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Dear IHI: How Do I Talk about Implicit Bias Without Making People Defensive?

Why It Matters

Talking about implicit bias can be difficult in health care, where professionals care deeply about what they do and try to do their best for patients.

Dear IHI — 

I’m an emergency room nurse, and I was recently promoted to a supervisor position. I’m passionate about health equity, and I’ve only become more convinced of the importance of addressing institutional racism after following the news on police shootings of black men over the last few years. I believe we may have some quality issues related to implicit bias, but when I’ve tried to bring up the topic of race and implicit bias, I’ve gotten nothing but defensiveness from my team. How would you suggest I approach this topic so that my team feels motivated rather than threatened by this issue? — TONGUE TIED


You have raised a very important and difficult issue, and I applaud your courage in tackling it. Talking about implicit bias can be difficult in health care, where professionals care deeply about what they do and try to do their best for patients. They may find it difficult to perform the deep self-examination needed to confront their own potential for implicit bias in caring for patients. But the uncomfortable truth is that we live in a society in which stereotypes about groups of people are ubiquitous, and it follows that almost everyone has some implicit bias.

I’ve found that even in enlightened organizations, there can be surprise, defensiveness, and resistance when someone brings up bias and racism, especially from people who haven’t experienced racism themselves. And it may be more difficult to initiate a conversation if one person has more power or higher status than the other, if one is black and the other white, or even if one is a woman and one is a man.

To get started, here are a few ideas.

  • First, your organization may have an individual or department that is charged with addressing equity and reducing disparities. They may have some very good ideas and resources and can help you coordinate your initiative with other current or planned programs.
  • Review your quality processes and outcomes stratified by race, ethnicity and/or language. This is a best practice for quality improvement, because we know QI initiatives can maintain or widen disparities in care. Looking at your data as a team is a great way to give people something concrete to discuss. Our colleagues at the Disparities Solutions Center have great tools to help you review your data in this way.
  • At IHI, we have used videos or articles to raise the subject of implicit bias. That way, the questions and ideas about the issue are coming from a third party. For example, IHI recently released a white paper on health equity that talks about the importance of addressing implicit bias in clinical encounters. You can then discuss these resources together in a team meeting.
  • Another tool for your team is the Implicit Association Test designed by Harvard to measure the strength of associations between concepts (e.g., Asian Americans, gay people) and evaluations (e.g., good, bad) or stereotypes. We recommend people take the race test and one other.
  • You might work with others interested in this topic to bring an organizational training on race and implicit bias to your staff. There are many organizations with trainings on implicit bias for health care professionals.

It can be useful as a leader to set the example that it’s OK to talk about the reality of implicit bias, and that people shouldn’t be ashamed of it — in most cases, it’s not any individual’s fault. I’m not proud to admit it, but the society I live in has conditioned me to associate black men with criminality even though I know that this is a gross, inaccurate generalization. Not long ago I noticed that I was feeling uncomfortable around a group of black men when I was the only white person in a subway car at night, and this prompted me to have a long dialogue with myself about why I felt the way I did and to confront my own implicit bias. Sharing this type of observation first can make your team more comfortable discussing their own bias.

If we want to make progress on this issue, we have to be honest about the impact of implicit bias on clinical interactions. Thanks for bringing up this difficult conversation.

Good luck,

Don Goldmann, MD
Chief Medical and Scientific Officer, IHI

Editor's Note: "Dear IHI" was an advice column in which IHI experts answer questions from health care change agents in the field. 

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