ABSTRACT

Background

Unconscious or implicit biases are universal and detrimental to health care and the learning environment but can be corrected. Historical interventions used the Implicit Association Test (IAT), which may have limitations.

Objective

We determined the efficacy of an implicit bias training without using the IAT.

Methods

From April 2019 to June 2020, a 90-minute educational workshop was attended by students, residents, and faculty. The curriculum included an interactive unconscious biases presentation, videoclips using vignettes to demonstrate workplace impact of unconscious biases with strategies to counter, and reflective group discussions. The evaluation included pre- and postintervention surveys. Participants were shown images of 5 individuals and recorded first impressions regarding trustworthiness and presumed profession to unmask implicit bias.

Results

Of approximately 273 participants, 181 were given the survey, of which 103 (57%) completed it with significant increases from pre- to postintervention assessments for perception scores (28.87 [SEM 0.585] vs 32.73 [0.576], P < .001) and knowledge scores (5.68 [0.191] vs 7.22 [0.157], P < .001). For a White male physician covered in tattoos, only 2% correctly identified him as a physician, and 60% felt he was untrustworthy. For a smiling Black female astronaut, only 13% correctly identified her as an astronaut. For a brooding White male serial killer, 50% found him trustworthy.

Conclusions

An interactive unconscious bias workshop, performed without the use of an IAT, was associated with increases in perceptions and knowledge regarding implicit biases. The findings also confirmed inaccurate first impression stereotypical assumptions based on ethnicity, outward appearances, couture, and media influences.

Objectives

We determined if implicit bias training without using the Implicit Association Test (IAT) is feasible.

Findings

A brief interactive workshop without using IAT can increase knowledge and perceptions of implicit bias and introduce the principle of intersectionality.

Limitations

External generalizability was limited by selection and participation bias.

Bottom Line

A brief interactive implicit bias workshop intervention can be used to train residents, other learners, faculty, and coordinators in the medical education continuum.

Introduction

Unconscious or implicit biases are attitudes or stereotypes that arise from preformed mental associations, which influence our understanding, actions, and decisions in an unconscious manner.1  Unconscious biases are universal and have adverse consequences for the workplace, health care, and the learning environment.24  Studies show that clinicians' negative implicit bias correlated with poorer quality of care, inadequate clinician-patient communication, and health care disparities and inequities.38  Unconscious biases adversely affect faculty recruitment and promotion, including the persistent underrepresentation of Black Americans and other minorities in medicine, further exacerbating racial health care disparities.9,10  Unconscious bias has been shown to be malleable and correctable with training.2,10  Consequently, strategies to mitigate unconscious bias are needed in medical education. Previously reported unconscious bias trainings have revealed that Implicit Association Tests (IAT) are ubiquitous.10  Studies have shown that IATs may induce defensiveness triggering denial of bias and existence of health disparities.11  Critics suggest that instead of reflecting authentic negative attitudes, IAT scores may stem from other associations such as victimization, maltreatment, and oppression.11,12  Authors of the IATs have noted that the tool may not reflect actual biases or acts of discrimination related to identified preferences.4  Subsequently, the objective of this study was to determine: (1) if a brief educational workshop can increase knowledge and perceptions regarding unconscious bias, and (2) show that inaccurate first impressions can be elicited without the IATs.

Methods

This was a retrospective study of an educational workshop presented from April 2019 to June 2020. The workshop was developed from the knowledge gained by the author on completing the Association of American Medical Colleges Healthcare Executive Diversity and Inclusion Certificate (provided as online supplementary data). Kern's 6-step approach for curriculum development was used.12  The conceptual framework utilized was “situated learning-guided participation” in which didactic and interactive activities facilitate independent learning.13 

The 90-minute educational workshop included an interactive presentation on unconscious bias. To briefly demonstrate implicit bias, participants were rapidly shown images of 5 individuals in succession and they recorded their first impressions of the persons regarding trustworthiness and presumed profession. This workshop also taught intersectionality, which is a theoretical framework conceptualizing that multiple social categories (eg, race, gender, sexual orientation, poverty) intersect to reflect multiple interlocking systems of privilege and oppression at the social-structural level (eg, racism, sexism, heterosexism).14 

The workshop utilized video clips of situational vignettes to demonstrate the impact of unconscious bias. Participants reflected on experiences of unconscious bias and mitigating strategies in small groups (Table 1). The workshop was presented at the 2019 CREOG & APGO Annual Meeting in New Orleans. Subsequently it was presented in multiple voluntary sessions to medical students, residents, and faculty in internal medicine, family medicine, psychiatry, and obstetrics and gynecology departments at California University of Science and Medicine and Arrowhead Regional Medical Center.

Table 1

Agenda for the Unconscious Bias Reflective and Interactive Workshop

Agenda for the Unconscious Bias Reflective and Interactive Workshop
Agenda for the Unconscious Bias Reflective and Interactive Workshop

A survey consisting of 9 perception and 11 knowledge questions on implicit bias was assessed for clarity and reliability by content experts and repeat testing. The survey was completed pre- and posteducational workshop to assess short-term learning (provided as online supplementary data). The survey was not offered to the incoming class of 92 medical students because of time constraints of the orientation schedule.

