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Empathy and Implicit Bias: Can Empathy Training Improve Equity?

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Teaching Empathy in Healthcare

Abstract

Bias is everywhere. Explicit biases include conscious attitudes or intentional discrimination towards certain groups. In contrast, implicit biases include attitudes or behaviors that exert powerful influence over individuals outside their awareness. These implicit biases can perpetuate health disparities by widening inequities and decreasing trust between patients and health professionals. Among the interventions to reduce the adverse impact of implicit bias on healthcare is empathy training. The authors describe a program of research on implicit bias towards individuals with mental illness, highlighting how enhancing empathy may improve equity for marginalized and underserved populations.

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References

  1. Chapman, E. N., Kaatz, A., & Carnes, M. (2013). Physicians and implicit bias: How doctors may unwittingly perpetuate health care disparities. Journal of General Internal Medicine, 28(11), 1504–1510.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Green, A. R., Carney, D. R., Pallin, D. J., Ngo, L. H., Raymond, K. L., Iezzoni, L. I., et al. (2007). Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. Journal of General Internal Medicine, 22(9), 1231–1238.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Dovidio, J. F., Penner, L. A., Albrecht, T. L., Norton, W. E., Gaertner, S. L., & Shelton, J. N. (2008). Disparities and distrust: The implications of psychological processes for understanding racial disparities in health and health care. Social Science & Medicine, 67(3), 478–486.

    Article  Google Scholar 

  4. Fallin-Bennett, K. (2015). Implicit bias against sexual minorities in medicine: Cycles of professional influence and the role of the hidden curriculum. Academic Medicine, 90(5), 549–552.

    Article  PubMed  Google Scholar 

  5. Haider, A. H., Schneider, E. B., Sriram, N., Scott, V. K., Swoboda, S. M., Zogg, C. K., et al. (2015). Unconscious race and class biases among registered nurses: Vignette-based study using implicit association testing. Journal of the American College of Surgeons, 220(6), 1077–86.e3.

    Article  PubMed  Google Scholar 

  6. Hall, W. J., Chapman, M. V., Lee, K. M., Merino, Y. M., Thomas, T. W., Payne, B. K., et al. (2015). Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: A systematic review. American Journal of Public Health, 105(12), e60–e76.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Sabin, J. A., & Greenwald, A. G. (2012). 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, 102(5), 988–995.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Sabin, J. A., Marini, M., & Nosek, B. A. (2012). Implicit and explicit anti-fat bias among a large sample of medical doctors by BMI, race/ethnicity and gender. PLoS One, 7(11), e48448.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Stone, J., & Moskowitz, G. B. (2011). Non-conscious bias in medical decision making: What can be done to reduce it? Medical Education, 45(8), 768–776.

    Article  PubMed  Google Scholar 

  10. Gaertner, S. L., & Dovidio, J. F. (1986). The aversive form of racism. San Diego, CA: Academic Press.

    Google Scholar 

  11. Byrne, A., & Tanesini, A. (2015). Instilling new habits: Addressing implicit bias in healthcare professionals. Advances in Health Sciences Education, 20(5), 1255–1262.

    Article  PubMed  Google Scholar 

  12. Carnes, M., Devine, P. G., Baier Manwell, L., Byars-Winston, A., Fine, E., Ford, C. E., et al. (2015). The effect of an intervention to break the gender bias habit for faculty at one institution: A cluster randomized, controlled trial. Academic Medicine, 90(2), 221–230.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Gonzalez, C. M., Kim, M. Y., & Marantz, P. R. (2014). Implicit bias and its relation to health disparities: A teaching program and survey of medical students. Teaching and Learning in Medicine, 26(1), 64–71.

    Article  PubMed  Google Scholar 

  14. Teal, C. R., Shada, R. E., Gill, A. C., Thompson, B. M., Frugé, E., Villarreal, G. B., et al. (2010). When best intentions aren’t enough: Helping medical students develop strategies for managing bias about patients. Journal of General Internal Medicine, 25(2), 115–118.

    Article  PubMed Central  Google Scholar 

  15. van Ryn, M., Hardeman, R., Phelan, S. M., Ph, D. D., Dovidio, J. F., Herrin, J., et al. (2015). Medical school experiences associated with change in implicit racial bias among 3547 students: A medical student CHANGES study report. Journal of General Internal Medicine, 30(12), 1748–1756.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Davis, M. H. (1980). A multidimensional approach to individual differences in empathy. Journal Supplement Abstract Service (JSAS) Catalog of Selected Documents in Psychology, 10, 85.

