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Implicit bias is the attitude or internalized stereotypes that unconsciously affect our perceptions, actions, and decisions. These unconscious biases often affect behavior that leads to unequal treatment of people based on race, ethnicity, gender identity, sexual orientation, age, disability, health status, and other characteristics. In medicine, unconscious bias-based discriminatory practices negatively impact patient care and medical training programs, hinder effective communication, limit workforce diversity, lead to inequitable distribution of research funding, impede career advancement, and result in carriers and disparities in the access to and delivery of healthcare services. This activity will address strategies to reduce the harm of implicit bias, clinician self-awareness and self-assessment of personal biases, and the role of the interprofessional team in increasing awareness and reducing bias-based discriminatory behavior. Objectives: Recognize how implicit bias affects the perceptions and treatment decisions of clinicians leading to disparities in healthcare delivery and health outcomes. Identify stigmatized groups and strategies to eliminate discriminatory behavior in healthcare delivery for these groups. Describe strategies to increase awareness of personal unconscious biases in daily interactions and change behavior accordingly. Discuss how interdisciplinary teams can reduce the harmful effects of implicit bias in medicine. Access free multiple choice questions on this topic.

Implicit biases are subconscious associations between 2 disparate attributes that can result in inequitable decisions. They operate throughout the healthcare ecosystem, impacting patients, clinicians, administrators, faculty, and staff. No individual is immune to the harmful effects of implicit biases. Unconscious bias-based discriminatory practices negatively impact patient care, medical training programs, hiring decisions, and financial award decisions, and also limit workforce diversity, lead to inequitable distribution of research funding, and can impede career advancement.[1] When implicit biases are ignored, they jeopardize the delivery of high-quality healthcare services.[2] A simple analogy can exemplify implicit bias in healthcare in action. Several physicians are reviewing the chest x-ray of a black man with a productive cough to determine a possible diagnosis. Another physician, not privy to the patient's demographics, joins the discussion later and quickly states that his condition most likely is cystic fibrosis. The patient's demographics initially influenced the clinicians. Then they realized the chest x-ray findings were diagnostic for late-stage cystic fibrosis, a condition more common in White populations than other races. Explicit versus Implicit Bias With explicit bias, individuals are aware of their negative attitudes or prejudices toward groups and may allow those attitudes to influence their behavior. The preference for a particular group is conscious. For example, a hospital CEO may seek a male physician to head a department because of an explicit belief that men make better leaders than women. This type of bias is fully conscious. Implicit bias encompasses the subconscious feelings, attitudes, prejudices, and stereotypes that an individual has developed due to prior influences and experiences throughout their life. Individuals are unaware that subconscious perceptions, rather than facts and observations, influence their decision-making. Implicit bias and explicit bias are both problematic because they lead to discriminatory behavior and potentially suboptimal healthcare delivery.

Implicit bias encompasses the subconscious feelings, attitudes, prejudices, and stereotypes that an individual has developed due to prior influences and experiences throughout their life. Individuals are unaware that subconscious perceptions, rather than facts and observations, influence their decision-making. Implicit bias and explicit bias are both problematic because they lead to discriminatory behavior and potentially suboptimal healthcare delivery. We all hold implicit biases. Implicit bias is challenging to recognize in oneself; awareness of bias is 1 step toward changing one's behavior.[1] Cultural safety refers to the need for healthcare professionals to examine how their own culture, power, privilege, and personal biases may affect clinical interactions and healthcare delivery. This requires healthcare providers to examine their own attitudes, assumptions, stereotypes, and prejudices that may contribute to lower-quality healthcare for some patients. Cultural safety compels healthcare professionals and organizations to engage in ongoing self-reflection and self-awareness, and to hold themselves accountable for providing culturally safe care as defined by patients and their communities.[3] Healthcare professionals and their organizations should collaborate to develop strategies to mitigate the harmful effects of bias and reduce bias-based decisions that contribute to barriers to healthcare access, healthcare disparities in patient care delivery, and a lack of workforce diversity. Stigmatized Groups and the Implicit Association Test (IAT) Although we may consciously reject negative associations with stigmatized groups, it is virtually impossible to dissociate from a culture impregnated with such stereotypes. Patients from stigmatized groups may have 1 or more of these characteristics or conditions: advanced age, non-White race, HIV, disabilities, and substance or alcohol use disorders.[4][5][6] Other factors include low socioeconomic status, mental illness, non-English speaking, non-heterosexual, and obesity.[7][8][9][10] Implicit biases, by definition, occur in the absence of salient understanding or conscious awareness.[11][12] However, we can implement harm-mitigation strategies to mitigate the destructive implications of implicit bias. To this end, recognition is the first step.

