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. Author manuscript; available in PMC: 2022 Dec 1.
Published in final edited form as: Med Teach. 2021 Feb 8;43(12):1368–1373. doi: 10.1080/0142159X.2021.1879378

Twelve Tips for Teaching Implicit Bias Recognition and Management

Cristina M Gonzalez 1, Monica L Lypson 2, Javeed Sukhera 3
PMCID: PMC8349376  NIHMSID: NIHMS1693536  PMID: 33556288

Abstract

Implicit biases describe mental associations that affect our actions in an unconscious manner. We can hold certain implicit biases regarding members of certain social groups. Such biases can perpetuate health disparities by widening inequity and decreasing trust in both healthcare and medical education. Despite the widespread discourse about bias in medical education, teaching and learning about the topic should be informed by empirical research and best practice. In this paper, the authors provide a series of twelve tips for teaching implicit bias recognition and management in medical education. Each tip provides a specific and practical strategy that is theoretically and empirically developed through research and evaluation. Ultimately, these twelve tips can assist educators to incorporate implicit bias instruction across the continuum of medical education to improve inequity and advance justice.

Introduction

Implicit bias refers to unconscious and unintentional mental associations that impact our understanding and actions. Such biases, when brought to the clinical encounter, can contribute to health disparities by influencing communication practices and medical decision-making (Zestcott, Blair, and Stone 2016). The effects of bias are pervasive and globally widespread. Research across several cultures and jurisdictions demonstrates the negative effects of bias on healthcare and medical education (Mellor et al. 2016; Gonzalez, Deno, et al. 2018). Implicit bias recognition and management (IBRM) training for health professionals provides an approach to addressing biases and reducing health disparities. Accreditation bodies in several countries also require instruction on implicit bias (Australian Medical Council Limited 2012; Committee on Accreditation of Canadian Medical Schools 2018; Liaison Committee on Medical Education 2020).

Despite increased attention to implicit bias in medical education, approaches to instruction are varied and often limited in scope. Well-intentioned attempts to meet accreditation standards have resulted in curricula often based on opinion, rather than research, thereby lacking appropriate theoretical frameworks and grounding in available evidence (Sukhera, Watling, and Gonzalez 2020). In addition, there are significant gaps in providing opportunities for learners to develop skills and in training faculty (Gonzalez, Garba, et al. 2018; Brooks, Rougas, and George 2016; Gonzalez et al. 2020). As a consequence of these limitations, questions are being raised regarding both the effectiveness and sustainability of implicit bias related instruction.

Given the importance of this topic and the need for improving instruction and outcomes related to IBRM, the authors identified a need to provide practical and evidence-informed teaching tips regarding IBRM for medical educators. Existing research on IBRM instruction suggests the need to enable learners to recognize when bias may be influencing an encounter and employ skills to manage the effects of bias to mitigate its negative influence (Sukhera, Watling, and Gonzalez 2020). The focus of IBRM is therefore best targeted at recognizing and managing biases within the context of interpersonal encounters in both clinical and non-clinical learning environments. This approach to IBRM recognizes that the elimination of all bias is not the goal of instruction and is distinct from approaches that seek to de-bias or entirely remove the influence of bias on an individual’s communication and decision-making. There is minimal evidence for short-term efficacy and no evidence for actual behavior change (FitzGerald et al. 2019; Forscher et al. 2019) for such approaches. The twelve tips in this paper reflect a synthesis of existing literature on bias-related instruction while remaining steeped in learning theory and the authors’ experiences in designing, implementing and evaluating curricula on IBRM.

