Implicit bias is rightfully the hot topic of the year, and it’s important to acquire a deeper understanding of it.
Implicit bias is that subtle, unconscious type of bias that is hard to pinpoint and hard to measure. It contrasts with the more outward and conscious explicit bias. Both are crucial for emergency physicians to recognize in ourselves and others.
There is a growing body of research showing that physicians have racial, gender, age, weight, LGBTQ, disability, and many other types of implicit bias toward patients and colleagues. There is also evidence that these biases translate to explicit health care disparities and professional limitations.
The ACGME requires dedicated residency training in implicit bias and health care disparities. Furthermore, the National ACEP Council regularly votes on resolutions related to this topic. This includes the 2019 resolution 14(19) which proposes creating and releasing a policy statement promoting implicit bias training for residents and physician leaders, and continuing to create and offer free online implicit bias training.1 The ACEP Board has been a driving force in progress, and has released several policy statements in recent years relating to this topic.2-4
How can implicit bias be helpful at times?
Implicit bias is present in almost everything we do. Humans have been taught to rely on it as a natural (almost instinctive) survival skill, and our brains are hardwired to use it. A great deal of implicit bias is actually helpful and very necessary. We use it in the absence of complete information, so emergency physicians especially use it to make quick decisions for patients. This is a major aspect of essential heuristic decision making.
“A heuristic is a mental shortcut that allows people to solve problems and make judgments quickly and efficiently… [They] allow people to function without constantly stopping to think about their next course of action.” --Kendra Cherry5
Without bias and heuristic decision making, our careers in emergency medicine would be unsustainable - we might see one patient every three hours, maximum. But improper use of bias and heuristics is harmful too. It can lead to numerous types of cognitive errors in medical decision making. Part of the battle is pinpointing which biases are helpful, and which are harmful.
Think of it this way: an unconscious mystery ED patient who just looks like an addict will probably get naloxone. Much of the time, that is a good thing; patients do benefit from the emergency physician’s pattern recognition and quick decisions. But what happens when the physician anchors on the idea of opiate overdose, prematurely closes the case after giving naloxone, and fails to consider other causes? Afterall, this patient just looks like an addict and nothing else. The patient’s blood glucose of 20 might be missed. That is where the harm appears.
How can implicit bias can be harmful?
While many implicit and explicit biases are functional and deep-rooted natural survival tendencies, some are dysfunctional and harmful. Prior studies have shown that the presence of bias in physicians is associated with lower quality of care. Research has also shown that collegial targets of destructive bias in the workplace suffer negative professional effects like reduced pay and professional limitations, as well as psychosocial effects like isolation, bullying, and depression.
We keep hearing that implicit bias can be harmful, but what specific evidence is out there?
The ACEP Diversity and Inclusion Task Force conducted a 2017 survey in which 14% of respondents reported feeling their career advancement was hindered or delayed by their gender.6 Prior research suggests general hiring preference for male over female candidates, as well as preference for male over female leaders.7 When women leaders show agentic (historically “masculine”) leadership characteristics, they receive worse evaluations.8 And, although there is a nearly equal female-to-male ratio of medical school employees, females hold only 38% of faculty positions, 21% of full professor positions, and 16% of dean positions.9
Then there is the wage gap. A 2016 study showed that overall, female physicians make over $18,000 less than their male counterparts after adjusting for work hours, productivity, and experience.10 Women who ask for a raise are also less likely to get one than their male counterparts.11
Female doctors are less likely than their male doctors to be referred to by their professional title. Dr. Julia Files, a physician and associate professor of medicine at the Mayo Clinic, experienced this phenomenon on a large scale. At a conference, she noticed that female doctors were not introduced as “Doctor” as frequently as males. She turned this into a research project, reviewing 321 introductions made at grand rounds at two Mayo Clinic locations. Female introducers used the formal title “Doctor” when introducing any other speaker about 96% of the time, while male introducers used it about 66% percent of the time.12
Implicit racial bias hurts patients. A 2019 meta-analysis and systematic review found that black and Latino patients were less likely than white patients to receive analgesia for acute pain in the ED.13 Another study found that relative to white patients, patients of color have their first electrocardiogram performed later and receive a less thorough workup for suspected coronary artery disease.14 And arguably most shockingly, pregnancy-related mortality ratios are more than three times higher for black women than white women, and more than twice as high for American Indian/Alaska Native women than white women.15
The patient experience suffers as well. A 2015 meta-analysis uncovered implicit racial bias among physicians toward black patients and revealed that this translated to patients feeling less respected and less collaborative. They also liked their physician less.16 Another study of over 34,000 patient visits in 353 emergency departments revealed that black patients experienced significantly longer mean ED wait times than white patients.17
Preliminary results of a 2019 study on collegial physician weight bias show that 83% of 640 physician respondents exhibit implicit anti-obesity bias toward other physicians.18 Furthermore, there is a direct, positive, significant correlation between implicit bias and explicit harmful views and practices. This includes decreased intent to collaborate with overweight physician colleagues; discomfort with and dislike of overweight physicians; decreased propensity to hire or promote overweight physicians; and in some respondents, even a belief that overweight physicians are less intelligent and trustworthy than their average-weight counterparts.
Patients who identify as LGBTQ experience poorer health care outcomes due to a myriad of obstacles along their health care pathway. Specifically, they have disproportionately higher rates of substance use disorders, HIV infection, psychiatric illness, domestic violence, and death by suicide and homicide.19 There is also inadequate physician training in LGBTQ health care in medical schools, residencies, and post-residency continuing education. This lack of adequate formal training leads to stigma toward patients identifying as LGBTQ and makes it difficult to establish effective communication between patients, physicians, and staff.
