Unconscious Bias in Healthcare

Last year we all had front row seats to witness a social justice moment that’s been fulminating for decades. We saw the shocking stories of George Floyd and Breonna Taylor and wondered how many similar stories are never told.

These are worst-case outcomes of unconscious biases. Some of these biases are personal and many are systemic. Physician leaders have a responsibility to familiarize themselves with racial bias and other unconscious biases, as it is the first important step in changing the world around us, one encounter at a time.

First, let’s begin with a definition. The University of California, San Francisco, Office of Diversity and Outreach defines unconscious biases this way:

“Unconscious biases are social stereotypes about certain groups of people that individuals from outside of their own conscious awareness. Everyone holds unconscious beliefs about various social and identity groups, and these biases stem from one’s tendency to organize social worlds by categorizing people.”(1)

Once we understand what unconscious bias is, we begin to realize that the organizational risks that come with unconscious biases are serious. Almost everything can be affected: hiring, meetings, teamwork, culture, performance reviews, innovation, promotions, consensus-building, and much more. The easiest way to see unconscious bias is to look for its effects and outcomes.

Effect on Healthcare Performance and Profitability

Progressive leaders have many admirable and important reasons to work on limiting the effect of unconscious bias in their organizations. One of the best reasons is performance. Studies have shown again and again that diverse companies perform better.

One of the most concise and compelling reports on this topic was produced by the CEB Corporate Leadership Council.(2) The results were conclusive. Here’s a summary:

When employees view their workplaces as diverse and inclusive, the organization’s profits exceed those of their non-diverse competitors. Here are the numbers:

• 1.12x more discretionary effort;

• 1.19x greater intent to stay with organization;

• 1.57x more collaboration among teams; and

• 1.42x greater team commitment.

The bottom line is that diversity is a performance accelerant, and unconscious bias is diversity’s most powerful enemy.

How is unconscious bias evident in healthcare? It intrudes in many ways and invisibly drives a lot of outcomes. The influence of unconscious bias appears in very predictable ways that leaders can learn to identify quickly. Five kinds of unconscious that show up in healthcare most often:

1. Affinity Bias – Warm up to people who are like us.

2. Halo Effect – Think everything about a person is good because you like them.

3. Perception Bias – Form stereotypes and assumptions about certain groups.

4. Confirmation Bias – Seek information that confirms pre-existing beliefs.

5. Groupthink – Try too hard to fit into a particular group by mimicking others or holding back real thoughts and opinions.

In our experience, once a certain kind of unconscious bias has a name, it’s much easier to address. Every form of unconscious bias creates risk for a team. Progressive leaders need to understand these risks.

Where Does Unconscious Bias Come From?

The root of unconscious bias is our survival instinct. Our brains evolved to help us survive, and their ability to subconsciously process thousands of pieces of information in an instant kept our ancestors from becoming food. This same ability now gets us through the day without having to slowly process every decision we make.

Research makes this very clear: We all receive about 11 million bits of information every moment, and we’re only able to process about 40 bits. Our conscious mind is processing only a minute fraction of what our unconscious mind is processing, so our unconscious mind is making 99.999996 percent of all of our decisions.(3) That’s a lot.

Everyone has biases; it’s part of being human. It’s important not to be ashamed of this basic fact. Part of developing yourself as a leader is learning to respond to unconscious bias. We all have to accept this truth before we can begin to take positive action. You are biased. So am I. It matters.

The State of Diversity in Healthcare

There is accumulating evidence that increasing diversity in healthcare employees improves healthcare delivery, especially to underrepresented segments of the population.

Most of us are familiar with the term “underrepresented minority.” Underrepresented in healthcare means those racial and ethnic populations that are underrepresented in the medical profession relative to their numbers in the general population. However, this definition does not include other nonracial or ethnic groups that may be underrepresented in healthcare, such as lesbian, gay, bisexual, transgender, or questioning/queer (LGBTQ) individuals or persons with disabilities.

