Bias is everywhere. Explicit biases include conscious attitudes or intentional discrimination toward certain groups.1 In contrast, implicit biases include attitudes or behaviors that exert a powerful influence over individuals outside their awareness.2–4 These implicit biases can perpetuate health disparities by widening inequities and decreasing trust between patients and health professionals. For example, implicit racial bias has been associated with inappropriate nonprescription of treatments for black compared with white patients.5,6 Implicit biases may also lead health professionals to appear dishonest to marginalized and underserved populations,1 leading to interactions that self-perpetuate cycles of distancing and disconnection.7,8
In response, educators are identifying potential interventions to mitigate the adverse impact of implicit bias on health care.9–16 Previous research describes how once biases are brought into awareness, there is an ensuing tension,14 which triggers a process that requires reflection and reconciliation.15–20 The first step in recognizing one’s biases requires seeking feedback through reflection; discussion; or tools such as the implicit association test (IAT), which is an online metric of response time that asks participants to associate words and assess automatic associations between certain concepts.18 The IAT measures response latency and has demonstrated several psychometric properties that support its use as a metric of implicit bias.18,21–27 Feedback information from the IAT may trigger long-lasting and powerful emotions such as shame or guilt,28,29 which require renegotiation each time they are encountered.30–33
In a recent study exploring health professional responses to feedback about implicit biases, we found that when physicians and nurses were provided with feedback about their implicit bias, this information evoked tensions related to their personal and professional identities. Participants struggled to reconcile feedback information about their biases, as they found it inconsistent with an aspirational version of themselves that seemed unrealistic to achieve.19 The implications of our initial findings suggest that antibias education takes place within a culture where health professionals hold themselves to unrealistic and perfectionistic standards,34,35 which contributes to psychological distress and self-doubt.36 If recognizing implicit bias has the potential to trigger self-doubt, and identity influences the reflection and reconciliation required to manage biases, we must seek deeper understanding of the process.
As individuals process and integrate information about their biases, there are several identity-related influences on how they evaluate their beliefs and behavior. They may appraise themselves according to their values and personal morals, or they may compare being biased to norms within their professional culture.20 Hernandez and colleagues15 found that medical students drew on personal standards more than professional norms when critically reflecting about their implicit biases. Personal and professional standards may also relate to how an individual views their identity according to themselves, their relationships with others, or their social group.28 For any health professional, learning that they hold implicit biases is unlikely to align with their ideal self-representation.
Without improving our knowledge about how identity influences implicit bias, we cannot leverage the full potential of implicit bias recognition and management curricula to reduce disparities and improve equity. To explore the relationship between identity and implicit bias management, we chose to explore implicit dangerousness biases toward individuals with physical or mental illness among psychiatry residents and faculty. Many mental health professionals view destigmatization as part of their role and therefore hold explicitly positive biases toward their patients, which do not always align with their implicit biases.37–39 This discrepancy between explicit attitudes and implicit biases about dangerousness may create tensions within an individual that must be processed and negotiated whenever they arise.
Negative attitudes toward patients with mental illness comprise a particularly pervasive and problematic set of implicit biases encountered in the health care system; these biases have been shown to result in mental health patients being overdiagnosed, undertreated, and more strongly associated with dangerousness compared with patients with physical illnesses.40–47 The stigma experienced by mental health patients, including feelings of stigmatization by mental health professionals, is a barrier to seeking and receiving sufficient medical care; thus, attempting to elucidate and address implicit biases held by mental health professionals is one potential route toward destigmatization and improvement of patient outcomes. The purpose of our study was to explore how learners and faculty reconcile identity tensions evoked during the process of implicit bias recognition and management. By exploring dangerousness bias within psychiatry, we hoped to elicit insights into how identity-related tensions are reconciled for other health professionals.
In this study, we defined implicit bias as associations, attitudes, or beliefs that exist and enact their influence outside of an individual’s conscious awareness.
We electronically shared recruitment notices among mental health professionals working within an academic health sciences center in Ontario, Canada. We sought roughly equal participation between resident learners and teachers, and 21 individuals (9 male and 12 female) responded with an interest in participation. We completed semistructured interviews with 11 practicing psychiatrists involved in clinical education and 10 psychiatry residents. Interviews took place from June to October 2017. Approval was obtained from the Western University Research Ethics Board to conduct the study.