Statistical analysis was performed using SPSS 21.0 (IBM Corp, Armonk, NY). Student's t tests were performed with calculation of 95% confidence interval and odds ratio with a P value of .05 as significant. The first impressions data was tabulated, and percentages of correct responses reported.

The study was approved by the Institutional Review Board of California University of Science and Medicine.

Results

Of approximately 181 participants, 103 (57%) respondents completed the surveys, including 28 (36%) females, 49 (64%) males, and 26 with missing gender. Twenty-three (22%) had previously taken the IATs, while 24 (22%) had previous implicit bias training. There were 61 (59%) physician faculty, 24 (23%) residents, 4 (4%) program coordinators, and 2 (2%) students. Medical specialties included 33 (38%) obstetrics and gynecology, 33 (38%) family medicine, 9 (10%) internal medicine, and 11 (13%) psychiatry. Sixty-three (61%) participants attended workshops in San Bernardino, California, while 40 participated at the APGO conference.

The results of testing for first impressions revealed that for a White male physician community advocate covered in tattoos and dressed in jeans, 2% correctly identified him as a physician. For a smiling Black woman astronaut, 13% correctly identified her as an astronaut. Of a brooding White male serial killer, 50% found him trustworthy. For a Cameroonian attorney, many incorrectly assumed she was Maya Angelou, and thus labeled her a writer (Table 2).

Table 2

Participants' First Impressions Regarding Trustworthiness and Likely Profession of Images of 5 Individuals Shown in Rapid Succession

Participants' First Impressions Regarding Trustworthiness and Likely Profession of Images of 5 Individuals Shown in Rapid Succession
Participants' First Impressions Regarding Trustworthiness and Likely Profession of Images of 5 Individuals Shown in Rapid Succession

There were significant increases from pre- to postintervention assessments for the total perception scores (28.87 [SEM 0.585] vs 32.73 [0.576], P < .001) and total knowledge scores (5.68 [0.191] vs 7.22 [0.157], P < .001). All 9 perception questions including only 4 of the 11 knowledge questions increased significantly after the intervention (Table 3). Significant subgroup differences are reported as online supplementary data.

Table 3

Preintervention and Postintervention Scores of the Unconscious Bias Workshopa

Preintervention and Postintervention Scores of the Unconscious Bias Workshopa
Preintervention and Postintervention Scores of the Unconscious Bias Workshopa

Discussion

This study demonstrates that a 90-minute interactive workshop significantly increased perception and knowledge regarding unconscious bias. Implicit bias may contribute to health care disparities by influencing physician behavior resulting in differences in medical treatment along race, gender, or other characteristics.1,15  Thus curricular activities allowing physicians to become aware of their biases may facilitate the provision of patient-centered care.

This intervention can be utilized for residents, other learners, faculty, and coordinators in the medical education continuum. Furthermore, a literature review of implicit bias training only revealed reports on medical students training with none noted on GME training.1624  This current study adds to the literature by reporting an educational workshop focused on all GME that detected biases in real time without a formal IAT.

In contrast to previous reports that utilized IATs, this study's participants recorded first impressions after brief exposures to images of real individuals with multiple identities that highlighted the principle of intersectionality. For example, a lesbian Black woman in African garb (4 oppressed identities) was not identified as a lawyer, while a young Black female astronaut (3 oppressed identities) was identified as an actress. A White male (2 privileged identities) serial killer was trusted by 50% and identified as a professor, while a tattooed and informally dressed White man (2 privileged and 2 oppressed identities) was not recognized as a doctor. These findings confirmed inaccurate first impression stereotypical assumptions based on ethnicity, outward appearances, couture, and media influences. These findings confirm that biases can be detected without relying on the use of a formal IAT and its limitations.

Limitations of this study included the likelihood of participation bias since approximately 57% of the participants completed the surveys. Selection bias may have occurred since participants self-selected. Ethnic data was not collected. Barriers to implementation include time to identify and train facilitators. Institutions and departments would have to prioritize implicit bias training and provide protected time for both faculty and residents. The workshop is relatively inexpensive, acceptable, and feasible with faculty time commitment as the major cost. The organization and planning of this program would require about 4 hours, and the workshop presentation would require approximately 2 hours to implement.

Conclusions

This study has demonstrated that a brief interactive workshop without using IAT can be implemented to increase knowledge and perceptions of unconscious bias.

