Humanizing Implicit Bias Training for Healthcare Organizations

Healthcare needs to get on the same page about implicit bias. Rather than thinking of unconscious bias as a scarlet letter, understanding that bias creeps into everyone from all kinds of sources—and that there is nothing we can do to stop it—will help health systems begin to rethink their implicit bias training strategies.

That’s at least where Danielle Brooks, director of health equity at AmeriHealth Caritas, starts when she holds implicit bias training sessions.

The Medicaid managed care organization (MCO), which serves 13 states and the District of Columbia, requires implicit bias training in some form for many of its employees, and it also offers training to its contracted providers.

The concept of implicit bias isn’t new, but the way healthcare experts think about its impact on medicine is relatively novel. While many organizations may say they have been doing health equity work for decades, one can appreciate the renewed energy these subjects got in 2020 after the initial COVID-19 outbreak and the nation’s racial reckoning in the wake of George Floyd’s murder.

As part of many healthcare payers’ and providers’ commitments to advancing health equity, many organizations have followed a similar path as AmeriHealth Caritas.

But it’s easy to misunderstand implicit bias and the intentions behind these trainings, Brooks told PatientEngagementHIT in a recent phone interview.

“Defining implicit bias is a tricky subject because it's something that everybody has,” Brooks stated. “Humans, just like any other animal that is out there, have instincts and other things baked into their way of being.”

“And for humans, implicit bias really is something that we develop from our lived experiences,” she continued. “Oftentimes when you hear implicit bias, everybody goes to the most negative thing possible, but it exists in so many other things.”

Take, for instance, the way Brooks begins many of her implicit bias training sessions. Surveying the group, Brooks asks if there are any sports fans and which team they support. She even reveals her own allegiance (the Iowa State Hawkeyes, but she said that she still isn’t much of a sports person.)

Nobody is born with that kind of sports allegiance, despite some fans’ claims that they bleed for their team’s colors and mascots. These are learned opinions, or learned biases, and those biases exist in humans regarding other topics, too.

“So, bias can be perceptions of certain groups, perceptions of certain geographic areas based, again, on your experience in your community and where you learn from,” Brooks explained.

The trouble is, sometimes the consequences of implicit biases are more serious than having a favorite athlete.

In healthcare, the consequences of unconscious bias can be disastrous, with emerging evidence linking implicit bias to poor patient experiences and poor clinical outcomes.

According to a December 2022 MITRE-Harris Poll survey, 4 in 10 patients of any demographic group reported perceived bias from their providers. That figure was bigger when looking at racial minority groups; 6 in 10 Hispanic people reported perceived bias, the survey said.

Reports of bias were also common among members of the LGBTQ+ community, individuals with limited English proficiency, those with chronic illness, and family caregivers.

Separate data has shown that those levels of bias impact what happens during the healthcare encounter. For one thing, implicit bias and the microaggressions that can come of it are creating a bad patient experience. Patients who report implicit bias have said they sometimes handle it by foregoing healthcare access altogether.

Moreover, evidence is emerging showing that implicit bias might be impacting actual clinical care. In December 2022, researchers found that Black people, who experience worse brain tumor outcomes than White people, were less likely to receive recommendations for surgical tumor removal. Those differences defied socioeconomic factors, suggesting to the researchers that some form of bias was involved.

Those broad consequences could be due to the way implicit bias creeps into all elements of the healthcare experience, Brooks said. Bias is present when healthcare professionals calculate risk, plan care coordination, or refer patients to certain services.

“Health is such a personal thing, it's such a need of everybody, and when you have bias creep up, it really does impact the way that people access, receive, and the types and quality of care that people have,” Brooks argued.

The healthcare industry is growing more conscious of these issues, and as part of the industry’s push for health equity, it is working to unwind some of the biases to create better clinical outcomes. But as Brooks noted above, tackling implicit bias is hard.

The concept of implicit bias can be nebulous and difficult to define. And from there, it can be challenging to teach individuals about bias in a way that is effective and promotes accountability but also makes everyone involved feel comfortable on some level.

AmeriHealth Caritas has three layers of training: one for providers, one for internal staff members, and then specific training for certain departments that are member-facing. Most of the trainings, which can be group or one-on-one, happen over Zoom these days.

Brooks said approaching unconscious bias training with a functional mindset—meaning she considers the person’s role in the healthcare organization—has helped her design more meaningful sessions. The goal is not to erase someone’s biases; that would be impossible.

Rather, helping to define what implicit bias is, how it affects healthcare, and how one can identify their own biases helps go a long way. Creating that awareness will help people act to counter their biases.

But even beyond curriculum, implicit bias training is challenging because trainees carry with them so much from their work and personal lives.

“People come to work, they have outside lives, they have outside pressures,” Brooks pointed out. “Some jobs are different from others, and it's sometimes hard to see, especially if you're in more of a production role, to see how your choices, judgments, and perceptions can impact the way the bias is trickled out.”

This is particularly salient for clinician providers, who have reported unprecedented levels of burnout in the past three years.

“I find it helpful to give those tools so that it becomes a framework and a functional way of thinking about it versus, ‘I have to think internally and try to figure it out myself,’” Brooks explained.

Along the way, Brooks and her team of social workers, clinicians, research and policy experts, behavioral health professionals, community engagement representatives, and data scientists, do extensive surveying. This helps Brooks determine how effective trainings were and where trainees would like to see the sessions improve.

Surveys also give the training team more insights into the specific needs of a market. Being that AmeriHealth Caritas serves 13 states plus DC, it’s important that implicit bias training does not take a one-size-fits-all approach. Trainees need the tools to be responsive to all patient needs, not a prescriptive strategy.

Above all else, Brooks asserted that implicit bias training needs to be empathic and humanized. Trainees are in a vulnerable position when they question their implicit biases, and further alienating them will not cultivate change.

“We don't try to make the experience ‘stuffy’ or ‘clinical,’” Brooks noted. “It's a very serious topic, don't get me wrong, but it is really critical to be able to come to these conversations with humility in yourself and say, look, ‘I'm a person. These are the things that we're talking about.’ And trying to make the environment as comfortable and as human as possible. Because if you approach it with too much clinical nature, then it's going to shut people down.”

Brooks works with the mantra that any question that is respectful gets a respectful answer. Implicit bias training is a marathon, not a sprint, so Brooks and her team understand that they need to create an environment in which people can grow and change over time, not overnight.

And the same policy goes for her team, Brooks said.

“For anybody who does this work, it is heavy. It is emotional, it is exhausting,” Brooks explained.

“You're often advocating for people that look like you or from areas that you're from, speak your language, whatever,” she concluded. “And so, I always encourage my team to take breaks, talk to me, and let me know if this is just not the day. If you choose to do this work, you have to know when self-care is critical and how that can also broaden and strengthen your work as well.”