Recognizing and Reducing

Unconscious Bias
in Healthcare
Patricia Flynn, Ph.D., M.P.H.
Assistant Professor
Department of Psychology; Department of Preventive Medicine
Director of Health Disparities Research, LLUHEC
pflynn@llu.edu
 Presentation Overview

• What is Unconscious Bias?

• Unconscious Bias in Healthcare
• Activity: Implicit Association Test
• Strategies to Reduce Unconscious Bias
 What is an implicit bias?
Unconscious • A bias in favor of or against another person or group that….

(Implicit) Bias – we are unaware of

– happens automatically (like a habit)
– outside of our control

Why do we have biases?

• Because we are exposed to lots of information, our brains have a
normal tendency to want to create shortcuts (e.g. associations
or categories) to more efficiently organize the world.
 Where do they come from?
• How we’ve been socialized…our personal and cultural
Unconscious experiences (or lack thereof), exposure to media, tv,
books, etc.
(Implicit) Bias • Emerge from socially shared beliefs and stereotypes about
groups (e.g. ethnicity, race, gender, sexual orientation).

When is it more likely to occur?

• Situations involving high cognitive load
– Stress, time pressure, fatigue, multiple demands,
ambiguous or subjective situations

What are the consequences?

• It affects the way we think, feel, and treat others
 How do we know if we have it?
• Implicit Association Test (IAT, Greenwald, et al., 1998)

Unconscious What does it look like to socially

(Implicit) Bias disadvantaged groups?
• Nonverbal behaviors are particularly important:
– eye contact, blinking, body language, emotional tone,
duration of interactions

• AA-White Interactions (Dovidio, et al., 2002)

– Explicit biasà verbal behavior and judgments
– Implicit biasà nonverbal behavior
– Whites felt the interaction went great….AA didn’t
agree!
– Whites low explicit but high implicit biasà AA &
observers had more negative evaluations
Unconscious Bias among Health Professionals
44,000 (2,500 physicians) completed Implicit Association Test (IAT)
• Race Bias (Sabin et al., 2009)
• Equal physicians & non-physicians
• Weight Bias (Sabin et al., 2012)
• Equal physicians & non-physicians
• Latino Bias (Blair et al., 2013)
• Equal among 210 primary care providers & 190 community members

Bias is universal and physicians are not immune!

Consequences of Unconscious Bias in Healthcare
• Medical Treatment Decisions
• Mixed Results (Sabin & Greenwald, 2012)
• Pediatricians’ implicit race bias à less pain medication for African Americans
• No effect for UTIs, ADHD, & asthma
• Consistent with psychological research indicating that unconscious bias is….
• Less associated with explicit judgments
• More associated with non-verbal (eye contact, body language) and paraverbal (how speech is
delivered) behaviors (Dovidio et al., 2002)

• Patient-Provider Interactions (Penner et al., 2016)

• Oncologists’ implicit bias, video recordings of clinical interactions with A.A. patients
• Communication: shorter; less patient-centered & supportive
• Patient: less confidence in tx plan; greater difficulty remembering contents of interaction
 Here is some good news…
Unconscious
Bias 1. It’s normal, and it doesn’t make us bad
people!!!
2. They are malleable, the implicit associations
that we have formed can be gradually
unlearned and replaced with new
associations.
3. There are evidence-based strategies we can
use to control or prevent our implicit
responses and behaviors.
Strategies for Busting through Unconscious Bias
Implicit
Association Test DIRECTIONS
1. Google search “project implicit” or go to
www.implicit.harvard.edu
2. Click on top yellow box—”we have
detected you are using a touch devise”
3. Scroll to bottom and click “I wish to
proceed”
4. Scroll down and select blue button for
“race IAT” or “weight IAT”
Implicit Discussion Questions
Association
Test Activity 1. What was your experience like taking the IAT
and receiving the results?

2. What kinds of personal, family, cultural, medical

training, or clinical experiences may have
contributed to the results?

3. What are the implications for how you interact

and care for your patients?
 Busting Through Unconscious Bias
1. Be aware and concerned
• van Ryn, et al., (2014) examined unconscious bias in over 3,500 med students
• Completed IAT à decreased implicit bias over the 4 years
• Take other IATs-- race, Asian, Arab-Muslim, gender, skin-tone, age, weight, sexuality, disability
• Implicit biases do NOT make you a bad person! It’s an opportunity to improve your skills.

2. Intergroup contact (imagined contact)

• Seek out others who are different from you (ethnic, socioeconomic, sexual backgrounds)

3. Counterstereotype thinking
• Think of people that defy stereotypic expectations

4. Put yourself in your patients’ shoes (perspective-taking / empathy)

• Stop and wonder– What is my patient’s life like (Latina)? What is it like to be an
immigrant in the US? What barriers may be getting in the way of her health?
What would it be like to be her for a day?
 Busting Through Unconscious Bias
5. Get to know your patient- seek individuating information (vs. categorization)
• See the person as an individual and try to understand the individual’s cultural context
• Practice cultural competence skills/communication (e.g. ASCN)

6. Find Commonality
• Penner et al (2013)--patients and providers signed a “team contract”, wore similar color pins, read a list
of common group statements.
• AA patients had better evaluations of clinical interactions and better adherence compared to those not in
intervention
• Ask yourself-- What similar values, beliefs, interests, life experiences do I share with my patients?
• Think– we are in this together, we’re part of a team together, working on a common goal

7. Mindfulness & Self-Monitoring

• Mindful of situations that are likely to elicit bias (stress, time, fatigue, ambiguity)
• Self-monitor non-verbal and paraverbal behaviors (eye contact, posture, emotional tone, length of visit)
 Physician Perspective-Taking (Empathy):
A Means for Overcoming Negative Healthcare Encounters among Latinas
Amador, Flynn, & Betancourt, 2015, Journal of Behavioral Medicine

Perceived Health
Professional .31** Continuity of
Empathy Care
(Perspective Taking)

- .18 -.32***
Anger
Associated with
Negative
Healthcare
Encounter

Latino Fit: CFI=1.00, S-Bc2 (31, n=98) = 25.82, p= .73, c2/df=0.83, Y-B F(31,67)=1.03, p=1.03, RMSEA= .000, 90% CI (.000, 0.057)
 Discussion Question
Which of the evidence-based bias reduction strategies are you
most likely to use and why?
• Awareness (IAT)
• Intergroup contact
• Counterstereotype thinking
• Perspective-taking/empathy
• Get to know your patient (cultural background)
• Find commonality (hobby)
• Mindfulness & self-monitoring
 Thank You….
Questions
CONTACT INFO: ?
Comments
Patricia Flynn, Ph.D., M.P.H. ? Concerns
Assistant Professor ?
Department of Psychology
Department of Preventive Medicine
pflynn@llu.edu