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Chapter 2: How Does a Lack of DE&I Show Up?

Welcome! This article is part of a Medscape Physician Business Academy course, . Visit the Course Page to take the full course and receive a certificate.

Physicians, nurses, and other healthcare workers choose careers in medicine because we want to help people. By our nature, we are empathetic, respectful, and passionate about improving our patients' health. We value honest and supportive communication, professionalism, knowledge, and the ability to analyze situations accurately.

Clinicians don't want to hurt patients or coworkers with our words or actions. But research shows that everyone has negative stereotypes and biases, even though we are often unaware of them.

One goal of a DE&I initiative is to help everyone in an organization recognize their own biases and learn how to avoid words or actions that might unintentionally cause harm.

What Is Explicit Bias?

Everyone has both explicit (or conscious) biases and implicit (or unconscious) biases.

Explicit bias refers to preferences, beliefs, and attitudes that people are aware of and may be willing to communicate. Revealing some types of conscious bias has become socially unacceptable, so we see displays less frequently than in the past. But marginalized groups still experience explicit bias.

Writing in Health Affairs, Michelle Ko, MD, PhD, an associate professor of health policy and management at the University of California, Davis, gave an example of conscious bias from her years in medical school:

A surgery resident loudly berated one of my classmates in the hallway, showering her with a litany of her faults: She was too slow, too ignorant, and too indecisive. The resident ended the tirade with a final denouncement: "You're only here because you're black!"
What Is Implicit Bias?

Whereas overt negative biases are less common than in in the past, implicit negative biases are widespread in healthcare. And they contribute to healthcare disparities.

Implicit biases are unconscious thoughts that lead to automatic, unintentional associations and favorable or unfavorable evaluations toward groups of people. Even though we're not aware of these implicit biases, they affect our words, decisions, and actions.

Examples of bias include:

  • Stereotyping based on gender, race, or other factors. "All old people are terrible with technology" is a stereotype.

  • Affinity bias. "I like to work with her because we both speak English that I can understand."

  • Halo effect. "You can tell he's a good worker because he's always wearing a coat and tie."

  • Perception bias."Don't invite her for happy hour after work — she goes to church, so she probably doesn't drink."

Research has shown that healthcare professionals have implicit biases at about the same level as the rest of the population. Studies have documented that some healthcare providers are biased against Black, Hispanic, and dark-skinned people; overweight individuals; members of lower social classes; people who are addicted to drugs; and wheelchair users with spinal cord injuries, among others.

An analysis of heterosexual providers' implicit preferences found that they consistently favored heterosexual over lesbian and gay people, whereas lesbian and gay providers implicitly and explicitly preferred lesbian and gay people over heterosexuals.

In fact, a systematic review of 15 studies conducted in 2015 found low to moderate levels of implicit racial/ethnic bias among healthcare professionals in all but one study.

Want to see if you have any implicit biases? The Harvard Implicit Bias Test, free and available online, measures attitudes and beliefs that people may not know they hold. You can test yourself for implicit biases based on race, weight, age, gender identity, religion, skin tone, and many other attributes.

The tests often reveal that people have an automatic preference for thin people over fat people, White people over Black people, and young people over old people, even if the test-takers do not recognize those preferences.

Implicit biases can show up in surprising ways. For example, when researchers analyzed physicians' electronic medical record notes, they found that stigmatizing language — "she is uncooperative" or "exaggerated pain out of proportion to exam" or "noncompliant" — was much more frequently used to describe people of color than White people.The researchers used machine learning to analyze notes about 18,459 patients and found that more than 58% of Black patients had at least one negative descriptor — "difficult," "challenging," "resistant," and others — in their notes, compared to fewer than 32% of White patients.

How Biases Affect Healthcare

Negative biases can be deadly, as was famously demonstrated in the 40-year Tuskegee syphilis study. Researchers recruited 600 Black men — 399 of whom had syphilis — to help learn the natural course of the disease. The men were not told that they had syphilis and were never treated, even though penicillin was found to cure the disease 15 years into the study. By the time the travesty was exposed in 1972, dozens of men had died and their wives, children, and others had been infected.

Although that horror is in our past, negative implicit biases continue to take their toll on patients. A review of 15 studies examining healthcare professionals' implicit attitudes about racial and ethnic groups found that implicit bias is related to:

  • Patient-provider interactions

  • Treatment decisions

  • Treatment adherence

  • Patient health outcomes

For example, a study of 655 emergency medicine physicians found that those who have negative attitudes about patients with sickle cell disease were less likely to follow national guidelines for pain management when treating those patients.