    Google Scholar 

  17. Davis, M. H. (1983). Measuring individual differences in empathy: Evidence for a multidimensional approach. Journal of Personality and Social Psychology, 44(1), 113.

    Article  Google Scholar 

  18. Batson, C. D., Fultz, J., & Schoenrade, P. A. (1987). Distress and empathy: Two qualitatively distinct vicarious emotions with different motivational consequences. Journal of Personality, 55(1), 19–39.

    Article  PubMed  Google Scholar 

  19. Hojat, M., Gonnella, J. S., Nasca, T. J., Mangione, S., Vergare, M., & Magee, M. (2002). Physician empathy: Definition, components, measurement, and relationship to gender and specialty. American Journal of Psychiatry, 159(9), 1563–1569.

    Article  PubMed  Google Scholar 

  20. Neumann, M., Edelhäuser, F., Tauschel, D., Fischer, M. R., Wirtz, M., Woopen, C., et al. (2011). Empathy decline and its reasons: A systematic review of studies with medical students and residents. Academic Medicine, 86(8), 996–1009.

    Article  PubMed  Google Scholar 

  21. Mercer, S. W., & Reynolds, W. J. (2002). Empathy and quality of care. The British Journal of General Practice, 52(Suppl), S9–S12.

    PubMed  PubMed Central  Google Scholar 

  22. Sukhera, J., Miller, K., Milne, A., Scerbo, C., Lim, R., Cooper, A., et al. (2017). Labelling of mental illness in a paediatric emergency department and its implications for stigma reduction education. Perspectives on Medical Education, 6(3), 165–172.

    Article  PubMed  PubMed Central  Google Scholar 

  23. McFarland, S. (2010). Authoritarianism, social dominance, and other roots of generalized prejudice. Political Psychology, 31(3), 453–477.

    Article  Google Scholar 

  24. Todd, A. R., Bodenhausen, G. V., Richeson, J. A., & Galinsky, A. D. (2011). Perspective taking combats automatic expressions of racial bias. Journal of Personality and Social Psychology, 100(6), 1027.

    Article  PubMed  Google Scholar 

  25. Batson, C. D., Polycarpou, M. P., Harmon-Jones, E., Imhoff, H. J., Mitchener, E. C., Bednar, L. L., et al. (1997). Empathy and attitudes: Can feeling for a member of a stigmatized group improve feelings toward the group? Journal of Personality and Social Psychology, 72(1), 105.

    Article  PubMed  Google Scholar 

  26. Whitford, D. K., & Emerson, A. M. (2018). Empathy intervention to reduce implicit Bias in pre-service teachers. Psychological Reports, 122(2), 670–688.

    Article  PubMed  Google Scholar 

  27. Burke, S. E., Dovidio, J. F., Przedworski, J. M., Hardeman, R. R., Perry, S. P., Phelan, S. M., et al. (2015). Do contact and empathy mitigate bias against gay and lesbian people among heterosexual medical students? A report from medical student CHANGES. Academic Medicine, 90(5), 645.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Vorauer, J. D., & Sasaki, S. J. (2009). Helpful only in the abstract? Ironic effects of empathy in intergroup interaction. Psychological Science, 20, 191–197.

    Article  PubMed  Google Scholar 

  29. Education LCoM. (2007). Functions and structure of a medical school. In Standards for accreditation of medical education programs leading to the MD degree. Washington, DC: Liaison Committee on Medical Education.

    Google Scholar 

  30. Committee on the Accreditation of Canadian Medical Schools. (2015). CACMS standards and elements: standards for accreditation of medical education programs leading to the M.D. degree. Ottawa (ON): Association of Faculties of Medicine of Canada. [accessed 2018 September 1] https://cacmscafmc.ca/sites/default/files/documents/CACMS_Standards_and_Elements_-_AY_2018-19.pdf

  31. US Department of Health and Human Services. National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. Retrieved March 24, 2019, from https://www.thinkculturalhealth.hhs.gov/assets/pdfs/EnhancedNationalCLASStandards.pdf

  32. Cross, T. L. (1989). Towards a culturally competent system of care: A monograph on effective services for minority children who are Severely emotionally disturbed. Washington, DC: Georgetown University, Child Development Center. CLAS standard.

