Implicit and Explicit Bias in Healthcare: What is the Difference and How to Address Both

Bias, whether implicit or explicit, is a critical issue in healthcare that can influence patient outcomes, workplace dynamics, and organizational culture. Understanding the differences between these two types of bias is important as healthcare leaders work to create more equitable and effective healthcare systems. This article explores the nuances of implicit and explicit bias, their impacts on healthcare, and practical strategies for addressing both.

Understanding implicit bias

Implicit bias refers to unconscious attitudes or stereotypes that affect our understanding, actions, and decisions. These biases are automatic and often occur without our awareness. In healthcare, implicit biases can influence:

• Patient care decisions — Studies show that implicit biases can affect diagnosis and treatment plans, often disadvantaging marginalized populations.
• Interactions with colleagues — Unconscious stereotypes can shape workplace relationships and contribute to inequitable team dynamics.

Examples of implicit bias in healthcare include making assumptions about a patient’s pain tolerance based on their race or making assumptions about a caregiver’s competence based on gender.

The Harvard implicit bias test

The concept of implicit bias emerged in the 1990s through the work of Mahzarin Banaji, Anthony Greenwald, and Brian Nosek, researchers at Harvard University. They developed the Implicit Association Test (IAT), which measures the strength of a person’s automatic associations between concepts, such as race and negative words. The test reveals biases that individuals may not consciously recognize.

The IAT was one of the first psychology experiments conducted online. At its launch in 1998, the research team expected modest participation. However, the test gained rapid popularity, with tens of thousands of people completing it within the first month. The unprecedented volume of participation transformed the IAT into one of the most significant longitudinal studies of implicit bias. Over 40 million tests have been completed to date, creating a massive database for analyzing societal trends.

Over time, the data has revealed consistent gaps between people’s stated beliefs and subconscious associations. Its findings have helped shape discussions about bias and systemic inequality, emphasizing the importance of addressing implicit biases by promoting fairness and equity to counteract these biases. For example, recent test data have shown a significant lessening of implicit bias against persons identifying as LGBTQ+, indicating that positive societal influences and associations have changed people’s unconscious beliefs about LGBTQ+ people.

Research on bias in healthcare

Research has shown that there is a significant relationship between implicit bias and lower quality of care. For example, Black, Alaska Native, and Native American women are 2-3 times more likely to die from pregnancy-related causes compared to white women. Studies over the past 20 years have shown that clinicians’ implicit biases have affected their interactions and decision-making, contributing to racial inequities throughout the care continuum. In one study, 70% of physicians showed some level of implicit bias against Black and Hispanic/Latinx Americans.

Understanding explicit bias

Explicit bias involves conscious attitudes or beliefs about individuals or groups. These biases are intentional and often stem from personal prejudices or cultural norms. Examples include:

• Discriminatory remarks — Verbalizing stereotypical beliefs about certain groups.
• Exclusionary policies — Implementing rules or practices that disadvantage specific populations.

While explicit bias is less socially acceptable and often more recognizable than implicit bias, it persists in healthcare settings, affecting hiring practices, resource allocation, and patient interactions. Occurrences are still common despite laws and policies to prevent it in workplaces and care settings.

Effects of implicit and explicit bias in healthcare

Both implicit and explicit biases contribute to disparities in healthcare. Their effects can include:

• Health disparities — Unequal treatment of patients based on race, gender, age, or socioeconomic status can lead to worse outcomes for those patients.
• Decreased patient trust — Patients who perceive bias are less likely to seek care, follow advice, or adhere to treatment and follow-up plans.
• Workplace inequality — Bias can lead to unequal opportunities, disrupt teamwork and collaboration, and cause higher staff turnover.

How to address implicit and explicit bias

Addressing both implicit and explicit bias requires a comprehensive approach that includes education, policy changes, and accountability. Here are actionable strategies for healthcare organizations:

1. Increase awareness and training

• Implement training programs on implicit and explicit bias for all staff, emphasizing self-awareness and cultural humility.
• Encourage regular reflection through tools like the IAT to help individuals identify their unconscious biases.

2. Build an inclusive workplace culture

• Promote diversity in leadership and decision-making roles.
• Create spaces for open dialogue about bias and its effects on patient care and workplace dynamics.

3. Standardize patient care practices

• Use clinical decision support tools to guide diagnosis and treatment, reducing the influence of bias.
• Develop protocols that minimize subjective judgments, such as standardized pain assessments.

4. Implement accountability measures

• Track and analyze data on patient outcomes to identify potential disparities linked to bias.
• Establish clear policies to address explicit bias, including reporting mechanisms and disciplinary actions.

5. Engage patients in their care

• Involve patients in shared decision-making processes to ensure their values and preferences are respected.
• Provide patient education materials in multiple languages and formats to enhance accessibility.

Moving toward just, equitable healthcare

Addressing both implicit and explicit bias in healthcare is crucial because they both contribute to inequitable care practices, reduce patient trust, and lead to health disparities. Leaders have the power to help shape an inclusive culture that mitigates bias and promotes equity — and they are instrumental in creating environments that prioritize equity in all operations.

When unaddressed, bias in any form can negatively impact patients, teams, and organizational reputation. By fostering awareness, promoting inclusivity, and implementing data-driven strategies, healthcare organizations can create environments that convey respect for both patients and employees.

Addressing bias is not only a strategic necessity for improving outcomes and ensuring the sustainability of our healthcare systems — it is considered by many to be a moral imperative. By understanding and addressing the problems head on, healthcare leaders help achieve fairness and justice within our healthcare system.