Uncovering implicit bias and microaggressions in healthcare

Everyone has bias, but we can learn to do something about, said Shanta Zimmer, MD, at the 2021 Institute for Functional Medicine Annual International Conference held virtually June 3-5.

Zimmer started the session by asking the audience questions about their preferred hobbies and where they grew up. She challenged attendees to consider how these experienced shaped their perspectives and how they view the world.

From there, she asked the audience about their gender and sexual orientation, noting the importance of including options for “none of these” and “prefer not to say” to be as inclusive as possible. If a patient is not represented, they will feel excluded, Zimmer said.

Next, Zimmer asked the audience whether or not they had children. She said many people have a bias about what is right or wrong or make assumptions about who should or should not have children. Zimmer said practitioners should keep in mind that having children or not is neither right nor wrong, but rather is a characteristic of that person. Regardless, having or not having children shapes how the individual views the world.

Lastly, Zimmer asked the audience to identify their race and ethnicity. In 2020, the U.S. Census Bureau included options to not only mark one or more boxes for race and ethnicity but included space to print origins as well. Zimmer again reminded practitioners to include “none of these” as an option, as it is impossible to capture all races and ethnicities.

These questions were meant to challenge practitioners to think of diversity from a number of different lenses, not only race and ethnicity.

Understanding implicit bias

The majority of human cognition is unconscious. When humans make decisions, they do so either through the fast unconscious or slow cognitive parts of the brain. Bias lives in the fast-thinking part of the brain, Zimmer said. Biases come from associations, and associations are everywhere. Consider the Starbucks logo—when most people see the logo on its own, they don’t think of a mermaid or a goddess, but rather the symbol for coffee. Biases from associations follow a similar thought process, Zimmer said.

The Implicit Association Test (IAT) developed by Harvard University measures bias or strength of implicit associations between concepts. Implicit associations, Zimmer said, may not align with our explicit beliefs.

Examples of implicit bias are everywhere, Zimmer said. A Yale University study on implicit bias in preschools found that teachers tend to more closely observe Black children than white children, especially Black boys, when challenging behaviors are expected.

There are many effects of stereotypes and biases that everyone should be aware of, Zimmer said. Attributional ambiguity is the uncertainty of stereotyped individuals to interpret the cause of others’ behavior toward them. Self-fulfilling prophecy is the behavior in which one’s inaccurate expectations about a person’s behavior prompt stereotype-consistent behaviors. Self-stereotyping is specific stereotypes that affect a person’s evaluations of their abilities. Lastly, a stereotype threat is when people are aware of a negative stereotype about their social group, then experience anxiety that they might confirm the stereotype, undermining performance.

In medicine, research shows practitioners are more susceptible to implicit biases with patients when they are fatigued, have excess cognitive load, time constrains, or ambiguous or incomplete data. Additionally, research is growing showing bias can occur with burnout.  

Health disparities exist in every specialty in medicine, said Zimmer. The reality is diverse populations produce better outcomes. On the other hand, biases impact decision making and contribute to poorer patient outcomes. Awareness of bias helps, but it’s only a start.

Implicit racial bias in patient care consistently correlates with poorer patient-provider interactions, Zimmer said. In a 2017 study published in the journal Social Science & Medicine, higher implicit bias was associated with disparities in treatment recommendations, expectations of therapeutic bonds, pain management, and empathy. Studying the impact of implicit provider bias on real‐world patient provider interaction found that providers with stronger implicit bias demonstrated poorer patient‐provider communication.

Zimmer encouraged practitioners to practice de-biasing strategies. Diversity builds on diversity, she said:

• Surround yourself with images that defy stereotypes
• Improve the circumstances of your decision making
• Be mindful of your reactions
• Consider the other person’s perspective
• Ask a colleague to help you
• Learn people’s stories

Addressing microaggressions

Addressing microaggressions requires moral courage, Zimmer said. A microaggression is a subtle but offensive comment or action directed at a minority or other nondominant group that is often unintentional or unconsciously reinforces a stereotype.

Categories and themes of racial microaggressions include:

• Alien in own land
• Myth of meritocracy
• Colorblindness
• Ascription of intelligence

Examples of microaggressions include:

• “You speak English really well,” to someone born and raised in the United States.
• “Are you a nurse?” to a female resident examining a patient.
• “Are you the sitter?” to a black resident walking into a patient room.
• “You look too masculine,” to a self‐identified lesbian resident.
• “Minorities are still hung up on race,” to a fellow resident.
• "Your people must be so proud of you," to a resident with an accent.

Individuals who perceive and experience racial microaggressions are likely to have negative mental health symptoms, such as depression, anxiety, negative affect or negative view of the world, and lack of behavioral control, Zimmer said. Racial battle fatigue is a theoretical framework for examining socialpsychological stress responses and the cumulative effects of microaggressions.

Microassaults are explicit and conscious, intended to hurt, Zimmer said. They can be characterized by being most similar to "old fashioned racism" towards an individual. They are typically expressed privately, but may be displayed publicly when there is a loss of control, or in a “safe” environment. Examples include name calling, derogatory epithets towards a personal characteristic, or displaying a swastika.

Microinsults are subtle and often unconscious. They are not intended to hurt. They may be characterized by communications that convey rudeness, insensitivity, and demean a person’s identity. They are expressed publicly. Examples may include:

• "I believe the most qualified person should get the job regardless of race"
• "You are black and a woman, you should have no trouble getting in to medical school
• "How did you get your job?"

Microinvalidation, also known as micro-disses, are unconscious and not intended to hurt. In fact, the intention is often positive. They may be characterized by communications that exclude, negate or nullify the psychological thoughts, feelings, or experiential reality of a person. Examples include:

• “I’ve never thought of you as a black person. I don’t see color."
• “All lives matter.”
• An Asian American being complimented for speaking English well
• A Muslim resident is snubbed at a cafeteria, to be told by a co‐resident “you are too sensitive. They were probably just busy.”

Microaggressions can have a tremendous impact, Zimmer said, likening the experience to, “death by a thousand paper cuts.” Institutions have a responsibility to take a strategic approach and update mission, vision, and policies, as well as improve processes and guidelines for promotion, hiring, awards, and appointments. Collect data, provide faculty development and training, state, seek, and measure inclusive outcomes, articulate no tolerance policies, and cultivate an inclusive culture.

We all have hidden biases, which can lead to microaggressions, Zimmer said. She challenged practitioners to speak up in the moment, or revisit later if not recognized in the moment. The key is we must support colleagues in the face of microaggressions.

“Diversity brings excellence,” Zimmer said. “Having diverse folks at the table improves the quality of care, the research we conduct, and the decisions we make.”

Editor's note: This article is part of our live coverage of the 2021 Institute for Functional Medicine Annual International Conference. Click here for a list of full coverage.