U.S. census data estimate that the prevalence of African American and Hispanic individuals in the U.S. population is 13 percent and 18 percent, respectively, while the prevalence of Americans identifying as LGBT was estimated by Gallup in 2017 to be about 4.5 percent.(4) Yet, African American and Hispanic physicians account for a mere 6 percent and 5 percent of medical school graduates, respectively, and account for 3 percent and 4 percent, respectively, of full-time medical school faculty, respectively, according to the Association of American Medical Colleges Diversity in Medical Education Report.(5)

Persons with disabilities are estimated to be 8.7 percent of the general population, while the prevalence of physicians with disabilities has been estimated to be a mere 2.7 percent. The AAMC does not report the prevalence for LGBTQ medical graduates. Although women currently outnumber men in first-year medical school classes, gender disparities still exist at higher ranks in women’s medical careers.

The Institute of Medicine (now the National Academy of Medicine) noted that bias, stereotyping, and prejudice may play an important role in persisting healthcare disparities and that addressing these issues should include recruiting more medical professionals from underrepresented communities.(6) Bias may unconsciously influence the way information about an individual is processed, leading to unintended disparities that have real consequences in medical school admissions, patient care, faculty hiring, promotion, and opportunities for growth.

For example, according to the Institute of Medicine, when compared with heterosexual peers, LGBTQ populations experience disparities in physical and mental health outcomes. Bias (both conscious and unconscious) projected by medical professionals toward the LGBTQ population plays a major role in perpetuating these disparities. Interventions to mitigate this bias that draw roots from race/ethnicity or gender bias literature can also be applied to bias toward gender/sexual minorities and other underrepresented groups in medicine.

The Journey of the Ally

Here we are at the “moments of truth” you’ve heard people talk about. It’s time for leaders to act on their principles. It’s time to identify yourself as an ally.

This is an activation moment that requires healthcare leaders to decide where they stand.

Apathy and ambivalence have been removed as an option. The journey of an ally has four district stages that are summarized below. We’re all somewhere on this continuum. Where are you on your journey as an ally?

Stage 1: Issue Blindness

• Has no understanding or effort to understand issues.

• Lacks empathy for victims and displaces blame for the issues being challenged.

• Is not an active detractor and is not emotionally invested in opposition.

• Does not understand that neutrality is a net-negative.

Stage 2: Social Awareness

• Knows what’s wrong and understands why people are upset.

• Is motivated by social forces; opinions are an aggregation of their social circle.

• Can see that the current situation is unsustainable.

• Processes issue as if it’s happening exclusively to someone else; is a spectator.

Stage 3: Personal Activation

• Is intentionally well-informed.

• Shares opinion when prompted and will join in with passionate voices.

• Is willing to be a group outlier in social and workplace situations.

• Acts as a necessary and undeniable part of the solution.

Stage 4: Active Advocacy

• Is fully committed to the cause and considers it to be “their” cause.

• Is proactive in challenging and changing opinions.

• Is willing to take social risks that reconfigure friendships and social circles.

• Is an agent and a force for good; brings the future into the present.

Those are the four stages in the journey to allyship. You should be able to identify exactly where you are right now. Now consider moving to whatever your next stage should be. Start by asking yourself ”What would that mean for me?” and ”How should I begin?” Make a decision. Make a difference.

References

1. University of California, San Francisco, Office of Diversity and Outreach. What Is Unconscious Bias? UCSF Office of Diversity and Outreach. Programs and Services. https://diversity.ucsf.edu/resources/unconscious-bias .

2. Gartner. CEB Corporate Leadership Council Global Labor Survey 2018. www.cebglobal.com/public/diversity-inclusion/login.html?resource=/member/diversity-inclusion/home.html&referrerComponentName=CEB%20List&pageRequestId=0858990e-e127-42d7-8a90-eb9b72d1c580%3f (account required for access).

3. Zimmerman, M. Neurophysiology of Sensory Systems. In Fundamentals of Sensory Physiology, Robert F. Schmidt (ed.). Berlin: Springer-Verlag; 1986.

4. Gallup. Gallup’s State of the Global Workplace. Gallup. 2017. https://fundacionprolongar.org/wp-content/uploads/2019/07/State-of-the-Global-Workplace_Gallup-Report.pdf .

5. Association of American Medical Colleges. Medical School Applications Information. Diversity in Medical Education Facts and Figures 2016. www.aamcdiversityfactsandfigures2016.org/index.html

6. Institute of Medicine. The Health of Lesbian, Gay, Bisexual and Transgender People: Building a Foundation for Better Understanding. Washington, DC: The National Academies Press; 2011. https://doi.org/10.17226/13128