Implicit Biases Have an Explicit Impact on Healthcare Outcomes

Implicit biases may be unconsciously formed, but they can have real impacts for patients in the healthcare system if physicians or other healthcare providers don’t take the time to recognize their own implicit biases.

In 2016, Kelly M. Hoffman, PhD, associate researcher at Future Laboratories, coauthored a study¹ on racial bias in pain perception and treatment that found black patients are undertreated for pain compared with white patients. The study examined false beliefs in 2 groups: laypeople without medical training and people with medical training.

While the individuals with medical training were less likely to endorse false beliefs—such as that black people have thicker skin or heal more quickly—Hoffman said it was still surprising how strong the endorsement of these beliefs were among people with medical training. Participants with medical training (medical students and residents) endorsed 11.55%, on average, of false beliefs compared with laypeople who endorsed 22.43% of the beliefs, on average.

These false beliefs are entrenched in the historical context of the United States, Hoffman explained.

“We know going back to slavery that physicians and slave owners perpetuated these types of ideas to help justify owning slaves and to help justify experimenting on black people’s bodies,” she said.

Yesenia M. Merino, MPH, a PhD candidate at the University of North Carolina at Chapel Hill, explained that in the health sciences, people don’t like to admit that observations can be subjective. In addition to considering the symptoms that present, providers need to also think about the context within which those symptoms present.

“We act as though our observations are objective truth and not influenced by our own context and our own biases and our own histories,” she said.

Implicit biases affect care all along the continuum, especially in mental health. Merino explained that not only are there assumptions about who has mental health issues, but also biases affect who is more likely to get a follow-up call from a provider or get an appointment.

Marginalized populations, such as the homeless or people of color, are more likely to been seen as criminal and violent in emergency situations and are more likely to be presumed to be noncompliant with their medication, but they’re also more likely to be presumed to be medication-seeking or having an ulterior motive other than trying to receive needed care.

In obesity, the stigma patients face can mean another health issue goes undiagnosed and untreated, explained Fatima Cody Stanford, MD, MPH, MPA, FAAP, FACP, FTOS, instructor of medicine and pediatrics at Harvard University.

Obesity stigma causes a "vicious cycle."

Unlike some other health conditions, such as an autoimmune disorder or opioid use disorder, obesity is a diagnosis that is visible, and a lot of judgements are made. Stanford explained that health providers often assume patients with severe obesity cannot conform to lifestyle modifications, that they haven’t looked at changing their diet, or that they have yet to try an exercise program.

“So, the assumption is that they’re just lazy, and they haven’t done all of these things,” she said.

The reality is that obesity is caused by multiple issues, including genetics, the gut microbiome, and the environment. Unfortunately, obesity, the many factors that cause it, and how to treat it are not really taught in medical school, Stanford said. As a result, providers assume the patient did something wrong, and it is only once patients lose weight that providers really start to listen to the other issues a patient mentions.

For example, she said, if a patient says his or her hip is hurting, the physician assumes it is the weight. It is only after the patient loses 100 pounds and still complains about hip pain that the provider will look closer and find something like a cancer that went undiagnosed for a long time and could have been treated earlier.

“Obesity is so complex and requires so much investment on the part of the clinicians that it’s easier to just put the onus back on the patient,” Stanford explained.

In obesity care, bias may not only come through with how a provider or other health professional interacts with the patient, Stanford said. There are aspects of the healthcare experience outside of human interaction that can make a patient feel ill at ease, such as if the waiting room does not have seating to accommodate a person with severe obesity.

“They didn’t get any negative feedback from the front staff, they were received in a very positive fashion by the medical assistants, but just not having a place to sit down, to wait for the doctor or other professional that might be seeing them in that space gives them a sign that they’re not welcome there,” she said.

Patients with obesity pick up on things like if a doctor’s office doesn’t have a scale that can weigh them or a blood pressure cuff that can fit around their arm. These might be things that the health providers don’t think about, even if they think they are being welcoming to patients with obesity.

Who Has Implicit Bias and Faces It

Patients who don’t look like the average or what is considered normal face the greatest barriers to care and are more likely to be on the receiving end of implicit biases that impact their care, explained Merino. In her research, she has seen that people from lower socioeconomic neighborhoods were presumed not to understand the science behind a clinical trial that could have been beneficial to them, and there was also a systematic exclusion of transgender patients. Diversifying the workforce can help, but it won’t be a cure-all.

“The fact of the matter is that everyone does have some biases, and it takes continual effort and possibly making mistakes to work with that,” Merino said. “It’s a lifelong journey.”

She found in a 2015 review² that most healthcare providers have implicit biases (positive attitudes toward whites and negative attitudes toward people of color), and this holds true regardless of the race or ethnicity of the provider. Merino trains health professionals and said this is something that can be surprising to providers of color.

Hoffman explained that her pain study found that “Racial bias in perceptions of pain (and possibly treatment) does not appear to be born out of racist attitudes.” When she and her team started studying racial bias and pain perception, they thought negative racial bias would be one explanation, but that didn’t necessarily hold true.

“What we found was that when we measure racial attitudes, whether explicit or implicit, those never predicted the racial bias,” Hoffman said. “And, in fact, black people also perceive other black people as feeling less pain than white people.”

Overcoming Implicit Bias

There were a few common suggestions of ways providers can overcome bias or ensure any implicit biases they do have don’t interfere with patient care. The first is better education. Stanford noted that physicians are governed by the testing environment, and yet even though obesity affects more than 94 million American adults, there are no significant questions on medical test. In comparison, Behcet’s disease, a rare disorder causing inflammation in the blood vessels that affects fewer than 20,000 Americans a year, has been on every test Stanford as ever taken.

“I feel like early exposure to [obesity] education in both the premedical environment all the way through medical school and residency and fellowship is important across all specialties,” Stanford said. “Because there’s not 1 individual who’s a physician who won’t encounter patients with obesity during the time of their career.”

Hoffman added that medical training will help ensure that professionals don’t believe there are biological differences between any race.

In addition, slowing down medical decisions is important. According to Hoffman, research has shown that this has been shown to be helpful in eliminating racial biases.

Merino added that a clinician who is in a standard setting can more concretely make decisions based on his or her explicit beliefs; however, it’s when a clinician is a stressful situation with little time to think that he or she is more likely to rely on implicit biases.

“It’s the rapid decision making where we’re more likely to be dependent on our implicit biases,” Merino explained.

Finally, trust is key. Merino said trust ties into spending more time making decisions, since trust cannot be built in just 7 minutes. It takes time, something that can be difficult under current payment models. But trust is important, especially for patients who may come from a place where they have many reasons not to trust providers.

Hoffman agreed that trust is important, and that comes from improve patient—physician relationships. Currently, the relationship is very paternalistic, with physicians in charge, but physicians need to work more with patients and trust them when they say something is wrong without making assumptions.

“If you can change that dynamic to be more cooperative—so a physician is working with the patient to get the best treatment plan—that’s been shown to be effective with racial bias in treatment,” Hoffman said.

1. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci. 2016;113(16):4296-4301. doi: 10.1073/pnas.1516047113.

2. Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health. 2015;105(12):e60-e76. doi: 10.2105/AJPH.2015.302903.

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