    Google Scholar 

  33. Betancourt, J. R. (2003). Cross-cultural medical education: Conceptual approaches and frameworks for evaluation. Academic Medicine, 78(6), 560–569.

    Article  PubMed  Google Scholar 

  34. Betancourt, J. R., & Cervantes, M. C. (2009). Cross-cultural medical education in the United States: Key principles and experiences. The Kaohsiung Journal of Medical Sciences, 25(9), 471–478.

    Article  PubMed  Google Scholar 

  35. Betancourt, J. R., Green, A. R., Carrillo, J. E., & Park, E. R. (2005). Cultural competence and health care disparities: Key perspectives and trends. Health Affairs, 24(2), 499–505.

    Article  PubMed  Google Scholar 

  36. Bourgois, P., Holmes, S. M., Sue, K., & Quesada, J. (2017). Structural vulnerability: Operationalizing the concept to address health disparities in clinical care. Academic Medicine, 92(3), 299–307.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Metzl, J. M., & Hansen, H. (2014). Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science & Medicine, 103, 126–133.

    Article  Google Scholar 

  38. Kumagai, A. K., & Lypson, M. L. (2009). Beyond cultural competence: Critical consciousness, social justice, and multicultural education. Academic Medicine, 84(6), 782–787.

    Article  PubMed  Google Scholar 

  39. Norman, G. (2009). Dual processing and diagnostic errors. Advances in Health Sciences Education., 14(1), 37–49.

    Article  PubMed  Google Scholar 

  40. Norman, G., Sherbino, J., Dore, K., Wood, T., Young, M., Gaissmaier, W., et al. (2014). The etiology of diagnostic errors: A controlled trial of system 1 versus system 2 reasoning. Academic Medicine, 89(2), 277–284.

    Article  PubMed  Google Scholar 

  41. Norman, G. R., & Eva, K. W. (2010). Diagnostic error and clinical reasoning. Medical Education., 44(1), 94–100.

    Article  PubMed  Google Scholar 

  42. Sibbald, M., & de Bruin, A. B. (2012). Feasibility of self-reflection as a tool to balance clinical reasoning strategies. Advances in Health Sciences Education: Theory and Practice, 17(3), 419–429.

    Article  PubMed  Google Scholar 

  43. Mamede, S., Schmidt, H. G., Rikers, R. M., Custers, E. J., Splinter, T. A., & van Saase, J. L. (2010). Conscious thought beats deliberation without attention in diagnostic decision-making: At least when you are an expert. Psychological Research Psychologische Forschung, 74(6), 586–592.

    Article  PubMed  Google Scholar 

  44. Moskowitz, G. B., Gollwitzer, P. M., Wasel, W., & Schaal, B. (1999). Preconscious control of stereotype activation through chronic egalitarian goals. Journal of Personality and Social Psychology, 77(1), 167.

    Article  Google Scholar 

  45. Ely, J. W., Graber, M. L., & Croskerry, P. (2011). Checklists to reduce diagnostic errors. Academic Medicine, 86(3), 307–313.

    Article  PubMed  Google Scholar 

  46. Greenwald, A. G., McGhee, D. E., & Schwartz, J. L. (1998). Measuring individual differences in implicit cognition: The implicit association test. Journal of Personality and Social Psychology, 74(6), 1464.

    Article  PubMed  Google Scholar 

  47. Nosek, B. A., Greenwald, A. G., & Banaji, M. R. (2005). Understanding and using the implicit association test: II. Method variables and construct validity. Personality and Social Psychology Bulletin, 31(2), 166–180.

    Article  PubMed  Google Scholar 

  48. Steffens, M. C. (2004). Is the implicit association test immune to faking? Experimental Psychology., 51(3), 165–179.

    Article  PubMed  Google Scholar 

  49. Greenwald, A. G., & Nosek, B. A. (2001). Health of the implicit association test at age 3. Zeitschrift für experimentelle psychologie., 48(2), 85–93.

    Article  PubMed  Google Scholar 

  50. Greenwald, A. G., & Farnham, S. D. (2000). Using the implicit association test to measure self-esteem and self-concept. Journal of Personality and Social Psychology, 79(6), 1022.