Although we may consciously reject negative associations with stigmatized groups, it is virtually impossible to dissociate from a culture impregnated with such stereotypes. Patients from stigmatized groups may have 1 or more of these characteristics or conditions: advanced age, non-White race, HIV, disabilities, and substance or alcohol use disorders.[4][5][6] Other factors include low socioeconomic status, mental illness, non-English speaking, non-heterosexual, and obesity.[7][8][9][10] Implicit biases, by definition, occur in the absence of salient understanding or conscious awareness.[11][12] However, we can implement harm-mitigation strategies to mitigate the destructive implications of implicit bias. To this end, recognition is the first step. Implicit biases in healthcare are well characterized by studies that use the Implicit Association Test (IAT) to evaluate medical decision-making regarding stigmatized groups. The IAT measures the strength of associations between concepts and evaluations or stereotypes to reveal an individual's implicit biases (Project Implicit: implicit.harvard.edu). The IAT is a well-validated measure of implicit bias; although susceptible to voluntary control, the tool remains a gold standard in implicit bias research.[13][14] Studies have shown that strong implicit biases hinder communication.[15] Effective communication between patients and healthcare providers (HCPs) is associated with reduced patient morbidity and mortality, lower healthcare costs, and decreased rates of HCP burnout.[16][17][18] Implicit biases become destructive when they translate into microaggressions, defined as verbal or nonverbal cues that communicate hostile attitudes towards those from stigmatized groups.[19][20] Although often unintentional, microaggressions maintain power structures and threaten the psychological safety of patients, resulting in adverse public health implications.[21] Reducing microaggressions has been shown to reduce HCP burnout and depression.[22][23] Implicit Bias Awareness and Training

Implicit biases become destructive when they translate into microaggressions, defined as verbal or nonverbal cues that communicate hostile attitudes towards those from stigmatized groups.[19][20] Although often unintentional, microaggressions maintain power structures and threaten the psychological safety of patients, resulting in adverse public health implications.[21] Reducing microaggressions has been shown to reduce HCP burnout and depression.[22][23] Implicit Bias Awareness and Training Comprehensive implicit bias training enhances the financial value, productivity, and longevity of the healthcare workforce. Recognizing implicit bias is the first step in mitigating its effects. Many states in the US require implicit bias training for employment and licensure in the healthcare profession. The ongoing engagement of implicit biases among HCPs promotes cultural safety in healthcare organizations, representing a critical consciousness that welcomes accountability in the collaborative effort to provide culturally safe healthcare as defined by patients and their communities. HCPs should be aware of their implicit biases but should not blame themselves when situations beyond their control arise—respect for themselves, peers, and patients is the utmost priority. Progress toward reducing implicit bias is limited without personal discomfort and vulnerability. Currently, there is very limited knowledge about how to conduct effective implicit bias training. However, studies show that incorporating mindfulness, coalition-building, and personal retrospection alongside broader structural changes is integral in reducing the harmful effects of implicit bias in the clinical environment.[2][24][25] This topic provides strategies to mitigate the impact of implicit biases among physicians, residents, physician assistants, pharmacists, registered nurses, nurse practitioners, medical assistants, medical scribes, certified registered nurse anesthetists, physical and occupational therapists, chiropractors, dentists, hygienists, licensed nutritionists, dieticians, social workers, counselors, psychologists, other allied health professionals, and healthcare trainees. Implicit bias training is required in many states. Implicit Bias Training: State Legislation and Requirements for Healthcare Providers California - AB241 (legislation) Illinois - Sec. 2105-15.7 (legislation)

Currently, there is very limited knowledge about how to conduct effective implicit bias training. However, studies show that incorporating mindfulness, coalition-building, and personal retrospection alongside broader structural changes is integral in reducing the harmful effects of implicit bias in the clinical environment.[2][24][25] This topic provides strategies to mitigate the impact of implicit biases among physicians, residents, physician assistants, pharmacists, registered nurses, nurse practitioners, medical assistants, medical scribes, certified registered nurse anesthetists, physical and occupational therapists, chiropractors, dentists, hygienists, licensed nutritionists, dieticians, social workers, counselors, psychologists, other allied health professionals, and healthcare trainees. Implicit bias training is required in many states. Implicit Bias Training: State Legislation and Requirements for Healthcare Providers California - AB241 (legislation) Illinois - Sec. 2105-15.7 (legislation) Michigan - R 338.7001 (legislation) Maryland - HB28. Sec. 1-225 (legislation) (HB28) Minnesota - Sec. 144.1461 (legislation) Washington - Sec. 43.70.613 (legislation) Massachusetts - 243 CMR 2.06(a)3 (legislation) New York - S3077 (legislation) Pennsylvania - HB 2110. Title 63. Sec. 2102a (legislation) Indiana - HB 1178 (legislation) Oklahoma - HB 2730 (legislation) South Carolina - H 4712. Session 123 (legislation) Tennessee - SB0956 and HB0642 (legislation)

