RxCe - Mitigating Implicit Bias in Healthcare Materials

MITIGATING IMPLICIT BIAS IN HEALTHCARE

Faculty:

The following continuing medical education team members were involved in the initial planning, development, and review of this activity:

L. Austin Fredrickson, MD, FACP

L. Austin Fredrickson is an Associate Professor of Internal Medicine at Northeast Ohio Medical University, where he serves as core faculty and teaches diagnostics, therapeutics, clinical skills, and health humanities. He is board-certified in general internal medicine and practices rural primary care. 

Steven Malen, PharmD, MBA

Steven Malen graduated with a dual degree in Doctor of Pharmacy (PharmD) and Master of Business Administration (MBA) from the University of Rhode Island. Throughout his career, he has worked as a clinical pharmacist across retail, specialty, and compounding sectors. He specialized in and taught topics ranging from vaccines to veterinary compounding.

Pamela Sardo, PharmD, BS

Pamela Sardo, PharmD, BS, is a freelance medical writer and licensed pharmacist. She is the founder and principal at Sardo Solutions in Texas. Pam received her BS from the University of Connecticut and her PharmD from the University of Rhode Island. Pam’s career spans many years in retail, clinics, hospitals, long-term care, Veterans Affairs, and managed health care responsibilities across a broad range of therapeutic classes and disease states.

Topic Overview

Implicit bias is the unconscious attitudes, stereotypes, and beliefs that can influence an individual's thoughts, feelings, and behaviors. Implicit bias can contribute to discrimination in healthcare, which results in patients receiving different levels of care due to uncertainty in communication and clinical decision-making related to these biases, prejudices, and stereotypes. Implicit biases can manifest as microaggressions. There are strategies to mitigate implicit bias; however, evidence suggests that one-time interventions are ineffective and that lasting change requires persistent, long-term strategies.

Accreditation Statements

In support of improving patient care, RxCe.com LLC is jointly accredited by the Accreditation Council^TM for Continuing Medical Education (ACCME^®), the Accreditation Council for Pharmacy Education (ACPE^®), and the American Nurses Credentialing Center (ANCC^®), to provide continuing education for the healthcare team.

Joint Universal Activity Number: The Joint Accreditation Universal Activity Numbers assigned to this activity are as follows:

Pharmacists: JA4008424-0000-26-013-H99-P

Pharmacy Technicians: JA4008424-0000-26-013-H99-T

Credits: 1 contact hour(s) (0.1 CEU(s)) of continuing education credit.

Credit Types:

AAPA Category 1 Credit™️ - 1 Credits

AMA PRA Category 1 Credit™️ - 1 Credits

Pharmacy - 1 Credits

Type of Activity: Knowledge

Media: Computer-Based Training (i.e., online courses)

Estimated time to complete activity: 1 contact hour(s) (0.1 CEU(s)), including Course Test and course evaluation.

Release Date: January 29, 2026 Expiration Date: January 29, 2029

Target Audience: This educational activity is for Physicians, Physician Assistants, Pharmacists, and Pharmacy Technicians

How to Earn Credit: From January 29, 2026, through January 29, 2029, participants must:

Read the “learning objectives” and “author and planning team disclosures;”

Study the section entitled “Educational Activity;” and

Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)

CME Credit: Credit for this course will be uploaded to CPE Monitor^® for pharmacists. Physicians may receive AMA PRA Category 1 Credit™️and use these credits toward Maintenance of Certification (MOC) requirements. Physician Assistants may earn AAPA Category 1 CME credit, reportable through PA Portfolio. All learners shall verify their individual licensing board’s specific requirements and eligibility criteria.

Learning Objectives: Upon completion of this educational activity, participants should be able to:

Describe what implicit bias is and how it can manifest in healthcare

Describe how implicit bias can affect clinical judgment and behavior in healthcare settings

Identify strategies for mitigating implicit bias in healthcare

Disclosures

The following individuals were involved in planning, developing, and/or authoring this activity: L. Austin Fredrickson, MD, FACP; Steven Malen, PharmD, MBA; and Pamela Sardo, PharmD, BS. None of the individuals involved in developing this activity has a conflict of interest or financial relationships related to the subject matter. There are no financial relationships or commercial or financial support relevant to this activity to report or disclose by RxCe.com or any of the individuals involved in the development of this activity.

