Cognitive bias Recognizing and managing our unconscious biases
Richard L. Byyny, MD, FACP
e all have biases, whether we are aware of them than they are in reality. We then use personal charac- or not. We hold opinions in favor of, or against, teristics—race, gender, etc.—as markers for personality, Wa thing, person, or group compared with another. behaviors, and other traits. This is compounded by media These preconceived opinions are often not based on rea- and cultural stereotypes presented by friends, family, col- son or actual experience. leagues, the news, and social media. Cognitive bias refers to the systematic pattern of devia- tion from norm or rationality in judgment, whereby infer- Biases drive behaviors ences about other people and situations may be drawn in Dr. Wiley Souba (AΩA, University of Texas McGovern an illogical fashion. Individuals create their own “subjec- Medical School, 1978), states, “Research in neuroscience tive social reality” from their perception of the input. has made it unambiguously clear that every aspect of our Unconscious or implicit bias refers to biases in judg- life experience, and every choice we make, is generated by ment or behavior resulting from subtle cognitive processes neuronal patterns in our brain. Both genome and experi- that we are unaware of, and which happen outside of our ences shape and mold our way of being at any point in time regular thought process and control. It occurs automati- in our life.” 3 cally and is triggered by the brain making quick judgments Most of us believe that our decisions are based on and assessments of people and situations that are influ- conscious deliberations of the available information about enced by personal background, experiences, memories, the choice options and deductive or inductive reasoning. and cultural environment.1 Social judgments and infer- However, we often use mental shortcuts, which is a part of ences, especially those guiding first impressions, are often being human and is related to self-preservation. We learn mediated by unconscious processes.2 The brain is extract- to use routinized procedures for social judgment, and may ing patterns from inputs and building predictive models form impressions of people without any conscious aware- that are the basis of the biases. ness of the perceptual cognitive basis. Biases presumably originated in response to fears, and Unconscious bias may be detrimental without consid- for the caveman—and cave woman—were helpful for eration of objective and known facts. safety, and useful for evolution and survival. It has been estimated that our brains are capable of Cognitive stereotyping helps perceive surroundings processing 11 million bits of information every second.4 quickly and efficiently, and unconsciously affect judg- In 2011, Daniel Kahneman described an accepted ment with missing information filled in from unconscious framework for understanding human cognitive function- cognition to guide behavior during social interactions and ing by illustrating mental processing in two parts: System 1 decision-making. Theoretically, this allows for simplifica- and System 2.5 System 1 is cognition, and used for informa- tion of complex environments to predict and respond to tion outside of conscious awareness, e.g., having learned to future events, even with incomplete information. stop for a red light and proceed with a green light without Over time, we intensify and reaffirm our perception using any conscious thought. System 2 is conscious cog- that members in a certain category are more homogeneous nition processing to think and make decisions requiring
2 The Pharos/Winter 2017 concentration through thoughtfulness, effort, and deliber- a higher starting salary, and offered more career mentor- ate concentration. These two systems work together to ing to the male applicants.8 And, among mentored career make sense of the world. K08 or K23 grant recipients, the mean salary for female Cognitive processing—System 1—helps us understand researchers was about 32,000 less than their male coun- that many of the mental associations that affect how we terparts.9 In addition, women scientists who are mothers perceive and act are operating implicitly or unconsciously, were found to be 79 percent less likely to be hired, and and are the source of our unconscious biases. if hired, were offered 11,000 less in salary than women Since our implicit associations are outside of our con- with no children. By contrast, parenthood conferred an scious awareness, they do not necessarily align and match advantage for men in the same study.10 Studies also show our explicit beliefs or our stated intentions. They have that evaluators consistently scored identical curriculum been learned over time and incorporated functionally in vitae and resumes lower when they are assigned a female our brains and neurons. Individuals with good intentions name.8,11 can unknowingly act from their unconscious biases, pro- In the tech world, 19 percent of software developers ducing unintended negative effects and consequences on are female, and of those, only 19 percent are in technology decision-making, unaware that these unconscious biases leadership roles. Eighty-eight percent of all information exist. technology patents filed between 1980 and 2012 have male Unconscious bias can be related to age, race, ethnicity, only invention teams, while two percent have female only gender, employment, selection and promotion, health care, teams.12 A 2008 London Business School study looked at religion, disability, nationality, socioeconomic status, law 100 teams from 21 companies and found that work teams and justice, education, etc. Unconscious bias can be fol- with equal numbers of women and men were more in- lowed by an unconscious tendency to try to relate informa- novative and more productive than teams of any other tion that confirms pre-existing beliefs. It becomes a habit composition.13 of which the person is actually unaware. In 2014, researchers created a fictitious legal memo A similar phenomenon is implicit stereotype, which is that contained 22 deliberately planted