    Article  PubMed  Google Scholar 

  51. Dasgupta, N., McGhee, D. E., Greenwald, A. G., & Banaji, M. R. (2000). Automatic preference for white Americans: Eliminating the familiarity explanation. Journal of Experimental Social Psychology, 36(3), 316–328.

    Article  Google Scholar 

  52. Bosson, J. K., Swann, W. B., & Pennebaker, J. W. (2000). Stalking the perfect measure of implicit self-esteem: The blind men and the elephant revisited? Journal of Personality and Social Psychology, 79(4), 631–643.

    Article  PubMed  Google Scholar 

  53. Nosek, B. A., Greenwald, A. G., & Banaji, M. R. (2007). The implicit association test at age 7: A methodological and conceptual review. In Automatic processes in social thinking and behavior (pp. 265–292). New York, NY: Psychology Press.

    Google Scholar 

  54. Gill, A., Thompson, B., Teal, C., et al. (2010). Best intentions: Using the implicit associations test to promote reflection about personal bias. MedEdPORTAL., 6, 7792. https://doi.org/10.15766/mep_2374-8265.7792

    Article  Google Scholar 

  55. Sukhera, J., & Watling, C. (2018). A framework for integrating implicit bias recognition into health professions education. Academic Medicine, 93(1), 35–40.

    Article  PubMed  Google Scholar 

  56. Burgess, D., van Ryn, M., Dovidio, J., & Saha, S. (2007). Reducing racial bias among health care providers: Lessons from social-cognitive psychology. Journal of General Internal Medicine, 22(6), 882–887.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Cosgray, R. E., Davidhizar, R. E., Grostefon, J. D., Powell, M., & Wringer, P. H. (1990). A day in the life of an inpatient: An experiential game to promote empathy for individuals in a psychiatric hospital. Archives of Psychiatric Nursing, 4(6), 354–359.

    Article  PubMed  Google Scholar 

  58. Henderson, P., & Johnson, M. H. (2002). Assisting medical students to conduct empathic conversations with patients from a sexual medicine clinic. Sexually Transmitted Infections, 78(4), 246–249.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Galinsky, A. D., & Moskowitz, G. B. (2000). Perspective taking: Decreasing stereotype expression, stereotype accessibility, and in-group favoritism. Journal of Personality and Social Psychology, 78(4), 708.

    Article  PubMed  Google Scholar 

  60. Vescio, T. K., Sechrist, G. B., & Paolucci, M. P. (2003). Perspective taking and prejudice reduction: The mediational role of empathy arousal and situational attributions. European Journal of Social Psychology., 33(4), 455–472.

    Article  Google Scholar 

  61. Dovidio, J. F., Ten Vergert, M., Stewart, T. L., Gaertner, S. L., Johnson, J. D., Esses, V. M., et al. (2004). Perspective and prejudice: Antecedents and mediating mechanisms. Personality and Social Psychology Bulletin., 30(12), 1537–1549.

    Article  PubMed  Google Scholar 

  62. Gaertner, S. L., & Dovidio, J. F. (2014). Reducing intergroup bias: The common ingroup identity model. New York, NY: Psychology Press.

    Book  Google Scholar 

  63. Gaertner, S. L., & Dovidio, J. F. (2005). Understanding and addressing contemporary racism: From aversive racism to the common ingroup identity model. Journal of Social Issues, 61(3), 615–639.

    Article  Google Scholar 

  64. Dovidio, J. F., Gaertner, S. L., Validzic, A., Matoka, K., Johnson, B., & Frazier, S. (1997). Extending the benefits of recategorization: Evaluations, self-disclosure, and helping. Journal of Experimental Social Psychology., 33(4), 401–420.

    Article  PubMed  Google Scholar 

  65. Condon, P., Desbordes, G., Miller, W. B., & DeSteno, D. (2013). Meditation increases compassionate responses to suffering. Psychological Science, 24(10), 2125–2127.

    Article  PubMed  Google Scholar 

  66. Lim, D., Condon, P., & DeSteno, D. (2015). Mindfulness and compassion: An examination of mechanism and scalability. PLoS One, 10(2), e0118221.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Hutcherson, C. A., Seppala, E. M., & Gross, J. J. (2008). Loving-kindness meditation increases social connectedness. Emotion, 8(5), 720.

