Q&A: Implicit bias may be overlooked in medical training

Key takeaways

• The study revealed that medical students held an implicit preference for people who were male, white, young, thin and non-LGBTQ+ at every level of training.
• A study author spoke with Healio about the findings and their implications for medical training.

CHICAGO — Students at every level of medical training have implicit biases that favor people who are male, young, white, thin and non-LGBTQ+, according to research presented at the Women in Medicine Summit.

Implicit biases, which “involve associations outside conscious awareness that lead to a negative evaluation of a person based on individual characteristics,” can result in the “further marginalization of vulnerable populations,” according to researchers.

Alisha Crump, MPH, a PhD candidate at the University of Arkansas, and colleagues wrote that “early evaluation of implicit bias in medical training can prevent long-term adverse health outcomes.” So, they conducted the systematic scoping review to analyze implicit bias at different stages of medical training: pre-medical, graduate and post-graduate.

The researchers examined existing publications that studied implicit bias. They included articles that contained a title and abstract regarding implicit bias and medical training, had full text, was conducted in the U.S. and was in English, had quantitative or qualitative research and “were within the scope of assessing implicit bias” at a stage of medical training.

After identifying 1,518 articles initially, the researchers included 87 that met inclusion criteria in the final analysis. One-fifth of the articles examined gender-based implicit bias and 17% examined race-specific biases, but 36% assessed general implicit biases. The largest proportion of papers — 43% — assessed post-graduate implicit bias; 34% analyzed graduate level biases; and 10% investigated pre-medical level biases.

At every level of training studied, the researchers found that students held an implicit preference for people who were male, white, young, thin and non-LGBTQ+.

“Our findings indicate the need for healthcare professionals to address implicit bias at all levels of medical training,” the researchers wrote. “Furthermore, this study highlights notable gaps within the sequential assessment of implicit bias, specifically at the pre-medical training level. Further research should be conducted on the impact of such biases and possible training programs aimed at addressing this healthcare disparity.”

Crump spoke with Healio about the “longitudinal nature of implicit bias,” the “revealing” gaps in literature and more.

Healio: Your study found a “need for healthcare professionals to address implicit bias at all levels of medical training.” Can you expand on that? How does implicit bias hurt people during medical training?

Crump: In short, implicit bias contributes to health-related disparities. The implications of implicit bias are best described through an example. Suppose Charles, a 56-year-old Hispanic man, presents to the hospital with what is presumed to be chest pain. If the attending physician harbors unconscious attitudes and negative stereotypes towards Hispanic individuals, implicit bias can surreptitiously influence patient treatment, leading to discriminatory behavior. This behavior can have several consequences, such as mistrust in the health system and failure to adhere to medical recommendations. As a result, Charles’ health suffers. This is how implicit bias infects vulnerable and marginalized populations. It is important to note that in this example, the attending physician’s behavior is unconscious. Simply put, the attending physician is not aware of their existing bias. Instead, these biases have been established over the course of years through personal encounters, social media, or even childhood teachings. Given the longitudinal nature of implicit bias, it is not enough to simply provide training at the level of attending, resident, or fellow. To completely mitigate the harms of implicit bias in health care, we must first recognize it as an inherent disease worthy of early intervention.

Healio: The online database you used found more than 1,500 articles, but a closer review saw that only 87 could be used. What was the reason for the disparity? Was this discouraging at all?

Crump: Research on the assessment of implicit bias in health care education is a relatively new phenomenon, dating back to the last 15 to 20 years. Additionally, our current understanding of implicit bias and its effects are constantly being redefined and expanded upon.

I wouldn’t say the findings were discouraging as much as they were revealing. I knew there were gaps in the current literature, but I did not expect such a dramatic decrease in eligible articles. These results further cemented the importance of informing and moving the needle towards a more impactful health care education system.

Healio: Your study also found “notable gaps within the sequential assessment of implicit bias, specifically at the pre-medical training level.” Can you expand on that? Why is this important?

Crump: Only 10% of all publications studied implicit bias at the pre-medical level, compared to 44% of articles that examined it at the medical graduate level (ie, physician residents). This gap represents a void in our current knowledge of implicit bias among pre-medical students. The cause of this disparity is multifaceted and requires a closer examination of our healthcare education system. However, based on the collected literature, I believe a key explanation is our current understanding of implicit bias in health care. Current literature discusses implicit bias as a singular event with a singular outcome. Emerging data has shown this not to be the case. Instead, implicit bias involves the accumulation of experiences, leading to pre-determined judgments and stereotypes. Through applying a reactionary response to the role of implicit bias in health care education, we neglect the experiences that have led to one becoming the physician treating the patient. To address the biases at the professional level, we employ institutional trainings with singular exposures to treatment for a chronic disease (in this case, implicit bias). Instead of using this idea, I think we should approach implicit bias with a chronic disease-like perspective and create ongoing assessment programs for people who are moving throughout the medical education system.

Healio: How can these issues be resolved? What do you think should be done to address them?

Crump: Let me start by saying that the recommendations to address these issues involve an interdisciplinary team. As researchers, we must first recognize implicit bias as a topic to be studied at all stages of medical education. As the platform grows, we can advocate for funding to support educational training aimed at decreasing the presence of implicit bias within health care education and, eventually, patient treatment.

Healio: Can you discuss why this is an important issue that deserves more attention?

Crump: Contrary to explicit bias, which involves the overt action of discriminatory behavior, implicit bias utilizes unconscious, unintentional behavior that affects judgement and ultimately actions. Most of the recent study focuses on the association of explicit bias in the health care system, which can be explained by a number of factors, including the practicality of measurement and reporting. Because implicit bias involves attitudes and thoughts unbeknownst to the individual, assessment of this bias can be a challenge. Due to this difficulty, there has been little research done and there is a need for greater scientific attention. However, innovative solutions exist and should be used to highlight this emerging research area.

Reference:

• Crump S, et al. Implicit Bias Assessment by Career Stage in Medical Training: A Scoping Review Presented at: Women in Medicine Summit; Sept. 16-17, 2022; Chicago (hybrid meeting).