A Practical Approach to Implicit Bias Training

Achieving social justice and addressing diversity, systemic racism, and inclusion in graduate medical education (GME) requires transformation at structural and individual levels. Implicit (or unconscious) bias is a root cause of these societal ailments. The challenge is to identify implicit social cognitions so that they can be mitigated in GME recruitment, curriculum, evaluation, and assessment efforts.

Implicit bias refers to the attitudes or stereotypes that arise from preformed mental associations, which influence our understanding, actions, and decisions in an unconscious manner. This bias can result in involuntary discriminatory practices.^1,2  Implicit bias is universal and present in everyone. Implicit associations can take many forms, starting in early childhood from exposure to social stereotypes and reinforced by repeated lifetime experiences, direct and indirect messaging, news, and social media.

To recognize and mitigate implicit biases, start with individual interventions:

1. Recognize the amygdala's role. Biases typically originate in the amygdala (the unconscious, fast thinking, automatic, emotional, stereotypic brain) and results in tendencies to categorize and discriminate. This process is hotwired to categorize people into “like-me” or “in-group” (those to be trusted) or “not-like-me” or “out-group” (those to be feared) as part of evolutionary survival. Stressful or time-pressured conditions may trigger amygdala system responses. These responses can be extinguished over time using associated learning approaches: repeated presentation of a conditioned stimulus in place of a previously associated unconditioned stimulus (eg, think classical conditioning, Pavlov's dog study: saliva with food then bell).^1,3 

2. Become aware of your implicit biases and reflect. Take the Implicit Association Test (IAT), an online reaction time test that assesses unconscious attitudes by measuring the ease with which an individual can sort concepts. The IAT's premise is that associated concepts will be sorted more quickly than less associated concepts.¹  There are multiple IAT forms (eg, race, skin tone, transgender, religion) available,⁴  and once completed you should engage in thoughtful reflection alone or in small groups to consider conscious bias mitigation.^1,5 

3. Mindfulness and resilience training. Taking short breaks, reflecting, being watchful, interrupting automatic biased thoughts, and engaging in brief mindfulness can facilitate more deliberate thought processing and decision-making. Meditations focused on specific marginalized populations can alter implicit biases.¹  By intentionally thinking about marginalized populations in a positive, loving manner, individuals may increase their empathy and decrease the strength of their implicit biases.¹ 

4. Provide counter-stereotypical examples. Exposure to counter-stereotypical individuals, such as inviting a prominent African American female scientist to give grand rounds, can subconsciously reduce implicit bias.³ 

5. Encourage mentoring and sponsorship. Creative pairings can allow every department, program, and administrative team member to feel included. Sponsors can expose diverse team members to additional mentorship on a national level for career-enhancing networking.³ 

6. Stereotype replacement. Recognize and label a response that is based on an automatic stereotype, then reflect on why the response occurred and replace with a new non-stereotypical response.³ 

7. Introduce perspective-taking and meaningful intergroup contact with different social, racial, religious, and/or identity groups. “Walking in someone else's shoes” enables each of us to look beyond our own limited viewpoints and to consider how someone else may think or feel. Diverse team members interacting in meaningful ways through individuation (ie, all team members treated as individuals, not as stereotypes) can reduce implicit biases as our brains form new associations.^1,3 

1. Work with your sponsoring institution (SI). SIs can develop standardized implicit bias educational workshops²  for all trainees and employees, with targeted training for recruitment committees and clinical competency committees. Cultural humility training, bystander training, reviewing social determinants of health, and intersectionality may facilitate empowerment of underrepresented and often marginalized individuals and improve cross-cultural patient care.² 

2. Develop an equity-advancing mindset. SIs should develop and empower diversity councils, identify, and engage diversity champions, and ensure that women, minoritized racial and ethnic groups, and other marginalized identities serve on key committees. Have a process for transitioning off residents and fellows as they graduate and onboarding new members.

3. Use holistic interviews. Use scoring rubrics based on standardized criteria with structured interviews. Use a balanced review of applicants' experiences, attributes, competencies, and academic metrics to ensure that more women (or men, as relevant) and underrepresented groups and identities are included in the finalist candidate pool. Assign a “devil's advocate” and consult everyone at meetings.

4. Continuously engage in institutional monitoring and accountability. Monitor GME-wide and program-specific diversity data and use the data to inform decisions. Routinely assess the culture of the institution. Develop and ensure equitable, standardized procedures and policies.³