Implicit Bias in Healthcare: Awareness and Practical Strategies

What Is Implicit Bias?

Implicit bias refers to attitudes or stereotypes that affect understanding, actions, and decisions in an unconscious manner. These associations develop over a lifetime through culture, media, and experience. Everyone has them, including people who are fully committed to fairness.

Explicit bias, by contrast, refers to attitudes a person is aware of and can state. A person can sincerely reject a stereotype while still holding an implicit association that influences quick, automatic judgments.

Implicit biases can relate to many characteristics, including race, ethnicity, sex, gender identity, age, weight, disability, language, socioeconomic status, religion, and mental health or substance use history.

Why It Matters in Healthcare

The National Academies' report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Institute of Medicine, 2003) concluded that differences in care exist even when factors such as insurance and access are accounted for, and identified clinician uncertainty, stereotyping, and bias among the contributing factors. The Joint Commission's Sentinel Event Alert 61 (2016) addressed implicit bias in healthcare and encouraged organizations to address it.

Healthcare settings often involve conditions in which automatic thinking is more likely to shape decisions:

• Time pressure and high workload
• Fatigue and stress
• Diagnostic uncertainty
• Incomplete information

Implicit bias can show up in subtle ways, such as less eye contact, interrupting more quickly, providing less explanation, or giving less weight to a patient's own description of their symptoms. These behaviors can affect trust, adherence, and outcomes.

Recognizing Bias in Yourself

Awareness is a starting point, not an endpoint. Approaches to self-reflection include:

• Noticing reactions: pay attention when you feel quick judgments about a patient or colleague, and ask what information they are based on.
• Reviewing patterns: consider whether you explain options, offer treatments, or respond to concerns differently across patient groups.
• Using reflective tools: research instruments such as the Implicit Association Test (IAT), developed by researchers associated with Project Implicit, can prompt reflection. They are educational and research tools, not diagnostic tests of an individual's behavior.
• Seeking feedback from trusted colleagues and from patient experience data.

Discovering an implicit association is not a moral failing. The professional responsibility is to recognize that it can influence behavior and to use deliberate strategies to prevent that.

Individual Strategies

Strategies commonly described in the research literature and in professional education include:

• Individuation: focus on the specific person in front of you, including their history, preferences, values, and goals, rather than group-based assumptions.
• Perspective-taking: consider the situation from the patient's point of view.
• Slowing down: when possible, pause before key decisions, particularly about pain assessment, triage, diagnosis, and treatment options.
• Partnership building: invite patients to share their concerns and participate in decisions.
• Teach-back: confirm understanding by asking patients to explain information in their own words, rather than assuming what they understand.
• Using professional interpreters for patients with limited English proficiency, consistent with civil rights requirements, rather than relying on family members, especially children.

System-Level Approaches

Individual effort is important, but systems can make fair care the default. Organizations can:

• Use standardized, evidence-based protocols and checklists for common decisions such as pain management, sepsis screening, and stroke evaluation, so that care does not depend on subjective impressions.
• Collect and stratify quality data by patient demographics to identify gaps in care processes or outcomes.
• Ensure language access services and accessible communication for people with disabilities.
• Provide ongoing training that pairs awareness with skill practice.
• Create channels for staff and patients to raise concerns without fear of retaliation.

Combining individual habits with structural safeguards is more effective than either alone.

Applying It in Daily Practice

Consider a busy shift where a patient reports severe pain, and a colleague comments that the patient seems to be exaggerating. A bias-aware response would be to use a validated pain assessment tool, ask open-ended questions about the patient's experience, review objective findings, and follow the established protocol, applying the same approach you would use for any patient.

Small, consistent habits matter: greeting every patient by their preferred name, asking every patient the same screening questions, and documenting objectively without labels such as 'noncompliant' when 'did not take medication due to cost' is more accurate. These practices support respectful, high-quality care for everyone.

Communication Skills That Support Equitable Care

Communication practices recommended by agencies such as the Agency for Healthcare Research and Quality (AHRQ), including its Health Literacy Universal Precautions Toolkit, help ensure every patient receives clear, respectful information:

• Assume every patient may have difficulty understanding health information, and communicate clearly with everyone, rather than guessing who needs help based on appearance.
• Use plain language and avoid medical jargon.
• Limit information to a few key points per conversation and check understanding.
• Ask open-ended questions, such as 'What questions do you have?' rather than 'Do you have any questions?'
• Ask about preferences, including preferred name, pronouns if the patient wishes to share them, language, and how they like to receive information.
• Acknowledge and repair: if you realize you made an assumption, acknowledge it, apologize when appropriate, and refocus on the patient's needs.

These practices benefit all patients and reduce the opportunity for assumptions to shape care.

Bias can also affect interactions among colleagues, including hiring, evaluation, assignments, and whose ideas are heard in team discussions. Applying the same strategies, such as structured criteria and deliberate reflection, supports a respectful workplace and better teamwork.