As individuals in a society, all people have implicit, or unconscious, beliefs that they have been socialized to hold; however, health care professionals’ implicit biases can impact patients’ lives.
Implicit bias is made up of the attitudes, the stereotypes, or the pictures that people have in their minds that affect their understanding, actions, and decisions in an unconscious way, explained Nicole Avant, PharmD, BCACP, founder, owner, and consultant at Avant Consulting Group, during a session at the National Community Pharmacy Association Annual Convention. Through implicit bias, people react involuntarily to biases they may not believe they actually hold; further, everyone who lives in a society is susceptible, according to Avant.
“I've been doing this work for 10 years, and I am still impacted by bias,” Avant said. “It is automatic, it is fast, it is effortless, and it can really undermine our true intentions.”
Avant explained further that implicit bias can often contradict what many would identify as what they actually believe or value. However, these biases are not a reflection on the individual, but rather a reflection on the society they live in. Society has taught that individual these biases through a variety of mediums and methods of communication.
“We are heavily socialized in our schools, by our family, by our friends, by our religious institutions, and we carry that socialization to the workplace,” Avant said. “If we are not careful, biases could impact how we treat others and [can lead us] to discriminate. We can be harassing people when we don't want to.”
In this way, the data demonstrating health inequities need not necessarily be a comment on explicit racism among individual health care professionals, but rather the structural racism that is implicit within the health care system, according to Avant. Specifically, she explained that patients of color (POC) have been found to receive fewer cardiovascular interventions and fewer renal transplants than White patients.
“We also see that Black women are more likely to die after being diagnosed with breast cancer,” Avant said. “Racialized patients are less likely to [be] prescribed pain medications, and we see this for children as well as adults. Black men are less likely to receive chemo and radiation therapy for prostate cancer and are more likely to have [their] testicles removed.”
Avant noted further that data have shown that POC are more likely to have their body parts removed across various disease states outside of cancer as well. For example, Avant explained that data have demonstrated POC are more likely to have their legs amputated from diabetes. Additionally, POC are more likely to be blamed for their poor health outcomes, with a common reason cited as being that POC are too passive toward their own health care, which then causes them to have poor outcomes.
Additionally, the distinction between implicit and explicit biases is also important, Avant explained. Implicit bias is unconscious, whereas explicit bias is what we say or believe we value. However, implicit bias may not align whatsoever with our explicit beliefs.
“When I have time to do a workshop, we used to take a couple hours to just unpack bias,” Avant said. “And I used a very old riddle. The riddle goes—and I hope I don't butcher it—father and son are in a car accident. The father dies at the scene of the accident, and the son is rushed to the hospital. The surgeon looks at the boy and says, ‘I cannot operate on him. He is my son.’ Now, how can that be?”
During the session, the audience responded to the question by calling out several answers. The first answer from the crowd was that the boy had 2 fathers—Avant responded by explaining that this riddle is heteronormative in nature, so that was not the correct answer. Another person called out from the audience that the surgeon was the boy’s mother. Avant explained that this was correct.
“I will tell you that most people do not get that it's the mother. I've heard it's a priest, I've heard it’s God. I've heard 2 fathers. I've heard godparents. But we rarely hear that the surgeon is his mother,” Avant said. “I would say that most people who cannot solve this riddle believe explicitly that women are just as qualified as men to be surgeons. Yet, they are stuck on this riddle. So it tells me that there is something implicit or unconscious happening.”
Avant explained that when she conducted research on bias at the University of Cincinnati College of Pharmacy, she observed that pharmacists were not excluded from having bias.
“I want to tell you that, as pharmacists, we are not excluded from having biases—we all have biases. I had my students in a pharmacy practice course complete the [Harvard] race implicit association tests for homework. This test allows you to understand what your unconscious biases are,” Avant said. “Most of us reported having a pro-White bias. I wasn't surprised by that because most of us cannot escape the biases that we have.”
Avant noted that a helpful way to begin to address implicit bias is by building authentic relationships with people from various races and cultures.
“That will be very eye opening,” Avant said. “When I went into pharmacy school, I had a very narrow view of what Muslims believed and what they practice.”
Avant explained that by going to pharmacy school and having a diverse group of friends, she began to change her worldview, her perspective, and her values. Specifically, she noted that by having a Muslim friend, she learned more about Muslim culture and faith through this relationship.
Avant noted another way of expanding one’s worldview and perspective is by traveling to various parts of the world that may be outside of one’s comfort zone or by watching films or movies that take place in social groups, communities, or cultures that are outside of someone’s comfort zone as well. Additionally, Avant noted that personal reflection on one’s first thoughts in response to certain people is a helpful way of becoming more aware of one’s own implicit biases.
“To mitigate bias individually, I want you to reflect on how your work may be impacted by your biases. I'm definitely aware of some of my biases because I'm watching my first thoughts, and that is very helpful for me,” Avant said.
Microaggressions, which are subtle insults directed toward people with marginalized identity, are one of the ways that implicit biases may show up in the workplace, Avant explained. However, not all rudeness or negative social experiences are innately a microaggression, as a microaggression is one that is targeted toward a person of a marginalized identity.
“When I say marginalized identity, I'm talking about people that live at the margins, or the extreme margins—so people of color, trans people, non-binary individuals, women, older people, disabled people, queer individuals. That is what I'm talking about,” Avant said. “Sometimes when we give our microaggression workshop, someone will talk about an experience that was very negative. It was very rude, but it is not a microaggression. Microaggressions are subtle insults directed toward people with marginalized identity.”
Additionally, much of the research on discrimination has not been focused on the impact of implicit bias and/or microaggressions on marginalized individuals and communities. Instead, the research is often focused on the impact of bias that is often more explicit in nature.
“Research on discrimination is usually focused on overt events, such as racial slurs. Some may believe that microaggressions are less harmful or serious than overt discrimination. However, researchers have found that daily common experiences of microaggressions may have significantly more influence on self-esteem than traditional overt forms of discrimination,” Avant said.
Further, microaggression can be much harder to prevent because they're invisible. This forces the target of the microaggression to decide if that experience was a microaggression.
But then often, targets of these experiences have been socialized to suppress their anger when something doesn't feel right. However, anger can be valuable as a tool for identifying when an injustice has occurred toward an individual of a marginalized identity/identities.
“We've been told that anger is a negative thing. So we suppress these emotions,” Avant said. “So once I identify, ‘Yes, that was definitely a microaggression,’ I have to decide if I want to even address it because I'm afraid that people might label me as overly sensitive, maybe unprofessional, or maybe I'm not a good fit for the job environment. And I don't want to lose my job.”
Avant said that in moments where she noted microaggressions, such as multiple colleagues wanting to touch her hair in a professional setting, and she identified that it was worth addressing, she would then practice extensively how she was going to say it before she would approach someone to discuss her experience.
“So when someone confronts you with bias, I would highly recommend that you be less defensive,” Avant said. “I know sometimes I get defensive and say, ‘That is not what I meant,’ and I tend to focus on my intention rather than the impact of my actions. But when someone confronts you with bias, the least you can do is be accountable because there's so much emotional labor involved with [the target of the microaggression] addressing it with you.”
Avant ND. Removing Barriers to Equitable Health Care. Kansas City, MO: National Community Pharmacists Association 2022 Annual Convention; October 1, 2022.