Skip to main content

Main menu

  • Home
  • Current Issue
  • Content
    • Current Issue
    • Early Access
    • Multimedia
    • Podcast
    • Collections
    • Past Issues
    • Articles by Subject
    • Articles by Type
    • Supplements
    • Plain Language Summaries
    • Calls for Papers
  • Info for
    • Authors
    • Reviewers
    • Job Seekers
    • Media
  • About
    • Annals of Family Medicine
    • Editorial Staff & Boards
    • Sponsoring Organizations
    • Copyrights & Permissions
    • Announcements
  • Engage
    • Engage
    • e-Letters (Comments)
    • Subscribe
    • Podcast
    • E-mail Alerts
    • Journal Club
    • RSS
    • Annals Forum (Archive)
  • Contact
    • Contact Us
  • Careers

User menu

  • My alerts

Search

  • Advanced search
Annals of Family Medicine
  • My alerts
Annals of Family Medicine

Advanced Search

  • Home
  • Current Issue
  • Content
    • Current Issue
    • Early Access
    • Multimedia
    • Podcast
    • Collections
    • Past Issues
    • Articles by Subject
    • Articles by Type
    • Supplements
    • Plain Language Summaries
    • Calls for Papers
  • Info for
    • Authors
    • Reviewers
    • Job Seekers
    • Media
  • About
    • Annals of Family Medicine
    • Editorial Staff & Boards
    • Sponsoring Organizations
    • Copyrights & Permissions
    • Announcements
  • Engage
    • Engage
    • e-Letters (Comments)
    • Subscribe
    • Podcast
    • E-mail Alerts
    • Journal Club
    • RSS
    • Annals Forum (Archive)
  • Contact
    • Contact Us
  • Careers
  • Follow annalsfm on Twitter
  • Visit annalsfm on Facebook
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
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: Irene.Blair@Colorado.edu
John F. Steiner
2Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
MDMPH
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Diane L. Fairclough
3Colorado Health Outcomes Center, University of Colorado Denver, Denver, Colorado
DrPH
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Rebecca Hanratty
4Division of Internal Medicine, Denver Health, Denver, Colorado
MD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
David W. Price
2Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
MD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Holen K. Hirsh
1Department of Psychology and Neuro-science, University of Colorado Boulder, Boulder, Colorado
PhD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Leslie A. Wright
2Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
MA
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Michael Bronsert
3Colorado Health Outcomes Center, University of Colorado Denver, Denver, Colorado
PhD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Elhum Karimkhani
5Division of Cardiology, Denver Health, Denver, Colorado
MPH
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
David J. Magid
2Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado
MD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Edward P. Havranek
5Division of Cardiology, Denver Health, Denver, Colorado
MD
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • eLetters
  • Info & Metrics
  • PDF
Loading

Article Figures & Data

Figures

  • Tables
  • Additional Files
  • Figure 1
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 1

    Predicted ratings of clinicians as a function of their implicit bias (IAT) score and their patients’ ethnicity/race. White patients always served as the reference group (data not shown).

    IAT = Implicit Association Test.

  • Figure 2
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 2

    Predicted composite scale ratings by black, Latino, and white (reference) patients for individual clinicians with specific IAT scores.

    IAT = Implicit Association Test.

    Note: The lines show the overall (unconditional) estimate of the relation between clinician implicit bias scores and predicted patient ratings. The symbols show the individual (conditional) estimates for each clinician with a specific IAT score by each ethnic/racial patient group.

  • Figure 3
    • Download figure
    • Open in new tab
    • Download powerpoint
    Figure 3

    Predicted ratings of clinicians by younger and older black patients, as a function of clinicians’ implicit bias score on the Black:White IAT.

    IAT = Implicit Association Test.

