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