By Emily Margosian, assistant editor

What do male receptionists and female department chairs have in common? We’re often surprised to see them. But why? Implicit bias — or the automatic attitudes and stereotypes that affect our understanding, actions, and decisions in an unconscious manner — is partly to blame.

“We are exposed to as many as 11 million pieces of information daily, but we can only process about 40 at any one time,” explained Alex Ortega-Loayza, MD, chair of the AAD’s Diversity Taskforce. “Biases act as mental shortcuts that enable faster decision-making.” While the effects of implicit bias can often play out in small, imperceptible ways, the topic has been catapulted into the national discourse after a profiling incident at a Philadelphia Starbucks garnered widespread media attention and led to company-wide anti-bias training.

Medicine is not exempt from the effects of its own underlying biases. Simply Google-searching “implicit bias in…” yields “health care” as the top result. Historically, the dermatology physician workforce has experienced an underrepresentation of minorities. The Aademy has recognized that gap and is actively addressing the lack of diversity in the physician workforce in a number of ways. Beyond physicians, however, bias often creeps into the hiring process for non-clinical employees as well — from the front desk to the coding department. “Unconscious racism, sexism, and ageism play a big role in whom we hire,” notes a 2015 Harvard Business Review article. “In fact, simply having a name that sounds black can reduce the chance of you getting an interview.”

In this first installment of a two-part series on the effects of bias in health care, Dermatology World tackles implicit bias in hiring, addressing:

• How to define bias
• Strategies to eliminate bias from the hiring process 

What constitutes bias?

For employers, it’s important to note that implicit bias does not equal deliberate discrimination. “When we think of conscious bias, that’s going to be the overt ‘isms,’” explained René Salazar, MD, assistant dean for diversity and professor of internal medicine at Dell Medical School at the University of Texas at Austin. “So overt racism, sexism, homophobia — which are obviously very much an issue. What can be more challenging to confront, however, are these unconscious biases — ideas and attitudes we have no idea that we have, but certainly play out in what we say and how we act.” Often these beliefs are highly internalized, and don’t necessarily reflect the opinions or attitudes that one would choose to consciously express. “We are constantly making assessments, often based upon our own experience, identity, and perspective, that result in unfair treatment,” explained Betty Jeanne Taylor, PhD, assistant vice president at the division of diversity and community engagement at the University of Texas at Austin. “Though these attitudes may be unintentional, they are still harmful and must be consciously interrupted.”

The effects of implicit bias are systematically reflected across the hiring landscape. A 2013 U.S. Equal Employment Opportunity Commission report identified bias and perceptions about African Americans as one of seven “major obstacles hindering equal opportunities for African Americans in the federal workforce.” However, bias can extend beyond race to include other factors such as gender, age, sexuality, and appearance. “There’s lots of obesity bias that’s becoming well documented. There’s ageism and bias toward individuals from LGBT groups — particularly those who are transgender,” said Dr. Salazar. “The way I like to think about it is: However you define diversity — whatever trait or feature you use — you can be biased against it.”

Gender can also be a huge source of bias among employers, particularly when hiring for certain positions that fit a ‘conventional’ gender stereotype. For example, gravitating toward a female applicant for an open nurse position, or away from a male candidate interviewing to be a kindergarten teacher. Likewise, “gut reaction” hiring decisions related to outward appearance are often rooted in internal biases concerning race and gender. For example, does an African-American candidate who wears their hair in a natural style invoke unfounded assumptions about their professionalism or job performance? Fortunately, there are several key steps physicians can take to not only become aware of their own biases, but also reduce their impact on the recruitment phase.

How to avoid bias during the hiring process:

1. Acknowledge your own bias.

The first step to overcoming bias sounds simple — but is often the most challenging. “Due to our human nature, we all have biases. That’s why I like calling unconscious bias ‘blind spots,’” said Dr. Ortega-Loayza. “Accepting the existence of these ‘blind spots’ can help physician employers deal with them more effectively.” One way to do this is to simply take a test. “There are a couple of instruments out there, but the one that’s most commonly used is called an Implicit Association Test (IAT). It’s free online and only takes about 10 minutes to complete,” said Dr. Salazar.

Physicians may also want to consider the benefits of formal anti-bias training for their office or department — anyone with a hand in the hiring process. “You’ve got to be intentional, and people have to be motivated to want to do this,” said Dr. Salazar. “It’s important to emphasize that your biases aren’t going to change; these are things that develop over years. For me, a lot of my biases come from growing up in south Texas with limited exposure to different races and ethnicities. I can’t undo a lot of that — and in fact every time I take one of these tests, I find out that those biases are still there — but what I do with the information is different. Now that I’m aware, I can act differently in the moment.”