Tables

  • Figures
  • Additional Files
    • View popup
    Table 1

    Characteristics of Participating and Nonparticipating Patients

    Recruitment SampleFinal Patient Sample by Ethnicity/Race (N = 2,908)
    CharacteristicNonparticipants (n = 3,221)Participants (n = 2,908)Black (n = 612)Latino (n = 859)White (n = 1,437)
    Female, No. (%)a,b1,690 (52)1,694 (58)369 (60)539 (63)786 (55)
    Age, No. (%)a,b
      18–35 y108 (3)67 (2)25 (4)29 (3)13 (1)
      36–55 y1,115 (36)973 (33)234 (38)314 (37)425 (30)
      ≥56 y1,958 (61)1,868 (64)353 (58)516 (60)999 (70)
    Ethnicity/race, No. (%)a
      Black560 (17)612 (21)–––
      Latino1,146 (36)859 (30)–––
      White1,515 (47)1,437 (49)–––
    Education, No. (%)b
      High school not completed–529 (18)91 (15)355 (42)83 (5)
      High school diploma or GED–773 (27)185 (30)237 (28)351 (24)
      1–3 y college–866 (30)215 (35)167 (19)484 (34)
      ≥4 y college–714 (24)118 (20)88 (11)508 (35)
      Unknown–26 (1)3 (<1)12 (1)11 (1)
    Household income, No. (%)b
      ≤$15,000–1,026 (35)274 (45)396 (46)356 (25)
      $16,000–$35,000–555 (19)133 (22)184 (21)238 (17)
      $36,000–$55,000–408 (14)68 (11)88 (10)252 (18)
      ≥$56,000–717 (25)100 (16)124 (14)493 (34)
      Unknown–202 (7)37 (6)67 (8)98 (7)
    Language proficiency,c No. (%)b
      Spanish > English–268 (9)5 (1)260 (30)3 (<1)
      Alternate category–2,640 (91)607 (99)599 (70)1,434 (>99)
    Proportion of primary care visits with clinician, No. (%)b
      .50–.59520 (16)446 (15)85 (14)137 (16)224 (16)
      .60–.69530 (16)471 (16)84 (14)133 (15)254 (18)
      .70–.79552 (17)519 (18)99 (16)161 (19)259 (18)
      .80–.89644 (20)594 (20)144 (24)182 (21)268 (19)
      .90–1.0975 (30)878 (30)200 (33)246 (29)432 (30)
    Visits with clinician in 3 y, mean No. (SD)a,b7.38 (5.35)7.81 (5.70)8.16 (6.05)8.51 (5.91)7.23 (5.36)
    Years with clinician, mean No. (SD)–3.40 (1.07)3.35 (1.09)3.37 (1.16)3.45 (1.00)
    GED = general equivalency degree.
    • ↵a Participants and nonparticipants differ, P < .05.

    • ↵b Ethnic/racial groups differ, P < .05.

    • ↵c Greater proficiency in Spanish than English was assigned if (1) patients completed the questionnaire in Spanish instead of English, or (2) patients reported on the questionnaire that they were fluent in Spanish and less than fluent in English.

    • View popup
    Table 2

    PCAS Scores by Patients’ Ethnicity/Race

    Score, Mean (SD)
    Scale (α) and DescriptionBlackLatinoWhite
    Subscalea
    Interpersonal treatment (α = .94); 5 items on the clinician’s patience, friendliness, caring, respect, and time spent with the patient84 (19)81b (19)86 (18)
    Communication (α = .93); 6 items on the thoroughness of the clinician’s questions, attention to the patient, clarity of explanations and instructions, and help in making decisions about care84 (18)80b (19)84 (17)
    Trust (α = .85); 8 items on the clinician’s integrity and role as the patient’s agent in the system79b (16)76b (15)82 (15)
    Contextual knowledge (α = .90); 5 items on the clinician’s knowledge of the patient’s medical history, life responsibilities, principal health concerns, and values and beliefs75 (19)73 (20)74 (20)
    Composite (α = .93); average of all 4 subscales weighted equally80 (16)78b (17)82 (16)
    • PCAS = Primary Care Assessment Survey.

      Note: α is a measure of internal reliability.

    • ↵a Each subscale is scored from 0 to 100, with higher scores indicating a higher level of the attribute.

    • ↵b Score is less than that for white patients, P <. 01.

    • View popup
    Table 3

    Effects of Ethnic/Racial Group and Interactions Between Group and Clinicians’ Implicit Bias on Patients’ PCAS Ratings of the Clinicians

    PCAS Score by Scale, Estimate (SE)
    PredictorInterpersonal TreatmentCommunicationTrustContextual KnowledgeComposite
    Intercept (average rating by white patients)85.69 (0.57)84.45 (0.56)81.88 (0.47)74.36 (0.62)81.62 (0.52)
    Black patients
       Group (black vs white)0.24 (1.11)0.64 (1.10)–2.25 (0.93)a2.42 (1.22)a0.20 (1.00)
       Group × clinicians’ implicit bias–5.81 (2.52)a–4.31 (2.47)b–2.65 (2.09)–5.58 (2.73)a–4.61 (2.25)a
    Latino patients
       Group (Latino vs white)–4.30 (0.97)c–3.93 (0.96)c–5.85 (0.81)c–1.31 (1.06)–3.86 (0.87)c
       Group × clinicians’ implicit bias–0.58 (1.71)–0.13 (1.68)0.85 (1.42)–0.19 (1.86)–0.04 (1.53)
    • PCAS = Primary Care Assessment Survey; SE = standard error.

    • ↵a P <. 0 5.

    • ↵b P <.0 9.

    • ↵c P <.0001.

Additional Files

  • Figures
  • Tables
  • The Article in Brief

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

    Irene V. Blair , and colleagues

    Background Bias can be explicit or implicit. Explicit bias is overt and freely expressed; implicit bias may not be consciously acknowledged and operates in more subtle ways. Clinicians are unlikely to directly express ethnic/racial bias yet may still deliver care that is influenced by unrecognized bias. In this study, patients evaluate the degree to which their clinicians are patient-centered during their interactions. Researchers then examine those evaluations in terms of patients' ethnicity/race and the clinicians' implicit and explicit ethnic or racial bias.