Our semistructured interviews lasted 30 to 90 minutes and consisted of reviewing the letter of information and consent followed by completion of the online version of the mental illness IAT. Once participants completed the IAT, they received a result that indicated whether they held strong, moderate, mild, or no dangerousness bias. During the initial interviews, participants were asked open-ended questions about the experience of taking the IAT and were asked to draw a rich picture which we discussed as part of their interview. A rich picture is a visual depiction of processes and human activity developed in systems engineering.48 Rich pictures have been used previously in health professional research to better understand conceptualizations of complex or challenging situations.49,50 We chose a visual method to foster deeper exploration of what we believed was an emotionally challenging situation. In particular, we hoped that a rich picture might address difficulties and limitations with a qualitative interview related to making implicit assumptions explicit.49 An example of a rich picture by one of our participants is provided as Figure 1. All our participants except one drew rich pictures. We asked participants to describe their picture and probed for how their picture related to questions in our discussion guide, which we adapted from previous research.19 Interviews were audio recorded, deidentified, and transcribed verbatim before analysis. The final version of our discussion guide is included as Appendix 1.
Team member composition included the principal investigator (J.S.), a child and adolescent psychiatrist, faculty member, and PhD candidate in health professions education; as well as research staff (M.W.) and three experts in health professions education (C.W., L.L., and P.T.) who do not work in mental health.
We used constructivist grounded theory to conduct our study as we worked on existing research to build theory toward a social process that is not well explained by an established theoretical construct.51–53 Constructivism assumes that individuals construct their understanding and knowledge of the world through a cycle of experience, reflection, and action.54 Once interviews were recorded and transcribed, coding and inductive analysis were conducted by a team consisting of J.S. and M.W. J.S. and M.W. met regularly, revising the discussion guide and ensuring that analysis was consistent with an effort to theoretically sample resident learners and faculty. Partway through the analysis, we found that several participants struggled with visual representations, so we chose to add visual prompts (Figure 2) to encourage reflection. Because of the limited number within our recruitment pool, we included full-time and part-time faculty and junior and senior resident learners. The first seven transcripts were transcribed and coded line-by-line by J.S. and M.W. Subsequent transcripts were coded line-by-line by J.S., who used constant comparative analysis and shifted toward focused consolidation of codes and analysis of relationship among themes. At regular intervals, analysis was shared and discussed with the team who worked toward the development of an explanatory theory and synthesized overall findings. Any discrepancies were addressed through collaborative debate. We continued to collect data and revise our discussion guide until the team felt there was enough data for a robust conceptual understanding of the process under study.55–57 Synthesis of results was shared in writing with all participants through individual e-mails. Those who reviewed the results described general agreement.
Out of our 21 participants, 18 demonstrated IAT results that indicated implicit dangerousness bias toward either mental or physical illness, while 3 showed no difference in their associations between dangerousness and physical or mental illness. The act of completing the IAT and receiving their result provoked reflection about bias in all participants, including those that demonstrated no bias in their result. There were no significant differences between groups.
Acknowledging identity tensions
Once they were provided feedback about their implicit biases, most of our participants acknowledged categorizing and compartmentalizing their identities as part of their experiences. The demands of working with patients with mental illness appeared to influence the pressure they place on themselves to strive for an ideal that was impossible to achieve. When asked how they reconcile bias, one resident described how they have compartmentalized personal and professional identities separated by a “filter” that they must constantly recalibrate to recognize and manage biases (R04). Another resident drew a “mountain” to depict the divide between their personal and professional identities (R07). Several participants also described weather metaphors using “clouds” to describe their actual self or with “sunshine” related to their ideal self (F02, R05, F06). Overall, participants contrasted an idealized professional identity that was calm, confident, and unbiased with an actual identity that was vulnerable and a product of their personal experiences.
So the idealized self will never have any bias. The idealized self will always be able to look at a situation and see it for its complexity and its various components. But the actual self, by virtue of the kind of society that we live in and our own personal environment or the conditions under which we grew up, we will always have these uncomfortable biases that inform our initial reaction to people. So the actual self I think will always have initial biases that we have to overcome. (R03)
The aspirational professional self was viewed as an ideal worth striving for. Some faculty described that they have developed a professional identity which contributes to “pressure” to not be biased (F03; F10). A faculty participant shared, “I feel like it’s part of my job to not be judgmental and that’s something I want at work … it’s an ideal, you know, at home or outside of work too” (F07), while another stated:
Yeah. I think there’s a lot of pressure to, for a professional to be not biased and to treat all patients fairly and not give preference to some over others. And I do find myself sometimes, you know, having preference for seeing certain types of patients just because of how unpleasant the others are. And so ideally I’d live in a world where I would have equal feelings of wanting to help all my patients equally but the reality is that, you know, I do find myself caring for some patients more than others. (F03)
A resident described the professional identity as being a sort of superordinate identity that “supersedes” the development of their authentic self during residency training (R01). The resident went on to say: “I guess we all have bias but professionals do not have bias. Whatever biases I do have, I either want to kind of reduce or at the very least, be aware of” (R01). Both resident and faculty participants acknowledged that there was a process or struggle associated with striving toward their idealized self.
