A Qualitative Study of New York Medical Student Views on Implicit Bias Instruction: Implications for Curriculum Development

  • Cristina M. GonzalezEmail author
  • Maria L. Deno
  • Emily Kintzer
  • Paul R. Marantz
  • Monica L. Lypson
  • Melissa D. McKee



For at least the past two decades, medical educators have worked to improve patient communication and health care delivery to diverse patient populations; despite efforts, patients continue to report prejudice and bias during their clinical encounters. Targeted instruction in implicit bias recognition and management may promote the delivery of equitable care, but students at times resist this instruction. Little guidance exists to overcome this resistance and to engage students in implicit bias instruction; instruction over time could lead to eventual skill development that is necessary to mitigate the influence of implicit bias on clinical practice behaviors.


To explore student perceptions of challenges and opportunities when participating in implicit bias instruction.


We conducted a qualitative study that involved 11 focus groups with medical students across each of the four class years to explore their perceptions of challenges and opportunities related to participating in such instruction. We analyzed transcripts for themes.

Key Results

Our analysis suggests a range of attitudes toward implicit bias instruction and identifies contextual factors that may influence these attitudes. The themes were (1) resistance; (2) shame; (3) the negative role of the hidden curriculum; and (4) structural barriers to student engagement. Students expressed resistance to implicit bias instruction; some of these attitudes are fueled from concerns of anticipated shame within the learning environment. Participants also indicated that student engagement in implicit bias instruction was influenced by the hidden curriculum and structural barriers.


These insights can inform future curriculum development efforts. Considerations related to instructional design and programmatic decision-making are highlighted. These considerations for implicit bias instruction may provide useful frameworks for educators looking for opportunities to minimize student resistance and maximize engagement in multi-session instruction in implicit bias recognition and management.


implicit bias unconscious bias medical education health disparities curriculum development 



The authors wish to thank Drs. Clarence Braddock, III, William Southern, and A. Hal Strelnick for their thoughtful feedback from study inception to completion; Ms. Veronica Aviles and Ms. Natalia Rodriguez for their generous assistance; and Drs. David Irby and Paula Ross for their thoughtful feedback on previous iterations of the manuscript.


Dr. Gonzalez was supported by the Harold Amos Medical Faculty Development Program of the Robert Wood Johnson Foundation grant number AMFDP 70639, Bureau of Health Professions of the Health Resources & Services Administration of US Department of Health and Human Services grant number D3 EHP16488-03, NIH/NICHD grant number R25HD068835, and the Macy Faculty Scholars Program of the Josiah Macy Jr. Foundation. Dr. Marantz was supported in part by NIH/National Center for Advancing Translational Science (NCATS) Einstein-Montefiore CTSA grant numbers KL2TR001071, TL1TR001072, and UL1TR001073, and by NIH/NICHD grant number R25HD068835. Dr. McKee was supported in part by 1R25HS023199-01 (Marantz) and NIMHHD U2400694102 (Tilley).

Compliance with Ethical Standards

All aspects of the study were approved by the Institutional Review Board of the Albert Einstein College of Medicine. Confidentiality safeguards were affirmed, and written informed consent was obtained from all participants.

Conflict of Interest

The authors declare that they do not have a conflict of interest.


The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the US government.

Supplementary material

11606_2019_4891_MOESM1_ESM.docx (16 kb)
ESM 1 (DOCX 15 kb)


