Conscious and Unconscious Biases in Health Care

Additional Findings

The Kaiser study also noted that African Americans (14%) and Latinos (13%) were more likely to report being treated unfairly when seeking medical care within the past few years compared with Whites (4%). Another question probed whether African Americans received the same quality of health care as Whites. A majority of Whites (67%) thought the quality of care was the same and 23% thought care was of lower quality. African Americas responded in almost the exact opposite way with 64% thinking care was of lower quality and 27% who thought it was the same.1 Unfortunately, some of these same perceptions and experiences of care have not changed appreciably since 1999.

Most of the literature focuses on patients’ reported experiences of bias based on their race, ethnicity, English language proficiency and fluency, SES, and gender.1-4 Selected findings from this literature follow:

  • “African Americans, Hispanics, and Asians were more likely than whites to agree that: 1) they would receive better medical care if they belonged to a different race/ethnicity; 2) medical staff judged them unfairly or treated them with disrespect based on their race/ethnicity; and 3) medical staff judged them on how well they speak English.”2(p106) These researchers also found that African Americans believe they are treated with disrespect and in an unfair manner because of how they speak English.
  • In a telephone survey of privately insured patients from 32 group practices, African American patients rated physician encouragement and negotiations worse when compared with White patients. Ratings for White and minority physicians were not different, but patients in race-concordant relationships believed visits were more participatory than those in race-discordant ones.3
  • Focus group interviews with low-income minority patients found that their definitions of culturally competent care (care that they experienced as sensitive to their needs) included the provider’s having good “people skills,” technical competence, offered individualized treatment, and effective communication.5
  • “A sample of 810 survey respondents included 397 White patients (49%), 152 African Americans (19%), and 114 Hispanics (14%), and 147 patients who were Asian, Pacific Islander, or other races/ethnicities (18%). A total of 14% of study participants reported that they had been discriminated against at least once by doctors or office staff in the prior year. Patients reporting one form were also likely to report other forms. For example, respondents reporting racial discrimination also reported age discrimination (48%) and education/income discrimination (63%).”6(pp43-44)

Although the phenomenon clearly exists, little in the literature documents implicit or explicit bias on the part of patients.7 Studies tend to describe patients who (1) perceived or experienced discrimination, prejudice, and disrespectful treatment in health care settings from non-race or non-ethnic concordant practitioners and as a consequence express a preference/bias for practitioners of their own race or ethnicity; or (2) received care from health care professionals whom they perceived as culturally sensitive or culturally competent practitioners and thus express a clear preference/bias based on these experiences with racial or ethnic concordant practitioners.2,5 The following video clip provides an example of bias on the part of a patient preferring the same gender physician.

In summary, many of the aforementioned studies rely on patient report of their experience of care or interactions with health care staff. One could critique these studies as less than the “gold standard” of evidence because they are based simply on patients’ perspectives. It is important to acknowledge that a patient’s perception is his or her reality, and in order to combat biases, we must seek to understand and be responsive to the world views and experiences across diverse patient population groups.