Provider implicit bias in healthcare settings produces health inequities for Black, Indigenous and people of color

Introduction

Existing research indicates that Black, Indigenous, and people of color have worse health outcomes than white people, including incidence, prevalence, severity of disease at diagnosis, rates of mortality, and lower quality of care, despite efforts to close these gaps. The health disparity gap begins at birth and persists throughout one’s life course. Though these disparate outcomes are evident, their causal mechanism is not yet clearly understood. Based on previous research, the authors suggest that implicit bias among healthcare providers is at least part of the answer.

This systematic review examines the bulk of literature published to date about the role of implicit bias among healthcare providers in racial and ethnic health disparities. In addition, the authors examine interventions intended to reduce bias in healthcare. 

Dr. Ivy W. Maina is a Resident Physician in Otolaryngology at the University of Pennsylvania affiliated hospitals and a Medical Writer for Buoy Health. Tanisha D. Belton is a Clinical Research Project Manager at the Children’s Hospital of Philadelphia. Dr. Sara Palazzo Ginzberg is a General Surgery Resident at the Hospital of the University of Pennsylvania and an Assistant Instructor in Surgery. Dr. Ajit Singh is a primary care provider and Resident at the Philadelphia College of Osteopathic Medicine. Dr. Tiffani J. Johnson is an Attending Physician in the Emergency Department and a Faculty Scholar at PolicyLab at the Children’s Hospital of Philadelphia.

Methods and Findings

The authors used standard protocol for systematic analyses, including defining their search terms: 1) healthcare providers, 2) implicit bias (measured using the Implicit Association Test only), and 3) racial/ethnic prejudice or stereotype activation. Next, they used these terms to search for relevant scientific articles published from 1997 to September 2016 in PubMed, PsycINFO, SCOPUS, and CINAHL. Each article was screened by two reviewers for inclusion into the meta-analysis based on standardized criteria, with a third reviewer resolving any disagreements. Of an initial 6249 articles (4934 after removal of duplicates), 29 studies passed the inclusion criteria and 8 additional studies were included from auto-search results. Two reviewers independently extracted relevant data from each study, including details about the study design, setting, participants, methods, and results, and the reported results were reviewed.

Overall, the 37 studies included 10,013 healthcare provider participants throughout the United States. The authors report four major findings:

Finding 1: Research shows that most healthcare providers — across multiple levels of training and disciplines — have implicit biases against Black, Latinx, Indigenous, and ‘dark skinned patients’ (terminology used by the researchers).

Finding 2: The level of bias differs based on provider characteristics: Black providers generally have little implicit racial bias compared to white, Latinx, and Asian providers.

Finding 3: Research about the impact of implicit bias on patient care and patient outcomes is limited; the authors identified only 7 studies that demonstrate a consistent association between higher provider implicit bias and poorer patient-provider interactions, while the rest report mixed results. Only the studies that examined real world patient-provider interactions, as opposed to simulated patients or clinical vignettes, demonstrated a clear association.

Finding 4: Only two published intervention studies tested methods to reduce implicit bias among healthcare providers, and only one demonstrated success in reducing implicit bias post-intervention.

Conclusions

Implicit bias plays a significant role in the provision of medical services. By examining a wide range of  literature, the authors demonstrate the role of provider implicit bias in healthcare and uncover significant gaps in existing research in both outcomes and reduction strategies.

Despite several limitations based on the studies included, the researchers’ systematic review and meta-analysis found that provider implicit bias contributes to health disparities, congruent with the findings of related studies. Furthermore, the authors suggest that patient-provider communication, particularly under the stresses of real-time interactions, may be the channel through which provider implicit associations lead to lower quality of clinical care and health outcomes.

The authors recommend additional research to uncover the impact of implicit provider bias on healthcare outcomes and to identify strategies to reduce provider implicit bias. Such studies would need to be more nationally representative of a wider base of patients and providers of different racial identities and lived experiences, and of geographic settings. The authors also identify several specific research areas for further exploration, including patient characteristics that impact patient-provider interactions; the impact of providers’ implicit negative stereotypes against Black, Indigenous and patients of color and their prescribed treatments; stress in healthcare provision and other system-level, setting, or specialty characteristics that may impact provider decision-making and implicit bias; how provider bias changes over time with increased clinical experience; the downstream effects of implicit bias on real world patient behavior and clinical outcomes; and successful methods to reduce provider implicit bias and sources of cognitive stress.

Review of healthcare research provides new insight in affirming common themes and findings, as well as gaps for further understanding.