Educational Activity

Mitigating Implicit Bias in Healthcare

Introduction

Health equity is an important concept in healthcare. It signifies a society in which all members can access quality healthcare; however, this goal has not been fully achieved, as health disparities persist. Health disparities occur when there is an unequal delivery of healthcare services to patients of a specific race, ethnicity, gender, sexual orientation, or socioeconomic status. Moreover, health disparities may, in part, be due to a provider’s unconscious or implicit bias. Implicit biases are present in all areas of healthcare settings. To confront and mitigate implicit bias, clinicians and staff must first understand how it manifests in healthcare settings and how it affects clinical judgment and behavior, patient trust, and treatment plan adherence. Once implicit bias is acknowledged, strategies can be developed to mitigate it.

Understanding Implicit Bias

Implicit bias originated in psychology decades ago.^1,2 Psychologists proposed that demographic characteristics such as race, gender, or age could influence a person’s judgment and behavior without the person being aware of the bias.¹ bn

Terminologies such as unconscious bias, systemic racism, and implicit bias were developed around this concept as ways to describe this subtle form of discrimination.¹ Today, this unconscious form of bias is generally referred to as implicit bias.¹

Implicit bias is also present in healthcare. In 2003, the Institute of Medicine (IOM) reported on healthcare disparities linked to demographics.³ This disparity was partly based on implicit bias.^1,3 The IOM stated that “[s]ome research suggests that differences in care may result from conscious or unconscious biases on the part of physicians and other healthcare providers.”³ Since 2003, numerous studies have investigated how implicit bias training in healthcare is designed and delivered and whether the training has been effective.⁴

There is a general understanding that implicit bias contributes to discrimination in healthcare.³ Discrimination in healthcare has been defined “as differences in care that emerge from biases and prejudice, [and] stereotyping” that can lead to “uncertainty in communication and clinical decision-making.”³ Implicit bias is an unconscious form of discrimination, where unconscious attitudes, stereotypes, and beliefs may influence an individual's thoughts, feelings, and behaviors.⁵

Studies have shown that implicit bias is pervasive, and people of all ages, races, and backgrounds hold unconscious biases.^4,6,7 A person’s unconscious perceptions and attitudes toward others (implicit biases) are shaped by the person's life experiences, media exposure, and cultural influences.⁸

Misunderstandings or Misconceptions about Implicit Bias

A fuller understanding of implicit bias can be gained by examining misconceptions that have developed around it. Greenwald, et al. (2022) reviewed five misunderstandings of implicit bias.¹

The first misunderstanding is that the IAT, and other tests for implicit bias, measure prejudice and racism.¹ This is incorrect. It is not appropriate to link implicit bias to racism or prejudice. A person may hold unconscious biases toward a particular group, but this does not necessarily reflect hostility or racism toward that group. A corollary of this misunderstanding is that “good people do not possess implicit biases.”¹ The opposite is true: people unavoidably acquire implicit biases from daily immersions in their culture.¹

The second misunderstanding is that tests for implicit bias only measure and predict “spontaneous (automatic) behavior,” and cannot measure and predict “deliberate (controlled, rational) behavior.”¹ Tests that measure implicit bias can do both. Several studies have found that implicit measures are equally effective at predicting both deliberate and spontaneous behavior.¹

The third misunderstanding is that explicit and implicit biases are unrelated. The reality is that implicit and explicit biases are positively correlated.¹ A number of studies confirmed this correlation.¹

The fourth misunderstanding is that long-established implicit biases may be modified and long-lasting or durable.¹ Forscher, et al. (2017) The prejudice habit-breaking intervention remains a highly promising candidate for empowering people to reduce their own biases through awareness, concern, and effort.⁹ The evidence seems to say that long-lasting change is the exception and that long-established biases are not easily reduced or durably modifiable.¹

The fifth misunderstanding is that group-administered anti-bias or diversity training effectively mitigates discriminatory bias.¹ Studies have found that these methods are not effective and that they may do more harm than good.¹⁰

By correcting these misunderstandings, clinicians can better understand implicit bias. In addition, they can set realistic expectations for what can be accomplished through mitigation methods and strategies.