  1. 1.
    Haider AH, Sexton J, Sriram N, et al. Association of unconscious race and social class bias with vignette-based clinical assessments by medical students. JAMA : the journal of the American Medical Association. 2011;306(9):942–951.Google Scholar
  2. 2.
    White-Means S, Zhiyong D, Hufstader M, Brown LT. Cultural competency, race, and skin tone bias among pharmacy, nursing, and medical students: implications for addressing health disparities. Med Care Res Rev. 2009;66(4):436–455.Google Scholar
  3. 3.
    Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231–1238.Google Scholar
  4. 4.
    Sabin JA, Greenwald AG. The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma. American journal of public health. 2012;102(5):988–995.Google Scholar
  5. 5.
    Hausmann LR, Myaskovsky L, Niyonkuru C, et al. Examining implicit bias of physicians who care for individuals with spinal cord injury: A pilot study and future directions. J Spinal Cord Med. 2015;38(1):102–110.Google Scholar
  6. 6.
    Hagiwara N, Slatcher RB, Eggly S, Penner LA. Physician Racial Bias and Word Use during Racially Discordant Medical Interactions. Health Commun. 2017;32(4):401–408.Google Scholar
  7. 7.
    Cooper LA, Roter DL, Carson KA, et al. The associations of clinicians’ implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. American journal of public health. 2012;102(5):979–987.Google Scholar
  8. 8.
    Blair IV, Steiner JF, Fairclough DL, et al. Clinicians’ implicit ethnic/racial bias and perceptions of care among Black and Latino patients. Ann Fam Med. 2013;11(1):43–52.Google Scholar
  9. 9.
    Eggly S, Hamel LM, Foster TS, et al. Randomized trial of a question prompt list to increase patient active participation during interactions with black patients and their oncologists. Patient Educ Couns. 2017;100(5):818–826.Google Scholar
  10. 10.
    Zestcott CA, Blair IV, Stone J. Examining the presence, consequences, and reduction of implicit bias in health care: A narrative review. Group Processes & Intergroup Relations. 2016;19(4):528–542.Google Scholar
  11. 11.
    Burgess D, van Ryn M, Dovidio J, Saha S. Reducing racial bias among health care providers: lessons from social-cognitive psychology. J Gen Intern Med. 2007;22(6):882–887.Google Scholar
  12. 12.
    Gonzalez CM, Bussey-Jones J. Disparities education: what do students want? J Gen Intern Med. 2010;25 Suppl 2:S102–107.Google Scholar
  13. 13.
    Vela MB, Kim KE, Tang H, Chin MH. Innovative health care disparities curriculum for incoming medical students. J Gen Intern Med. 2008;23(7):1028–1032.Google Scholar
  14. 14.
    Kumagai AK, Lypson ML. Beyond cultural competence: critical consciousness, social justice, and multicultural education. Acad Med. 2009;84(6):782–787.Google Scholar
  15. 15.
    Teal CR, Shada RE, Gill AC, et al. When best intentions aren’t enough: helping medical students develop strategies for managing bias about patients. J Gen Intern Med. 2010;25 Suppl 2:S115–118.Google Scholar
  16. 16.
    Gonzalez CM, Kim MY, Marantz PR. Implicit bias and its relation to health disparities: a teaching program and survey of medical students. Teach Learn Med. 2014;26(1):64–71.Google Scholar
  17. 17.
    Gonzalez CM, Fox AD, Marantz PR. The Evolution of an Elective in Health Disparities and Advocacy: Description of Instructional Strategies and Program Evaluation. Acad Med. 2015;90(12):1636–1640.Google Scholar
  18. 18.
    Hernandez RA, Haidet P, Gill AC, Teal CR. Fostering students’ reflection about bias in healthcare: cognitive dissonance and the role of personal and normative standards. Med Teach. 2013;35(4):e1082–1089.Google Scholar
  19. 19.
    White AA 3rd, Logghe HJ, Goodenough DA, et al. Self-Awareness and Cultural Identity as an Effort to Reduce Bias in Medicine. J Racial Ethn Health Disparities. 2018;5(1):34–49.Google Scholar
  20. 20.
    Wear D, Aultman JM. The limits of narrative: medical student resistance to confronting inequality and oppression in literature and beyond. Med Educ. 2005;39(10):1056–1065.Google Scholar
  21. 21.
    Gonzalez CM, Garba RJ, Liguori A, Marantz PR, McKee MD, Lypson ML. How to Make or Break Implicit Bias Instruction: Implications for Curriculum Development. Acad Med. 2018;93(11S Association of American Medical Colleges Learn Serve Lead: Proceedings of the 57th Annual Research in Medical Education Sessions):S74-S81.Google Scholar
  22. 22.
    Thomas PA, Kern DE, Hughes MT, Chen BY. Curriculum Development for Medical Education: A Six-Step Approach. Baltimore, MD: Johns Hopkins University Press; 2016.Google Scholar
  23. 23.
    Gonzalez CM, Deno ML, Kintzer E, Marantz PR, Lypson ML, McKee MD. Patient perspectives on racial and ethnic implicit bias in clinical encounters: Implications for curriculum development. Patient Educ Couns. 2018;101(9):1669–1675.Google Scholar
  24. 24.
    Patton MQ. Qualitative research and evaluation methods. Thousand Oaks, CA: SAGE Pubilcations; 2002:194–195.Google Scholar