Shifting Focus from Internalization to Appropriation of Racial Oppression

Introduction

Scholarship has examined many forms of racism, but research on how racism impacts individuals’ everyday experiences is still developing. Some scholars have studied how racism can be internalized by members of oppressed groups. For example, psychologists Kenneth and Mamie Clark’s famous experiment presenting Black children with Black and white dolls continues to be referenced as an example of internalized self-hatred among Black people. More recent scholars, however, have proposed a shift away from the term “internalized racism,” arguing that it limits the impact of racism on people of color, narrowly focuses on negative self-image, and places the blame of oppression on marginalized groups. 

In this article, Versey et al. support emerging research that recommends a new framing known as “appropriated racial oppression.” This term refers to the process of both oppressed and non-oppressed groups appropriating, or taking up racial oppression through repeated exposure to racial messages centered on whiteness. Appropriated racial oppression can be a response to, or strategy for, navigating normative white ideals in society. This framing centers white supremacy, rather than individual pathology, as the driver of racism and the source of race-related stress. Appropriated racial oppression has consequences for mental health and public health more broadly, both for dominant and marginalized groups. 

H. Shellae Versey is an Assistant Professor of Psychology at Fordham University. Dr. Versey is a psychologist and critical health researcher, and her research explores health and intersectionality. Courtney D. Cogburn is an Associate Professor at the Columbia School of Social Work. Dr. Cogburn directs a research group that uses innovative means to characterize and measure racism and evaluate its effects on mental and physical health. Clara L. Wilkins is an Associate Professor of Psychological & Brain Sciences at Washington University in St. Louis. Dr. Wilkins is a social psychologist whose research examines prejudice, stereotyping, and the self. Nakita Joseph is an adjunct lecturer at the Borough of Manhattan Community College and a ParentCorps Educator at NYU Langone Health. Ms. Joseph is a graduate of the Columbia School of Social Work, where she researched systemic oppression, trauma, and inequality.

Methods and Findings

In this commentary, Versey et al. describe how managing racism may be as harmful to health as exposure to racism. Responses to racism can be both negative and adaptive, which is an important distinction the authors make. For groups of color, appropriated racial oppression can include responses to “fit in” or navigate white norms and practices. The authors illustrate this with two examples:

• Respectability and vigilance: Respectability behavior, such as mimicking whiteness to counter negative stereotypes about one’s group, is considered to be a form of appropriated racial oppression. While respectability provides social benefits, anticipating discrimination can be taxing and yield more costs than benefits. Researchers have found that vigilantly guarding against racial stereotypes is correlated with negative health outcomes, including risk of chronic disease and increased depressive symptoms.
• Code-switching: To accommodate different social contexts and avoid evoking negative stereotypes, Black people and other racial/ethnic groups may modify speech in ways that are aligned with normative whiteness. While code-switching may be effective in achieving ‘success’ by some metrics, it may be psychologically damaging when practiced over time. Moreover, by focusing on individuals who practice (or fail to practice) strategies like code-switching, we divert attention away from white supremacy and fail to address systems that force people of color to code-switch in the first place.

The authors also discuss how white people are harmed by racism. This may seem counter-intuitive, as whiteness is a system that produces gains and privileges for white people as members of the dominant group. But when expectations of success are not met, when losses to economic or social positions do occur, and when the system of racism does not confer benefits as expected, appropriated racial oppression can lead to negative health outcomes. Versey et al. describe three ways this can operate:

• Threats to worldviews: When experiences violate a white person’s worldview (such as a job loss), they may feel threatened by a perceived loss of status in an increasingly diverse world. These threats may have meaningful consequences for individuals’ mental health and broader health policy.
• Perceived loss of status and mental health outcomes: Political events and demographic shifts may evoke fear among dominant groups and compromise their feelings of safety and security. For example, some research has shown that, compared to other groups, white people’s perceived loss of status is associated with increased emotional stress. One way that white people may be able to shift their interpretation of such events is by developing a critical consciousness, or an understanding of how social, economic, and political systems contribute to inequity. 
• Health policy:  If white Americans are unaware about how the system of whiteness makes certain privileges possible, then any policy perceived to level the playing field can contribute to feelings of threat, resentment, or anger. These feelings can be heightened by inaccuracies that play on racial stereotypes, such as the misperception that the Affordable Care Act primarily benefits groups of color. When such feelings lead to health policy changes that hurt everyone, then the process of appropriated racial oppression can undermine one’s own health.

