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Research ArticleOriginal Research

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

Irene V. Blair, John F. Steiner, Diane L. Fairclough, Rebecca Hanratty, David W. Price, Holen K. Hirsh, Leslie A. Wright, Michael Bronsert, Elhum Karimkhani, David J. Magid and Edward P. Havranek
The Annals of Family Medicine January 2013, 11 (1) 43-52; DOI: https://doi.org/10.1370/afm.1442
Irene V. Blair
1Department of Psychology and Neuro-science, University of Colorado Boulder, Boulder, Colorado
PhD
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  • For correspondence: Irene.Blair@Colorado.edu
John F. Steiner
2Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
MDMPH
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Diane L. Fairclough
3Colorado Health Outcomes Center, University of Colorado Denver, Denver, Colorado
DrPH
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Rebecca Hanratty
4Division of Internal Medicine, Denver Health, Denver, Colorado
MD
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David W. Price
2Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
MD
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Holen K. Hirsh
1Department of Psychology and Neuro-science, University of Colorado Boulder, Boulder, Colorado
PhD
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Leslie A. Wright
2Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
MA
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Michael Bronsert
3Colorado Health Outcomes Center, University of Colorado Denver, Denver, Colorado
PhD
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Elhum Karimkhani
5Division of Cardiology, Denver Health, Denver, Colorado
MPH
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David J. Magid
2Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
MD
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Edward P. Havranek
5Division of Cardiology, Denver Health, Denver, Colorado
MD
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  • Digging deeper on unconscious biases
    Alexander R. Green
    Published on: 18 March 2013
  • Useful or Merely Interesting?
    Richard D. Iliff
    Published on: 27 January 2013
  • Published on: (18 March 2013)
    Page navigation anchor for Digging deeper on unconscious biases
    Digging deeper on unconscious biases
    • Alexander R. Green, Associate Professor of Medicine

    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...

    Show More

    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

    Show Less
    Competing Interests: None declared.
  • Published on: (27 January 2013)
    Page navigation anchor for Useful or Merely Interesting?
    Useful or Merely Interesting?
    • Richard D. Iliff, family physician

    I took the test in order to detect my implicit bias, and found that I am moderately biased towards whites on the "good/bad" spectrum. There is a pretty obvious reason for this: 90% of the mug shots in my local paper are blacks. Jesse Jackson shared the same bias when he chose to cross the street when he saw a group of blacks approaching at night. So let's recognize reality, and admit that implicit bias against blacks is...

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    I took the test in order to detect my implicit bias, and found that I am moderately biased towards whites on the "good/bad" spectrum. There is a pretty obvious reason for this: 90% of the mug shots in my local paper are blacks. Jesse Jackson shared the same bias when he chose to cross the street when he saw a group of blacks approaching at night. So let's recognize reality, and admit that implicit bias against blacks is understandable. The only cure for this is a revolution in the black culture. On the other hand, explicit bias can and should be opposed. In college I led a campaign to pledge the first black into a campus fraternity, and over the years I have acquired a disproportionate number of prominent local blacks in my practice. We are friends, really. What hope is there, however, to exterminate my acknowledged implicit bias which is clearly based on seeing the world the way it exists (alas)? I hope the authors can use the publication to climb the academic totem pole, but I don't think anything is going to roll off the assembly line as a result.

    Competing interests:   None declared

    Show Less
    Competing Interests: None declared.
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Clinicians’ Implicit Ethnic/Racial Bias and Perceptions of Care Among Black and Latino Patients
Irene V. Blair, John F. Steiner, Diane L. Fairclough, Rebecca Hanratty, David W. Price, Holen K. Hirsh, Leslie A. Wright, Michael Bronsert, Elhum Karimkhani, David J. Magid, Edward P. Havranek
The Annals of Family Medicine Jan 2013, 11 (1) 43-52; DOI: 10.1370/afm.1442

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Clinicians’ Implicit Ethnic/Racial Bias and Perceptions of Care Among Black and Latino Patients
Irene V. Blair, John F. Steiner, Diane L. Fairclough, Rebecca Hanratty, David W. Price, Holen K. Hirsh, Leslie A. Wright, Michael Bronsert, Elhum Karimkhani, David J. Magid, Edward P. Havranek
The Annals of Family Medicine Jan 2013, 11 (1) 43-52; DOI: 10.1370/afm.1442
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More in this TOC Section

  • Teamwork Among Primary Care Staff to Achieve Regular Follow-Up of Chronic Patients
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  • Convenience or Continuity: When Are Patients Willing to Wait to See Their Own Doctor?
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