What is implicit bias? The invisible racism that makes Black women dread the doctor's office

"I just know not to get too rebellious." In medical settings, Black women are forced to play against stereotypes.
Implicit Bias in Healthcare MAIN
The emotional toll of negative experiences can lead Black women to distrust doctors, and eventually, some people just stop going. Celia Jacobs / For TODAY
By Vidya Rao

When Tina Sacks worked for the Centers for Disease Control years ago, she and her Black female colleagues would make it a point to wear their government IDs when going to the doctor for checkups, to telegraph that they were professionals who understood medical terminology, and had good health insurance — all so medical staff would take them seriously. “In other words, we were playing against a type,” Sacks wrote in her book “Invisible Visits,” which looks at the biases middle-class Black women face when seeking health care.

Sacks, now an assistant professor at the Berkeley School of Social Welfare, says that not much has changed since then. The 30 women she interviewed for her book echoed the experiences of many of the women we interviewed for TODAY’s “Denied” series. Their concerns about their bodies are dismissed or ignored; they are often met with suspicion from doctors; they have to “prove” they are in pain and not seeking drugs; they aren’t thoroughly examined; and they aren’t told about the full array of treatment options available to them.

“Many of the women I interviewed would have that inkling that they weren’t getting the same care as their white counterparts, but there really is no way to know for sure, because you are only one person and you don't really have a control group,” Sacks said. “And part of the challenge of that experience is the anxiety about whether or not it is true. ‘Can I trust my own perceptions? And what can I do about it?’”

What is implicit bias?

Bias, both implicit and explicit, is rife within every structure of American society. While explicit bias is easy to spot and weed out (the blatant racist using the N-word, for example), implicit bias is more difficult to recognize, especially because it often doesn’t line up with the overall values of the person exhibiting bias. Everyone has implicit biases, whether we admit it or not. These biases are the automatic associations we make, driven by stereotypes, that ultimately can skew how we perceive others and how we make decisions.

“The more that you’re exposed to stereotypes, the stronger that implicit association becomes,” explained Preshuslee Thompson, a training and development specialist at Ohio State’s Kirwan Institute for the Study of Race and Ethnicity. These implicit biases cause people to rely on assumptions to inform how they read and react to various situations.

“Our associative memory really is about quickly being able to accurately assess threat and responses,” said Thompson. “But we do live in a racist society. So now we've associated those different levels of threat to people with different identities.”

Tina Sacks is the author of "Invisible Visits" which chronicled the experiences of Black women who felt dismissed or ignored by the medical community. Carlos Javier Ortiz

Because implicit biases are unconscious, they are most likely to emerge when we have to make quick decisions — a given in healthcare with doctors rolling through patients every 15 minutes. In fact, a 2015 review found that “most health care providers appear to have implicit bias in terms of positive attitudes toward whites and negative attitudes toward people of color.”

“We know people in society are biased, so there certainly will be doctors who are biased, too,” said Janice Sabin, a research professor at the University of Washington who was one of the first academics to study implicit bias in healthcare. “Doctors go into a room with a whole set of assumptions by reading a chart description of the patient and seeing the patient for two minutes.” She conducted a 2008 study that found doctors were more likely to stereotype Black people as being medically noncompliant. “If a doctor perceives that a patient is less likely to comply with what they’re going to say, they may actually give a different recommendation or scrap their recommendation altogether,” Sabin explained.

The impact on Black women

For Black women, these biases mean they are perceived as not being knowledgeable about their bodies, that they are difficult to deal with, that they don’t have insurance, and that they have higher levels of pain tolerance, among other stereotypes. There’s a clear connection between these biases and health outcomes regardless of their economic status, as study after study shows that Black women are not getting the same standard of care as their white counterparts.The maternal mortality rate of Black women is more than three times what it is for white women, a fact that gained national attention when tennis star Serena Williams opened up about being ignored by doctors before nearly dying from a pulmonary embolism during childbirth. Black mothers experience the highest infant mortality rate. Black women with endometriosis are more likely to be misdiagnosed compared to white women. Black people are chronically undertreated for pain.

“There’s a pervasive de-valuing of Black people's lives and Black people's bodies in general and Black women in particular,” said Sacks. Black women undergo hysterectomies at three times the rate of white women, and Black people with diabetes have a limb amputated at three times the rate of white people with the same condition, who are more likely to be presented with other options.

When Black women do advocate for themselves as patients, they worry about being seen as the “angry Black woman” stereotype and compromising their care as a result.

“I heard that over and over again,” said Sacks, recalling one interviewee who wanted more information than she received from her podiatrist about an upcoming surgery. “She was mad at herself afterward for not asking more questions about it ahead of time. But, she said, ‘I just know not to get too rebellious.’

“Most of them felt like they had to come into the healthcare encounter really ready,” Sacks continued. “You know, it was sort of like an attack. You’ve got to walk in with your research, you’ve got to dress a certain way, talk a certain way, carry yourself a certain way to be taken seriously. There's so much of a power difference, because the provider has specialized knowledge.That's why you're going there. And then a lot of times you're naked. I mean, it's an incredibly vulnerable experience.”

The emotional toll of these negative experiences leads to distrust of doctors, and eventually, some people just stop going. This becomes problematic for preventative care and just continues healthcare disparities.

If you’re convinced you have no implicit biases, if you think you’re above it, you will never see how implicit biases are actually impacting your decision-making.

Janice Sabin, a research professor at the University of Washington

“The medical system has really done a number on people of color, especially Black people in this country, so there's a lot of distrust,” said Dr. Tursha Hamilton, a New Orleans-based naturopathic doctor who often sees patients after they’ve been frustrated by their interactions with doctors. “Not only do we have what's going on right now, but we have what's gone on historically. Families pass on these experiences, these fears. And so if someone has heard these things from their community, and then they are not being heard by the doctor that's sitting in front of them, that's just going to perpetuate the distrust.”

Confronting implicit bias in medical settings

Just because implicit biases are unconscious, “doesn't mean we don't have any control over them and we don't have that moral responsibility to mitigate our biases,” said Thompson, who pointed to Kirwan’s implicit bias training as a resource.

Sabin created an implicit bias curriculum that is currently being taught in medical schools across the country and says that more people in the health care industry are open to learning about and confronting their own biases. She’s also researching how non-verbal cues transmit implicit bias and how technology might detect that in clinical settings. “As the research continues, people realize that good intentions just aren't enough, that we have to track equity, and when inequities are discovered, really dig deep.”

In implicit bias training she’s done with medical students and professionals, Sabin said the key to evolving is to let go of the shame and defensiveness around implicit bias, and just approach the subject with “a certain humility.”

“If you’re convinced you have no implicit biases, if you think you’re above it, you will never see how implicit biases are actually impacting your decision-making.”