This study confirms prior findings of implicit bias against African Americans with a sample of more experienced providers working in three different health care settings and with a higher response rate than obtained in prior work35
. More importantly, however, is the new finding of substantial implicit bias against Latinos, a target group that has been neglected in research on ethnic/racial bias. Approximately two thirds of the providers in this sample demonstrated implicit bias against Latinos, even as they explicitly reported egalitarian attitudes toward the group. Neither implicit nor explicit bias against Latinos was related to the providers’ age, gender, medical specialty or years practicing medicine.
Comparisons between the providers and community members using the same clinics revealed no substantial differences in ethnic/racial biases. These null results suggest that the implicit biases observed are not a problem particular to health care professionals, but reflect broader community or societal issues. The remarkable similarity between providers and community members raises the question of how those similarities are perceived. Is it enough for patients that no more bias is likely to appear within the health care setting than outside, or are health care providers held to a higher standard? What is the standard to which providers hold themselves?
Although it is common practice to focus on the central tendencies of a group, it is important not to lose sight of the differences that appear among individuals. In this study, approximately 18% of the providers showed no implicit bias when considering Latinos and 28% showed no implicit bias when considering African Americans. These are not insubstantial numbers and they suggest a somewhat different approach to the problem of health disparities. That is, instead of focusing on what biased providers might be doing wrong, it may in fact be more productive to consider what this select group of providers is doing right. Do they have an approach that allows them to work more effectively with diverse patients? Do patients seek out these providers as a means to work within a system that otherwise seems biased? What allows these providers to have attitudes that are both implicitly and explicitly egalitarian? Can it be taught to others?
Although research is just beginning on the conditions under which implicit bias may or may not affect health care,29,31,33,34
one may wonder whether anything can be done to combat an unintentional or even unconscious process. Laboratory research in social psychology shows that implicit bias is potentially malleable and does respond to changes in situational cues and social norms.42
These laboratory methods have yet to be adapted and tested in clinical setting, but the findings nonetheless suggest the real possibility of change. Additional interventions may also be developed for other points of contact, for example by bolstering patients’ defenses against bias or altering care delivery systems to mitigate the effects of bias.
The general lack of explicit bias against both African Americans and Latinos (i.e., generally egalitarian explicit attitudes) is noteworthy because it points to the types of judgments and behaviors that may contribute to ethnic/racial disparities in health care and the situational factors that are likely to exacerbate the problem. In particular, explicit egalitarian attitudes are more likely to produce egalitarian outcomes when (a) a person is thinking more deeply about what he or she is doing, (b) the situation contains fewer competing demands on the person’s time and attention, and (c) the relevant evidence is clear and consistent.8,9,10,13,14
Health care encounters that lack one or more of those conditions would be less likely to gain the benefits of providers’ explicit egalitarian attitudes, and simultaneously more likely to suffer from implicit biases.43
The lack of explicit bias among PCPs also suggests that widely practiced efforts to combat this form of bias (i.e., rational arguments about the importance of cultural sensitivity) may be ineffective.
The strengths of this study include the assessment of bias against both Latinos and African Americans, the sampling of experienced PCPs across three clinical settings that represent different models of health care delivery in the U.S., and the comparison of PCPs with other members of the community. Our 60% participation rate is also higher than most prior studies on this topic.35
Most research on implicit bias has occurred in laboratory settings with narrow populations (college students) or with un-denominated volunteers. Moving the research into actual health care settings permits stronger conclusions about the potential effects of implicit bias in health care, specifically, and at the same time it also validates the laboratory work in the consistency of results.
The limitations of the research begin with the possibility that response bias affected the results. The study is also limited in its focus on primary care providers and community members within a clinical setting. Because our provider sample is predominantly White, we have inadequate power for detailed sub-analyses of other ethnic/racial groups of PCPs. Our study also does not address the link between providers’ (implicit) ethnic/racial biases and actual health disparities, an important next step.