  25. 25.
    Tavakol M, Sandars J. Quantitative and qualitative methods in medical education research: AMEE Guide No 90: Part I. Med Teach. 2014;36(9):746–756.Google Scholar
  26. 26.
    Corbin JM, Strauss A. Grounded theory research: Procedures, canons, and evaluative criteria. Qualitative Sociology. 1990;13(1):3–21.Google Scholar
  27. 27.
    Morell VW, Sharp PC, Crandall SJ. Creating student awareness to improve cultural competence: creating the critical incident. Med Teach. 2002;24(5):532–534.Google Scholar
  28. 28.
    Satterfield JM, Mitteness LS, Tervalon M, Adler N. Integrating the social and behavioral sciences in an undergraduate medical curriculum: the UCSF essential core. Acad Med. 2004;79(1):6–15.Google Scholar
  29. 29.
    Schmader T. Stereotype Threat Deconstructed. Current Directions in Psychological Science. 2010;19(1):14–18.Google Scholar
  30. 30.
    Teal CR, Gill AC, Green AR, Crandall S. Helping medical learners recognise and manage unconscious bias toward certain patient groups. Medical education. 2012;46(1):80–88.Google Scholar
  31. 31.
    Williams RL VC, Getrich CM, Kano M, Boursaw B, Krabbenhoft C, Sussman A. Racial/gender biases in student clinical decision-making: a mixed-method study of medical school attributes associated with lower incidence of biases J Gen Intern Med. 2018;33(12):2056-2064Google Scholar
  32. 32.
    Burgess DJ, Burke SE, Cunningham BA, et al. Medical students’ learning orientation regarding interracial interactions affects preparedness to care for minority patients: a report from Medical Student CHANGES. BMC medical education. 2016;16(1):254.Google Scholar
  33. 33.
    Hernandez R. Medical Students’ Implicit Bias and the Communication of Norms in Medical Education. Teach Learn Med. 2018;30(1):112–117.Google Scholar
  34. 34.
    Sukhera J, Watling C. A Framework for Integrating Implicit Bias Recognition Into Health Professions Education. Acad Med. 2018;93(1):35–40.Google Scholar
  35. 35.
    Emerson KT, Murphy MC. Identity threat at work: how social identity threat and situational cues contribute to racial and ethnic disparities in the workplace. Cultur Divers Ethnic Minor Psychol. 2014;20(4):508–520.Google Scholar
  36. 36.
    Major B, O’Brien LT. The social psychology of stigma. Annu Rev Psychol. 2005;56:393–421.Google Scholar
  37. 37.
    Bandura A. Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice- Hall, Inc.; 1986.Google Scholar
  38. 38.
    Branch WT Jr. Supporting the moral development of medical students. J Gen Intern Med. 2000;15(7):503–508.Google Scholar
  39. 39.
    Smith S, Shochet R, Keeley M, Fleming A, Moynahan K. The growth of learning communities in undergraduate medical education. Acad Med. 2014;89(6):928–933.Google Scholar
  40. 40.
    Ecker DJ, Milan FB, Cassese T, et al. Step Up-Not On-The Step 2 Clinical Skills Exam: Directors of Clinical Skills Courses (DOCS) Oppose Ending Step 2 CS. Acad Med. 2018;93(5):693–698.Google Scholar
  41. 41.
    Hafferty FW. Beyond curriculum reform: confronting medicine’s hidden curriculum. Academic medicine : journal of the Association of American Medical Colleges. 1998;73(4):403–407.Google Scholar
  42. 42.
    Shapiro J, Lie D, Gutierrez D, Zhuang G. “That never would have occurred to me”: a qualitative study of medical students’ views of a cultural competence curriculum. BMC medical education. 2006;6:31.Google Scholar
  43. 43.
    van Ryn M, Hardeman R, Phelan SM, et al. Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report. Journal of General Internal Medicine. 2015;30(12):1748–1756.Google Scholar
  44. 44.
    Acosta D, Ackerman-Barger K. Breaking the Silence: Time to Talk About Race and Racism. Acad Med. 2017;92(3):285–288.Google Scholar
  45. 45.
    Ashburn-Nardo L, Morris KA, Goodwin SA. The Confronting Prejudiced Responses (CPR) Model: Applying CPR in Organizations. Academy of Management Learning & Education. 2008;7(3):332–342.Google Scholar
  46. 46.
    Phillips SP, Clarke M. More than an education: the hidden curriculum, professional attitudes and career choice. Med Educ. 2012;46(9):887–893.Google Scholar

Copyright information

© Society of General Internal Medicine 2019

Authors and Affiliations

  • Cristina M. Gonzalez
    • 1
    • 2
    Email author
  • Maria L. Deno
    • 3
  • Emily Kintzer
    • 2
  • Paul R. Marantz
    • 1
  • Monica L. Lypson
    • 4
    • 5
    • 6
    • 7
  • Melissa D. McKee
    • 1
  1. 1.Albert Einstein College of MedicineBronxUSA
  2. 2.Montefiore Medical Center-Weiler DivisionBronxUSA
  3. 3.La Universidad IberoamericanaSanto DomingoDominican Republic
  4. 4.Office of Academic Affiliations, Veterans AdministrationWashington, D.C.USA
  5. 5.George Washington University School of Medicine and Health SciencesWashington, D.C.USA
  6. 6.University of Michigan Medical SchoolAnn ArborUSA
  7. 7.F. Edward Hébert School of MedicineUniformed Services University of the Health SciencesBethesdaUSA

Personalised recommendations