Women have a higher rate of missed myocardial infarction. Black patients wait longer to receive care in the emergency department for chest pain. Transgender patients get asked questions about their orientation that have nothing to do with their clinical condition. A Latina woman does not get adequate pain medication because she is being “dramatic.” A female physician’s opinion is dismissed by her male colleagues. An older physician views residents as being “lazy” because they get to limit their work hours. Male physicians get paid more and achieve leadership positions more frequently than female physicians. You’ve heard this before and seen the research behind these disparities. None of this is intentional, yet somehow these things continue to happen and are a part of our daily lives. While the causes for these disparities are multifactorial, unconscious bias plays a big role.
Bias is a tendency or an inclination that results in judgment without question. In its most extreme, negative form, it is a prejudice against someone who is not like you that results in some harm to the “other.” It can also be positive. In reality, bias serves two purposes. It helps us to function on a daily basis, and most important, it serves to protect us from harm. Think about it. You are walking down the street at night in an unfamiliar area. Just ahead, you see the shadow of a figure walking toward you and see a glint of light off of a long pointy object in what looks like that figure’s hand. What do most of us instinctively do? We quickly move away from the figure. Why? Because most of us have developed a strong bias against strange and unknown figures holding presumably sharp objects that may cause us harm. While the figure may not be a true threat, our bias causes us to instantaneously perform certain protective actions. It is unlikely that we would approach the figure, do a careful and detailed assessment, review a long list of potential actions, and choose our option—we may not be alive if we did so.
Each of us is a unique individual who has our own individual experiences and education (both formal and informal). These can be described as our “book of rules.” Our “schema” organizes these rules. Together, these form the background, our “lens,” through which we view the world. We are constantly experiencing rules and reshaping our schema and background on a minute-by-minute basis. Background is context, and context is the lens through which we view the world. We cannot help having biases; it is a part of who we are.
No explicit preference for white or black patients or perceived cooperativeness was found. However, the IATs demonstrated implicit preference for white patients and implicit stereotypes of black patients as less cooperative with medical procedures and less cooperative in general.
In 1998, Anthony Greenwald, Debbie McGhee, and Jordan Schwarz created an implicit association test (IAT).1 This tool is the most recognized and commonly used test to measure unconscious bias and measures the strength of automatic associations between concepts (eg, black people, gay people) and evaluations (eg, good and bad). The IAT score is based on how long it takes a person, on average, to associate certain evaluative words with the concept being tested. Thus, if one quickly associates “good” words with “white” and “bad” words with “black,” there may be a preference of white over black. (A more detailed description can be found in the “Education” section at Implicit.Harvard.edu.) Currently, there are 13 tests on the Project Implicit website: Native American, Gender-Science, Asian American, Race (Black-White), Age, Disability, Weight, Presidents, Arab-Muslim, Skin-Tone, Sexuality, Weapons, and Gender-Career.2