References

1. 
Chapman
EN,
Kaatz
A,
Carnes
M.
Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities
.
J Gen Intern Med
.
2013
;
28
(11)
:
1504
1510
.
2. 
DiBrito
SR,
Lopez
CM,
Jones
C,
Mathur
A.
Reducing implicit bias: association of women surgeons #HeForShe Task Force best practice recommendations
.
J Am Coll Surg
.
2019
;
228
(3)
:
303
309
.
3. 
Hall
WJ,
Chapman
MV,
Lee
KM,
et al.
Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review
.
Am J Public Health
.
2015
;
105
(12)
:
e60
e76
.
4. 
Motzkus
C,
Wells
RJ,
Wang
X,
et al.
Pre-clinical medical student reflections on implicit bias: implications for learning and teaching
.
PLoS One
.
2019
;
14
(11)
:
e0225058
.
5. 
Dovidio
JF,
Fiske
ST.
Under the radar: how unexamined biases in decision-making processes in clinical interactions can contribute to health care disparities
.
Am J Public Health
.
2012
;
102
(5)
:
945
952
.
6. 
FitzGerald
C,
Hurst
S.
Implicit bias in healthcare professionals: a systematic review
.
BMC Med Ethics
.
2017
;
18
(1)
:
19
.
7. 
Blair
IV,
Steiner
JF,
Fairclough
DL,
et al.
Clinicians' implicit ethnic/racial bias and perceptions of care among black and Latino patients
.
Ann Fam Med
.
2013
;
11
(1)
:
43
52
.
doi:10/1370/afm.1442.
8. 
Dehon
E,
Weiss
N,
Jones
J,
Faulconer
W,
Hinton
E,
Sterling
S.
A systematic review of the impact of physician implicit racial bias on clinical decision making
.
Acad Emerg Med
.
2017
;
24
(8)
:
895
904
.
9. 
Association of American Medical Colleges.
Diversity in Medicine: Facts and Figures 2019
.
2021
.
10. 
Capers
Q,
Clinchot
D,
McDougle
L,
Greenwald
AG.
Implicit racial bias in medical school admissions
.
Acad Med
.
2017
;
92
(3)
:
365
369
.
11. 
Zestcott
CA,
Blair
IV,
Stone
J.
Examining the presence, consequences, and reduction of implicit bias in health care: a narrative review
.
Group Process Intergroup Relat
.
2016
;
19
(4)
:
528
542
.
12. 
Sweet
L,
Palazzi
D.
Application of Kern's six-step approach to curriculum development by global health residents
.
Educ Health (Abingdon)
.
2015
;
28
(2)
:
138
141
.
13. 
Zackoff
MW,
Real
FJ,
Abramson
EL,
Li
ST,
Klein
MD,
Gusic
ME.
Enhancing educational scholarship through conceptual frameworks: a challenge and roadmap for medical educators
.
Acad Pediatr
.
2019
;
19
(2)
:
135
141
.
14. 
Bowleg
L.
The problem with the phrase women and minorities: intersectionality-an important theoretical framework for public health
.
Am J Public Health
.
2012
;
102
(7)
:
1267
1273
.
15. 
Green
AR,
Carney
DR,
Pallin
DJ,
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
1238
.
16. 
Vela
MB,
Kim
KE,
Tang
H,
Chin
MH.
Innovative health care disparities curriculum for incoming medical students
.
J Gen Intern Med
.
2008
;
23
(7)
:
1028
1032
.
17. 
Kumagai
AK,
Lypson
ML.
Beyond cultural competence: critical consciousness, social justice, and multicultural education
.
Acad Med
.
2009
;
84
(6)
:
782
787
.
18. 
Teal
CR,
Shada
RE,
Gill
AC,
et al.
When best intentions aren't enough: helping medical students develop strategies for managing bias about patients
.
J Gen Intern Med
.
2010
;
25
(suppl 2)
:
115
118
.
19. 
Gonzalez
CM,
Kim
MY,
Marantz
PR.
Implicit bias and its relation to health disparities: a teaching program and survey of medical students
.
Teach Learn Med
.
2014
;
26
(1)
:
64
71
.
20. 
Gonzalez
CM,
Fox
AD,
Marantz
PR.
The evolution of an elective in health disparities and advocacy: description of instructional strategies and program evaluation
.
Acad Med
.
2015
;
90
(12)
:
1636
1640
.
21. 
Coria
A,
McKelvey
TG,
Charlton
P,
Woodworth
M,
Lahey
T.
The design of a medical school social justice curriculum
.
Acad Med
.
2013
;
88
(10)
:
1442
1449
.
22. 
Hernandez
RA,
Haidet
P,
Gill
AC,
Teal
CR.
Fostering students' reflection about bias in healthcare: cognitive dissonance and the role of personal and normative standards
.
Med Teach
.
2013
;
35
(4)
:
e1082
e1089
.
23. 
Gill
A,
Thompson
B,
Teal
C,
Shada
R,
Fruge
E.
Best intentions: using the implicit associations test to promote reflection about personal bias
.
MedEdPORTAL
.
2021
.
24. 
Haider
A,
Sexton
J,
Sriram
N,
et al.
Association of unconscious race and social class bias with vignette-based clinical assessments by medical students
.
JAMA
.
2011
;
306
(9)
:
942
951
.
26. 
Cook
Ross.
Everyday Bias: Further Explorations into How the Unconscious Mind Shapes Our World at Work
.
2021
.

Author notes

Editor's Note: The online version of this article contains the development and validation of the Unconscious Bias Educational Workshop, pretest and posttest, and reported significant subgroup differences.

Funding: The author reports no external funding source for this study.

Competing Interests

Conflict of interest: The author declares no competing interests.

The abstract was presented at CREOG and APGO Annual Meeting, New Orleans, Louisiana, February 27–March 2, 2019.

Supplementary data