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What You Don’t Know Can Hurt Your Patients

Posted By Lisa Zak-Hunter, Wednesday, December 14, 2016


NOTE: in an earlier blog, I addressed how personal definitions of family impact care (explicit biases). Therefore, this blog focuses only on implicit biases.


A physician was in disbelief. He anchored himself in the belief that people were not inherently better or worse than others based on factors such as gender, race, disability, sexual orientation, religion etc. Yet here he sat, faced with his online score on the Implicit Association Test (IAT) hosted by Harvard University. It read: strong preference for light skin over dark skin. He struggled to comprehend what this meant. Deep down, was he racist? He so firmly believed otherwise, that he didn’t understand how to comprehend the results and what it meant for how he practiced.


Stereotypes surround us. They are the learned associations between a characteristic and a social group. They may be true at a group level but inaccurate individually. For example, most people in Kansas City are Royals fans but some may be Cardinals fans. Although some stereotypes are benign, there are a number of stereotypes that are more contentious and have implications related to power, equity, safety, and legal concerns. Explicit bias refers to the stereotypes one readily acknowledges that they hold. "I believe women are more nurturing than men”.


By contrast, implicit bias refers to the stereotypes or associations that occur unconsciously or outside of conscious control. They develop early based on reinforced social stereotypes. For example, implicit beliefs about race are established in childhood whereas explicit beliefs change with age1. By definition we are ignorant to our implicit biases and not immune to their power. Simply knowing a stereotype can distort information processes, despite self-reported beliefs. For example, college students’ implicit race bias did not impact self-reported egalitarianism, but did predict friendliness towards Black students.2 Students who thought they felt Blacks and Whites should be treated equally, were not, in fact, as friendly to Black students.


What are the implications for healthcare delivery? The literature on bias and physician decision making reveals that even when physicians endorse no explicit negativity to various groups, they still hold a number of implicit biases such as: Blacks were associated with being uncooperative, especially regarding procedures, Whites were linked with greater compliance, and obese persons were correlated with negative words such as lazy, stupid, or worthless.3-5 If physicians have these biases but don’t realize it, what impact does that have? It’s hard to completely tell, but we do see that patients view physicians more negatively, and physicians make different assessments and treatment choices.


For instance, even if physicians think they hold little race bias but have high implicit race bias, Black patients rate them as less team-oriented, friendly, and warm.6 If patients have negative perceptions about their physician or their ability to establish a relationship with their physician, how likely are they to adhere to treatment regimens or return for follow-up appointments? Other examples indicate that elderly patients are offered less treatment than younger patients for depression and suicidality, or women are less likely than men to receive knee arthroplasty when indicated. These findings have led some to propose that implicit biases are a contributing factor to health disparities.7


An area of research that has yet to be explored is family composition or constellation bias. This is a term I coined to refer to the type of bias about who makes up a family or who is ‘in’ a family. Nuclear family bias has been examined in stepfamily research, but this term fails to address parental sexual orientation. Traditionally, the preferred family is a heterosexual married couple with children.


Based on the research of other forms of bias in healthcare, it would not be surprising if provider implicit bias about who should be in a family would impact how they work with that family. I argue this could have important implications for relationship building, treatment adherence, assessment, and treatment choice- similar to what the literature indicates with other implicit biases. Even providers who ascribe to the notion ‘the patient defines their family’, may have some strong implicit biases that negatively impact their care.


What are some ways to address this?

1. Accept your implicit biases. Respect they impact your work. Understand they come from reinforced stereotypes. The more you see a stereotype- in the clinic, on the news, with friends, at the movies etc, it reinforces the stereotype.

2. Address the source of implicit biases: stereotypes.

a. Be mindful when you encounter a stereotype and call it out as such. There is power in making the implicit explicit, moving the unconscious to conscious.

b. Commit to learning.

i. Read the research. For example, what ARE the outcomes for children raised by gay or lesbian parents?

ii. Get connected with local community centers, churches, organizations that support different forms of family. Have a liaison speak to your organization.

iii. Stay humble and curious. Don’t assume. Always ask about personal experience.

iv. If you don’t already, try letting the patient define who is ‘family’. Ask how family members should be included in care. This may get tricky with legal concerns, documentation, or space concerns (how many people can we realistically cram into an exam or labor and delivery room?).

c. Be careful about venting. Venting has the tendency to reinforce stereotypes and feed implicit biases.

3. Do your own work or provide a space for others to do theirs.

a. Make your own genogram complete with all the relationship connections- many a genogram look like a defensive coordinator’s playbook. Examine how your experiences shape your understanding about family.

b. Think about the types of families you encountered growing up. What were your impressions of them/how were they discussed? How did that inform your thoughts about ‘family’? Where did you learn what makes a ‘preferred family’ vs. a ‘non-preferred family’?

c. If you work in a training facility, consider a lecture or didactic on this topic.


1. Baron AS, Banaji MR. The development of implicit attitudes. Evidence of race evaluations from ages 6 and 10 and adulthood. Psychol Sci. 2006;17(1):53–8.

2. Dovidio JF, Kawakami K, Gaertner SL. Implicit and explicit prejudice and interracial

interaction. J Pers Soc Psychol. 2002; 82(1):62–8.

3. Green AR, Carney DR, Pallin DJ, Ngo LH, Raymond KL, Iezzoni LI, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231–8.

4. Sabin JA, Rivara FP, Greenwald AG. Physician implicit attitudes and stereotypes about race and quality of medical care. Med Care. 2008;46(7):678–85.

5. Schwartz MB, Chambliss HO, Brownell KD, Blair SN, Billington C. Weight bias among health professionals specializing in obesity. Obes Res. 2003;11(9):1033–9.

6. Penner LA, Dovidio JF, West TV, Gaertner SL, Albrecht TL, Dailey RK, et al. Aversive racism and medical interactions with Black patients: a field study. J Exp Soc Psychol. 2010;46(2):436–40.

7. Chapman, EN, Kaatz, A, Carnes, M. Physicians and implicit bias: How doctors may unwittingly perpetuate healt care disparities. J. Gen Intern Med. 2013 28(11) 1504-10.

Lisa Zak-Hunter, PhD, LMFT is Assistant Professor and Coordinator of Behavioral Science at St. John’s Family Medicine Residency at the University of Minnesota Department of Family Medicine and Community Health. Her interests include family healthcare, practitioner wellness, resident education, and the impact of trauma and adverse events on health outcomes and point of care interventions to address these. Within CFHA, she co-edits the Families and Health Blog and serves as Social Media Director.

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