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March 30, 2015

Unconscious Bias: An Introduction

Prepared by Jan Hanson, MPH – Case Comprehensive Cancer Center and

Valerie Vinson, M.Ed, LSW – University Hospitals Seidman Cancer Center Community Outreach Program


What is unconscious bias?

Unconscious bias, also known as implicit bias or implicit social cognition, is the concept that many of our everyday decisions are made on an unconscious level (Banaji. 2013). It refers to the stereotypes and cultural concepts which influence our behavior without realization (Kirwan Institute, 2014). These biases are important because they allow people to function within societies (Ross, 2013). They allow us to quickly assessing situations by comparing current experience to past experiences and by categorizing ideas and people based on what we have learned from our parents, personal experience, and society. These can be survival mechanisms that allow us to know what is dangerous and what is safe. They can also be limiting or even harmful when these biases result in mistreatment of people based on broad characteristics such as race, religion, culture, language, political view, education, or social class. Unconscious biases generally favor ingroup relationships, although people can still hold biases against these relationships with the tendency of favoring the group holding the most social power (white, wealthy, men, without disability) (Banaji, 2013; Kirwan Institute, 2014). It is important to understand that no one can, or should, remove all biases since they shape how human societies interact, but people can bring awareness to personal biases to recognize potential areas of injustice.

What situations are affected by unconscious bias?

Unconscious bias affects all parts of life (Banaji, 2013). It influences social interactions, what jobs people are hired for, where people live, and the types of medical care people receive (Moule, 2009; Teal et al., 2012). The focus of this review is on how implicit bias impacts clinical trials. Unconscious bias affects clinical trials at all stages of recruitment and retention (Miller et al., 2001). Biases influence which patients are asked to take part in clinical trials, who consents to be on a clinical trial, individual adherence to a protocol, and providing quality data. Researchers need to be aware of biases at all stages of research and try to mitigate negative effects when possible.

Why is unconscious bias important?

It is clear that unconscious bias affects health outcomes of minorities in negative ways (Blair et al., 2014; Green et al., 2007; Ramirez et al., 2013; Nolan et al., 2014; Chu & Freedland, 2010). Blair and team showed that poor hypertension outcomes were associated with racial biases of clinical care providers (2014). These data supported findings Green and team found in 2007. A similar study with oncologists treating majority Latino populations identified barriers to enrolling Latinos in studies, suggesting a possible route of addressing ethnic disparities in oncology outcomes (Ramirez et al., 2013). Delays in cervical cancer screening were showed to be associated with implicit biases of patients towards medical care providers (Nolan et al., 2014). In 2010, Chu and Freedland described the need to be wary of unconscious bias because of known disparities in prostate cancer treatment linked to socioeconomic status. In describing the pervasiveness of implicit bias on clinical trials, Debra Collyar, president of Patient Advocates in Research, discusses how all people have implicit biases and these biases effect trial diversity (2009). The Patient Advocate showed that misconceptions or assumptions about race, ethnicity, majority or minority position, socioeconomic status, and other patient factors effects practitioner’s decisions to even mention a clinical trial as an option. 

While the injustice of racial health disparities is undeniable, there is reason for optimism. A promising study by Hanna and Carpenter-Song in 2013 showed that while all medical students in their study were shown to have unconscious biases, that these biases did not affect patient care or treatment plans.

What can we do about unconscious bias?

Bringing the unconscious, conscious is one of the most effective ways of mitigating negative effects of implicit bias (Teal et al., 2012; Ross, 2013). One of the most widespread tools for recognizing unconscious bias is the implicit association test (IAT) (Banaji, 2013). This tool was developed by Brian Nosek, Mahzarin Banaji, and Tony Greenwald, who now head the Project Implicit team at Harvard University (Banaji, 2013). This self-administered test lets people assess their own biases in age, disability, weight, religion, race, gender and careers, skin tone, and others although some limitations to this test exist (van Ryn & Saha, 2011). A methodical program of addressing unconscious bias was set up by Harvard Medical School (Hannah & Carpenter-Song, 2014). These voluntary faculty development courses promoted self-awareness and introspection to create a safe-space to share concerns. This strategy was affective at increasing awareness and acceptance of personal biases. By making racial equality a priority, national political policy changes can also decrease health disparities (Williams & Rucker, 2000). Additional tools may be needed to further address implicit biases on clinical decision making (Oliver et al., 2014). With conscious and constant efforts it may be possible to bring awareness to implicit biases and provide equitable treatment to all people.

Unconscious bias in ACTION: Bringing the unconscious, conscious!

  • Take a test: Explore the IAT website and find out what some of your own biases may be:
  • Before entering a new situation, reflect on how your own biases may influence the situation and make an effort to be aware of your biases throughout the situation
  • Get support: Openly discuss your biases with a group you can trust. By talking about your biases you bring them conscious and can limit harmful stereotyping
  • Be honest: Everyone has biases. It is part of how people function in societies. What is important is how we act on these biases

Cultural Inclusion and Awareness Series

The Case CCC Minority Accrual Committee (MAC) would like to introduce a new name, Cultural Inclusion and Awareness Series for the Cultural Competency Series.  The new name will allow the Committee to broaden the Series scope and post information which will have more research focus. 

September 19, 2017: Engaging Underrepresented Racial/Ethnic Populations in Clinical Trials

June 15, 2017: Health Disparities Data Widget

May 8, 2017: FDA Drug Trials Snapshots and Diversity When Testing New Drugs

December 1, 2016: SRHEC Debuts Cultural Competency Resource Guide and White Paper

April 5, 2016: National Minority Health Month

December 15, 2015: Case Comprehensive Cancer Center Cultural Competency Series

November 18, 2015: Cultural Competency and the Informed Consent Process

October 14, 2015: October is Health Literacy Month

October 2, 2015: Unconscious Bias: Cancer Clinical Trial Disparities in Racial and Ethnic Minority Populations

August 24, 2015: Revised: Case CCC Clinical Research Brochure for African Americans

July 17, 2015: Reshaping Research: A Guide to Integrating Cultural Considerations into Research

June 19, 2015: What We Really Talk About When We Talk About Food

May 18, 2015: Think Cultural Health

March 30, 2015: Implicit Bias: An Introduction

February 9, 2015: Eliciting the Patient's Experience of Illness through Narrative and Reflection

January 26, 2015: Cultural Competency and the Research Process

January 12, 2015: Understanding Cultural Competency: Definitions and Concepts

December 8, 2014: Operationalizing Culturally Competent Research