Understanding Healthcare Students’ Experiences of Racial Bias: A Narrative Review of the Role of Implicit Bias and Potential Interventions in Educational Settings

An overview of implicit racial bias in medical education.

Introduction

The field of research studying implicit racial bias in the healthcare and medical sectors is continuing to grow. While there is significant research examining implicit bias among healthcare professionals, the field has yet to produce many studies focusing on the specific effects on medical students experiencing that bias. 

Black, Latino, Indigenous, and Pacific Islander representation within the medical field remain lower than the general population, which ultimately results in adverse patient experiences and health outcomes for those minoritized patient groups.  

The authors offer three primary justifications for the importance of diving deeper into the role of implicit racial bias in medical education, citing the negative impact of implicit bias on:

1. Minoritized students’ mental health and academic performance,
2. Professional development of qualified minority healthcare professionals, and
3. Perpetuation of continued racial inequities in health outcomes. 

Olivia Rochelle Joseph is a PhD candidate at the University of Leeds School of Psychology. Stuart W. Flint is an Associate Professor at the University of Leeds School of Psychology. Rianna Raymond-Williams is a PhD candidate at the Glasgow Caledonian University School of Health and Life Sciences. Rossby Awadzi is a medical doctor for the United Kingdom National Health Service. Judith Johnson is an Associate Professor at the University of Leeds School of Psychology.

Methods and Findings

The authors begin with a narrative literature review of existing research published between 1995 and 2021. This covers the effects of implicit racial bias on medical education, contributors to bias, and possible solutions. 

Key findings on the causes and effects of implicit racial bias:

• Students’ implicit racial biases are consistent over time and may increase with healthcare education. Yet, longitudinal studies specifically assessing healthcare students’ implicit racial bias are extremely limited, which makes it challenging to understand the perceptions and effects of implicit racial bias across time or geographies.
• Peers, educators, clinical environments, and educational environments were all identified as sources of implicit racial bias within the medical education system. 
• Minoritized students are likely affected by interactions with other healthcare students and educators whose biases reflect those of the general population.  In turn, these students are victims of negative stereotypes, which leads to them altering their behaviors to counter negative stereotypes and enduring heightened pressure to demonstrate academic abilities. 
• Implicit racial biases shape educators’ lecture materials, clinical assessments, recommendation letters, and award distribution.
• Senior healthcare professionals propagate unconscious biases, which also leads to students of color’s disproportionate stress relative to their white peers. As a result, minoritized students report lower levels of social support, harmful educational environments, and higher rates of racial discrimination as a result of their race.

Effective interventions to address implicit racial bias in healthcare education include:

• Raise awareness of implicit racial bias
  “On an institutional level, recommended interventions include developing a commitment to auditing current practices and processes to identify and eliminate biased language, ideology, and misrepresentations of race, allocation of adequate resources to build capacity amongst staff, enforcement of accountability, and implementing transparent reporting systems for students and faculty to report experiences of bias.”
• Teaching bias mitigation strategies
  “At the organizational level, the author proposed the development of an inclusion strategy to show commitment to reducing bias, from hiring and retaining diverse faculty to admissions and assessment committees.”
• Reduce misrepresentation of race in the curriculum
  The authors highlight a successful implementation of a multi-stage approach comprised of “asking first-year medical students to engage with materials about implicit bias (e.g., books and film), encouraging students to take the IAT to identify personal biases, and engaging in open discussions with peers and faculty.”
• Organizational commitment to recruit and retain diverse staff
  The authors point to a study recommending “assessing the use of language in recruitment materials, considering where job opportunities are advertised, improving faculty reviewing processes to recognize talent within the diverse staff and provide clear information, mentoring, and support regarding formal processes for promotion.” They add that it is equally important to implement an effective inclusion strategy along with efforts to increase diversity.
• Creating trusting spaces
  “Many studies indicate the importance of informal networks and support groups and suggest faculty should help students to benefit from interracial communication by allocating diverse peers for group work.”

Conclusions

The authors highlight that medical students experience the effects of implicit racial bias, but the effects remain unclear. Hence, they conclude that more research should be conducted into the specific consequences of implicit bias on the well-being and academic progression of medical students of color. The authors also recommend conducting more longitudinal studies to understand the effects of different interventions and techniques across time and place. Lastly, they highlight the need for both interventions that target various contributing factors of racial bias and high-quality corresponding studies that assess the efficacy of these interventions.