Implicit Bias Training – An Important Step Toward Equity

The journey to advancing health equity has been quite an adventure for me - and bringing attention to addressing implicit bias among health professionals has been one of the more challenging parts of it. It took years for my colleagues and I to publish the results of a study on this issue because of a higher than usual level of scrutiny of our methods and skepticism about our findings by our peers. We demonstrated that implicit racial bias and stereotyping among physicians was associated with poor clinical communication and ratings of care among Black patients. Our results were published in the American Journal of Public Health in 2012. Since then, more than 20 studies have provided evidence linking biases to diagnosis and treatment decisions or levels of care that could have a negative influence on the health of people in marginalized groups.

It’s been a decade since the publication of our study, and finally, there are actions being taken across the country to make implicit bias training a requirement for medical professionals. This is progress!

Recently, I was interviewed for an important article in “Stateline,” a news website on state policy published by Pew Charitable Trusts, as were several other colleagues in the “good trouble” fight for implicit bias training, including Quinn Capers, MD, Associate Dean for Faculty Diversity, Department of Internal Medicine at the University of Texas Southwestern Medical School, and Michelle van Ryn, PhD., Senior Scientist and CEO of Diversity Science. Reported by Michael Ollove, the article finds that since 2019 at least four states, including Maryland, I’m excited to say, have adopted policies requiring at least some health care workers to take implicit bias training, some as a prerequisite for professional licensure or renewal. The other states are California, Michigan, and Washington. Bills on implicit bias training have also been introduced in state legislatures since 2019 in Illinois, Indiana, Nebraska, New York, Oklahoma, South Carolina, Tennessee, and Vermont.

In my book, “Why Are Health Disparities Everyone's Problem?” (Johns Hopkins Wavelengths), I shared a checklist for implicit bias which incorporates what we know about effective physician-patient communication behaviors to drive behavioral change.

The checklist follows the mnemonic RELATE:

Respect. Respect the humanity of the person in front of you, regardless of whether you like them or agree with what they’re saying;

Empathize. Imagine yourself in the person’s shoes;

Listen. Listen more and talk less;

Ask. Ask yourself what assumptions you’re making and whether they’re based on facts about this particular person;

Talk. Talk with people about their personal lives, and get to know them as individuals;

Engage. Engage people in problem-solving and decision-making by asking their opinions about any joint activities you’re considering.

To be clear, I am not naïve enough to think that implicit bias training for health professionals, by itself, will resolve disparities in healthcare delivery. The science is evolving, but we still need more research to identify the most effective ways to change the behaviors resulting from implicit bias that have negative effects on people from marginalized groups. We need approaches that address not only the behaviors of individuals, but also policies and resources of governments, businesses, organizations, and their partnerships with groups outside of health care to improve opportunities and environments in communities. But we can each play our part and serve as role models for the change we want to see in the world. So as a first step, I urge my colleagues in health care – and anyone else who wants to see health equity become a reality - to consider the attitudes and behaviors included in the RELATE checklist as guide for the lifelong journey we all travel towards stronger relationships with people we encounter -- no matter where we live, work, play, or pray.

Lisa Cooper, MD, MPH

Director, Johns Hopkins Center for Health Equity

Director, Johns Hopkins Urban Health Institute

Bloomberg Distinguished Professor, Equity in Health and Healthcare, Johns Hopkins University Schools of Medicine, Nursing, and Public Health

James F. Fries Professor of Medicine, Johns Hopkins School of Medicine

Follow Dr. Cooper on @LisaCooperMD. Dr. Cooper is the author of “Why Are Health Disparities Everyone's Problem?” (Johns Hopkins Wavelengths).