Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health Care Disparities

ABSTRACT

Although the medical profession strives for equal treatment of all patients, disparities in health care are prevalent. Cultural stereotypes may not be consciously endorsed, but their mere existence influences how information about an individual is processed and leads to unintended biases in decision-making, so called “implicit bias”. All of society is susceptible to these biases, including physicians. Research suggests that implicit bias may contribute to health care disparities by shaping physician behavior and producing differences in medical treatment along the lines of race, ethnicity, gender or other characteristics. We review the origins of implicit bias, cite research documenting the existence of implicit bias among physicians, and describe studies that demonstrate implicit bias in clinical decision-making. We then present the bias-reducing strategies of consciously taking patients’ perspectives and intentionally focusing on individual patients’ information apart from their social group. We conclude that the contribution of implicit bias to health care disparities could decrease if all physicians acknowledged their susceptibility to it, and deliberately practiced perspective-taking and individuation when providing patient care. We further conclude that increasing the number of African American/Black physicians could reduce the impact of implicit bias on health care disparities because they exhibit significantly less implicit race bias.

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REFERENCES

  1. 1.

    Nelson A. Unequal treatment: confronting racial and ethnic disparities in health care. J Natl Med Assoc. 2002;94(8):666–8.

    PubMed  Google Scholar 

  2. 2.

    Devine PG. Stereotypes and prejudice: their automatic and controlled components. J Personal Soc Psychol. 1989;56(1):5–18.

    Article  Google Scholar 

  3. 3.

    Devine PG, Plant EA. Advances in Experimental Social Psychology. San Diego: Academic; 2012.

    Google Scholar 

  4. 4.

    Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Smedley BD, Stith AY, Nelson AR, eds. Washington, D.C. : The National Academies Press 2001

  5. 5.

    Dovidio JF, Penner LA, Albrecht TL, Norton WE, Gaertner SL, Shelton JN. Disparities and distrust: the implications of psychological processes for understanding racial disparities in health and health care. Soc Sci Med. 2008;67(3):478–86.

    PubMed  Article  Google Scholar 

  6. 6.

    Association of American Medical Colleges. What You Don’t Know: The Science of Unconscious Bias and What to Do About It in the Search and Recruitment Process. Available at: https://www.aamc.org/initiatives/leadership/recruitment/178420/unconscious_bias.html. Accessed February 14, 2013.

  7. 7.

    Green AR, Carney DR, Pallin DJ, Ngo LH, Raymond KL, Iezzoni LI, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231–8.

    PubMed  Article  Google Scholar 

  8. 8.

    Biernat M, Manis M. Shiftings standards and stereotype-based judgments. J Personal Soc Psychol. 1994;60:485–99.

    Google Scholar 

  9. 9.

    Hodson G, Dovidio JF, Gaertner SL. Processes in racial discrimination: differential weighting of conflicting information. Pers Soc Psychol Bull. 2002;28(4):460–71.

    Article  Google Scholar 

  10. 10.

    Isaac C, Lee B, Carnes M. Interventions that affect gender bias in hiring: a systematic review. Acad Med. 2009;84(10):1440–6.

    PubMed  Article  Google Scholar 

  11. 11.

    Moss-Racusin CA, Dovidio JF, Brescoll VL, Graham MJ, Handelsman J. Science faculty’s subtle gender biases favor male students. Proc Natl Acad Sci U S A. 2012;109(41):16474–9.

    Google Scholar 

  12. 12.

    Bigler RS, Liben LS. A developmental intergroup theory of social stereotypes and prejudice. Adv Child Dev Behav. 2006;34:39–89.

    PubMed  Article  Google Scholar 

  13. 13.

    Newheiser AK, Olson KR. White and Black American Children’s Implicit Intergroup Bias. J Exp Soc Psychol. 2012;48(1):264–70.

    PubMed  Article  Google Scholar 

  14. 14.

    Dunham Y, Baron AS, Banaji MR. From American city to Japanese village: a cross-cultural investigation of implicit race attitudes. Child Dev. 2006;77(5):1268–81.

    PubMed  Article  Google Scholar 

  15. 15.

    Baron AS, Banaji MR. The development of implicit attitudes. Evidence of race evaluations from ages 6 and 10 and adulthood. Psychol Sci. 2006;17(1):53–8.

