Implicit Bias

by Elizabeth Smith, MPH, ICCE, IBCLC, RLC, PCQI

I, like many of you, had the opportunity to attend the Evidence Based Birth Conference in Lexington, Kentucky, USA. One theme was overarching throughout the conference. It’s a topic that is very important for all of us to remember. That topic is Implicit Bias.

Implicit bias can be defined as “attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner.” What is means is that we act or make decisions/assumptions without conscious thoughts. It is important to remember that “implicit bias is a universal phenomenon, not limited by race, gender, or even country of origin.” (Perception Institute 2019) Every one of us holds some bias whether we want to admit to it or not. Bias is not limited to the things that often come to mind such as race, age, social group, or gender but can also include marital status, disability, weight, height, political affiliation, or education. If you would like to test your own bias (and I suggest you do), you can take tests on Project Implicit’s website.

We all have bias, so why does it matter? Our bias can affect perception and clinical decision making. Studies show that implicit bias is significantly related to patient provider interactions and treatment decisions. In 1966 at the National Convention of the Medical Committee for Human Rights, Martin Luther King Jr said, “Of all forms of inequity, injustice in health care is the most shocking and inhumane.” In 2016, fifty years later, The Joint Commission published a paper titled, “Implicit bias in health care.” In this paper, they state that “Unequal Treatment found that even with the same insurance and socioeconomic status, and when comorbidities, stage of presentation and other confounders are controlled for, minorities often receive a lower quality of health care than do their white counterparts.” Other findings in this paper include:

  • Non-white patients are less likely to be prescribed pain medications (non-narcotic and narcotic)
  • Black men are less likely to receive chemotherapy and radiation therapy for prostate cancer and more likely to have testicle(s) removed
  • Patients of color are more likely to be blamed for being too passive about their health care
  • Non-white patients receive fewer cardiovascular interventions and fewer renal transplants
  • Black women are more likely to die after being diagnosed with breast cancer

Attention to the critical issue of bias in the care of black women has come to the forefront after tennis star, Serena Williams, and singer, Beyoncé, publicly discussed the medical complications they both experienced from pregnancy and childbirth. In the United States, black women are at 3-4 times greater risk for pregnancy related deaths. This is true even when stratifying the data for education, income, and socio-economic status. Senator Holly Mitchell (D) from California is working on legislation to combat this problem. She stated, “Black women deserve better. Bias, implicit or explicit, should no longer impact a woman’s ability to deliver a full-term baby or to survive childbirth.”

In my practice as a lactation consultant, I have seen/heard other examples of very common biases that have an impact on our patients. “Mexican mom’s never breastfeeding in the hospital, they wait until the milk comes in.” Whether there is truth or no truth in this statement, by saying, thinking, or believing it, a disservice is done to this family. Critical education may be skipped because someone on the care team doesn’t believe it’s important.

Another common area of bias I hear revolves around obese women. Obesity is a huge and overlooked issue in healthcare. In a study done on patient care, “stepping on the scale” was identified as one of the biggest barriers to receiving care. Overweight and obese patients are thought to be lazy, unmotivated, and non-compliant. They frequently feel embarrassed and belittled while receiving care. Because of this they are less likely to discuss their concerns and their health needs are not met.

So many other areas of bias exist. They impact our patients, families, clients, and ultimately, our population as a whole. This is an area that needs to be addressed so that we can work together to reduce health and medical omissions and errors that are preventable.

Bias exists, so the biggest question is what can I do about my bias? The most important thing to do is to understand and identify your own areas of bias. Take some of the online tests on bias. I have taken at least ten of the trainings. They were very accurate; even in areas where I knew I may struggle and don’t want to admit I have bias. Many organization, universities, and employers are offering Implicit Bias Training.  I encourage you to find a course in your area and let others know about its availability. Let’s all be part of the solution.