Physicians' Unconscious Racial Bias Could Impair Health Outcomes

An 'unconscious' racial bias by some physicians could harm relations with African-American patients and ultimately may impair health outcomes.

A study in the American Journal of Public Health found that primary care physicians who held these unconscious racial biases spent more time with African-American patients during routine office visits, but also spoke slowly and dominated the conversations.

As a result, African-American patients queried by the researchers said they felt less respected, less trustful, and less engaged in the decisions related to their health.

"It could negatively affect the patient because although the visits tended to be longer and the doctors were talking slower the patients reported feeling less involved in the decisions," says Lisa A. Cooper, MD, a professor in the Division of General Internal Medicine at the Johns Hopkins University School of Medicine, and lead author of the study.

"What we know from other studies looking at those kinds of indicators is that when patients don't feel as involved in decisions about their care they are not as likely to follow through on what is recommended to them, or come back for follow up visits."

Cooper and other researchers examined audio recordings of office visits among 40 primary care physicians and 269 patients in Baltimore-area medical practices. The recordings were from earlier studies examining care regimens for patients with chronic diseases such as hypertension and depression. The patients were mostly middle-aged women, and 80% were African-Americans. Of the physicians, 48% were white, 30% were Asian, and 22% were African-American. Two-thirds of the physicians were women.

The researchers used the standard Implicit Association Test to assess the physicians' unconscious racial attitudes. The physician took two versions of the IAT—one related to race bias and one that assessed whether the physicians thought patients of different races were compliant with medical advice.

"I don't know if these physicians were aware that they were acting this way because of the unconscious stereotype," Cooper says. "I don't think we were quite prepared for the finding that when physicians would have that unconscious stereotype, it almost seem like they were trying to compensate by talking more slowly and lecturing the patients. That was surprising."

Cooper says there is a lack of awareness in the general public as well as among physicians about this unconscious bias. "A lot of people feel on a conscious level they have very positive attitudes about people of different racial and ethnic backgrounds. So they don't feel on a conscious level that there is a problem," she says. "But we are socialized in such a way that these unconscious biases are there from an early point in our lives. We don't realize that we are behaving in a certain way."

To make her point, Cooper, who is African-American, says she took the IAT and it showed that she had a slight bias against African-American patients.

"I grew up in Africa and spent time in Europe before I came to the United States. I thought of myself as so multicultural. I have lived with so many different people. Surely I wouldn't have any unconscious biases," she says. "I found out of my test I had a slight preference for whites over blacks."

Cooper says she was surprised at the extent to which the patients sensed the bias in the study. "When there was more bias, particular the African-African patients talked of feeling less respected, not as well liked and felt like they didn't trust the doctor as much. Even though this was not overt, there was something patients could pick up on."

Cooper recommends that physicians take the IAT to learn if they may be harboring unconscious biases. The test is free and confidential and can be done online. If the test determines that a bias exists, Cooper says that does not make the physician a racist or a bad person, only human.

"Our experience has been that when physicians are made aware that something they are doing is not resulting in a good impression with a patient they are more than willing to try something different," she says.

"You don't say 'I can't appear racist' because when you do that you raise the patient's anxiety level so they behave more poorly," she says. "We focus on the positive. 'What is the best way I can behave in this interaction to make sure this person knows I value his opinion?'"

To confront her own biases, Cooper says she does a quick self-assessment before meeting with patients.

"I question myself before I move forward in my interaction," she says. "What assumptions am I making about this person where I could be wrong? Just doing that is an excellent first step. Have people make sure they stop and question their assumptions and ask themselves 'Am I behaving any differently than I would if this person appeared to be different?'"