Humans have developed many automatic responses that can help us move through our daily lives efficiently and without conscious thought. We don’t think about how our bodies maintain balance, when to withdraw our hand from a hot stove, or why it is important to avoid rotten food. We have developed automatic and reflexive responses that allow us to function efficiently, without conscious thought.

Implicit biases might be viewed in this light. They occur below the level of consciousness, using information developed from our life experiences and habits. They help us to make sense of the world, allowing us to classify individuals into categories quickly and automatically. Although efficient and easy, biases have caused considerable harm to people who are their target, leading to discrimination and lack of access to the benefits available to members of society who do not experience these biases.

Expressions of explicit bias may have declined, but implicit, unconscious bias has remained unrelenting. Healthcare providers often still hold negative biases against many marginalized groups of people. Implicit bias permeates the healthcare system and affects patient–clinician communication, clinical decision making, and institutionalized practices (Vela et al., 2022).

Higher education systems, including medical schools and academic hospitals, have been affected by the discrimination and bias that have long permeated healthcare. A complex system of discrimination and bias causes devastating health inequities that persist despite a growing understanding of its root causes. These biases hinder improvement in healthcare provider diversity, which has long been recognized as an important mechanism for reducing disparities (Vela et al., 2022).

2.1 What is Implicit Bias?

Implicit bias affects a person’s perception, action, or decision-making in an unconscious manner. It can contribute to unequal treatment based on characteristics such as race, ethnicity, nationality, gender, gender identity, sexual orientation, religion, socioeconomic status, age, or disability.

Decades of research has demonstrated that discrimination, driven by implicit bias, impacts healthcare access, trust in clinicians, care quality, and patient outcomes (Dirks et al, 2022). The troubling thing for healthcare professionals is the possibility that biased judgment and biased behavior can affect patient care (FitzGerald et al., 2019).

Implicit bias is widespread, even among individuals who explicitly reject prejudice. It persists through structural and historical inequalities that have been slow to change (Payne et al., 2019).

2.2 What is Explicit Bias?

Explicit or conscious bias, unlike implicit bias, occurs when we are aware of our prejudices and attitudes, which can lead to positive or negative preferences for a particular group. Explicit bias can lead to unequal treatment, lack of access to care, and influence diagnostic and treatment decisions.

Explicit forms of bias include preferences, beliefs, and attitudes of which people are generally consciously aware, personally endorse, and can identify and communicate (Vela et al., 2022).

2.3 What are Stereotypes?

Stereotypes are fixed, oversimplified beliefs about a particular group or culture. They occur when we categorize people by age, gender, race, or other criteria (Brusa et al., 2021). In the healthcare setting, stereotyping occurs when a provider categorizes a patient in a certain way, whether or not the individual fits the stereotype (Galanti, 2019).

When people are exposed to or are invited to think about traits or behaviors that counter their stereotypes, they became less prejudicial toward that social group. Equality of status, social and institutional support, pleasant contact, and intergroup cooperation often produce positive results (Brusa et al., 2021).

Recognizing stereotypical thoughts can have a powerful impact on bias. Putting yourself in the shoes of the other person, creating a non-stereotypical alternative to a particular stereotype, and seeing the person as an individual can reduce bias.

2.4 What is Perception Bias?

Well, I found out that race runs deeply throughout all of medical practice. It shapes physicians’ diagnoses, measurements, treatments, prescriptions, even the very definition of diseases. And the more I found out, the more disturbed I became.

Dorothy Roberts
University of Pennsylvania

Perception bias is a type of unconscious or implicit bias that occurs when a person’s perception is skewed based on inaccurate and overly simplistic assumptions about a group a person “belongs” to. This may include biases or stereotypes about age, gender, ethnicity, and appearance.

Perception biases can create a conflict between what a person believes and what they want to do (FitzGerald and Hurst, 2017). Perception bias can affect a provider’s ability to make sound medical decisions.

