Clinicians’ Implicit Ethnic/Racial Bias and Perceptions of Care Among Black and Latino Patients

In their recent article (1) Irene Blair and colleagues have made an important contribution to our understanding of how unconscious biases may contribute to racial and ethnic disparities in health care. In this well designed and carefully described study, the authors show that black patients rate their primary care physicians as less patient-centered when those physicians are more unconsciously biased against them. While it might seem obvious that this would be the case, it really isn't. Unconscious biases can very subtle and, by definition, are not recognized by the physician himself or herself. The fact that patients apparently can recognize them is both fascinating and disconcerting. Maybe it would do physicians (and other providers) some good to take note.

What is particularly important about this study is that it was done with real physicians seeing real patients. Most of the limited number of earlier studies examining unconscious biases in health care (including my own) were done with students or residents viewing hypothetical patient vignettes (2,3). Besides the difference between physicians and physicians- in-training, there is another important distinction here. Unconscious biases are activated most in times of stress, under time pressure, and when multitasking. As a primary care doctor, I know exactly how well this describes my own clinical practice and that of my peers. The way we respond to a couple of paragraphs on a page may be vastly different than how we act when we are in a small office with a person who looks, speaks, and acts in ways that might trigger a host of preconceived stereotypes and assumptions. It is all too easy to rationalize that "this patient really wouldn't want a flu shot" when you've got ten more patients scheduled that afternoon and three already waiting.

In an era when patient-centeredness is widely accepted as an essential quality goal, health care professionals will be increasingly held accountable for the way we are perceived by our patients. In addition, patient-centeredness has been directly linked to better health care outcomes (4). Some health care systems such as Kaiser Permanente are already implementing strategies to help physicians overcome their own unconscious biases by making them conscious (5). We need to continue exploring how unconscious biases work and how we can prevent them from contributing to disparities in health care.

1. Blair IV, et al. Clinicians' Implicit Ethnic/Racial Bias and Perceptions of Care Among Black and Latino Patients. Ann Fam Med 2013;11:43-42.
2. Green AR, Carney DR, Pallin DJ, Ngo L, Raymond K, Iezzoni LI, Banaji MR. Implicit Bias among Physicians and its Prediction of Thrombolysis Decisions For Black and White Patients. J Gen Intern Med 2007;22:1231-8.
3. Haider AH, Sexton J, Sriram N, et al. Association of unconscious race and social class bias with vignette-based clinical assessments by medical students. JAMA. 2011;306:942-51.
4. Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract 1998;47:213-220.
5. Newhouse D. The use of Analytics to identify potential unconscious bias in physician-patient encounter. http://dx.confex.com/dx/13/webprogram/Paper3874.html (accessed March 14, 2013).

Competing interests:   None declared