California: Implicit Bias for Healthcare Providers (341)Page 2 of 10

1. Bias, in All Its Forms

Humans have developed many automatic responses to 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’s 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 even easy, biases have caused considerable harm to people who are the target of unconscious bias, leading to discrimination and lack of access to the benefits available to members of society who do not experience these biases.

Over time, expressions of explicit bias have declined, but implicit bias has remained unrelenting. Healthcare providers may still hold negative explicit and implicit 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).

Test Your Knowledge

You may find it helpful to try these 10 “True or False” questions first before reading the course. The answers are at the end of the question list.

  1. Implicit bias is a conscious process based on intentional mental associations.
  2. Health equity means that everyone has a fair and just opportunity to be as healthy as possible
  3. Structural racism refers to ideologies, practices, processes, and institutions that produce and reproduce differential access to power and to life opportunities along racial and ethnic lines.
  4. Cultural sensitivity is a respect for another person’s strengths, culture, and knowledge.
  5. A type of unconscious bias that occurs when our perception is skewed based on inaccurate and overly simplistic assumptions about a group or person is called perception bias.
  6. Evidence shows that interventions focusing on social determinants of health rarely lead to better health outcomes.
  7. Perception bias is a type of unconscious or implicit bias that occurs when our perception is skewed based on inaccurate and overly simplistic assumptions about a group a person “belongs” to.
  8. Historically embedded structural racism is a fundamental cause of health inequities in the United States.
  9. Measures of implicit bias rely on the assumption that automatic associations between two concepts will influence behavior in a measurable way.
  10. Bias training has been shown to be more effective when the approach is multipronged, designed with context and professional identity in mind, and when people work and train together.

Answers: Questions 1 and 6 are False; all the others are True.

What is Implicit Bias?

Implicit bias is an attitude or internalized stereotype that 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 (, 2021, September 24). What is troubling 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). 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).

What is Explicit Bias?

Explicit or conscious bias, unlike implicit bias, occurs when we are aware of our prejudices and attitudes toward certain groups. This can lead to positive or negative preferences for a particular group.

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). Explicit bias can lead to unequal treatment, lack of access to care, and influence differential diagnostic and treatment decisions.

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 can occur when a provider categorizes a patient in a certain way, regardless of whether the individual in question fits the stereotype (Galanti, 2019).

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.

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).

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 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. These attitudes, beliefs, or stereotypes can affect a provider’s ability to make sound medical decisions.

Perception biases can create a conflict between what a person believes and what they want to do (FitzGerald and Hurst, 2017). 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 is eliminated by technology, instrumentation, automation, or artificial intelligence (Dror, 2020).

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

Many biases have been described in the healthcare literature, and many of these have been shown to influence decisions (Featherston et al., 2020). 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).


  • Bias: the unintended influence of factors that are not meant to be considered; a tendency to prefer one person or thing to another.
  • Diversity: ways in which people differ; characteristics that make one individual or group different from another.
  • Equality: when every individual has the same rights, resources, and opportunities, regardless of their circumstance.
  • Equity: the idea that all individuals have equal access to healthcare services and resources, regardless of their race, ethnicity, socioeconomic status, gender, sexual orientation, or other characteristics.
  • Explicit (conscious) bias: conscious and intentional discrimination against certain groups of people.
  • Implicit (unconscious or hidden) bias: bias that is outside a person’s consciousness; may directly contradict a person’s stated beliefs and values.
  • National origin discrimination: Treating people unfavorably due to where they are from, their ethnicity or their accent.
  • Prejudice: a bias, opinion, idea, or belief about something; an assumption or dislike for a person or group simply based on the person’s membership in that group.
  • Racial discrimination: treating a person adversely due to race or characteristics associated with that race, such as hair texture, facial features, or skin color.
  • Structural racism: the history and current reality of racism across all institutions combining to create a system that negatively impacts communities of color.
  • Stereotype: beliefs and opinions about the characteristics, attributes, and behaviors of members of a group; a generalization, often exaggerated, or untrue.