Tip One: Create a safe learning environment

A safe learning environment is paramount to teaching and learning about emotionally charged topics such as implicit bias. Learners and facilitators need to work together to create a learning environment where there is safety, and room to grow; a “safe but brave” learning environment (Sotto-Santiago et al. 2020). Ground rules must be set to ensure confidentiality, learners must have the psychological safety to grapple with challenging concepts and minimize fear of being labeled as a racist (for example) if they struggle while articulating their thoughts (Gonzalez et al. 2019). In addition, bias related instruction is a challenging topic for faculty to teach, many of whom are experiencing the same worries as the learners (Gonzalez, Garba, et al. 2018). From our experience and research, we have found that explicitly layering instruction by role modeling empathy and vulnerability help to co-create brave spaces for sensitive discussions (Sukhera, Wodzinski, et al. 2018). A practical suggestion to cultivate psychological safety involves using index-sized cards with “honest inquiry” written on one side and “honest reaction” written on the other. Students can hold up the card when they have an honest inquiry and ask a question to learn and grow, but that they may otherwise be nervous to ask (Zestcott, Blair, and Stone 2016). The honest reaction side enables other students to react to the question, explain how it made them feel, and suggest alternate phrasing, if applicable.

Tip Two: Flatten the hierarchy in facilitation

Building on the need for a safe and brave learning environment, flattening the hierarchy in facilitation (disabling the power of rank and differential) serves multiple purposes (Gonzalez et al. 2019). Students have suggested having a senior student facilitate or co-facilitate with a faculty member to ease any tension they feel when discussing implicit bias with someone in an evaluative role. Learning from a senior student may also enhance the relevance of the discussion to their level of training (Gonzalez et al. 2019). Reducing the power differential between learners and teachers aligns with evidence-based approaches to instruction that recognize how learners’ lived experience and prior learning can be activated during instruction (Merriam 2007). Attention to hierarchy also benefits faculty by providing opportunities to pose problems and role model being both a teacher and a lifelong learner (Freire 1993). Using this approach allows teachers and learners to address the discomfort related to the topic and co-construct the ensuing critical reflection and guided discourse. Research suggests that students appreciate when faculty role model vulnerability (Sukhera, Wodzinski, et al. 2018; Gonzalez et al. 2019) and faculty may feel more comfortable exposing such vulnerabilities in an environment where the pressure of being “all knowing” is relieved (Gonzalez, Garba, et al. 2018).

Tip Three: Normalize bias while reducing self-blame

Discussions about bias often trigger a defensive and emotional reaction (Teal et al. 2012). When provided feedback about their biases, individuals often experience tensions related to their self-identity as well-intentioned people working hard to take excellent care of patients (Sukhera, Milne, et al. 2018a). Normalizing bias while reducing self-blame can effectively address these negative emotions by building trust, enhancing comfort, and increasing engagement (Gonzalez et al. 2019). We suggest emphasizing that although bias is human nature and therefore not anyone’s fault, we must engage in skill development and practice so that it does not influence our clinical practice behaviors. This call to action while avoiding blame can also enhance self-compassion and self-forgiveness (Sukhera 2018; Sukhera 2019).

In our experience, there are several practical ways to reduce self-blame within IBRM. For example, presenting data from other industries outside of health professions may enable learners to accept the ubiquitous nature of implicit bias. In addition, video observation and debrief can be helpful for multiple reasons. Practicing observing and discussing behaviors of others eases learners into the idea of discussing their own behaviors. Videos from the lay press or examples within popular culture that involve humor offer an opportunity to recognize bias as part of human nature and bring down defenses (Gonzalez et al. 2020).

Tip Four: Integrate the science behind implicit bias and evidence base for its influence on clinical care

A multi-faceted approach is more likely to engage learners by including reasons to participate in IBRM that they find personally relevant. Describing the neuroscience and cognitive psychology behind implicit bias will ground instruction in content that is similar to much of the basic science taught in medical schools; this approach lends legitimacy to IBRM instruction as well while enhancing relevance (Merriam 2007). By highlighting the influence of bias through relevant clinical examples, resistant or uncertain learners may be motivated to engage in instruction by their desire to provide excellent, high quality care to all patients. Tailoring the evidence, when available, to the clinical specialty or learning context of the audience may further enhance the relevance for differentiated learners further along in their careers (Sukhera et al. 2020).

