Conscious and Unconscious Biases in Health Care

Bias Among Practitioners

Healthcare professional overseeing patientA number of salient themes emerge from the well-documented body of literature on practitioner bias and are presented below:

  • Health care practitioners and other health professionals enter their chosen professions for altruistic reasons-to help individuals and communities maintain optimum health and well-being. Most find it incongruent that they can have such good intentions yet harbor biases that can have negative consequences and outcomes for their patients.8

“Physicians rated African Americans as less likely to be the kind of person they could be friends with, as being less likely to be free of substance abuse problems, and less likely than non-Hispanic whites to be interested in an active lifestyle and cardiac rehabilitation. Moreover, physicians rated African Americans as less intelligent and less educated than non-Hispanic whites. All of these relationships were stronger if the patient was from a lower socioeconomic class.”3(p357)

  • Most practitioner bias is at an unconscious level and is influenced by multiple factors, including exposure over time to negative images and messages about certain groups of people.9-11

“Individuals who:

  • perceive more provider discrimination have higher unmet needs for health care utilization.
  • have negative experiences within the health care setting will be less likely to continue to seek health care services, even when they report a recognized need for care.
  • perceive more provider discrimination are more likely to have poor health.”

“Negative experiences within the health care setting will create additional vulnerabilities in an already vulnerable population, and acts as one mechanism for creating and sustaining health disparities in African Americans, Hispanics, and Asians.”12(p8)

  • Perceived discrimination and bias have an adverse effect on patient health and are closely linked to health and health care disparities.13-15
  • Perceived discrimination may be related to both mental and physical health outcomes. This relationship may occur through the mechanisms of patient stress responses and health behaviors.16
  • Implicit bias has been demonstrated to impact clinical decision-making. Findings have reflected differences in care or proposed care based on race and ethnicity for cardiac conditions, HIV/AIDS, end-stage renal disease, psychiatric treatment, surgical safety and outcomes, and treatment of pain, among others.9,17-20

Learn more from Kimberly Papillon, Esq.
Judicial Educator
Regular Faculty at the National Judicial College

Click here to read an essay on the study described in the previous video. (PDF)*

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A complex array of factors contributes to the impact of implicit biases on decision-making.21-23 Fatigue, stress, and cognitive overload are closely linked to health care practitioners and the environments in which they work. In high-demand, high-performance situations, practitioners are vulnerable to the “hard wiring” employed by the brain to circumvent cognitive overload by simplifying information through group generalizations and stereotyping. Ultimately, such behaviors result in biased or compromised medical decision-making that cannot be fully explained by specific clinical factors of the patients involved.18-20

Kimberly Papillon provides more detail about how bias can impact decision-making.

Click here to read an essay on the study described in the previous video.(PDF)*

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"Physician’s affect could be a powerful though unconscious, determinant of the outcomes of medical care.” 23 (p.145), 24

  • Implicit bias can be conveyed through interpersonal communication (body language and posture, facial expressions, distance) and can have a negative effect on patient-practitioner interactions.

A confidential survey was completed by family practice physicians about extremely obese patients. Respondents indicated that these patients:

  • Lacked discipline (80%); and
  • Were not motivated to lose weight (52%)

Respondents (50%) thought treatment for obesity is ineffective.25
A cross-section of military family physicians was surveyed to determine attitudes and practice regarding obesity.

  • 56% did not find counseling obese patients to be “professionally satisfying”;
  • 18% thought obese patients were “sad”; and
  • 25% of obese patients lacked self-control.26

Dental students (420) were surveyed and responded as follows:

  • 30% felt negatively toward the appearance of an obese patient;
  • 14% said they would be uncomfortable examining an obese patient; and
  • 17% found it difficult to feel empathy for obese patients.27

Racial bias is most prevalent in the literature and indicative of the continuing inequities between racial groups in the United States, its territories, and tribal communities. It should be noted that overt racial bias has diminished over time. However, there is rapidly growing literature on the negative attitudes and conscious bias about providing care to obese patients across health care disciplines (i.e., nursing, medicine, dentistry).

While this body of literature offers compelling evidence of the impact of bias on health and health care, there is a contingency of researchers who discount practitioner implicit and explicit biases as a contributor to health and health disparities. It would be an oversight if we did not examine the literature that critiques the concept of practitioner bias. After the Schulman study was published in 199920 and sent shock waves throughout the national health care arena, there were a number of published opinion and research articles that took aim at the quality of the research.28 This response was also noted after Unequal Treatment, the Institute of Medicine’s landmark report, was published in 2002.29-31

Some of these researchers view the causal factors of health disparities as differences in socioeconomic status, geographic factors, unhealthy behaviors, and life history rather than the biases of physicians, whereas others protested and blame the physician mentality expressed in the health care disparities and bias literature.