Identifying Unconscious Bias

A Movement Toward Equity and Inclusion in the Classroom and Beyond

By Kirsten Mickelwait

Consider this scenario: a member of a dental school’s clinical faculty responds to a student’s question with the assumption that the student is part of the International Dental Studies program. “They should have taught you this in dental school in your own country,” the professor says. In fact, the student is a U.S. citizen and is part of the Doctor of Dental Surgery program. 

Or this one: a transgender patient enters a dental clinic and requests to be referred to as “she.” Despite the request, a clinical staff member refers to her as “he” within earshot of the patient.

Or this: a student, for whom English is her second language, asks the professor for clarification on an exam question. “There was some confusion about question five related to learning English in general,” the professor announces to the class.

All of these interactions actually occurred within the Arthur A. Dugoni School of Dentistry. And they demonstrate “unconscious bias”—situations where perfectly well-intended people make unfair assumptions about others based on long-held stereotypes about race, gender, sexual identity, physical or mental ability or appearance. Despite dramatic progress in diversity in both academia and the professional fields, we have a long way to go toward being fully equitable and inclusive in our interactions—in the classroom, in the clinic or in society at large.

At Faculty Development Day in December, Dr. Magali Fassiotto, assistant dean in the Office of Faculty Development and Diversity at Stanford University School of Medicine, used these examples during a presentation to dental school faculty and staff on how they can identify unconscious bias in the classroom and clinical settings. Fassiotto manages Stanford’s efforts in professional development activities, strategic initiatives related to the recruitment and retention of a diverse and inclusive faculty and research related to faculty development and diversity.

“Becoming aware of our biases and developing strategies to address unconscious bias is so critical for the medical education environment because both education and clinical care are built on human relationships,” Fassiotto says. “On the educational front, students need to be able to have faith that their faculty were, in fact, once in their shoes. In the patient context, research has shown that patients may place greater trust in their care providers if they perceive that the provider understands their cultural backgrounds.”

“At the Dugoni School, we strive to be inclusive, foster diversity and be respectful of all voices and ideas,” says Stan Constantino, assistant dean for admissions, student affairs and diversity, who serves on the school’s Diversity and Inclusion Committee and the University’s Diversity Leadership Committee. “Dr. Fassiotto’s presentation encouraged all of us to be aware of potential personal or institutional biases that can affect our school and work environment.”

Becoming aware of our biases and developing strategies to address unconscious bias is so critical for the medical edcation environment because both education and clinical care are built on human relationships.

The greatest predictor of group success? Diversity

Why is unconscious bias such a critical factor in the dental and medical fields? To begin with, studies have repeatedly shown that diversity is, in fact, the greatest predictor of group success. “When forming teams, we often default to the familiar,” Fassiotto says. “But homogeneous groups operate with less information, have fewer opportunities for learning (because everyone already agrees) and lack fresh perspectives. What results is ‘groupthink’—the illusion of being right because your own group is in agreement.”

Heterogeneous groups, on the other hand, benefit from distinct experiences, diverse points of view and differing opinions. Even after reaching a consensus, the group is open to the possibility that its opinion isn’t always the right one. 

How serious a problem is unconscious bias? Here are just a few examples:

• The Implicit Association Test (IAT) conducted by Harvard University among three million subjects between 2002 and 2015 revealed that 78% of the American population showed an automatic preference for a European American to an African American. 
• In the same test, 72% of respondents showed an automatic association of males with science and females with liberal arts.
• Another study, conducted by the National Academy of Sciences, reported that people believe that hurricanes cause significantly more deaths when the hurricanes have female names than when their names are masculine.
• In a study by the research firm Nextions, 60 partners from 22 law firms participated in a “writing analysis study” in which they were given a memo with 22 errors written by “Thomas Meyer.” When told that Meyer was African American, they ranked him 3.2 out of 5 points, and commented that his work was “average at best” and “needs a lot of work.” When Meyer was represented as white, he was ranked 4.1 out of 5, and received comments that he “has potential” and “good analytical skills.”
• In an analysis of 14 million reviews on RateMyProfessor.com, male professors scored much higher in “brilliance,” while female professors scored higher for “niceness.” 

Even more important in clinical care

It’s not difficult to imagine how these unspoken preferences might play out in an academic or professional environment. And the consequences of such biases are even more critical in clinical care. Research demonstrates that some populations are disproportionately affected by certain conditions, which can create disparities in treatment. Puerto Ricans, for example, have a four-times-greater mortality rate due to asthma compared to European Americans. When it comes to pain management, prescription rates for analgesics and opioids are dramatically different depending on race. And weight bias in medicine can make obese patients reluctant to seek health care, increasing the likelihood of medical problems and costs.

At the Dugoni School, we strive to be inclusive, foster diversity and be respectful of all voices and ideas.

Whether it’s in a clinical setting, a classroom or merely in our day-to-day encounters, our biases stem from cognitive shortcuts. And they’re commonly activated by four key conditions that make us rush to judgment: stress, multitasking, time constraints and/or a need for closure.

Our biases are expressed in what are known as “microaggressions”—acts that aren’t intended to be cruel, but that carry negative subtexts. Asking where a person is from and observing that they speak English really well says, “You’re not American.” A person of color being mistaken for a service worker says, “You couldn’t possibly occupy a high-level position.” A patient who speaks only to the white male in the room says to the female, “You’re not qualified to be the attending physician.” These microaggressions happen with such regularity that they can have an overwhelming effect on those who receive them. 

Strategies for change

How can we as individuals change the culture around unconscious bias? “While you can’t control the actions of other people, you can teach by example,” Fassiotto says. “First, remember that intent and impact are two different things. Consider another person’s past experiences before saying something without thinking. Second, own your actions. If you recognize that your behavior was biased, own the consequences. And finally, reinforce and repair. Rebuild the trust you may have inadvertently broken. And, self-reinforce unbiased behavior in the future. The best possible outcome is addressing the bias and educating the offender so it doesn’t happen again.”

Some active bystander strategies might include: asking questions, which can allow for self-reflection; using humor, which can feel less confrontational; being literal, which can show that unspoken assumptions don’t make sense; expressing your discomfort, which serves as a “speed bump” and allows others to chime in; and communicating directly, which can explain your reaction.

“Research around workplace dynamics shows the importance that diversity and feelings of belonging have for both innovation and individual employee well-being,” Fassiotto says. “Given the impact that an understanding of unconscious bias has across disciplines, it becomes incumbent upon all of us who are a part of medical education to address it head on.”

Since Faculty Development Day, “We’ve received feedback that Dr. Fassiotto’s thoughts were interesting, well-presented and engaging for attendees,” says Dr. Terry Hoover, associate professor and vice chair of the Department of Diagnostic Sciences. “What we have learned will continue to be discussed as we strengthen our teaching strategies, our patient care and our personal interactions.”

Kirsten Mickelwait is a San Francisco-based copywriter and professional storyteller.