Striving while accepting
When asked to reflect on how implicit bias could be recognized and managed, participants described two salient but distinct processes. One was a constant striving for self-improvement that was intrinsic to most participants’ identity. The other was a gradual acceptance of their flaws and humanity. Most participants described that through reflection and dialogue, an individual could strive for an idealized self while accepting the actual. A resident described accepting imperfections by saying:
It’s just the reality that no human is ever perfect … just because someone has bad qualities doesn’t make them all bad and that good qualities can still exist and it doesn’t destroy the good. (R02)
Once their implicit biases were revealed through the IAT, participants described reflecting on this information. Several participants described the “constant questioning” of themselves (F03) suggesting an ongoing process of reflection and action that was central to how they reconciled tensions related to implicit bias (F09). A resident described this process as checking themselves “on a daily basis” (R10), while a faculty participant described the process as “a journey” that required “being constantly vigilant” (F06). One resident described the process as working toward “self-betterment” (R03), while a faculty participant described “self-compassion” (F05).
In addition to striving for betterment, most participants described a gradual acceptance of their own biases. One resident described working to be “more aware” of their biases while accepting that they would not “dissipate” (R01), while another resident stated:
I’ve come to terms with it … so working towards this means checking your biases, realizing when you might have let a bias come in between an interaction or a decision. I think it’s something you strive for. But I’m not going to wake up tomorrow and say, “hey, nobody has biases,” right? We all have them … so I think it’s something you strive for, accepting that it’s not necessarily going to be achieved. (R05)
There was variation in participants’ description of how they balanced striving with accepting. Some emphasized the need to self-improve, some emphasized acceptance, and one suggested that they had already reached what others strive for. One participant described that they had close to “full insight” and stated, “I pretty much know who I am, and with all the biases and everything, I am aware of this” (F10). Although this individual felt they had come close to reaching what others strive for, they continued to emphasize the need to keep striving. Another faculty participant offered an alternative perspective, stating that they reconcile tensions by
… growing myself, developing myself and understanding my own self better and talking with colleagues and being part of a community that kind of is working together on things I think that that helps me to get over to this place rather than just being isolated and on my own. (F11)
The role of relationships
Most participants reconciled identity tensions through relationships—emphasizing that implicit bias cannot be managed alone. Several faculty described how they valued sharing with others to reconcile their tensions. One faculty participant stated:
So I think I need to recognize that I’m not the only person … who is in need of help with this endeavor. There are many other people who share the same sort of drive that I have so I’m not alone in this. I think as more and more people join forces we’ll be able to achieve that idealized destination. (F04)
Faculty and residents differed in their description of how reconciliation is achieved through the relationships between teachers and learners. Most faculty participants described themselves as “role models” (F02, F03, F05, F06, F08, F10, F11), while most residents emphasized the need for guidance from faculty mentors. For example, when describing how they reconcile biases by “constantly introspecting and meditating,” a faculty participant stated,
So my role now for the rest of my life that I’m going to be working on professionally is to share the fact that our potential is huge and if I can get to be a role model for my residents, medical students and clinical professionals working with me to realize that they have a much bigger potential than they think they have, then I think I would have done a good job. (F06).
While most residents mentioned the potential of faculty mentors in helping them to recognize and manage implicit biases, there were variable responses on whether faculty could support these efforts. For residents, the potential support from their relationship with their teachers was colored with tension when mentors were not available. Residents also noted that mentors could only bring clarity and reassurance within the context of safety. One resident stated that variation in faculty mentors led to a constant sense of “unpredictability” (R01), while another mentioned that there were only “few” faculty preceptors that encouraged reflecting on biases and questioned whether faculty received enough “formalized training” on biases which motivated the resident to “seek external advice on this process” (R04). The lack of available guidance was clearly identified by resident participants as a barrier to addressing implicit biases that are incongruent with the health professional they aspired to be. Although faculty viewed themselves as role models, residents also suggested that there were issues limiting the availability and reflective capacity of some faculty to effectively role model how to address implicit biases. Another resident accepted the “humanity” of their teachers, emphasizing the importance of “sympathizing” with each other (R02). One resident went on to state:
I think it’s invaluable to hear the mentor’s own experiences as they were going through … if they struggled with something similarly … because they have more expertise and more time that they’ve spent working with people and we’re just novices. So I think that is an important piece. And it also, like I guess, creates a space where if they … if you’re willing … you’re opening up.… (R10)
We learned from our participants that implicit bias recognition and management is fraught with challenges. Like previous research,17,19,58 our results suggested that recognizing one’s implicit biases triggers compartmentalization between the idealized professional identity and the actual personal identity. Successfully managing implicit biases requires reconciliation of these identities through safe and supportive relationships between teachers and learners, and the concept of “striving while accepting” may hold promise for faculty and learners engaging in the process.
