Chapter 1 – Introduction
In this book, we will explore the impact of bias on the experiences of healthcare providers, learners preparing to be providers, and patients in the healthcare setting.
All human beings have biases, which seem to be a type of primal defense mechanism that is hard-wired. Implicit or unconscious biases deal with thoughts and behaviors that happen without our awareness and outside of our control; they are triggered by social judgments and inferences which we often do not notice as having an impact on our cognition. These judgments and inferences are in turn triggered by personal appearance or other obvious characteristics of an individual, often compounded by social stereotypes regarding those characteristics. Having formed an unconscious bias regarding an individual, we then may tend to use information learned later to confirm our preexisting beliefs.1
Experts have found that time pressure, fatigue, stress, and information overload increase our tendency to use unconscious biases to shortcut our decision making.1 These factors are prevalent parts of the medical landscape for patients and providers.
Unconscious or implicit biases may often lead to decisions that one would not make based on rational thought, stated or deeply—held personal beliefs, or egalitarian principles; the results can be prejudicial, and can negatively affect patient care, interprofessional and collegial behaviors, educational decisions, and quality of life.1
Fortunately, unconscious or implicit biases can be exposed and acknowledged, and their impacts reduced to allow a more diverse and inclusive medical environment.2
The IAT, or Implicit Association Test, is available online at implicit.harvard.edu and reveals implicit biases of test takers toward a variety of characteristics. Awareness of our biases is the first step toward reducing them and their impacts on our daily lives and the lives of others. Among the findings of Project Implicit, which has analyzed over 4.5 million IAT results between 1998 and 2006, are that implicit biases are pervasive; that they impact behavior; and that people are not aware of their own biases.1
Fortunately, there is a way forward; once biases are discovered, they may be reduced and their effect on decisions in the healthcare arena may be reduced. Several strategies are offered by the Institute for Healthcare Improvement to accomplish these goals. These include: Stereotype replacement (adjusting the response to acknowledge the stereotype one would otherwise address); Counter-stereotype imaging (imagining the individual as opposite of the stereotype); Individuation (learning about the individual as a person and about their health care context, vs. looking at them as representative of the bias they would otherwise represent); Perspective-taking (putting oneself in the other person’s place); and Increasing networking and Partnership building with diverse persons, framing them as equals. The rigorous practice of employing evidence-based medicine, regardless of the identity of the patient, has also proven a way to de-bias patient care. 2
Purpose of this Book
“Perspectives on Bias in Medicine” begins each chapter with the IAT that correlates with the bias being discussed in that passage. The exception is Poverty, which generates bias but has no assigned IAT; an alternative opening exercise is recommended for this Chapter. The technique of individuation, or allowing health providers and patients affected by bias to speak for themselves so you can see through their eyes, is used to helping reduce bias and is incorporated in the form of patient interviews and videos. Questions at the end of each chapter are designed to help you recall factual details relevant to the discussed bias, alluded to in the accompanying chapter text which amplifies on the bias being discussed. They should also serve as a springboard to allow you to reflect on how to further reduce and speak out against the incorporation of bias into collegial relationships and patient care in the future.
We hope you enjoy this book.