implicit bias

Implicit bias in healthcare is real. This is not just a story about that. But I will get there. It’s more about my recent reflections and observations given the current heightened awareness of racial tensions.

I’ve been holding off on responding to the racial tensions and topics of late.  Not for lack of wanting to, but for wanting to be educated first.

I saw a lot of people responding right out of the gates and often wondered….how do these folx already have an answer?  I really needed to delve a little deeper. To discover and perhaps dissolve my upbringing..uncover my beliefs in ways I had never done before. Because I never really had to. Life was comfortable. Until it wasn’t.


It was time to practice my yoga off the mat by engaging in svadhyaya (self-learning). So, I’ve been doing a lot of reflecting, reading, listening, and observing.


I’d been in the middle of reading Michelle Obama’s, Becoming, when the news became flooded with not one, but numerous incidents of black lives being taken. It’s a story of her and her family. But within that a story of race and class. Touching on systemic racism and where it rises, where it doesn’t change.


From then I went on to read Barrack Obama’s, Dreams of My Father: A Story of Race and Inheritance. Again, a story of his coming of age and why he became the human that he did, and more conversations about systemic racism and his efforts towards trying to make change. Fascinating to read from its roots in Africa and current times to the states.


But I have to say, my exploration began when I head Anthony Ray Hinton on Oprah. I had somehow missed the beginning when they talked about the year this took place. I remember thinking, this must have been in the 50’s or before.  Upon looking the story up, I was shocked to find out it was in 1985! Anthony is an American man who was wrongly convicted of the 1985 murders of two fast food restaurant managers in Birmingham, Alabama, sentenced to death, and held on the state’s death row for 28 years. When he was released, he was noted to look up and exclaim, “the sun does shine.”  He went on to write the book of a similar title, The Sun Does Shine: How I Found Life, Freedom and Justice.


You might appreciate a short write up on his case by the Equal Justice Initiative, founded by the attorney, Bryan Stevenson who helped to free this man, as well as many other black persons that were wrongfully convicted. When you don’t have the finances or the knowledge to fight for yourself, you’re often lost in the system that doesn’t always aim to treat each with equal justice. Click here to read the short write up:


I read a book that came recommended by so many at this time, How to Become an Anti-Racist by Ibram X Kendi. This had to be the most stirring of my explorations,  to access my deep-seeded beliefs. It really got me thinking about my own unconscious bias. And it led me to a more compassionate view from everything  about education, to music to clothing styles, to beyond.  As well as an exploration of history, laws and politics surrounding racism of all kinds.


I listened to podcasts by black activists and writers. I came to the realization that I don’t listen to black-led podcasts (except for Oprah–she’s an iconic figure that has passed all classes and races, I believe). But unless one of the regular podcasters I listen to are interviewing someone black, I realize that I’m not driven to find black podcasters. I never felt like I was actively choosing White people to listen to. I think in some way, I subconsciously felt that I would better relate to a White person’s view.  Not true. Here are some things I’ve been listening to and watching.

How to be an Anti-Racist, Brene Brown and Ibram X Kendi

Brene Brown and Austin Channing Brown –this led me to Austin’s podcast, The Good Life Project 

Jeff Krasnos on One Commune with Anasa Troutman 

Anasa Troutman on Cultural Joy for Everyone–this one brought tears to my eyes

8:46 by Dave Chappelle’s–stirring for sure. I have followed Dave Chappelle’s comedy career but this will be a spin for you if you’re familiar with him

I Am Not Your Negro on Netflix–Based on James Baldwin’s unfinished book, this visual essay explores racism through the stories of Medgar Evers, Malcolm X and Martin Luther King Jr. Watching the images and really grasping that these men all died before age 40…..when have White activist men been gunned down for standing up?

When They See Us on Netflix–I watched this one while donating platelets. And tears streaming down my face, unable to wipe them off. About the ‘Central Park Five’–in April 19, 1989, everything changed for New York City teenagers Antron McCray, Kevin Richardson, Yusef Salaam, Raymond Santana, and Korey Wise. That night, a young female jogger would be brutally beaten and raped in Central Park — and they would ultimately wrongfully convicted, spending time in prison for a crime they didn’t commit. This demonstrates family support vs not,  a faulty media, an unjust justice system and failed prison system when people are not able to fight for themselves—


see above for Bryan Stevenson’s work on racial bias in the justice system and his teams efforts to help find Just Mercy.  These cases are happening all of the time….they don’t always make it to the media.


Along the lines of my mostly White podcast implicit preferences may be the same reason I might feel uncomfortable going to a yoga class where I was the only White person. Guessing it was my implicit biases seeping in without conscious thought to it. Until I thought about it.  It’s not that I wouldn’t think they would have something to offer me—I know the instructor and others in the class, most definitely would. It’s that I feel I might feel out of place. But this happens all the time for BIPOC–at least I imagine it does, because it’s rare that I feel that way. Maybe I’ve been avoiding those situations unconsciously.  I’ve thought about it a million times though, when there are all White people in the yoga class I’m teaching and someone of color is in the class. I find myself thinking, “are they ok? do they feel taken care of by me? what is it like to be the only one in the room?”


Silly right? We’re all human. I know this. We all want the same things: love, respect, comfort, compassion. But here it is, I don’t know what it’s like to be treated differently because of the color of my skin. So, I’m curious. I’m asking the internal questions. Though that person may have never been thinking any of those things. Maybe I’m too much of an empath. I do care. Or naiveté perhaps, or ‘isolation from diversity’ stemming from my upbringing (see below).


I would often have the fear that I would be treated differently for the color of my skin. And for being a woman. When I used to work per diem home health, I was often assigned to patients home’s in Oakland.  My subconscious bias would lead me to thinking that I should be afraid. Afraid of being a white woman going into neighborhoods where white women don’t live.