    PubMed  Article  Google Scholar 

  16. 16.

    Dovidio JF, Kawakami K, Gaertner SL. Implicit and explicit prejudice and interracial interaction. J Pers Soc Psychol. 2002;82(1):62–8.

    PubMed  Article  Google Scholar 

  17. 17.

    Tversky A, Kahneman D. Judgment under Uncertainty: Heuristics and Biases. Science. 1974;185(4157):1124–31.

    PubMed  Article  CAS  Google Scholar 

  18. 18.

    Tait RC, Chibnall JT, Kalauokalani D. Provider judgments of patients in pain: seeking symptom certainty. Pain Med. 2009;10(1):11–34.

    PubMed  Article  Google Scholar 

  19. 19.

    Croskerry P. Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med. 2002;9(11):1184–204.

    PubMed  Article  Google Scholar 

  20. 20.

    Martell RF. Sex bias at work: the effects of attentional and memory demands on performance ratings of men and women. J Appl Soc Psychol. 1991;21(23):1939–60.

    Article  Google Scholar 

  21. 21.

    Uhlmann EL, Cohen GL. I think it, therefore it‘s true’: Effects of self-perceived objectivity on hiring discrimination. Organ Behav Hum Decis Process. 2007;104(2):207–23.

    Article  Google Scholar 

  22. 22.

    Greenwald AG, McGhee DE, Schwartz JL. Measuring individual differences in implicit cognition: the implicit association test. J Pers Soc Psychol. 1998;74(6):1464–80.

    PubMed  Article  CAS  Google Scholar 

  23. 23.

    Nosek BA, Banaji M, Greenwald AG. Harvesting implicit group attitudes and beliefs from a demonstration web site. Group Dyn: Theory Res Pract. 2002;6(1):101–15.

    Article  Google Scholar 

  24. 24.

    Greenwald AG, Poehlman TA, Uhlmann EL, Banaji MR. Understanding and using the Implicit Association Test: III. Meta-analysis of predictive validity. J Personal Soc Psychol. 2009;97(1):17–41.

    Article  Google Scholar 

  25. 25.

    Eisenberg T, Johnson SL. Implicit racial attitudes of death penalty lawyers. Cornell Law Facutly Publications, Paper 353. 2004. Available at: http://scholarship.law.cornell.edu/facpub/353. Accessed on February 14, 2013.

  26. 26.

    Sabin JA, Rivara FP, Greenwald AG. Physician implicit attitudes and stereotypes about race and quality of medical care. Med Care. 2008;46(7):678–85.

    PubMed  Article  Google Scholar 

  27. 27.

    Corporation I. Project Implicit.

  28. 28.

    Sabin J, Nosek BA, Greenwald A, Rivara FP. Physicians’ implicit and explicit attitudes about race by MD race, ethnicity, and gender. J Health Care Poor Underserved. 2009;20(3):896–913.

    PubMed  Article  Google Scholar 

  29. 29.

    Sabin JA, Greenwald AG. The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma. Am J Public Health. 2012;102(5):988–95.

    PubMed  Article  Google Scholar 

  30. 30.

    Cooper LA, Roter DL, Carson KA, Beach MC, Sabin JA, Greenwald AG, et al. The associations of clinicians’ implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. Am J Public Health. 2012;102(5):979–87.

    PubMed  Article  Google Scholar 

  31. 31.

    White-Means S, Zhiyong D, Hufstader M, Brown LT. Cultural competency, race, and skin tone bias among pharmacy, nursing, and medical students: implications for addressing health disparities. Med Care Res Rev. 2009;66(4):436–55.

    PubMed  Article  Google Scholar 

  32. 32.

    Penner LA, Dovidio JF, West TV, Gaertner SL, Albrecht TL, Dailey RK, et al. Aversive racism and medical interactions with Black patients: a field study. J Exp Soc Psychol. 2010;46(2):436–40.

    PubMed  Article  Google Scholar 

  33. 33.

    Schwartz MB, Chambliss HO, Brownell KD, Blair SN, Billington C. Weight bias among health professionals specializing in obesity. Obes Res. 2003;11(9):1033–9.

