It was book buy-back week at the University of Kansas. I made my way from my campus apartment to the student union that housed the bookstore. Books in hand, I headed to the counter. As I approached, the woman at the counter looked to me and said, "Football players return their books over there", as she gestured toward the other side of the bookstore. Mind you, I was a pre-med, human biology major who effectively retired from football in the 7th grade—an African American pre-med, human biology major. Her assumption upset me and at no point did I take a moment to, nor care to question her intentions. Giving her the benefit of the doubt was the last thing on my mind. I was pissed.
Looking back, now through a lens that is 15 years older, time and insight have allowed for a more constructive assessment of that situation. It is crystal-clear that the bookstore clerk and I were both victims of the power of association. She had an association with black males in college being there on the merits of their athletic ability. For her, that association was so strong, that she failed to realize how unlikely it was that a 5'10", 150 lb. (rounding up) student was a Division I football player. In retrospect, it is not hard to imagine that her intentions were completely pure and free of ill intent. Fifteen years ago, I'm not sure that I would have agreed with that.
It is important to recognize that intentions do matter, and that implicit bias is very different from explicit prejudice. Unconscious associations about race, gender, sexuality, and other social categories are not equivalent to racism, sexism, homophobia, or other forms of bigotry. Equally important to recognize, is that regardless of intent, the collective weight of our society’s implicit biases burden certain groups in disproportionate ways. For these groups, egalitarian intentions do very little to lighten the burden of inequality.
Unconscious attitudes, also known as implicit biases, are ubiquitous and their effects are wide-ranging. From something as seemingly insignificant as the clutching of a purse in the presence of a passerby, to something of potential great consequence, such as not referring a client for surgery, the fingerprints of implicit bias are on many of the decisions we make. Explicit discrimination undoubtedly persists; however, implicit bias plays a major role in many of the disparities that are still pervasive in society. In the workplace, women are still undervalued and undercompensated. The latest data shows that women make 80 cents on the dollar, compared to their male colleagues. Leadership and management opportunities are much less available for women. In 2019, only 33 of the Fortune 500 CEOs were female, while there were 24 male CEOs named Michael, 20 Jameses, 18 Johns, and 15 Davids. Many disturbing racial disparities exist in the criminal justice sector. Black and brown individuals face a system that is historically not impartial, fair, or just. Hispanics and African Americans frequently receive harsher punishments and are much more likely to be wrongfully convicted. Other forms of implicit bias such as those regarding age, weight, socioeconomic status, and sexuality are also quite prevalent in society and unfortunately, often overlooked.
As with other high-stakes arenas, medicine is fraught with bias, and the light currently being shed on its role in medical disparities is bright. Simply being Black, Native, or Hispanic and pregnant comes with a risk of death as high as three times that of other women. Obese women are significantly less likely to get routine health screenings than non-obese women. African American patients’ pain is treated less aggressively than whites. The 2003, Institute of Medicine report titled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care documented a healthcare system in which quality varies significantly, depending on patient race and ethnicity. The findings showed that across the board, minorities suffer worse health outcomes. In addition to disparities in cancer, heart disease, and HIV treatment, minorities receive fewer routine screenings and less surgical and dialysis referrals. They are less likely to receive organ transplants, while more likely to receive limb amputations.
The question is not “do we have a problem?” it is “how can we fix it?” There are varying opinions, but one thing that can be agreed upon is that the answer remains elusive. Changing the associations that have been engrained in us via our past experiences and the society that we live in is a difficult task, likely requiring an approach that is two-fold: combating our biases from an individual and an institutional level. This allows for a focused, personal approach, while also addressing the root of many of our associations: the world around us.
One of the biggest barriers to constructive dialogue about implicit bias is that it is often stigmatized with feelings of guilt and shame, making a constructive discussion very difficult. A common response to guilt and shame is avoidance, therefore, removing these stigmas from the discussion gives us a better chance of having these necessary conversations. Understanding that we all hold biased attitudes is an important step in removing barriers to discussion.
Many experts argue that we may not be able to facilitate changes in our associations or that change is transient at best. Even if this is the case, it can be argued that changing associations is not required for us to intervene upon biased behaviors. Simply recognizing and acknowledging that our unconscious attitudes can drive our decisions and actions may provide us with the necessary insight to catch potentially biased decisions before we send them into action. Increased scrutiny and vigilance should especially be given to high-stakes decisions that could result in significant consequences. Simply asking yourself, “If this were a different patient/client, would my decision be the same?” may provide you with an opportunity to discover a potential bias in your clinical practices. Additionally, in response to a poor outcome, a retrospective analysis on the potential impact of implicit bias should become routine in our clinical practices.
Given that our subconscious is perpetually bombarded by stereotypes and biases in the world in which we live, it is unlikely that sustainable change can be made without addressing the primary roots of implicit bias. Institutional change is necessary, because structural inequality is highly correlated with implicit bias. Diversity and inclusion reduce the collective bias of an institution by altering the negative associations of the members working within it.
The recent rising interest in the implicit bias provides us with an opportunity to use its momentum to have these discussions often. Discussions on race, gender, sexuality, inequality, and discrimination are uncomfortable. If we can make them routine, there is hope that we can become more comfortable being uncomfortable.