Tip Five: Create activities that embrace discomfort

Discomfort is an essential ingredient in bias-related instruction. One of the models that may be useful for recognizing and reconciling discomfort comes from the literature on Transformative Learning Theory. Transformative Learning Theory seeks to create dissonance through a “disorienting dilemma” and foster critical reflection, guided discourse, and action through behavior change. (Mezirow 1997; Sukhera, Watling, and Gonzalez 2020). Therefore, eliciting discomfort leads to questioning of previous assumptions and catalyzes a paradigm shift for the learner. To create and embrace discomfort, educators can create first-thought exercises; these exercises often demonstrate to participants their own bias in a non-confrontational matter, for example, by recognizing mental images that appear in response to hearing a series of spoken words (Vela et al. 2008). Another option is to use the Implicit Association Test (Sukhera et al. 2019) as an elicitation prompt. In addition, interviewing standardized patients (SP) may provide a direct demonstration of how of bias is perceived during a clinical encounter, while providing an opportunity to debrief the encounter and reconcile their discomfort as they embrace a growth mindset (Morell, Sharp, and Crandall 2002).

Tip Six: Implement Critical Reflection Exercises

Another important component to IBRM fosters both critical reflexivity and critical reflection (Sukhera, Watling, and Gonzalez 2020). Both concepts are distinct processes. While critical reflexivity involves recognizing one’s position in the world to better understand the limitation of one’s knowledge and appreciate the social realities of others, critical reflection involves examining assumptions, power relations, and how these assumptions and relations shape practice (Ng, Wright, and Kuper 2019). Both can be encouraged through the use of well-designed prompts with guiding questions that encourage learners to question assumptions and revisit previous encounters viewing them through a new lens. For example, learners can be encouraged to pause during an emotionally charged encounter that is influenced by bias. The PAUSE model suggests learners should pay attention to the situation, acknowledge their interpretations, judgments, and biases, while understanding other possible interpretations (Ross 2014). In addition, a developmental approach to critical reflection helps move learners from bias awareness towards action for behavior change (Teal et al. 2010; Gonzalez et al. 2020).

Tip Seven: Explore the dynamic relationship between experience, implicit, explicit, and structural biases

Any individual’s implicit biases are a product of their lived experience, socialization processes, (Banaji and Greenwald 2013), and reflect biased norms within their personal and professional contexts (Hernandez et al. 2013; Sukhera, Milne, et al. 2018b). Therefore, exploring the influence of this lived experience may foster acceptance of bias in oneself. Identity or narrative exercises can effectively foster reflection on how an individual’s experiences contribute to their existing biases including the power/oppression/privilege of the system in which they live (Avant and Gillespie 2019; Gonzalez et al. 2020). Building on individual experiences also helps learners to recognize how implicit racial biases can become structurally embedded to contribute to concepts such as systemic racism (Feagin and Bennefield 2014; Bailey et al. 2017; Payne, Vuletich, and Brown-Iannuzzi 2019). Since implicit biases are woven into the fabric of medical organizations and society at large, any educational interventions related to bias must emphasize that individuals alone cannot address implicit biases without addressing structural biases reflected in broader policies and practices (Byrne and Tanesini 2015).

Tip Eight: Perspective-Taking Exercises

Patients experience varied levels of interpersonal and systemic discrimination in society, in addition to their previous experiences within the healthcare system (Gonzalez, Deno, et al. 2018). Recognizing the impact of such lived experience is essential to recognizing and managing biases. Building perspective taking exercises into bias related instruction can serve to enhance learner awareness of how standard procedures may be interpreted differently by patients who are sensitized to experiences of bias, based on their unique lived experience (Gonzalez et al. 2020). Empowering learners with the knowledge that the patient’s reaction occurs in the context of previous experience will enable learners to step back and acknowledge the perceived bias and explain the rationale behind the question or the behavior to the patient, in order to restore rapport with the patient (Gonzalez, Deno, et al. 2018).