In addition to ineffective treatment decisions, negative implicit biases can have other bad repercussions for patients. Responding to anonymous questionnaires, a large majority of advanced students in the health professions said that they had witnessed healthcare providers making negative comments or jokes about obese patients. More than one third of those students had their own negative attitudes, believing that patients with obesity lack motivation to make changes and don't follow treatment plans.

Another danger: Patients who perceive discrimination in healthcare because of their race or sexual orientation are more likely to delay care, which can lead to poor health.

What Are Microaggressions?

Microaggressions are generally verbal — although sometimes nonverbal — insults, either intentional or unintentional, that convey messages that are derogatory, negative, or even hostile.

"You look too young to be a doctor." "Why is a pretty woman like you wearing that white coat all day?" "I told my friend you're just as good a doctor as anyone I ever had" (said to a Black physician). "I'm just going to call you Dr Voodoo because your name is too hard to pronounce."

People who make microaggresive comments may sincerely believe they're giving a compliment or being friendly. And our tendency may be to laugh such remarks off. But the subtexts of these remarks are not funny. They convey: "I wonder if you are a competent doctor." "Women don't belong in medicine." "Black people are not considered good doctors." "You are not important enough for me to learn to pronounce your name."

Three types of microaggressions are:

  • Microassaults.Discriminatory verbal abuse, such as "Stop acting like an angry Black woman" or "Why can't you people ever listen?"

  • Microinsults.Insensitive and disparaging comments, such as referring to diverse healthcare professionals as "those people" or suggesting that someone obtained a position due to affirmative action policies.

  • Microinvalidations.Dismissive and exclusion practices, which invalidate the feelings of a group of people who have been disproportionately discriminated against by law enforcement officers.

A recent Harvard Business Review article pointed out that microaggressions may seem like innocuous remarks, but their impact suggests otherwise. "They should be taken seriously because at their core they signal disrespect and reflect inequality," the article said.

Just because a person doesn't mean to cause harm doesn't mean that no harm occurs. The intent of a remark does not excuse the impact it has on the person who receives it — and people who make such remarks need to learn, either via a social science course or through experience, how their remarks affect others.

Research has shown that microaggressions, especially over the course of a person's career, can lead to depression and physical problems such as headaches, high blood pressure, and sleep deprivation.

If you have a high turnover rate among your diverse staff members, you should consider whether microaggressions make your office an uncomfortable place to work.

Microaggressions are related to increased burnout and less job satisfaction, because hearing them all day can be exhausting. It takes a mental and emotional toll to repeatedly loop through a series of thoughts: "Did that person realize they were being offensive?" "I need to let this go; there's nothing to be gained by making a fuss." "Why am I being disrespected?"

In her new book, The Necessary Journey: Making Real Progress on Equity and Inclusion, organizational psychologist Ella F. Washington, PhD, a professor at Georgetown University's McDonough School of Business, gives examples of microaggressions.

  • Race/ethnicity."I didn't realize you were Jewish. You don't look Jewish." This suggests that people of Jewish heritage have a stereotypical appearance.

  • Citizenship."But where are you really from?" This suggests that even though a person grew up in, say, Brooklyn, that isn't their true origin. It may imply they are "less American" or more exotic than others.

  • Class."How did you get into that school?" signals that a person's background does not fit with the reputation of a prestigious school.

  • Mental health."You don't seem like you are depressed. Sometimes I get sad too" minimizes the experience of a person with mental illness.

  • Gender."Don't be so sensitive" suggests that a person, likely a woman, is being overly emotional.

  • Sexuality."That's so gay," describing something that is undesirable, suggests that being gay is a bad thing.

  • Parental status."You don't have kids to pick up, so you can work later, right?" signals that a person without children does not have a life outside of work.

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Welcome! This article is part of a Medscape Physician Business Academy course, . Visit the Course Page to take the full course and receive a certificate.


Lisa Herbert, MD; Lola Butcher

| Disclosures | January 01, 2022

Authors and Disclosures


Lisa Herbert, MD

Lisa Herbert, MD, is a board-certified family physician, a physician leadership coach, and a DE&I consultant. Through her company, Just The Right Balance LLC, she does speaking engagements with healthcare organizations. She is the author of Physicians Rise Up: The Guide to Evolving as a Healthcare Leader and Take Back Your Life: A Working Mom's Guide to Work-Life Balance. Dr Herbert is adjunct faculty at Morehouse School of Medicine, Atlanta, Georgia.

Disclosure: Lisa Herbert, MD, has disclosed the following relevant financial relationships:
Serve(d) as a director, officer, partner, employee, advisor, consultant, or trustee for: Just The Right Balance; Allcare Family Medicine
Serve(d) as a speaker or a member of a speakers bureau for: AAFP

Lola Butcher

Lola Butcher is a freelance healthcare writer from Springfield, Missouri.

Disclosure: Lola Butcher has disclosed no relevant financial relationships.