Take Action with Implicit Bias

May 31, 2019 by

How We Can Lead the Way in Quality Improvement
by Karin Skeen

Karin Sceen

As we care for an increasingly complex group of patients in an increasingly complex system of health care we first, do no harm. If there was a possibility that we are unintentionally harming those in our care, would we take action?

In the United States, health outcomes and treatment offerings for racial and ethnic minorities are not equal, even when income, socioeconomic status, and education are similar.

Here are a few statics and examples to explain:

  • Black Americans have higher morbidity and premature death rates for chronic diseases such as heart disease, stroke, cancer, HIV/AIDS, asthma, homicide, and diabetes.1
  • The U.S. maternal mortality rate increased 26.6% between the years of 2000-2014. 2
  • With maternal mortality rates 2-4 times higher than their white counterparts, black women experience a disproportionate share of this increase. 3
  • In a recent study of neonatal intensive care units, there were statistically different outcomes by race with white infants faring better than non-Hispanic black very low birth weight babies. 4
  • Rates of preterm birth rates for black and Hispanic women are 5 to 7% greater than whites while the black fetal death rate is twice that of whites.5

Although the prevalence and magnitude of health disparities have been well-documented, we still do not understand the causal mechanisms. Getting to the bottom of these mechanisms may lead to the development of more effective interventions.

One promising area of research is implicit bias in health care professionals. Implicit biases affect our understanding, actions, and decisions influencing behavior beyond a person’s conscious control and exist contrary to one’s explicit beliefs.6 Explicit beliefs are those one is aware of and consciously endorses.7

My own exploration into implicit bias has led me to a dissertation topic. How our own unconscious beliefs could drive unhelpful or even harmful communication or behaviors is a puzzle I hope to help solve. The link between implicit bias and health outcomes was recognized two decades ago.

In 1999, the United States Congress charged a committee of the Institute of Medicine to report on the state of racial and ethnic disparities in health care. The resulting publication, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, was a landmark addition to the body of knowledge about health care disparity. The publication specifically called out implicit bias as a contributor to health disparities.8

Since the publication of this report, multiple studies have focused on the role of implicit bias in health care with no clear intervention identified.9

Unfortunately, the focus of many of these studies is on individual provider bias versus the collective biases of the health care team. Everyone has prejudice. Prejudice plus power equals racism. While prejudice is multidirectional, racism is not. Marginalized groups rarely have the power to benefit from racism.

What if we considered for a moment how the collective unconscious bias of the health care team could become structural racism? If we think of racism in terms of being the union  of prejudices and legal or institutional control, it moves beyond one individual and manifests in a systematic and more powerful way. Collective biases that play out in policy formation, processes that disadvantage marginalized groups, or influence a “group think” phenomenon in a care team’s decision making are all examples of structural racism.

How might other aspects of implicit bias play out in a pediatric health care setting? Unconsciously preferring white values, communication styles, and parenting styles as the ideal state sets up a good/bad dichotomy. The opposite of what is “good and right” is “bad and wrong”. This “white” measuring stick has potential for undermining communication between the care team and the patient/parent.

Without clear empirical evidence on solutions that interrupt implicit bias, some common sense approaches include:

  • Self-checking: for one week check in on your first impressions when you meet or pass a person of discordant race. If it’s negative, try picking something positive about that person to mentally say to yourself.
  • Get informed: Here’s a list in somewhat of a chronological reading order that includes the parts of American history most of us were not taught in school:

The following is a reading list that I found helpful in understanding how we got to our current place in this country. I arranged them in a reading order from a somewhat chronological historical perspective.

  • Stamped from the Beginning, by Ibram X. Kendi
  • Slavery by Another Name: The Re-Enslavement of Black Americans from the Civil War to World War II, by Douglas A. Blackmon
  • The Color of Law: A Forgotten History of How Our Government Segregated America, by Richard Rothstein
  • The New Jim Crow: Mass Incarceration in the Age of Colorblindness, Book by Michelle Alexander
  • Fatal Invention: How Science, Politics, and Big Business Re-create Race in the Twenty-first Century, by Dorothy Roberts

Understanding and addressing how implicit bias affects our thoughts and behaviors extends well beyond the walls of the hospital and clinics in which we work. Health care providers have an opportunity to lead the way in narrowing the racial divide. I encourage us as health care professionals to be aware and to take action as individuals and as teams. Together, we can make a difference.

If you are interested in this topic, let’s connect. Children’s Hospital has a history of leading the way in quality improvement and this is another opportunity to demonstrate our commitment to achieving greatness.


1 U.S. Department of Health and Human Services Office of Minority Health, 2019
2 MacDorman, Declercq, Cabral, & Morton, 2016
3 Alkema et al., 2016
4 Lake et al., 2014
5 American College of Obstetricians and Gynecologists, 2015
6 Greenwald & Banaji, 1995; Greenwald & Krieger, 2006
7 Greenwald & Krieger, 2006
8 Institute of Medicine, 2003
9 Blair, Steiner, & Havranek, 2011; Drewniak, Krones, & Wild, 2017; FitzGerald & Hurst, 2017; Hall et al., 2015

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