Although the relationship between implicit bias and interdisciplinary teams remains underexplored, it is evident that no single member is responsible for shaping a healthcare team's culture. A culture that values open discussion of biases and protects psychological safety promotes team productivity, whereas rudeness and negative behaviors in healthcare teams may adversely affect team performance.[141] The "butterfly effect" is the idea that small team changes can significantly impact other parts of the process or system; it occurs in a system where implicit biases are openly recognized without repercussions.[142] Tools for self-reflection of implicit biases among healthcare teams have been shown to improve patient trust in the quality of care. Clear communication of expectations and responsibilities minimizes the impact of bias in role selection.[143] Implicit bias training can provide new team knowledge when additional learning is needed. Graduate medical education that includes implicit bias training has been shown to improve trainees' leadership qualities, thereby fostering an equitable team culture.[144] However, isolated training does not ensure equitable care unless team members apply the knowledge acquired in daily interactions.[1] Therefore, regular check-ins and debriefs are essential to ensuring that team members feel prepared to engage in self-improvement.[143] Interprofessional Education Collaborative and Core Competencies Interprofessional teams share values, perspectives, and strategies for planning interventions, and each team member plays a role in delivering patient care. Team members share their expertise and skills to provide effective patient care and achieve optimal outcomes. Teams function optimally when members communicate effectively and have mutual respect for one another and their individual roles. Four core competencies have been established for interprofessional collaborative practice (see IPEC Core Competencies for Interprofessional Education Collaborative):

Interprofessional teams share values, perspectives, and strategies for planning interventions, and each team member plays a role in delivering patient care. Team members share their expertise and skills to provide effective patient care and achieve optimal outcomes. Teams function optimally when members communicate effectively and have mutual respect for one another and their individual roles. Four core competencies have been established for interprofessional collaborative practice (see IPEC Core Competencies for Interprofessional Education Collaborative): Work with individuals of other professions to maintain a climate of mutual respect and shared values. (Values/Ethics). When team members place a high value on treating patients and one another equally and respectfully, and operate ethically, interventions to reduce the harmful effects of implicit bias that lead to health disparities can be developed within a culturally safe and accepting environment. Use the knowledge of one's own role and those of other professions to appropriately assess and address the health care needs of patients to promote and advance the health of populations. (Roles/Responsibilities) Each interprofessional team member is responsible for identifying how implicit bias affects perceptions and clinicians' treatment decisions, leading to disparities in healthcare delivery and health outcomes. Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner, thereby supporting a team approach to promoting and maintaining health and to preventing and treating disease. (Interprofessional Communication) Discussions regarding cultural safety and the continued need for clinicians to engage in ongoing self-reflection and self-awareness, and to hold themselves accountable for providing culturally safe care, should be a priority. Open discussions that acknowledge everyone's implicit biases, recognize them, and encourage behavior change through interventions such as counter-stereotyping are helpful. Strategies to improve patient-clinician communication are beneficial, especially with patients in stigmatized groups.

Communicate with patients, families, communities, and professionals in health and other fields in a responsive and responsible manner, thereby supporting a team approach to promoting and maintaining health and to preventing and treating disease. (Interprofessional Communication) Discussions regarding cultural safety and the continued need for clinicians to engage in ongoing self-reflection and self-awareness, and to hold themselves accountable for providing culturally safe care, should be a priority. Open discussions that acknowledge everyone's implicit biases, recognize them, and encourage behavior change through interventions such as counter-stereotyping are helpful. Strategies to improve patient-clinician communication are beneficial, especially with patients in stigmatized groups. Apply relationship-building values and the principles of team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient/population-centered care and population health programs and policies that are safe, timely, efficient, effective, and equitable (Teams and Teamwork) Teams should work together to develop strategies to eliminate discriminatory practices that result in disparities in healthcare delivery, limited access, and suboptimal patient outcomes. Time should be allocated to interventions that embrace and expand workforce diversity.

If members of an interprofessional health team don’t acknowledge their individual implicit biases, we leave a significant gap in the potential to address bias in healthcare. The entire interprofessional team, including clinicians, nurses, pharmacists, therapists, and other ancillary and administrative personnel, is responsible for openly discussing implicit biases that influence the care provided and for keeping one another accountable.