Microaggression as a Form of Implicit Bias

Microaggression is a subtle form of discrimination or prejudice that can have a harmful impact on the person experiencing it.¹¹ Microaggressions are regular, daily, or common exchanges or insults intended to demean a particular group of people.^11,12 This may take the form of racial or ethnic jokes.¹² Microaggressions can be unintentional.¹³ The person making the comment or joke may even believe it was “a compliment” and become defensive when confronted.¹³ The use of the morpheme “micro” in the word microaggression is not intended to minimize the impact or seriousness of these exchanges but refers to the regular, ongoing nature of these encounters.¹¹

What is the relationship between microaggressions and implicit bias? “Microaggressions are often based on implicit bias, which is the tendency to automatically associate people with stereotypical characteristics of the identity group to which they belong.”¹¹

In the healthcare setting, microaggression can negatively affect the patient, healthcare clinician, and staff.¹¹ Coworkers subjected to microaggressions may become disaffected or dissatisfied with their job.¹¹ As with all forms of discrimination, microaggressions can lower a patient's quality of care.¹¹ Implicit bias may negatively impact patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes; however, implicit bias does not appear to affect treatment processes as much as patient-provider interactions and patient outcomes.⁷

Healthcare Professionals have Implicit Biases

Everyone has some degree of implicit bias, and healthcare professionals are not immune to this.⁷ Research has shown that healthcare providers can hold implicit biases against certain groups of patients, which can affect the quality of care that these patients receive. For example, a healthcare provider may have an implicit bias against people of a certain race or ethnicity, which could lead to a lower quality of care, such as underestimating the patient's reported pain or discomfort.⁵

Consequences of Implicit Bias

In healthcare, implicit bias can have significant consequences, influencing how healthcare providers interact with and care for their patients.^6,7 Patients experiencing implicit bias also report lower trust in their provider.⁷ It is important to remember that some studies found an insignificant correlation between healthcare outcomes and implicit bias.⁷ Nevertheless, a large body of research found that “racial and ethnic minorities experience a lower quality of health services, and are less likely to receive even routine medical procedures than are white Americans.”³

Implicit Bias and Clinical Judgments and Behaviors

Implicit bias can affect clinical judgment and behavior in several ways.^5,14 For example, healthcare providers may hold unfounded beliefs about a racial group, which can affect care.¹⁴ Hoffman, et al. (2016) reported on how beliefs about perceived biological differences between African American and White patients related to pain can lead to undertreatment of pain in African American populations.¹⁴ One of the prejudices reported in this study was that African Americans had a higher pain threshold than White patients.¹⁴ These types of generalizations are not only wrong, but they undermine the individualized care all patients are entitled to receive.

Implicit Bias, Patient Trust, and Treatment Adherence

Implicit bias erodes patients' trust in their healthcare providers, which can lead to nonadherence to treatment plans.^7,15 The IOM reported on studies showing that African Americans were less likely to receive appropriate cardiac medication when compared to Whites.³ This does not appear to be tied to clinical judgment but is more likely due to nonadherence, which may be linked to implicit bias;^15,16 that is, nonadherence leads to disparities in care for patients of different races, ethnicities, and other characteristics.¹⁵ Disparities in healthcare must be eliminated; therefore, it is important for healthcare professionals to recognize and overcome their biases to provide the best possible care for all patients.

Implicit bias may be unconscious, but patients often feel it. As mentioned above, this may or may not affect the treatment process, but it significantly impacts patient trust and treatment adherence. Casanova-Perez, et al. (2022) reported how many LGBTQ+ patients described biased healthcare experiences when visiting their healthcare provider.¹⁷

Assessing Implicit Bias

The Implicit Association Test (IAT) was developed in 1998 by Greenwald, McGhee, and Schwartz.¹⁸ It is currently implemented through the Harvard Project Implicit, assessing implicit bias in healthcare toward people based on race, ethnicity, sex, gender identity, sexual orientation, weight, and age.¹⁹ The IAT is generally accepted as the most effective tool for measuring implicit bias, and it is in common use.²⁰ Clinicians and staff can consider utilizing the IAT to help assess and identify unconscious biases.

Strategies for Mitigating Implicit Bias in Healthcare

Eliminating implicit bias entirely is ideal, but it may not be realistic; nevertheless, it is important to take steps to reduce its impact and, where possible, achieve long-lasting change.¹ Strategies to mitigate should be viewed realistically. Evidence supporting the effectiveness of mitigation strategies may be limited.²² FitzGerald, et al. (2019) state starkly that “[c]urrent data do not allow the identification of reliably effective interventions to reduce implicit biases. As our systematic review reveals, many interventions have no effect or may even increase implicit biases.”²² This expresses the serious approach professionals must take when confronting implicit bias. They should not approach this topic flippantly and “check the box” that they have completed diversity training. In addition, this highlights the importance of ongoing training and education to address this complex yet critical issue.