I remember one time I was parked on the side of the road because it wasn’t yet time to go see my patient. I put my hoodie up so I didn’t look like a target, sitting there.  Trying to “blend in.” UNTIL, a police car drove by and then I was pulling my hoodie down as fast as I could. Too late. I felt the police officer eyeing my car, me with my hoodie. And I felt it…..their subconscious or conscious bias.


And we know these subconscious biases, or implicit bias exist in most of us. And definitely in health care workers. I just took a course called, “Implicit Bias: Strategies to Counter Bias in Clinical Interactions.”  Implicit bias can show up from a variety of social determinants of health: race, gender, age, class, education level, whether someone has insurance or not, language, residential location, culture, just to name a few.


A course at the University of Washington, Center for Health Workforce Studies, implemented a course on the history of racism in medicine, social determinants of health, the science of implicit bias, evidence of implicit bias in health care, and strategies to mitigate the impact of implicit bias. The subjects were clinical teaching faculty: medical doctors (MDs), nurse practitioners (NPs), and physician assistants (PAs). The results indicated:

  • Positive implicit scores favor White vs. Black
  • Positive implicit scores favor male vs. female
  • Positive explicit scores associate males with career and females with family


Another study in health disparities research related to rehabilitation, “Racial Disparities in Post-Discharge Healthcare: Utilization After Trauma” (Chun Fat et al., 2019), found:

  • Blacks were 41% less likely than Whites to utilize injury- related outpatient visits
  • Blacks were 36% less likely than Whites to utilize rehabilitation services


In “Disparities in Access to Outpatient Rehabilitation Therapy for African Americans With Arthritis (Sandstrom & Bruns, 2017) found:

  • Black patients are 45% less likely than Whites to have a PT visit
  • Hispanic patients are 27% less likely than Whites to have a PT visit
  • Increased affordability decreased the disparity, especially for Hispanic patients, but did not erase it


In a systematic review of 15 studies by Hall et al., 2015 on Implicit Bias in healthcare:

  • 14/15 studies used the Implicit Association Test (IAT)
  • 14/15 studies found evidence of low-to-moderate levels of implicit bias against people of color
  • Findings suggest that implicit bias may be activated under stressful working conditions–who doesn’t get stressed out in most healthcare environments?


So, yes, implicit bias does exist heavily in the medical world. I’ve seen it and I know I’ve demonstrated it.


I once was assigned to see a home health patient in Oakland that was a victim of a gun shot and had been treated for that wound. Instead of making sure he was taken care of and was well on his way to healing before discharge, they discharged him without access to much care. He was discharged to his mother’s apartment. I’ll just say this–he would have rather lived in his car (which is where he lived prior to this) rather than live with his mother. And he did receive home health PT, but that was all. If he wanted to get any services to the wound, he would have to end up back in the ER to be seen.


And here is where my implicit bias came in before even seeing him. I saw on his health history sheet, “African American male, age 20, gun shot wound.” Alarm bells off in my mind for sure. But I thought…it would be for any reason. He could have been an innocent bystander. He could have been caught in cross fire.


But I’m a White woman going alone into see him. My boss saw the same thing (she’s Asian if it means anything) and her alarm bells rung enough for her to join me on the visit. That was likely the wrong way, as it’s likely he felt ambushed. He was angry. Rightfully so. He’d been shot by a competitor. He was released early from the hospital, still in a tremendous amount of pain. He was living with his mother, whom he disliked very much. He couldn’t walk, couldn’t drive. He couldn’t access his friends easily. And now here we were sitting in front of him. An Asian woman and a White woman. Asking him to sign papers.


He yelled, he screamed. He called my boss names. I’m not going to lie, it was frightening.


But in my mind, I kept thinking….he has every right to be angry. And it’s not our fault. There’s a human in there that is hurting.


After he demanded that my boss leave and I could stay, we ended up building a trusting relationship.  My boss didn’t want me to go back there alone.  But I continued to visit him and help him progress. Some biases still settled in, but I continued to help him as one human to another.

Think you don’t have implicit biases? Take this test for yourself and see how you perform, Implicit Association Test (IAT).  You can take it for gender, race, age, weight, political party, etc.  It’s hard to not see your own biases popping up while taking it.


I wasn’t raised in a family that outwardly spoke about racism or biases. My parents didn’t outrightly talk down about anyone (that I remember). We weren’t taught to hate because of skin color or culture.  But growing up….I lived in a White neighborhood. I went to a mostly White school in an affluent area. There were maybe 5 Black students in the whole school–the only one I was somewhat friends with was on my basketball team.


I went to school at UCSD, which while very diverse, all of my friends were White or Asian. I can’t even think of any Black students in my dorm. And there was not even a Black person on my basketball team. So, while I was not raised with a racist or discussed biased upbringing, I do feel like I was part of a world where racism just existed because I was growing up in privilege. I don’t necessarily see that as a bad thing….it just is.


And I’m grateful in some sense. And in other aspects, it would have been more enriching to grow up with more diversity. 


So, I’ve divulged what I feel I need to at this time. I’m still reflecting, reading, listening, and observing.  In the middle of an online Anti-Racism Training out of the Diversity and Resiliency Institute of El Paso, which looks at racism across all BIPOC, including Native Americans, Asian Americans, Hispanic Americans, as well as Black Americans.


And I’ve signed the Pledge to End Racism in this generation per the manifesto by Just Michael Williams. Once you read, you can sign the Pledge too.

sign the pledge to end racism

I welcome your feedback and if you find this information helpful, please share with your colleagues, friends & family. I would love to hear how you’re reflecting, reading, listening and observing during this point in history.  Contact Tianna and let me know—there’s always more to learn.