The path to health equity: How to address implicit bias in medicine and better understand health disparities

The COVID-19 pandemic has exacerbated health disparities along racial and ethnic lines. In response, healthcare organizations are reexamining their role in contributing to these inequities and assessing potential action steps to address this vast and urgent challenge. This work is driving more healthcare leaders toward an essential realization: One of the most subtle and dangerous ways in which the medical profession perpetuates health inequities is through the practice of implicit bias.

Becker’s Hospital Review recently spoke with Khadeja Haye, MD, TeamHealth’s national medical director of obstetrics and gynecology, about ways implicit bias makes its way into medicine and why physicians must practice self-awareness in order to prevent such bias from contaminating patient care.

Implicit bias in clinical settings affects those already discriminated against in society

Implicit bias refers to a set of deeply held beliefs and attitudes that lead one to act favorably or dismissively toward people based on their ethnicity, nationality, gender, religion or other social group.

Because implicit bias is generally subconscious, people who exhibit various behaviors as a result of implicit bias are often not even aware that their behavior is affected by bias. In an environment such as healthcare, where human judgment and health-related vulnerabilities coexist, implicit bias can have serious consequences.

“How that [manifests] in healthcare is when you’re interacting with patients; your perception of those patients and your beliefs about what the patient is presenting with is shaped by those implicit biases,” Dr. Haye said. She cited the example of popular culture references that associate members of certain ethnic communities with drug-seeking behavior and how those influences may inform the way some physicians perceive the clinical presentations of patients from those communities.

A common pattern of implicit bias in healthcare — and particularly in Dr. Haye’s specialty of obstetrics — can be observed around pain management. “There have been studies showing that Hispanic and Black women tend to be perceived as having less pain, so their pain is not treated in the same fashion or as often as their white counterparts, even though their pain score and their reported pain may be similar,” Dr. Haye said. She added that the implicit bias that often underlies such behavior stems from an inaccurate belief that Black and Hispanic patients either have a higher pain threshold or are drug seeking.

As a result of their implicit biases, some clinicians may be less likely to prescribe a needed medication or to order a CT scan or an X-ray, even when those interventions are clinically justified and necessary. This failure to provide the appropriate tests or medications could result in a misdiagnosis or delayed care — and eventually to systemic disparities in health outcomes, such as those observed in maternal mortality rates. “That’s why it’s really important to become self-aware of implicit bias, so that we can hopefully avoid those pitfalls,” Dr. Haye said.

Self-awareness can go a long way toward eliminating implicit bias

Dr. Haye pointed out that while implicit bias is well understood in the abstract, more emphasis needs to be placed on internalizing what it means for each individual physician. “Understanding the definition of bias is one thing, but the next step is being aware of it and then taking the time to reflect,” she said. “We all have personal biases and oftentimes they are steeped in privilege. If you have the benefit of a certain privilege, you may not take the time to even realize that you may have had experiences that shaped certain preconceived notions about someone else.”

To counteract their own biases, Dr. Haye recommends that clinicians establish a personal system of checks and balances to ensure that all patients are treated equally. In her own practice, she said she uses the litmus test of asking herself with respect to a patient she is attending, “Would I treat my mother, my grandmother or my sister that way?”

“It’s not foolproof, it’s very difficult and it takes a lot of time to develop that reflex of being aware and checking yourself, but it’s really important that we have the discussion so that everybody can begin the process of implementing that for themselves,” Dr. Haye said.

Forging ahead on health equity also requires speaking up

In a perfect healthcare world, physicians would not only be self-aware about their own implicit biases and actively working to correct them, but would also actively speak up when they observe biased behavior on the part of colleagues.

Dr. Haye, who mentors aspiring clinicians, said one of the key ideas she tries to impart to them is the importance of being an active observer of their environment. “If you see something that doesn’t quite look right, don’t be afraid to call it out if it is in the benefit of the patient,” she said. “Part of our role is not only addressing our personal biases, but also being a patient advocate as it might help someone else to reflect on their behavior and understand how they could improve.”


While the crisis provoked by COVID-19 has thrust into view the magnitude of health disparities in the U.S., differences in maternal mortality rates along racial and ethnic lines predate the pandemic. As numerous studies have shown, those disparities are often attributable to institutional factors and have complex root causes — and it is undeniable that implicit bias plays an important role in them.

“Black women who are highly educated, have access to early prenatal care, are compliant with all of their doctors’ visits, screening evaluations, eat well and have the benefit of a higher income level, are still dying at a higher rate than their white counterparts,” Dr. Haye said. “A lot of it has to do with bias.”

To overcome these ingrained tendencies across clinical specialties, she urged healthcare professionals to become more educated on this topic with the goal of developing a better self-awareness, increased reflection and a system of internal checks and balances to guide the way.


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