Unconscious Barriers to Equity

By Anne Berlin

Originally posted March 22, 2013 on the Equity of Care blog.

When the Founding Partners convened to determine core goals of the National Call to Action to Eliminate Health Care Disparities, there was ready consensus around increasing diversity in leadership as a key to promoting equitable health systems. By elevating workforce diversity within the mission, we acknowledge the dividends that emerge from creating inclusive organizational cultures and eliminating remaining barriers to fair treatment.

Diversifying our leadership ranks is easier said than done; however, it’s not simply a matter of taking best practice programs and interventions off the shelf. If we approach it right, this work will prompt a challenging and disruptive examination of organizational culture and the policies and practices that define it. To make real progress on diversity requires the courage to change deeply ingrained ways of working, fueled by the recognition that historically marginalized groups are often disadvantaged by current operating procedures.

As we look under the hood at the behaviors and norms that power our organizations, we often discover back-channel networks of influence that favor the cultural majority. Lurking beneath this collegial practice is the natural human affinity to connect with like others that, when unchecked, can make navigating the path to leadership more about relationships with powerful insiders than about talent and accomplishments. Particularly in science and medicine, research continues to indicate that stereotypes about the competence or character of certain groups of people may have unconscious impacts on our evaluations of their performance.

Addressing these unconscious biases should not be an afterthought: it should be woven into organizational change efforts around promoting diversity. Agrowing number of medical schools and teaching hospitals are implementing unconscious bias training as part of their efforts to create fair and inclusive pathways to leadership. These interventions vary in length and format but typically include the Implicit Association Test, the Selective Attention Test and other well-known exercises that illuminate how many cognitive blind spots and shortcuts are constantly at work, layering over our interpretation of reality and influencing our choices.

Whether directed at promotion and tenure teams or admissions committees or used as part of cultural competence education for health care professionals, unconscious bias training should be administered with the goal of creating checklists and decision aids that further extract subjectivism from important choices. At the Association of American Medical Colleges, our experience with unconscious bias training and exercises has shown that they can produce positive role models who serve as ambassadors for organizational change.

It is important to note that awareness of implicit cognitive patterns does not obviate the need for legal protections and other policies to address overt discrimination within health care organizations. There continue to be groups that are overtly marginalized and suffer explicit bias. The battle to alleviate all barriers to equity is far from won, but unconscious bias training provides a promising platform for progress.