Perspective-taking exercises enable learners to practice improved interpersonal communication skills and cultivate empathy (Riess 2017). Effective ways to incorporate perspective taking into IBRM include using videos of lived experience narratives, which have been deemed both relevant and authentic by learners (Gonzalez et al. 2020). Patient narratives also allow individuals to learn and practice ways to restore rapport with a patient if bias is perceived due to a standard behavior (Gonzalez, Deno, et al. 2018).

Tip Nine: Skill-Building Exercises

A lack of skill development and practice is a major gap in IBRM approaches in the literature. Skill development should occur in a graded fashion and encompass skills to address perceived bias from others within the learning environment, as well as addressing biased behaviors by individual learners. For example, role-play and vignettes help to identify strategies to address bias (Gonzalez et al. 2020). Learners can practice verbalizing potential statements they could make to address bias during case-based discussions: A vignette is reviewed with a reflection prompt asking learners to articulate statements they could use to interrupt bias witnessed among others or address bias within themselves. Finally, role-plays that recreate experiences in the learning environment enable learners to develop skills to address perceived bias while in the unscripted role (Gonzalez et al. 2020).

Newly learned skills should also be iteratively practiced and improved upon as part of IBRM. For example, we have previously described our approach of conducting the role-play, engaging learners in a structured debrief, and then providing a “do-over” opportunity so that the same learner has an opportunity to succeed (Gonzalez et al. 2020). Skill-building can also be fostered through the use of SPs. Training SPs to adjust their nonverbal behaviors and/or make statements reflecting perceived bias on anticipated routine questions or behaviors give learners real-time feedback about their efficacy in restoring the rapport within the encounter. These aspects of IBRM instruction should be written into formative SP exercises to provide opportunity for further skill building and practice before any summative assessments are made. In both the role-plays and the SP exercises, learners can identify alternative phrasing and behaviors to enhance their existing communication skills (Sukhera, Watling, and Gonzalez 2020).

Tip Ten: Reinforce IBRM as part of life-long learning

Any attempts at bias-related instruction can be difficult to sustain due to biases perceived within the hidden curriculum and its powerful influence on professional identity formation (Hafferty and Franks 1994; van Ryn et al. 2015; Hernandez 2018). Therefore, singular teaching sessions or workshops are unlikely to produce sustainable change (Teal et al. 2012; Gonzalez, Garba, et al. 2018). We suggest that IBRM must be re-framed as an epistemology of practice that is essential to the professional identity of medical learners to be effective (Sukhera, Watling, and Gonzalez 2020). Medical schools who recognize the personal and professional tensions associated with implicit bias instruction and cultivate a growth mindset around the issue help students make less biased decisions (Williams RL 2018).

The suggestion that IBRM is iterative and cyclical additionally complements efforts to reduce self-blame regarding implicit bias. If all team members have some experience with IBRM, we anticipate this could facilitate discussions during routine clinical and teaching encounters. Team members should be encouraged to seek feedback regarding their own biases from others, debrief encounters where they believe bias may have had an influence, and lean into uncomfortable feedback about their biases in order to grow (Sukhera 2018). Such an approach also addresses student concerns about not feeling empowered to advocate for patients when they perceive bias without risking retribution from supervisors on the team (Gonzalez et al. 2019).

Faculty development programs designed to instruct faculty on debriefing about bias during inpatient rounds or outpatient precepting sessions could equip them with skills to be positive role models about IBRM. In our experience, faculty have suggested a set of stock questions to prompt discussion about potential bias which may serve as a visual aide to highlight the institutional support for these discussions. These ‘pre-reviewed’ questions also provide scaffolding and readily accessible reminders for team members. If discussions of bias are emotionally charged, these questions alleviate one of the many burdens placed on facilitators. Finally, providing dedicated time and space to discuss IBRM and integrate those discussion into existing educational programming such as didactics, journal clubs, and grand rounds, among others, could further serve to normalize and reduce self-blame regarding IBRM and make it another clinical skill to develop and practice.