    PubMed  Article  Google Scholar 

  34. 34.

    Uncapher H, Arean PA. Physicians are less willing to treat suicidal ideation in older patients. J Am Geriatr Soc. 2000;48(2):188–92.

    PubMed  CAS  Google Scholar 

  35. 35.

    Reuben DB, Fullerton JT, Tschann JM, Croughan-Minihane M. Attitudes of beginning medical students toward older persons: a five-campus study. The University of California Academic Geriatric Resource Program Student Survey Research Group. J Am Geriatr Soc. 1995;43(12):1430–6.

    PubMed  CAS  Google Scholar 

  36. 36.

    Madan AK, Aliabadi-Wahle S, Beech DJ. Age bias: a cause of underutilization of breast conservation treatment. J Cancer Educ. 2001;16(1):29–32.

    PubMed  CAS  Google Scholar 

  37. 37.

    Madan AK, Cooper L, Gratzer A, Beech DJ. Ageism in breast cancer surgical options by medical students. Tenn Med. 2006;99(5):37–8. 41.

    PubMed  Google Scholar 

  38. 38.

    Borkhoff CM, Hawker GA, Kreder HJ, Glazier RH, Mahomed NN, Wright JG. The effect of patients‘ sex on physicians’ recommendations for total knee arthroplasty. CMAJ. 2008;178(6):681–7.

    PubMed  Article  Google Scholar 

  39. 39.

    Chapman KR, Tashkin DP, Pye DJ. Gender bias in the diagnosis of COPD. Chest. 2001;119(6):1691–5.

    PubMed  Article  CAS  Google Scholar 

  40. 40.

    Heins JK, Heins A, Grammas M, Costello M, Huang K, Mishra S. Disparities in analgesia and opioid prescribing practices for patients with musculoskeletal pain in the emergency department. J Emerg Nurs. 2006;32(3):219–24.

    PubMed  Article  Google Scholar 

  41. 41.

    Miner J, Biros MH, Trainor A, Hubbard D, Beltram M. Patient and physician perceptions as risk factors for oligoanalgesia: a prospective observational study of the relief of pain in the emergency department. Acad Emerg Med. 2006;13(2):140–6.

    PubMed  Article  Google Scholar 

  42. 42.

    Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA. 1993;269(12):1537–9.

    PubMed  Article  CAS  Google Scholar 

  43. 43.

    Todd KH, Deaton C, D’Adamo AP, Goe L. Ethnicity and analgesic practice. Ann Emerg Med. 2000;35(1):11–6.

    PubMed  Article  CAS  Google Scholar 

  44. 44.

    Todd KH, Lee T, Hoffman JR. The effect of ethnicity on physician estimates of pain severity in patients with isolated extremity trauma. JAMA. 1994;271(12):925–8.

    PubMed  Article  CAS  Google Scholar 

  45. 45.

    Petersen LA, Wright SM, Peterson ED, Daley J. Impact of race on cardiac care and outcomes in veterans with acute myocardial infarction. Med Care. 2002;40(1 Suppl):I86–96.

    PubMed  Google Scholar 

  46. 46.

    Allison JJ, Kiefe CI, Centor RM, Box JB, Farmer RM. Racial differences in the medical treatment of elderly Medicare patients with acute myocardial infarction. J Gen Intern Med. 1996;11(12):736–43.

    PubMed  Article  CAS  Google Scholar 

  47. 47.

    Canto JG, Allison JJ, Kiefe CI, Fincher C, Farmer R, Sekar P, et al. Relation of race and sex to the use of reperfusion therapy in Medicare beneficiaries with acute myocardial infarction. N Engl J Med. 2000;342(15):1094–100.

    PubMed  Article  CAS  Google Scholar 

  48. 48.

    Weitzman S, Cooper L, Chambless L, Rosamond W, Clegg L, Marcucci G, et al. Gender, racial, and geographic differences in the performance of cardiac diagnostic and therapeutic procedures for hospitalized acute myocardial infarction in four states. Am J Cardiol. 1997;79(6):722–6.

    PubMed  Article  CAS  Google Scholar 

  49. 49.