errors for spelling an unconscious attribution of presumed qualities to a cer- and grammar, and factual, analytical, and technical writ- tain social group—race or gender—referred to as implicit ing. The memo was distributed to law firm partners as a social cognition and bias. In contrast, explicit stereotypes writing analysis study. The partners were asked to edit and are the result of intentional, conscious, and controllable evaluate the memo. Half of the memos listed the author as thoughts and beliefs resulting in conscious bias, or preju- African-American, and half as Caucasian. When the au- dice.6 We consciously use information about character- thor was listed as African-American, the evaluators found istics, gender, race, ethnicity, age, socioeconomic status, more of the embedded errors and rated the memo as lower sexual orientation, and other factors to help understand quality than those who believed the author was Caucasian. the etiology and epidemiology of diseases and in diagnosis They concluded unconscious confirmation bias was pres- of individual patients. Our unconscious biases can influ- ent, despite the reviewers’ intention to be unbiased.14 ence every step of this process. Unconscious bias among health care professionals can influence their behaviors and judgments.15 Since 1997, Becoming aware of the unconscious more than 30 studies have been published relevant to un- Through self-reflection and personal awareness, people conscious bias in clinical decision-making. Racial bias was can become aware of their biases. For decades, uncon- found to be prevalent among health care providers, and scious bias has been studied and tested in nearly every race can influence medical decision-making.16 profession and personal setting. In 2006, researchers tested implicit bias among physi- One study found that fictitious resumes with Caucasian- cians and their prediction of thrombolysis for African- sounding names sent in reply to help wanted ads were 50 American and Caucasian patients. They used the Implicit percent more likely to receive callbacks for interviews Associations Test (IAT), a social psychology measure compared to resumes with African-American sounding designed to detect the strength of a person’s automatic names.7 association between mental representations of objects In another study, faculty rated male applicants for a lab- (concepts) in memory. They specifically measured implicit oratory manager position as significantly more competent race preference and perceptions of cooperativeness. Before and employable than female applicants. Faculty selected taking the test, physicians reported no explicit preference
The Pharos/Winter 2017 3 Unconscious bias
for Caucasian versus African-American patients, and white, good or bad—and relies on differences in response stated they didn’t have any preconceived perceptions of latency to reveal unconscious bias. The larger the perfor- cooperativeness. mance difference, the stronger the unconscious bias. The IATs revealed otherwise, identifying implicit pref- Between 1998 and 2006, more than 4.5 million IAT tests erence favoring Caucasians, and implicit stereotypes were completed on the IAT website. The project found of African-Americans as less cooperative with medical that: procedures and less cooperative in general. As physi- • Implicit bias is pervasive. cians’ pro-Caucasian implicit bias increased, so did their • People are often unaware of their implicit biases. likelihood of treating Caucasian patients and not treating • Implicit biases predict behavior. African-American patients with thrombolysis.17 • People differ in levels of implicit bias.21
Diversity and inclusion The IAT is a powerful and useful instrument to explore Decades of work by investigators from myriad disci- and document the impact of bias on behavior. It can be plines show that socially diverse groups, with a mix of race, used to increase awareness of cognitive bias, and help ethnicity, gender, and sexual orientation are more innova- individuals and groups to compensate and learn about in- tive than homogeneous groups. Social diversity provides fluences on decision-making and social interactions. The advantages in solving complex, non-routine problems. IAT is available online at implicit.harvard.edu. It is free Interacting with individuals from different backgrounds and takes about 10 minutes to complete a test. affects group members’ preparation, evaluation of alterna- tive views, and ability to reach consensus. Unconscious bias in medicine and leadership Diversity enhances creativity and encourages searching Because time pressures, fatigue, stress, and information for novel information and perspectives that lead to better overload impact physicians’ and clinical educators’ cogni- decision-making and problem solving, and lead to higher tion, there is a corresponding increase in unconscious quality scientific research.18 Unconscious assumptions and cognition resulting in increased implicit biases. bias limit the science and technology pool, and undermine In 1999, Parker J. Palmer, writer and activist, observed: scientific innovation. Studies of the medical and scientific peer-review pro- Why must we go in and down? Because as we do so, we cess have shown that African-Americans and women are will meet the darkness that we carry within ourselves—the held to higher standards to be judged competent, which ultimate source of the shadows that we project onto other has resulted in efforts to minimize implicit bias in peer people. If we do not understand that the enemy is within, review, including double-blind peer review when authors we will find a thousand ways of making someone “out there” and peer-reviewers are unaware of each other’s identity19 into the enemy, becoming leaders who oppress rather than Dr. Eve Higginbotham (AΩA, Morehouse School of liberate others….Good leadership comes from people who Medicine, 2008, Faculty), notes, “While there has been have penetrated their own inner darkness and arrived at the focus on diversity—the differences among people in a place where we are at one with one another, people who can group or community—for decades, there has not been lead the rest of us to a place of “hidden wholeness” because as much attention paid to inclusion, which is the process they have been there and know the way.22 of respectfully engaging all members of a community, organization, or nation.” 