Tip Eleven: Include Formative and Summative Assessments

“Assessment drives learning” is a common adage. Learners may not value IBRM instruction if it is not assessed (Gonzalez et al. 2019). The educational strategies in this paper reflect existing education approaches that are tailored to IBRM, adapting assessment strategies is also necessary. Formative feedback can be given throughout, and also reinforced in the clinical phases of instruction and trainings as described in Tip Ten. We suggest that assessments should not focus on the idea that bias is can be measured, fixed or eliminated through instruction (Sukhera et al. 2019). Rather, the behavioral focus of IBRM necessitates assessments focused on the knowledge, attitudes, and skills of recognizing the influence of bias in a clinical encounter and then managing this influence to mitigate negative consequences and restore rapport with patients (Gonzalez, Deno, et al. 2018). Formative assessment can be seamlessly woven into all of the tips in this paper. For example, facilitated discussions, following critical reflection as well as the role-play and SP exercises. In addition to formative assessment, we believe opportunities for summative assessment include knowledge tests while assessment of skills in IBRM would naturally fit into objective structured clinical examinations.

Tip Twelve: Obtain explicit support from leadership (formal and informal)

Published frameworks, along with our experience, suggest delivering multiple sessions on IBRM in order to achieve skill development and practice (Teal et al. 2012; Sukhera and Watling 2018; Sukhera, Watling, and Gonzalez 2020; Gonzalez et al. 2020). Integrating multiple sessions into the compulsory curriculum requires central coordination and explicit support from institutional leadership. In addition, support from the leadership may dismantle perceived barriers to instruction and enhance the ability to foster a culture where IBRM is seen as an important part of professional identity formation relevant to all physicians as described in Tip 10. We expect leadership support will allow for central coordination obviating unintentional redundancy, maximizing efficiency, and facilitating the design of a developmentally appropriate curriculum. Institutional support will demonstrate the value of IBRM to faculty, trainees, and students, potentially fostering engagement of learners who are motivated more by professional norms than personal norms (Hernandez et al. 2013). Leadership support should also reflect authentic and meaningful approaches towards structural change as performative statements without action may perpetuate cynicism and mistrust. Lastly, funding and evaluation must be central to leadership support (Gray et al. 2020). IBRM can only produce sustained changes if it is adequately resourced and supported as part of continuous quality improvement initiatives.

Conclusion

The prevalence of implicit bias curricula suggests great interest in the topic. Despite proliferation in IBRM, there are still many challenges for implementation. For example, many existing approaches to foster IBRM often fall short of skill development and practice in IBRM, perpetuating frustration for learners who are faced with knowledge of a problem, but lack skills to adequately address it and improve patient care (unpublished data under review). Our proposed tips were compiled to address this gap while elaborating on actionable tools for educators and curriculum developers. We also sought to address the emotionally charged nature of the subject matter, resistant learners, and unsupportive or unaware institutional climates (Gonzalez, Garba, et al. 2018). With a better understanding of the evidence base and existing frameworks, educators can design curricula in IBRM that engage learners, garner institutional support, and achieve skill development and practice. Integration of such instruction throughout the spectrum of training and practice may empower team members and facilitate meaningful and sustainable learning outcomes over time. Increased individual successes could ease future curriculum development efforts and foster professional growth and life-long learning. In this paper we attempt to provide evidence-informed and practical tips that facilitate awareness and skill development related to IBRM. We recognize that more research is needed bias-related instruction, particularly in clinical learning environments and in relation to patient-centered outcomes. Our hope is that as skills-based instruction in IBRM expands, the required research to investigate its impact on patient outcomes can also be strengthened as we collectively work towards a more just and equitable health system for all.

Contributor Information

Cristina M. Gonzalez, Department of Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York, USA..

Monica L. Lypson, Professor of Medicine, Department of Medicine, The George Washington University School of Medicine and Health Sciences, Washington, D.C., USA, Adjunct Clinical Professor of Internal Medicine and Learning health Sciences at the University of Michigan Medical School, Ann Arbor, Michigan, USA.

Javeed Sukhera, Departments of Psychiatry/Paediatrics and Scientist, Centre for Education Research and Innovation, Schulich School of Medicine and Dentistry, Western University Canada.

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