Transgender and Gender-Nonconforming Bias
A 2018 study found that almost 44% of transgender and gender-nonconforming survey participants avoid the ED when they need acute care. They cited fear of discrimination, longer wait times, and negative previous ED experiences as the reasons. Furthermore, the investigators sought input from participants on how to solve these issues. Participants recommended staff training in gender and trans health care; assurance of private gender identity disclosure; and accurate capture of sex, gender, and sexual orientation information in the EMR.19
When multiple biases are layered on top of one another, outcomes get much worse. For example, one study compared annual physician salaries across the medical specialties and found that white males earn $64,812 more than black males, $89,808 more than white females, and $100,258 more than black females.20
What can we do about it?
Individuals who strongly believe they are unbiased are often the source of the most harmful prejudice. It can take some individuals a ton of convincing that sexism, racism, ageism, weight bias, LGBTQ bias, and other classically harmful biases should be their concern.
Some individuals will never be convinced, but it is our responsibility as physicians (especially emergency physicians) to fight for the principle of providing optimal care to every patient. And this means understanding our own inner tendencies toward implicit bias.
How can we tell if we are implicitly biased? How do we know when this translates to harmful explicit prejudice? And how can we correct harmful types of bias? Stay tuned for our discussion of these questions in Part 2.
The authors are grateful to Abbas Husain, Miriam Kulkarni, Resa Lewiss, Laura Melville, Pik Mukherji, Kat Ogle, and Livia Santiago-Rosado for their guidance. They are also grateful for the NY ACEP Empire State Epic for the publication of the original version of this article.21
- Dubey E; ACEP AAWEP, DIHE, and QIPS Sections; and ACEP Wisconsin Chapter. ACEP Resolution 14(19): Implicit Bias Awareness and Training. 2019.
- Non-Discrimination and Harassment. ACEP Policy Statement. 2018. /siteassets/new-pdfs/policy-statements/non-discrimination-and-harassment.pdf
- Workforce Diversity in Health Care Settings. ACEP Policy Statement. 2017. /siteassets/new-pdfs/policy-statements/workforce-diversity-in-health-care-settings.pdf
- Cultural Awareness and Emergency Care. ACEP Policy Statement. 2014. /siteassets/new-pdfs/policy-statements/cultural-awareness-and-emergency-care.pdf
- Cherry K. Heuristics and Cognitive Biases. Verywell Mind. March 2019. https://www.verywellmind.com/what-is-a-heuristic-2795235
- ACEP/AAMC Diversity and Inclusion Survey. Web-based. July to September 2017.
- Eagly A, Karau S, Makhijani M. Gender and the effectiveness of leaders: a meta-analysis. Psychol Bull. 1995;117(1):125-145.
- Eagly A, Karau S. Role congruity theory of prejudice toward female leaders. Psychol Rev. 2002;109(3):573-598.
- Lautenberger D, Dandar, V, Raezer, C. The state of women in academic medicine: the pipeline and pathways to leadership. Association of American Medical Colleges. 2015-2016. https://www.aamc.org/data-reports/faculty-institutions/data/state-women-academic-medicine-pipeline-and-pathways-leadership-2015-2016
- Desai T, Ali S, Fang X, et al. Equal work for unequal pay: the gender reimbursement gap for healthcare providers in the United States. Postgrad Med J. 2016;92(1092):571-575.
- Artz B, Goodall A, Oswald A. Do Women Ask? Industrial Relations: A Journal of Economy and Society. 2018;57:611-636.
- Files J, Mayer A, Ko M, et al. Speaker Introductions at Internal Medicine Grand Rounds: Forms of Address Reveal Gender Bias. J Womens Health (Larchmt). 2017;26(5):413-419
- Lee P, Le Saux M, Siegel R, et al. Racial and ethnic disparities in the management of acute pain in US emergency departments: Meta-analysis and systematic review. Am J Emerg Med. 2019;37(9):1770-1777
- DeVon H, Burke L, Nelson H, et al. Disparities in patients presenting to the emergency department with potential acute coronary syndrome: it matters if you are Black or White. Heart Lung. 2014;43(4):270–277.
- Petersen E, Davis N, Goodman D, et al. Racial/Ethnic Disparities in Pregnancy-Related Deaths - United States, 2007-2016. MMWR Morb Mortal Wkly Rep. 2019;68(35):762–765.
- Hall W, Chapman M, Lee K, 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.
- Qiao W, Powell E, Witte M, et al. Relationship between racial disparities in ED wait times and illness severity. Am J Emerg Med. 2016 Jan;34(1):10-5.
- McLean M, McLean L, McLean-Holden A, Campbell L, Melville L, Horner A, Fernandez E, Kulkarni M. Collegial Physician Obesity Bias. 2020. Unpublished manuscript. www.physicianbias.com
- Samuels E, Tape C, Garber N, et al. Sometimes You Feel Like the Freak Show: A Qualitative Assessment of Emergency Care Experiences Among Transgender and Gender-Nonconforming Patients. Ann Emerg Med. 2018;71(2):170-182.
- Ly D, Seabury S, Jena A. Differences in incomes of physicians in the United States by race and sex: observational study. BMJ. 2016;353:i2923.
- McLean M, Campbell L. “Implicit Bias Is Both Helpful and Harmful – What Can We Do?” Empire State Epic. 2019;37-02:19.