The problem with implicit bias training

The Problem with Implicit Bias Training - Scientific American https://www.scientificamerican.com/article/the-problem-with-implicit-...
It’s well motivated, but there’s little evidence that it leads to meaningful changes in behavior
While the nation roils with ongoing protests against police violence and persistent
societal racism, many organizations have released statements promising to do better.
These promises often include improvements to hiring practices; a priority on
retaining and promoting people of color; and pledges to better serve those people as
customers and clients.
As these organizations work to make good on their declarations, implicit bias

training is often at the top of the list. As the thinking goes, these nonconscious
prejudices and stereotypes are spontaneously and automatically activated and may
inadvertently affect how white Americans see and treat Black people and other
people of color. The hope is that, with proper training, people can learn to recognize
and correct this damaging form of bias.
In the health care industry, implicit bias is among the likely culprits in many
persistent racial and ethnic disparities, like infant and maternal mortality, chronic
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diseases such as diabetes, and more recently, COVID-19. Black Americans are about
2.5 times more likely to die from COVID-19 relative to whites, and emerging data
indicate that Native Americans are also disproportionately suffering from the
pandemic. Implicit biases may impact the ways in which clinicians and other health
care professionals diagnose and treat people of color, leading to worse outcomes. In
response to these disparities, Michigan and California have mandated implicit bias
training for some health professionals.
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There’s just one problem. We just don’t have the evidence yet that implicit bias
training actually works.
To be sure, finding ways to counter unfair treatment is critical. The evidence is clear
that implicit prejudice, an affective component of implicit bias (i.e., feeling or
emotion) exists among health care providers with respect to Black and/or Latinx
patients, as well as to dark-skinned patients not in those categories. In turn, these
biases lower the quality of patient-provider communication and result in lower
satisfaction with the healthcare encounter.
But while implicit bias trainings are multiplying, few rigorous evaluations of these
programs exist. There are exceptions; some implicit bias interventions have been
conducted empirically among health care professionals and college students. These
interventions have been proven to lower scores on the Implicit Association Test
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(IAT), the most commonly used implicit measure of prejudice and stereotyping. But
to date, none of these interventions has been shown to result in permanent, long-
term reductions of implicit bias scores or, more importantly, sustained and
meaningful changes in behavior (i.e., narrowing of racial/ethnic clinical treatment
disparities).
Even worse, there is consistent evidence that bias training done the “wrong way”
(think lukewarm diversity training) can actually have the opposite impact, inducing
anger and frustration among white employees. What this all means is that, despite
the widespread calls for implicit bias training, it will likely be ineffective at best; at
worst, it’s a poor use of limited resources that could cause more damage and
exacerbate the very issues it is trying to solve.
So, what should we do? The first thing is to realize that racism is not just an
individual problem requiring an individual intervention, but a structural and
organizational problem that will require a lot of work to change. It’s much easier for
organizations to offer an implicit bias training than to take a long, hard look and
overhaul the way they operate. The reality is, even if we could reliably reduce
individual-level bias, various forms of institutional racism embedded in health care
(and other organizations) would likely make these improvements hard to maintain.
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Explicit, uncritical racial stereotyping in medicine is one good example. We have

known for many years that race is a social construct rather than a proxy for genetic or
biological differences. Even so, recent work has identified numerous cases of race-
adjusted clinical algorithms in medicine. In nephrology, for example, race
adjustments that make it appear as if Black patients have better kidney function than
they actually do can potentially lead to worse outcomes such as delays in referral for
needed specialist care or kidney transplantation. Other more insidious stereotyping
characterizes Native Americans and African Americans as more likely to be
“noncompliant” with diet and lifestyle advice. These characterizations of
noncompliance as a function of attitudes and practices completely ignore structural
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factors such as poverty, segregation and marketing—factors that create health

inequities in the first place.
Meaningful progress at the structural and institutional levels takes longer than a few
days of implicit bias training. But there are encouraging examples of individuals who
have fought successfully for structural change within their health care organizations.
For example, medical students at the University of Washington successfully lobbied
for race to be removed as a criterion for determining kidney function—a process that
took many years. Their success may have important implications for closing gaps in
disparities among patients with renal disease. And innovative new programs like the
Mid-Ohio Farmacy have linked health care providers with community-based
organizations, and help providers address food insecurity among their low-income
patients—an issue that disproportionately impacts people of color. (Doctors can write
a “food prescription” that allows their patients to purchase fresh produce.)
None of this, of course, means that we should give up on trying to understand

implicit bias or developing evidence-based training that successfully reduces
discriminatory behaviors at the individual level. What it does mean is that we need to
lean into the hard work of auditing long-standing practices that unfairly stigmatize
people of color and fail to take into account how health inequities evolve. Creating
organizations that value equity and ultimately produce better outcomes for people of
color will be long, hard work, but it’s necessary and it’s been a long time coming.
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The Problem with Implicit Bias Training - Scientific American https://www.scientificamerican.com/article/the-problem-with-implicit-...

As these organizations work to make good on their declarations, implicit bias

1 van 5 29/11/2020 14:30

2 van 5 29/11/2020 14:30

Explicit, uncritical racial stereotyping in medicine is one good example. We have

3 van 5 29/11/2020 14:30

factors such as poverty, segregation and marketing—factors that create health

None of this, of course, means that we should give up on trying to understand

ABOUT THE AUTHOR(S)

4 van 5 29/11/2020 14:30

5 van 5 29/11/2020 14:30

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