Implicit bias in medical training

Implicit bias, perpetuated through medical education, is a key factor driving health disparities in the U.S. Medical education is an inherently biased process that disadvantages people of color, with these impacts carrying over into residency admissions. This lack of diversity is compounded by biased and outdated teaching that often does not adequately address racial disparities and neglects how conditions manifest differently across racial groups.

Overall, this institutional discrimination widens health inequities and has led to significant differences in disease, mortality, and complication rates across racial and ethnic groups. For example, in 2021 the CDC reported that the Black maternal mortality rate was 2.6 times higher than that of White women. There are many reasons why populations of color experience worse health outcomes in the U.S., including inequities in social determinants of health and the impact of medical mistrust, stemming from the historical exploitation of Black and Indigenous peoples. Implicit bias is one of many issues that need to be addressed to fully tackle the systemic challenges faced by people of color in this country.

Implicit bias refers to the subconscious attitudes, prejudices, and stereotypes that can influence decision-making, such as believing that certain racial groups are more resistant to pain and therefore prescribing less pain medication. Explicit bias occurs when individuals are aware of and actively engage in discriminatory views, such as a healthcare provider refusing to treat a patient due to disagreement with the patient’s religion or sexual orientation. Both implicit and explicit bias can lead to discrimination, especially in healthcare settings. 

Previous research has shown that engaging with diverse settings and viewpoints can help rewrite biases. It is crucial to understand the environment in which medical students learn to treat patients. Educational factors, such as how students are taught to care for patients and address healthcare disparities, as well as the diversity of their learning environment, play a critical role in shaping implicit bias. These structural factors help reinforce and sustain implicit bias, which then trickles down into interpersonal interactions, contributing to greater health disparities.

Many medical schools still lack the diversity needed to enhance cultural competence, broaden perspectives, and increase exposure to diverse populations. A study of nearly 80,000 MCAT examinees found that Indigenous, Black, and Hispanic populations faced greater financial and educational barriers, which were linked to a lower likelihood of applying to and matriculating in medical school, highlighting the impact of these obstacles. Medical school faculty lacks diversity as well, with under 10% identifying as Black, Hispanic, or of Indigenous background. This shortage of mentors and role models may discourage people of color from applying to medical school, with only about 23% of matriculants in 2024 identifying as Black, Hispanic, or of Indigenous background. Legacy admissions further reinforce privileges often unavailable to people of color and those from low socioeconomic backgrounds. 

Finally, racism impacts residency admissions, with Black, Hispanic, Asian, and low-income URM applicants facing higher odds of not matching into residency compared to White men, even when adjusted for US Medical Licensing Exam scores. This affects diversity in the physician workforce and contributes to an especially stark lack of representation in more competitive specialties like dermatology and neurology. Low-class diversity leads to less culturally rich learning environments that can indirectly influence students’ implicit biases.

Fundamentally, medical schools lack a well-rounded education that teaches students to take care of diverse patients appropriately. For example, race is often still used as a biological concept or risk factor in medical school, rather than considering the social impact of race on a patient. For example, the historical effects of redlining have resulted in many Black people living in areas that experience higher levels of environmental pollution. This is largely due to segregation, as areas around Black neighborhoods were underdeveloped and used for industrial sites, highways, and landfills. These high levels of air and water pollution can make Black communities more likely to develop health conditions like asthma. In the classroom, students may be taught that Black people are more predisposed to asthma, but not given the historical context for why this is. As a result, students may view being black as a risk factor for asthma. However, this effect is not because they are black, but rather because of the environmental and social conditions created by systemic discrimination, like redlining, that expose Black communities to more pollution.

All in all, without historical context, the root causes of health disparities can easily be overlooked. In addition, this method of teaching can perpetuate misconceptions, as patients of different races may share the same genetic predisposition to a disease but face widely different risks due to environmental and social factors. Harmful stereotypes also continue to persist in medicine, especially in outdated teaching materials, such as the idea that Black people are more resistant to pain than White people. One study found that half of their sample of medical students and residents still endorsed this idea. There is also, generally, a need for more training regarding the impact of social determinants of health and the many factors that cause racial disparities to continue. According to the Association of American Medical Colleges, only 40% of medical schools reported teaching about racial disparities in 2018.

In addition, the materials used to teach medical students are not fully inclusive and may impact their clinical knowledge when dealing with diverse patients. In the field of dermatology, students are often taught to recognize conditions on lighter skin. In fact, an analysis of over 4,000 images in anatomy textbooks used at top medical schools found that only 4.5% of pictures showed darker skin tones. Training that is not inclusive can perpetuate stereotypes or misconceptions about certain racial groups, such as they do not experience certain conditions or symptoms the same way as others. In this way, clinicians can make decisions overlooking symptoms, and people of color may not be able to get proper preventative treatment, leading to greater health disparities down the line. 

“Training that is not inclusive can perpetuate stereotypes or misconceptions about certain racial groups, such as they do not experience certain conditions or symptoms the same way as others.”

Medical schooling in the U.S. should be restructured and employ new strategies to reduce implicit bias. Improving the diversity of the medical class itself has the potential to produce more empathetic, open-minded, and diverse physicians who will better serve diverse patient populations. Finally, restructuring the curriculum to focus on social justice and racial disparities, while addressing misconceptions through scientifically accurate training, is crucial.