The quality of health care in the United States varies by race and ethnicity.¹ Numerous studies have consistently found that black and Hispanic patients receive lower quality of care than white patients, not all explained by financial or socioeconomic
barriers.² The Institute of Medicine’s (IOM) report “Unequal Treatment” states that disparities in health care emerge from bias against minorities, greater clinical uncertainty when interacting with minority patients, and stereotypes held by clinicians about the health of racial minorities.³ There is growing evidence that healthcare providers’ attitudes toward black patients are more negative than white patients and include stereotypes about noncompliance. When surveyed, ethnic minority patients rate interpersonal quality of care from physicians and trust factors⁴ more negatively than white patients.⁵ Negative associations and implicit racial biases mediate racial disparities in physician treatment decisions. Clinicians’ implicit biases affect communication, overall ratings of care, and trust relationships.⁶

Bias may also be at the core of achievement gaps and inequities in advancement of underrepresented groups in academic medicine. The Implicit Association Test (IAT) was developed in 1998 and is the most broadly utilized tool for measuring implicit bias. The IAT connects thoughts and reaction times to mental concepts. It provides insight into unconscious mindsets. For example, participants who demonstrated implicit racial bias in the assessment rapidly associated black faces with words such as bad and white faces with words such as good. Salles et al. examined data from health professionals taking the gender-based IAT.⁷ The study found that both men and women have explicit and implicit biases in mental models of women with families and men with careers. This was further explored for biases that specifically exist within surgery, finding that surgeons perceived men with surgical careers and women with careers in family medicine. This is important because women are underrepresented in surgical fields, and implicit bias may affect their success and the contexts in which they are perceived. The IAT is not perfect because it is not known if higher bias scores translate into discriminatory behaviors and low scores may be falsely reassuring. Other studies have shown that when participants are presented with identical job resumes for hypothetical jobs in Science, Technology, Engineering, and Mathematics (STEM) fields, male candidates were considered more competent, offered greater mentoring, given higher salaries, and offered more career mentoring.⁸ Preexisting subtle bias against women is associated with less support in general⁸ (Figure 4.1).

Understanding and addressing such bias is complex because it occurs beneath consciousness and is difficult to measure. Best practices or proven approaches do not currently exist. It is important that academic leaders begin to acknowledge and decrease the influences of implicit bias in order to achieve equity for all. This will require implementing innovative processes for career advancement that are specifically aimed at eliminating unequal barriers to achievement for women and underrepresented ethnic groups.

Tamika Cross, MD, was a resident in obstetrics and gynecology when she volunteered her services on an airplane when another passenger required medical attention. She describes that she rose her hand when asked if there were any doctors on the plane only to be met with skepticism and told that “we are looking for actual physicians.”⁹ Dr. Cross then shared her experience on social media and explained that a white man offered his assistance and was allowed to help without questioning. She wrote “I’m sure many of my fellow young, corporate America working women of color can understand my frustration when I say I’m sick of being disrespected.”^9,10 Dr. Cross is a black, female physician who didn’t fit the picture of a doctor in the eyes of those requesting help. This is just one example of the implicit bias in medicine faced by anyone who doesn’t “look the part.” The post that Dr. Cross shared went viral and #WhatADoctorLooksLike was born. This hashtag has been used by anyone whose physician identity has been questioned because of race or gender, and the numbers are overwhelming.¹⁰

It would be easy for the profession to blame society and perceive this issue as one that is external to medicine. However, despite the fact that women make up approximately half of the medical school admissions and residency spots, the percent of women in advanced faculty positions and leadership roles plummets.¹¹ Reasons for this are multifactorial. In 2013, a survey of academic surgeons revealed that 54% of women had experienced being treated differently due to their gender, and 36% of women reported experiencing negative comments about gender, significantly more than male respondents (16% and 4%, respectively, P < .001 for both).¹² In 2017, a retrospective study of milestone achievement among 359 emergency medicine residents at eight different residencies showed that although female residents were equivalent to male residents in the first year of training, male residents had a nearly 13% higher rate of milestone attainment by graduation.¹³ This gender gap in evaluations was seen in men and women faculty evaluations, leading the authors to suggest that implicit gender bias was present and that it should be recognized as a potential factor limiting advancement of women.¹³ The same authors reviewed the quality of comments made by attending physicians in the resident evaluations in a follow-up publication. They showed that ideal residents had more stereotypically masculine traits and that male residents were more likely to receive clear and consistent feedback for areas of improvement than women residents.¹⁴ These are all examples of gender inequity ingrained in academic medicine that spans disciplines. Implicit bias is a systemic limitation with opportunities to recognize, discuss, and address openly, without shame or fear of career hindrance at all ranks.