Conclusions

This article makes two novel contributions to emerging research on appropriated racial oppression. First, by providing examples in which white supremacy affects both non-oppressed and oppressed groups, the authors highlight how appropriated racial oppression has implications for mental health and public health more broadly. Second, by discussing how people, particularly oppressed groups, negotiate racism on an individual level, the authors suggest new opportunities to research how racism influences people’s attitudes and behaviors.

Versey et al. conclude that, if we accept that appropriated racial oppression is an inevitable by-product of racism, then we must examine the full range of consequences associated with responding to normative whiteness. The authors pose questions for future research, including: In the long-term, are the strategies of code-switching and respectability more toxic or beneficial? How is the process of appropriated racial oppression interconnected with assimilation, health disparities, and racial identity? How can worldviews be rebuilt? How can we promote dialogue about the symptoms of racism, including appropriated racial oppression, in a way that both addresses and changes the systems of power that created those symptoms?

Pushing Beyond “Cultural Competency” to “Structural Competency” in Medical Education

Introduction

Medical professionals recognize that physicians must learn both the science of medicine and the art of patient communication. Currently, much of the medical field is focused on the concept of “cultural competency” and “cultural humility.” These concepts have pushed medical education to move beyond “colorblindness” and recognize that social factors, such as race, ethnicity, sexual orientation, and class, impact how patients’ symptoms can present. These factors also play a role in patients’ understanding of illness, health, well-being, cultural stigma, and compliance with treatment. Training on cultural competency and humility are essential to understanding the patient as a whole person. Culturally sensitive, non-judgmental communication, diagnosis, and treatment strategies improve health outcomes and reduce health-related stigma.

Medical professionals also recognize the limitations of “cultural competency.” Health is all-encompassing, with the social determinants of health (social, economic, education, political, and physical systems) impacting a patient’s well being long before they arrive for treatment and after they leave. An individualized approach towards healthcare that focuses only on addressing disease’s biological components is limited in its effectiveness because it does not see or treat the whole patient. Metzl and Hansen argue that doctors need to incorporate learnings from public health, social sciences, and critical race studies in a new approach to training medical students that equips them with an understanding of structural analysis. In their view, structural analysis refers to the language to engage with and communicate about structural impacts on health and propose interventions that address structural factors of care.

Jonathan M. Metzl, MD, Ph.D. is the Frederick B. Rentschler II Professor of Sociology and Medicine, Health, and Society; Director of the Center for Medicine, Health, and Society; and Professor of Psychiatry at Vanderbilt University as well as the Research Director of the Safe Tennessee Project. Helena B. Hansen, MD, Ph.D., is an Associate Professor of Psychiatry of Anthropology at New York University. 

Methods and Findings

This paper advances the idea of  “structural competency” and theorizes that structural competency should be incorporated into medical curricula. The authors draw from social science to guide their thinking. 

Metzl and Hansen propose five core competencies that a structural competency curriculum should prepare medical students to achieve. These are:

1. Recognizing the structures that shape clinical interactions: introducing an understanding of the broader socio-political, economic, and physical contexts that influence the healthcare system from the macro-level (e.g., decisions about insurance or drug pricing) to the micro-level (e.g., interpersonal interactions with patients)
2. Developing an extra-clinical language of structure: creating a more interdisciplinary, social science-based curriculum that trains students to understand the impact of social structures on biology and to engage with the complex broader contexts of individual patients and cases.
3. Rearticulating ‘cultural’ formulations in structural terms: connecting the useful pieces of “cultural competency” that inform patient interaction practices to reduce stigma with a structural understanding of the contexts that create and sustain that stigma.
4. Observing and imagining structural interventions: connecting training to the real world and empowering students to learn how they could change the structures influencing health.
5. Developing “structural humility”: training students to embrace humility and recognize that their role is to be continually learning and listening in addition to speaking and leading.

Conclusions

A medical curriculum that incorporates each of these components would prepare future physicians to understand and recognize the structural forces that impact their patients’ health. Further, it would train medical students with the skills they need to use language from across disciplines to communicate and think about the impact of structural forces. At the same time, it would prepare medical students to apply this structural knowledge to design health interventions and to recognize the limits of this approach. In essence, this would allow physicians to engage with the full complexity of health and illness and recognize when they need to bring in additional experts to advise on care. This curriculum also prepares physicians to step into the expanded and increasingly important non-clinical public health role. Finally, by shifting the focus of clinical treatment from individuals to addressing structures, infrastructure, and contexts, structural competency allows medicine to adopt a framework that would enable the field to engage in antiracist practices, both within medicine and in addressing the social determinants of health.