    Taylor HA Jr, Canto JG, Sanderson B, Rogers WJ, Hilbe J. Management and outcomes for black patients with acute myocardial infarction in the reperfusion era. National Registry of Myocardial Infarction 2 Investigators. Am J Cardiol. 1998;82(9):1019–23.

    PubMed  Article  Google Scholar 

  50. 50.

    Hawker GA, Wright JG, Coyte PC, Williams JI, Harvey B, Glazier R, et al. Differences between men and women in the rate of use of hip and knee arthroplasty. N Engl J Med. 2000;342(14):1016–22.

    PubMed  Article  CAS  Google Scholar 

  51. 51.

    Coyte PC, Hawker G, Croxford R, Attard C, Wright JG. Variation in rheumatologists‘ and family physicians’ perceptions of the indications for and outcomes of knee replacement surgery. J Rheumatol. 1996;23(4):730–8.

    PubMed  CAS  Google Scholar 

  52. 52.

    Wright JG, Coyte P, Hawker G, Bombardier C, Cooke D, Heck D, et al. Variation in orthopedic surgeons’ perceptions of the indications for and outcomes of knee replacement. CMAJ. 1995;152(5):687–97.

    PubMed  CAS  Google Scholar 

  53. 53.

    Carnes M, Devine PG, Isaac C, Baier Manwell L, Ford CE, Byars-Winston A, Fine E, Sheridan J. Promoting institutional change through bias literacy. J Divers High Educ. 2012;5(2):63–77.

    PubMed  Article  Google Scholar 

  54. 54.

    Devine PG, Plant EA, Buswell BN, Oskamp S. Breaking the prejudice habit: Progress and obstacles. Reducing Prejudice and Discrimination. Mahwah, NJ, US: Lawrence Erlbaum Associates Publishers; 2000:185–208.

  55. 55.

    Devine PG, Forscher PS, Austin AJ, Cox WTL. Long-term reduction in implicit race prejudice: a prejudice habit-breaking intervention. J Exp Soc Psychol. 2012;48:1267–78.

    PubMed  Article  Google Scholar 

  56. 56.

    Bandura A, Kazdin, A.E. Social-cognitive theory. Encyclopedia of psychology, Vol. 7. Washington, DC, New York, NY, USUS: American Psychological Association, Oxford University Press; 2000:329-32.

  57. 57.

    Prochaska JO, DiClemente CC. Stages of change in the modification of problem behaviors. Prog Behav Modif. 1992;28:183–218.

    PubMed  CAS  Google Scholar 

  58. 58.

    Lebrecht S, Pierce LJ, Tarr MJ, Tanaka JW. Perceptual other-race training reduces implicit racial bias. PLoS One. 2009;4(1):e4215.

    PubMed  Article  Google Scholar 

  59. 59.

    Galinsky AD, Moskowitz GB. Perspective-taking: decreasing stereotype expression, stereotype accessibility, and in-group favoritism. J Pers Soc Psychol. 2000;78(4):708–24.

    PubMed  Article  CAS  Google Scholar 

  60. 60.

    Todd AR, Bodenhausen GV, Richeson JA, Galinsky AD. Perspective taking combats automatic expressions of racial bias. J Pers Soc Psychol. 2011;100(6):1027–42.

    PubMed  Article  Google Scholar 

  61. 61.

    Drwecki BB, Moore CF, Ward SE, Prkachin KM. Reducing racial disparities in pain treatment: the role of empathy and perspective-taking. Pain. 2011;152(5):1001–6.

    PubMed  Article  Google Scholar 

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Acknowledgements

Dr. Chapman is a Geriatric Fellow at the Madison GRECC and Dr. Kaatz is a postdoctoral fellow at the Center for Women’s Health Research. This is GRECC Manuscript No. 2013-14. Dr. Carnes’s research on implicit bias is supported by NIH grant no. R01 GM088477 and DP4 GM096822.

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The authors declare that they do not have a conflict of interest.

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Correspondence to Elizabeth N. Chapman MD.

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Chapman, E.N., Kaatz, A. & Carnes, M. Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health Care Disparities. J GEN INTERN MED 28, 1504–1510 (2013). https://doi.org/10.1007/s11606-013-2441-1

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KEY WORDS

  • implicit bias
  • health care disparities
  • physicians