How psychiatrists describe striving for the ideal
As part of their training, many psychiatrists undergo psychotherapy supervision where a framework is provided to question their assumptions and focus on unconscious aspects of their interactions with parents. Therefore, the identity of psychiatrists is likely to shape how our participants described their responses to feedback about implicit biases and influence how they reconcile these biases. Our participants described how their unique professional identity increased their self-imposed pressure to manage biases related to dangerousness involving their patients. They also shared how they interpreted striving for the ideal as a process of continuous reflection and improvement.
Striving while accepting is challenging within health professions education
Our finding that participants described a constant process of reflection and self-improvement can be interpreted in the context of previous literature on professional identity formation. The health professional learner is gradually socialized through their experiences,24,25,59 the influence of role models,60,61 and the formal and informal elements of their curriculum.62 When health professionals face experiences that suggest they are not living up to expectations, they may face feelings of inadequacy63–65 and imposter syndrome.36,66 Constantly striving to manage one’s implicit biases within a culture that rewards and incentivizes high achievement and perfectionism66,67 has the potential to produce psychological distress for learners. Since striving on its own may have negative consequences, what do we know about accepting?
Facilitated acceptance is currently described either in the context of the “struggling” learner or in the feedback literature.68–70 Teal and colleagues14 suggest that cognitive strategies are required to facilitate a developmental trajectory from denial of implicit bias to gradual acceptance. Our study extends previous research to emphasize the importance of fostering acceptance throughout the continuum of health professions education. While our previous research highlighted how feedback about implicit bias triggers tensions related to health professional identity, our findings build on previous theory to suggest that cognitive strategies that facilitate balance between seemingly opposite processes are integral to recognizing and managing implicit biases. We also learned that this process can be facilitated through relationships.
Reconciling through relationships is different for faculty and learners
We found that recognizing and managing implicit biases requires looking outside oneself toward relationships with others. Several authors have proposed models for facilitated reflection of negative or challenging feedback.71,72 For our participants, there was dissonance between how teachers and learners reconciled their implicit biases. While both groups brought up the importance of reconciling through relationships, they viewed role modeling differently. Residents desperately wanted guidance on bias management and saw potential in their faculty mentors to provide it, but this potential is too often unrealized. While faculty may identify their own struggles and see themselves as role models, they are not recognizing and managing their biases convincingly enough for many of their learners. If the potential for honest conversations between resident and faculty is not being actualized, we must investigate the role of relationships and implicit bias further. A deeper investigation into the relational dynamics of emotionally challenging topics such as implicit bias is necessary to advance efforts toward equity.
Leveraging an individual’s desire to strive for an idealized professional self may facilitate practice changes related to implicit bias recognition if balanced through facilitated reflection on accepting one’s shortcomings. These findings are useful for individuals and organizations looking for evidence-informed approaches to integrate implicit bias recognition and management.
Our deliberate choice to sample psychiatrists from a single institution and explore implicit biases toward mental illness flavors the findings of this research. Future work could explore our findings among community psychiatrists who do not work in an academic setting and are not actively involved in working with resident or undergraduate learners. The IAT has its own limitations as a measure and has been critiqued in the literature.73–76 We therefore emphasized the use of the IAT as a prompt to trigger reflection.
Discussions about implicit bias within health professional education trigger identity tensions, and striving for self-improvement while accepting individual shortcomings may provide a model for successfully reconciling such tensions and managing implicit biases. Enacting the concept of striving while accepting may require honest and authentic relationships between teachers and learners.
The authors would like to acknowledge the participants of this research and Dr. Sayra Cristancho.
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Appendix 1 Discussion Guide
Prompt for drawing rich picture:
A rich picture in this study is a visual representation of your thoughts, feelings, and reflections about your role as person or professional and any associated tensions within these identities. The picture provides an opportunity to visually depict how you may or may not reconcile any such tensions.
We encourage you to reflect on the experience of the test by considering two tensions:
- “What do the results say about who I am in personal versus professional contexts?”
- “What do the results say about the tension between who I actually am versus the idealized version of a health professional I aspire to be?”
Prompt after discussing picture:
Reflect on role as teacher versus learner.
How do you reconcile these tensions?
How do you process and integrate this information (or other information) about your biases and stigma from here?