20 A limiting factor on inclusivity Souba discusses the importance of the inward journey is unconscious bias. This also is evident in developing ef- in leadership where biases—overt and unconscious—are fective inter-professional education and patient care where critically important: there are often unconscious biases related to professional background and roles. We each come to the table with a set of fixed and unchal- lenged beliefs and assumptions that unconsciously lead us Measuring unconscious bias to listen to what we hear in predetermined ways. We each Reliable computer-based tests have been developed to make sense of (interpret) the world through the lenses measure implicit and unconscious bias. The most com- (contexts) of world views and frames of reference. Context monly used is the IAT, which measures differential as- becomes a critical determinant of making sense of a leader- sociation of two target concepts—male or female, black or ship challenge. Change the context and you can shift yourself
4 The Pharos/Winter 2017 and your sense-making in relationship with it. unconscious bias in academic medical centers, recogniz- ing that in the profession and medical education it is an Context is always alterable. It is always created by you, and important issue that must be addressed.26 only you, and thus always a matter of choice. However, One of the most effective ways to mitigate unconscious before creating a new context you must expose the cur- bias is “habituation of egalitarian goal pursuit.”28 Approach rent one and the hidden assumptions that make up the every encounter with patients, colleagues, employees, current/reigning context. Once exposed, crafting a new students, and especially those who are members of under- context can alter the occurring such that your correlated privileged or stereotyped social groups, different genders, ways of being and acting give rise to more of your natural races, ethnicities, ages, socioeconomic status as an oppor- self-expression—you at your best.23 tunity to reinforce and act consistently with commitment to egalitarian values. By making egalitarian goals habit, Can we change and be alerted to our unconscious bi- they become unconsciously accessible and automatically ases? How can we gain awareness of unconscious biases activated in the presence of groups different than yourself. that may be affecting our decisions and resulting out- Create an inclusive learning environment to build posi- comes? Even when we believe, and strive to be egalitar- tive associations with others. This is a primary element of ian—believing in the principle that all people are equal medical professionalism and the care of patients. and deserve equal rights and opportunities—unconscious Skills to abate unconscious bias include: biases can slip into our thoughts and processes. Since unconscious biases are not permanent, they are • Perspective taking which is the cognitive component of malleable and can be changed by devoting intention, atten- empathy; tion, and time to developing new associations. It involves • Emotional regulation to use more inclusive social cat- taking the time to consciously think about potential and egories; and possible biases prior to acting or making decisions.24 There • Partnership-building for clinicians to create partnerships is evidence that even minimal interventions in reducing with patients working as a team toward common goals.29 stereotyping and discrimination are efficacious. For exam- ple, “simply giving whites instructions to imagine a day in The Joint Commission provides several actions that health the life of a black person, looking at the world through his/ care providers can practice to combat unconscious bias: her eyes and walking through the world in his/her shoes led to less implicit stereotyping and in-group favoritism.” 25 • Have a basic understanding of the cultures from which Programs testing mental imagery—cognitive therapy your patients come. —have shown a change in unconscious and automatic • Avoid stereotyping patients; individuate them. stereotyping. People who are made aware of the influence • Understand and respect the magnitude of unconscious of their stereotypes can be motivated to mentally change bias. their initial biased responses. • Recognize situations that magnify stereotyping and bias. • Assiduously practice evidence-based medicine, by mak- Becoming aware to effect change ing the most objective evaluation and decisions possible. Educate yourself, take action, and be accountable. Work Consciously gather and assess the evidence for diagnosis, consciously to be aware, and be able to tell the difference treatment, and caring. between real threats and unconscious bias-driven impul- • Participate in techniques to de-bias patient care, includ- sive actions. ing training, intergroup contact, perspective-taking, emo- In 2014, thousands of medical students joined the tional expression, and counter-stereotypical exemplars.21 community movement WhiteCoats4BlackLives, and par- ticipated in demonstrations across the United States to One of the most important predictors of learning is safeguard the lives and well-being through the elimination willingness to recognize and work toward understanding. of racial bias in the practice of medicine. The group’s three This is the only way to modify and eradicate our own un- goals are to raise awareness of racism as a public health conscious biases. concern; end racial discrimination in medical care; and We can all work to educate others—colleagues, stu- prepare future physicians to be advocates for racial justice. dents, leaders, managers—that unconscious bias exists, The students demanded an examination of racial bias and and that it has detrimental unintended consequences.
The Pharos/Winter 2017 5 Unconscious bias
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