    Article  PubMed  Google Scholar 

  68. Garcia, J. A. (2017). The effect of loving-kindness meditation on physiological and psychological reactions to violent stimuli [Thesis for Doctor of Psychology in Clinical Psychology] Statesboro Georgia, USA: Georgia Southern University.

    Google Scholar 

  69. Krasner, M. S., Epstein, R. M., Beckman, H., Suchman, A. L., Chapman, B., Mooney, C. J., et al. (2009). Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. Journal of the American Medical Association, 302(12), 1284–1293.

    Article  PubMed  Google Scholar 

  70. Lamothe, M., Rondeau, É., Malboeuf-Hurtubise, C., Duval, M., & Sultan, S. (2016). Outcomes of MBSR or MBSR-based interventions in health care providers: A systematic review with a focus on empathy and emotional competencies. Complementary Therapies in Medicine, 24, 19–28.

    Article  PubMed  Google Scholar 

  71. Lueke, A., & Gibson, B. (2015). Mindfulness meditation reduces implicit age and race bias: The role of reduced automaticity of responding. Social Psychological and Personality Science, 6(3), 284–291.

    Article  Google Scholar 

  72. Regehr, C., Glancy, D., Pitts, A., & LeBlanc, V. R. (2014). Interventions to reduce the consequences of stress in physicians: A review and meta-analysis. The Journal of Nervous and Mental Disease, 202(5), 353–359.

    Article  PubMed  Google Scholar 

  73. Dobkin, P. L., Bernardi, N. F., & Bagnis, C. I. (2016). Enhancing clinicians’ well-being and patient-centered care through mindfulness. Journal of Continuing Education in the Health Professions, 36(1), 11–16.

    Article  PubMed  Google Scholar 

  74. Irving, J. A., Park-Saltzman, J., Fitzpatrick, M., Dobkin, P. L., Chen, A., & Hutchinson, T. (2014). Experiences of health care professionals enrolled in mindfulness-based medical practice: A grounded theory model. Mindfulness, 5(1), 60–71.

    Article  Google Scholar 

  75. Mamede, S., van Gog, T., Moura, A. S., de Faria, R. M., Peixoto, J. M., Rikers, R. M., et al. (2012). Reflection as a strategy to foster medical students’ acquisition of diagnostic competence. Medical Education, 46(5), 464–472.

    Article  PubMed  Google Scholar 

  76. Ross, H. J. (2014). Everyday bias: Identifying and navigating unconscious judgments in our daily lives. Lanham, MD: Rowman & Littlefield.

    Google Scholar 

  77. Sukhera, J., Milne, A., Teunissen, P. W., Lingard, L., & Watling, C. (2018). Adaptive reinventing: Implicit bias and the co-construction of social change. Advances in Health Sciences Education, 17, 1–3.

    Google Scholar 

  78. Sukhera, J., Milne, A., Teunissen, P. W., Lingard, L., & Watling, C. (2018). The actual versus idealized self: Exploring responses to feedback about implicit bias in health professionals. Academic Medicine, 93(4), 623–629.

    Article  PubMed  Google Scholar 

  79. Edmondson, A. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(2), 350–383.

    Article  Google Scholar 

  80. Cooper, L. A., Roter, D. L., Carson, K. A., Beach, M. C., Sabin, J. A., Greenwald, A. G., et al. (2012). The associations of clinicians’ implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. American Journal of Public Health, 102(5), 979–987.

    Article  PubMed  PubMed Central  Google Scholar 

  81. Burgess, D. J., Beach, M. C., & Saha, S. (2017). Mindfulness practice: A promising approach to reducing the effects of clinician implicit bias on patients. Patient Education and Counseling, 100(2), 372–376.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. University of Western Ontario, London, ON, Canada

    Javeed Sukhera

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Editors and Affiliations

  1. Department of Psychiatry and Behavioral Health, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA

    Adriana E. Foster

  2. Department of Psychiatry and Behavioral Health, Icahn School of Medicine, Mount Sinai Beth Israel, New York, NY, USA

    Zimri S. Yaseen

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Sukhera, J. (2019). Empathy and Implicit Bias: Can Empathy Training Improve Equity?. In: Foster, A.E., Yaseen, Z.S. (eds) Teaching Empathy in Healthcare. Springer, Cham. https://doi.org/10.1007/978-3-030-29876-0_14

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