
  • She is responding to past experiences of implicit bias by providers who make assumptions based on her race and appearance

Sharee’s Other Experiences

  • Providers may believe that acute pain episodes are caused by poor self-care. They may assume that her disease experience was completely within her control, regardless of her school, work, and personal life demands
  • At school, teachers and classmates often are uninformed about SCD, and fail to make accommodations for her special needs

National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS Standards)

  • These standards were developed by the Office of Minority Health, which works under the Department of Health and Human Services
  • Goal: Provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy and other communication needs
  • Can help reduce implicit bias and help better serve minority patients
  • Free, accredited online CE to support the implementation of these standards (https://www.thinkculturalhealth.hhs.gov/education/physicians)

The Joint Commission. “Quick Safety: Implicit Bias in Health Care.” April 2016.

Precautions for Provider Implicit Bias

  1. Assume that implicit bias is operating at the health system and provider levels
  2. Get the big picture: From what population are our patients? Providers?
  3. Take social and personal inventories of unconscious bias (https://implicit.harvard.edu/implicit/)
  4. Focus on the individual patient in their social context; avoid comparisons that may be unintentionally loaded with implicit bias
  5. Recognize situations that amplify stereotyping and bias so common in healthcare
  6. Apply the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (CLAS Standards) - https://www.thinkculturalhealth.hhs.gov/
    • Stress, fatigue, high pressure environments, weak communication further weakened by illness, etc.
  7. Use translators and teach-back methods.
  8. Add another check to your care pathway: If I reimagine this patient as white and upper income would this diagnosis and therapy be consistent with evidence-based medicine?


The Joint Commission. "Quick Safety: Implicit Bias in Health Care." April 2016.

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