Providers may feel they can overcome biases through sheer will power. They may feel that bias does not occur among professionals and experts, or they may believe that they are impartial and immune to bias. They may perceive bias as only associated with corrupt or malicious people or with “bad apples” rather than systemic issues. Although research has shown this to be incorrect, they often feel that bias can be eliminated by technology, instrumentation, automation, or artificial intelligence (Dror, 2020).

2.5 What is Diagnostic and Treatment Bias?

The use of racial terms to describe epidemiologic data perpetuates the belief that race itself puts patients at risk for disease, and this belief is the basis for race-based diagnostic bias. Rather than presenting race as correlated with social factors that shape disease or acknowledging race as an imperfect proxy for ancestry or family history that may predispose one to disease, the educators we observed portrayed race itself as an essential—biologic—causal mechanism.

Amutah, et al., 2021
New England Journal of Medicine

Patient-provider interactions, treatment decisions, patient adherence to recommendations, and patient health outcomes can be influenced by bias. This can lead to an unintentional form of discrimination that affects decision-making structurally and systematically and is hard to identify and uncover (Nápoles et al., 2022).

Studies have shown that implicit racial bias profoundly influences clinical decision-making. Its affects nonverbal behaviors such as eye contact and posture and has been shown to influence the quality of physicians’ interpersonal communication with African American patients and, in turn, patients’ trust and perceptions of their physicians (van Ryn et al., 2015).

2.6 Indirect Discrimination

Indirect discrimination happens when there is a policy that applies in the same way for everybody but disadvantages a group of people sharing a protected characteristic. * You are disadvantaged if you are a member of that group. A “policy” can include a practice, a rule, or an arrangement. It makes no difference whether anyone intended the policy to disadvantage you or not (EHRC, 2019).

* Protected characteristic: Also referred to as a protected class. A category of a group of people who have historically been discriminated against.

Indirect discrimination often operates under the guise of legitimacy and fairness. It can be related to sex, gender reassignment, sexual orientation, race, belief, age, disability, marriage or civil partnership, or religion. While direct discrimination is often evident, indirect discrimination can be subtle and difficult to prove.

If you are affected by indirect discrimination, the person or organization applying the policy must show that it is in place for a good reason. A “policy” can include a practice, a rule, or an arrangement. It makes no difference whether anyone intended the policy to disadvantage you or not (EHRC, 2019).  

To prove that indirect discrimination is happening or has happened, a person must be able to show that the policy has disadvantaged them personally or that it will disadvantage them. Additionally, indirect discrimination can occur if the organization is unable show that there is a good reason for applying the policy despite the level of disadvantage to people with a protected characteristic (EHRC, 2019).

Examples of indirect discrimination include:

• Prohibiting certain types of hairstyles.
• Requiring patients to be given care by someone of the same gender—some people may prefer certain caregivers of the opposite gender or transgender people may want to be seen by the gender with which they identify.
• Providing protective clothing that is too small or large for an employee.
• Establishing height requirements for jobs where height is irrelevant or refusing a job to someone because the company’s equipment is not designed for people of a certain height.
• Providing generic toiletries that may not be suitable for some skin and hair types could constitute indirect discrimination for those, for example, with curly or coily hair.

In hospital organizations owned by religious organizations, indirect discrimination—although well-intentioned can include:

• Refusing to pay for an employee’s required training on Saturday because of the employer’s religious beliefs.
• Requiring prayer at the start of staff meetings.
• Promoting only members who share the religious beliefs of the hospital’s owners or managers.
• Serving lunch at a certain time each day without consideration for religious requirements such as fasting.

It is important to carry out impact assessments on all the protected characteristics when creating and reviewing policies, procedures, or rules.

Several tools have been developed to help an organization prevent policies and assumptions that can lead to indirect discrimination. For example, the Equality Pay Act of 1963 requires employers to pay each employee equally for the same role regardless of gender identity and disability. It also ensured that Black Americans had equal access to public accommodations and material goods. (Also see the module 12, Best Practices for Improving Health Equity.)