2. Standardize the interview.

By implementing a clear structure for interviews with identical questions for each candidate, employers are better guided to keep their focus on factors that have a direct impact on performance. “Research has shown that interviews are poor predictors of job performance because we tend to hire people we think are similar to us rather than those who are objectively going to do a good job,” explained Dr. Ortega-Loayza. Another technique for reducing subjectivity during the interview phase involves requiring work samples or on-the-job skill tests, ensuring that candidates’ work are being critiqued directly. To ensure total neutrality, employers may want to take the additional step of obtaining software that blindly sorts resumes by obscuring the name of an applicant. “There have been numerous studies across disciplines about implicitly biased attitudes regarding candidate names when evaluating resumes,” said Dr. Taylor. “Often this bias is related to assumptions about gender and race. Once these assumptions are made, they can persist throughout the candidate review process.”

Dr. Salazar also recommends developing and discussing candidate criteria as a hiring committee when possible to ensure group accountability throughout the process. “A lot of times hiring is based on, ‘It’s a good fit,’ or ‘I’ve got a gut feeling,’ but we’re not really basing it on any objective data. So creating guidelines, setting up criteria, and being really rigid and adherent to that criteria is extremely important. You can really begin to undermine some of these biases the more objective and consistent you can be.”

3. Use careful phrasing in job descriptions.

Even the wording used in a job posting can convey an implicit bias to applicants regarding their suitability. Employers should be particularly careful to use gender-neutral phrasing, as many adjectives can suggest a preference for a particular gender over another. According to the Journal of Personality and Social Psychology, “There is an established literature documenting widely held gender stereotypes and differences in the way men and women use everyday language. On the whole, women are perceived as more communal and interpersonally oriented than men, whereas men are more readily attributed with traits associated with leadership.” For example, job descriptions that include adjectives such as “competitive” or “leader” may unconsciously dissuade female candidates from applying for particular roles, as the “mere presence of these masculine words...cue that women do not belong” (2011;101(1): 109-128). On the opposite end, job descriptions that feature language such as “collaborative” and “cooperative” may send similar signals to male applicants, discouraging them from pursuing the role further

According to Dr. Taylor, “Even words that are used to describe candidates can be implicitly biased as to whether the same descriptor is perceived as positive or negative. For example, the word “aggressive” may be seen as positive for a candidate who is a man, whereas “aggressive” to describe a candidate who is a woman is most often viewed as a negative attribute.” While employers should be mindful of these subtle wording differences, technology can also step in to lend an impartial hand. Software programs such as Textio or the free Gender Decoder can highlight stereotypically gendered words, and help employers create less biased job descriptions.

4. Avoid gravitating toward the “status quo.”

As a grimly titled 2016 Harvard Business Review article, “If There’s Only One Woman in Your Candidate Pool, There’s Statistically No Chance She’ll Be Hired,” observes, “Why does being the only woman in a pool of finalists matter? For one thing, it highlights how different she is from the norm. And deviating from the norm can be risky for decision makers, as people tend to ostracize people who are different from the group. For women and minorities, having your differences made salient can also lead to inferences of incompetence.”

Dr. Salazar echoed this point. “Often we want to hire folks who look like us, who are part of what we assume are similar communities. For example, if you have a unit of white individuals, people are going to tend to want to hire folks who look like them — other white people. You’re missing out on candidates who are talented because they don’t look like you.”

If “likeability” remains an important metric to a particular practice or group, employers may want to consider assigning it a numerical score, as they would other skills on an interview, to make it a more controllable variable. And although set diversity goals are not without their critics, Dr. Salazar said practices often see clear benefits from building a more inclusive work environment. “Having a diverse team means more than just numbers. Diversity means excellence, and I think people mistake that,” he explained. “They say, well if I’m going to become diverse, I’m going to compromise excellence, and that’s absolutely not true. Diverse teams are more productive; they get stuff done. They have different ideas that come to the table, and they’re more creative.”

According to Dr. Ortega-Loayza, the numbers back this observation up. “A 2015 McKinsey report on 366 public companies found that those in the top quartile for ethnic and racial diversity in management were 35% more likely to have financial returns above their industry mean, and those in the top quartile for gender diversity were 15% more likely to have returns above the industry mean,” he said. “We live in a diverse country, and should have health care organizations where diversity is valued. Addressing implicit bias has implications for physicians, their employees, and patients. It is the cornerstone to addressing health disparities, and it is our responsibility to continue moving in that direction.”