Implicit bias training and education can be done at the individual or organizational levels.^12,13 Education and training aim to create more inclusive and equitable environments.^12,13 By acknowledging and addressing implicit bias, individuals and organizations can help create a fairer, more equitable healthcare system. As FitzGerald, et al. (2017) said, “A patient should not expect to receive a lower standard of care because of her race, age, or any other irrelevant characteristic.”⁵

There are also specific strategies that healthcare facilities can use to help their clinicians and staff address implicit bias. They include increased awareness of implicit bias, learning to control automatic responses, creating an inclusive work and learning environment, using objective decision-making, seeking feedback, encouraging open and honest communication, and monitoring and evaluating progress toward mitigating implicit biases. These may be implemented at the individual or organizational levels.

Increased Awareness

The first step in addressing implicit bias is to recognize its existence.⁶ This can be accomplished through “self-reflection activities,” which can help people challenge the views they have about themselves and help them become aware of biases they may not know they have.⁶ Clinicians and staff can educate themselves about the ways that implicit bias can affect patient outcomes and seek out training and resources to help them become more aware of their biases.

Controlling Automatic Responses

Once a person is aware of implicit biases, it is essential to provide the person with strategies to control his or her “automatic responses” toward patients within a stigmatized group.⁶ This may include “affirming egalitarian goals, seeking common-group identities, perspective-taking, and individuation via counter-stereotyping.”⁶ A powerful way to identify with a person from a different race, ethnicity, etc., is to engage in perspective-taking.^22,23 Perspective-taking is the “ability to understand how a situation appears to another person and how that person is reacting cognitively and emotionally to the situation.”²³ Pharmacists and pharmacy staff can use this strategy to put themselves in the place of a co-worker or patient to help control their “automatic responses.”

Creating an Inclusive Work and Learning Environment

Creating a welcoming and inclusive environment for all patients and coworkers can help reduce the impact of implicit bias.^10,24 This can include using inclusive language, actively listening to patients, and understanding their unique needs and concerns.^10,24

Using Objective Decision-making

When making treatment recommendations or decisions, pharmacists and pharmacy staff should use objective criteria rather than subjective opinions or stereotypes.²⁵ This can help to ensure that patients receive the best possible care, regardless of their background or identity.²⁵

Seeking Feedback

Pharmacists can ask staff and patients for feedback on their experiences in the pharmacy and use this information to identify areas where implicit bias may affect patient care.⁶ This can help pharmacists to make necessary changes and improve the quality of care they provide. However, this must be done without awakening a defensive or resistant response to the issue.⁶

Encouraging Open and Honest Communication

Encouraging open and honest communication among employees can help create a culture where people feel comfortable speaking up about bias or discrimination.²⁶ This can include providing anonymous reporting mechanisms or setting up regular check-ins to discuss diversity and inclusion issues.

Monitoring and Evaluating Progress

Regularly monitoring and evaluating progress on diversity and inclusion efforts can help organizations identify areas where implicit bias may impact employee experiences and make necessary changes.²⁷ This can include collecting and analyzing data on employee demographics, retention rates, and promotion rates, and soliciting employee feedback through surveys or focus groups.

Long-lasting Mitigation of Implicit Bias

When speaking of long-lasting changes that reduce or eliminate implicit biases, it is important to recall Greenwald, et al. (2022)’s assertion that long-established implicit biases are usually not modifiable over the long term.¹ If they are correct, and the evidence seems to say they are, then education, training, and efforts to create more inclusive and equitable environments cannot be one-time affairs. Long-term education and training are needed. As FitzGerald, et al. (2019) point out, “[i]f change is really to be produced, a commitment to more in-depth training is necessary.”²² It is not enough to provide “short, one-shot sessions that can be completed and the requisite diversity boxes ticked.”²²

Healthcare organizations are working to address implicit bias through employee training and education. As stated above, this cannot be a one-time affair. This education and training must be ongoing. This can raise awareness of how implicit bias affects patient care and provide tools and strategies to reduce its impact. It is essential for healthcare providers to recognize their biases and take steps to ensure they provide the best possible care to all patients, regardless of background or identity.