    What This Study Found Clinicians with higher levels of implicit ethnic or racial bias are rated less favorably by black patients than are clinicians with lower levels of implicit bias. Surveys of nearly 3,000 patients found black patients rated clinicians who had greater implicit bias against blacks lower in patient-centered care than they did clinicians with little or no such implicit bias. Latino patients' ratings were not correlated to clinicians' implicit bias, though they tended to give clinicians lower ratings overall than did other groups.

    Implications

    • Clinicians' implicit bias may jeopardize their clinical relationships with black patients, which could have negative effects on other care processes, including adherence to medical advice.
    • The authors conclude these findings support the Institute of Medicine's suggestion that clinician bias may contribute to health disparities. They note that implicit bias is malleable, and they encourage interventions that may help render bias less implicit and unconscious, thereby fostering real reflection, analysis, and change.
PreviousNext
Back to top

In this issue

The Annals of Family Medicine: 11 (1)
The Annals of Family Medicine: 11 (1)
Vol. 11, Issue 1
January/February 2013
  • Table of Contents
  • Index by author
  • In Brief
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on Annals of Family Medicine.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Clinicians’ Implicit Ethnic/Racial Bias and Perceptions of Care Among Black and Latino Patients
(Your Name) has sent you a message from Annals of Family Medicine
(Your Name) thought you would like to see the Annals of Family Medicine web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
6 + 9 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
Citation Tools
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

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Get Permissions
Share
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
Twitter logo Facebook logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Abstract
    • INTRODUCTION
    • METHODS
    • RESULTS
    • DISCUSSION
    • Footnotes
    • References
  • Figures & Data
  • eLetters
  • Info & Metrics
  • PDF

Related Articles

  • PubMed
  • Google Scholar

Cited By...

  • Trends and Disparities in Newer GLP1 Receptor Agonist Initiation among Real-World Adult Patients Eligible for Obesity Treatment
  • County-level racial bias is associated with worse care for white and especially black older US adults: a cross-sectional observational study
  • Investigating Unconscious Race Bias and Bias Awareness Among Vascular Surgeons
  • Storylines of family medicine X: standing up for diversity, equity and inclusion
  • Le racisme comme determinant de la sante et des soins de sante: Sommaires narratifs des donnees probantes produits par le projet SAFE pour les etablissements de sante
  • Racism as a determinant of health and health care: Rapid evidence narrative from the SAFE for Health Institutions project
  • Diversity, equity and inclusion in acute care surgery: a multifaceted approach
  • Discrimination and Medical Mistrust in a Racially and Ethnically Diverse Sample of California Adults
  • Color-Blind Racial Attitudes in Dental Hygiene Students: A pilot study
  • Nonverbal synchrony as a behavioural marker of patient and physician race-related attitudes and a predictor of outcomes in oncology interactions: protocol for a secondary analysis of video-recorded cancer treatment discussions
  • Placebo effects and racial and ethnic health disparities: an unjust and underexplored connection
  • Study protocol for investigating physician communication behaviours that link physician implicit racial bias and patient outcomes in Black patients with type 2 diabetes using an exploratory sequential mixed methods design
  • Color-Blind Racial Beliefs Among Dental Students and Faculty
  • Talking With Patients Is Better Than Talking to Patients
  • Texas Medicaid Payment Reform: Fewer Early Elective Deliveries And Increased Gestational Age And Birthweight
  • Shared Goal Setting in Team-Based Geriatric Oncology
  • The Effects of Oncologist Implicit Racial Bias in Racially Discordant Oncology Interactions
  • Social Determinants of Risk and Outcomes for Cardiovascular Disease: A Scientific Statement From the American Heart Association
  • Unconscious Biases: Racial Microaggressions in American Indian Health Care
  • In This Issue: How We Think and Feel Influences Patient Care
  • Google Scholar

More in this TOC Section

  • Teamwork Among Primary Care Staff to Achieve Regular Follow-Up of Chronic Patients
  • Shared Decision Making Among Racially and/or Ethnically Diverse Populations in Primary Care: A Scoping Review of Barriers and Facilitators
  • Convenience or Continuity: When Are Patients Willing to Wait to See Their Own Doctor?
Show more Original Research

Similar Articles

Subjects

  • Person groups:
    • Vulnerable populations
  • Methods:
    • Quantitative methods
  • Other research types:
    • Professional practice
  • Core values of primary care:
    • Personalized care
    • Relationship

Keywords

  • race
  • ethnicity
  • communication
  • prejudice
  • patient-centered care
  • healthcare disparities
  • primary care
  • practice-based research

Content

  • Current Issue
  • Past Issues
  • Early Access
  • Plain-Language Summaries
  • Multimedia
  • Podcast
  • Articles by Type
  • Articles by Subject
  • Supplements
  • Calls for Papers

Info for

  • Authors
  • Reviewers
  • Job Seekers
  • Media

Engage

  • E-mail Alerts
  • e-Letters (Comments)
  • RSS
  • Journal Club
  • Submit a Manuscript
  • Subscribe
  • Family Medicine Careers

About

  • About Us
  • Editorial Board & Staff
  • Sponsoring Organizations
  • Copyrights & Permissions
  • Contact Us
  • eLetter/Comments Policy

© 2025 Annals of Family Medicine