As individual providers, we often unknowingly contribute to health disparities due to the impact of implicit biases on clinical practice. Implicit bias influences provider communication patterns and medical decision-making.1 Our profession’s egalitarian and altruistic values have led to a greater prevalence of implicit bias instruction across the spectrum of medical training and practice. Such instruction is often offered as an “add-on,” or as one-time, mandated implicit bias training. Single-session trainings can lead to increased awareness of implicit bias, but the assumption that awareness will lead to behavior change pervades medical education despite no evidence to support this assertion. There is unfortunate evidence of unintended consequences of increased awareness of implicit bias as a sole strategy, including avoidance of the social groups against whom one is biased.2 Without specific attention to skill development, learners become aware of implicit bias and are left powerless to advocate for patients, colleagues, and even themselves.
My research over the past decade has focused on the design, implementation, and evaluation of curricular innovations to empower learners with the knowledge, attitudes, and skills to recognize and manage implicit bias as it relates to communication within clinical and nonclinical encounters. As part of this work, students have discussed perceiving bias in the hidden curriculum in both classroom and clinical settings.3 The hidden curriculum—the informal, unwritten processes of socialization within medical education—is replete with instances perceived as bias.3, 4 Medical students describe cognitive dissonance when their actions do not match their values in the face of perceived bias.3 Students often accept their implicit bias and recognize its potential influence on clinical care; yet, they are unable to bridge their deep, emotional reactions to this awareness with meaningful strategies to mitigate it (unpublished data under review).
Education focused only on increasing awareness of implicit bias for our most junior, and therefore most vulnerable, learners is unfair and unjust. It is my view that we cannot keep disappointing our learners because we struggle with our discomfort with this emotionally charged topic and our assumptions about the difficulty of achieving skills in this area. Our learners need tools to address this crucial issue. Multiple frameworks exist to guide skills-based curriculum development; it is no longer an issue of not knowing how to teach about implicit bias, it is a matter of institutional will.4, 5
Given our national discourse focused on anti-racism, I will make a few points for clarification and understanding. My approach to teaching about implicit bias involves instruction on bias recognition and then the employment of skills to manage the encounter and mitigate the negative outcomes of implicit bias, a process called implicit bias recognition and management (IBRM).5 This approach is behaviorally based, moves beyond knowledge and awareness to address attitudes (which affect behavior), and provides opportunities for skills development, regardless of what type of bias is perceived (i.e., skills do not need to be developed separately for racial bias, gender bias, weight bias, etc).5 While much of my work is centered on racial implicit bias, we were pleased to discover that the skills are relevant across biases.4 IBRM instruction focuses on the individual learner with room to influence the culture and learning environment to enhance patient and organizational outcomes. Anti-racism work inherently includes an examination of systemic and structural racism, addresses multiple levels of racism, and has been eloquently addressed by our colleagues in previous Forum articles. Given the complexity of inequities in health, academic medicine, and society at large, a multi-faceted approach to addressing them is more likely to succeed. We must, however, resist the urge to fold these concepts into one another, as this will only serve to dilute efforts—these efforts merit dedicated time and institutional resources.
IBRM instruction is feasible. It requires minimal hours of dedicated time to deliver basic content and clarify concepts, an “Implicit Bias 101;” subsequent instruction can be integrated into existing instruction in reflection, perspective taking, empathy building, and communication skills.4 Many programs in medical education already utilize role-plays, standardized patient exercises, and observed structural clinical encounters. Opportunities for skill development in IBRM can be integrated into those active learning exercises.4 We can no longer say that we don’t know how to teach about implicit bias—we do know how. The biggest barrier is time in the curriculum; securing buy-in from leadership is essential. Faculty development programs that empower faculty and enhance their self-efficacy are imperative. Although time constraints may limit opportunities for IBRM instruction for practicing clinicians, changing the culture to allow for exploration of bias and empowering junior learners on the team to lead discussions (analogous to when they are giving clinical topic presentations during inpatient rounds) will solidify their own learning, and enhance discussions of this important topic by the team. We must de-stigmatize discussions of implicit bias and treat this topic like any other issue relevant to patient outcomes.3
We want and deserve to develop skills to give excellent care to all our patients in line with our egalitarian values. Our patients deserve to feel respected and leave each encounter with their dignity intact. Other drivers for culture change include patient safety and quality improvement efforts, payment structures, and grant dollars for continued research. We have an opportunity to collaborate to improve the culture of our healthcare system and academic institutions. While many approaches will be necessary to achieve social justice and equity in health care and academic medicine, skills-based training in implicit bias recognition and management is pivotal to these efforts.