Summary

Implicit bias is the unconscious attitudes, stereotypes, and beliefs that can influence an individual's thoughts, feelings, and behaviors. Differences in care may result from conscious or unconscious biases among healthcare providers.

Microaggressions are regular, daily, or common exchanges or insults intended to demean a particular group of people. Microaggressions can be unintentional, in which case, they fall within the concept of implicit bias.

Training and education on implicit bias are used to mitigate its effects on healthcare. This training and education can be done at the individual or organizational levels. Education and training aim to create more inclusive and equitable environments. By acknowledging and addressing implicit bias, individuals and organizations can help create a fairer, more just healthcare system.

There are specific strategies that pharmacies can use to help their pharmacists and pharmacy staff address implicit bias. They include increased awareness of implicit bias, learning to control automatic responses, creating an inclusive work and learning environment, using objective decision-making, seeking feedback, encouraging open and honest communication, and monitoring and evaluating progress toward mitigating implicit biases. These may be implemented at the individual or organizational levels.

Long-lasting changes that mitigate implicit bias require a commitment to in-depth training. It is not enough to provide one-time sessions. Healthcare organizations that use training and education for their employees must commit to ongoing, regular interventions.

Course Test

Implicit bias refers specifically to

unconscious forms of bias.

intentional racism.

bias in healthcare only.

deliberate, controlled, rational behavior.

The Implicit Association Test (IAT) can test for

intentional racism.

explicit prejudices.

unconscious biases.

All of the above

Microaggression is a form of discrimination or prejudice that

is always intentional and distinct from implicit bias.

has a minimal impact on a stigmatized person.

is not in jest and is not really discriminatory.

involves demeaning a stigmatized person on a regular, daily basis.

Implicit bias has consequences that may be best described by which of the following statements?

A provider’s clinical judgment will be impaired if implicit bias is present.

Implicit bias can erode a patient’s trust in the healthcare provider, leading to nonadherence to the provider’s treatment plan.

Implicit bias has consequences, but does not lead to healthcare disparity for stigmatized ethnic or racial groups.

A clinician with implicit biases cannot treat patients.

True or False: In healthcare, microaggression can negatively affect the patient, clinician, and staff.

True

False

Implicit bias is best assessed using

tests that look for microaggressions only.

the Implicit Association Test (IAT).

clinical judgment tests.

patient outcome tests.

Strategies that pharmacies may use for their pharmacists and pharmacy staff to deal with implicit bias include

increased awareness of implicit bias.

learning how to control automatic responses.

creating an inclusive work and learning environment.

All of the above

The evidence clearly shows that sustained changes to long-established implicit biases

require long-term education and training.

only require a single training session.

are impossible.

may be accomplished by taking the Implicit Association Test (IAT).

True or False: Some communities do not have implicit biases toward other groups.

True

False

_____________ can be used to help a person identify with a person from a different race or ethnicity by understanding how that person may react cognitively and emotionally to a situation.

Microaggression

Reverse discrimination

Perspective-taking

Demographics

References

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Daugherty SL, Helmkamp L, Vupputuri S, et al. Effect of Values Affirmation on Reducing Racial Differences in Adherence to Hypertension Medication: The HYVALUE Randomized Clinical Trial. JAMA Netw Open. 2021;4(12):e2139533. Published 2021 Dec 1. doi:10.1001/jamanetworkopen.2021.39533

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Marini M, Waterman PD, Breedlove E, et al. The target/perpetrator brief-implicit association test (B-IAT): an implicit instrument for efficiently measuring discrimination based on race/ethnicity, sex, gender identity, sexual orientation, weight, and age. BMC Public Health. 2021;21(1):158. Published 2021 Jan 19. doi:10.1186/s12889-021-10171-7

Prasad-Reddy L, Fina P, Kerner D, Daisy-Bell B. The Impact of Implicit Biases in Pharmacy Education. Am J Pharm Educ. 2022;86(1):8518. doi:10.5688/ajpe8518

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The information provided in this course is general in nature, and it is designed solely to provide participants with continuing education credit(s). This course and materials are not meant to substitute for the independent, professional judgment of any participant regarding that participant’s professional practice, including but not limited to patient assessment, diagnosis, treatment, and/or health management. Medical and pharmacy practices, rules, and laws vary from state to state, and this course does not cover the laws of each state; therefore, participants must consult the laws of their state as they relate to their professional practice.

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