RxCe - Implicit Bias in the Pharmacy Setting Materials

MITIGATING IMPLICIT BIAS IN THE PHARMACY SETTING

Steve Malen, PharmD, MBA

Dr. Steve Malen graduated with a dual degree: Doctor of Pharmacy (PharmD) and Master of Business Administration (MBA) from the University of Rhode Island. Over his career, he has worked as a clinical pharmacist in the retail, specialty, and compounding sectors. He specialized and taught on topics from vaccines to veterinary compounding. Dr. Malen has also written a science fiction novel and taught and co- founded the concept of Patient Empowered Blockchain (P.E.B.). Currently, Dr. Malen continues to write, teach, and consult various companies in the healthcare sector.

Topic Overview

Implicit bias is the unconscious attitudes, stereotypes, and beliefs that can influence an individual's thoughts, feelings, and behaviors. Implicit bias can contribute to discrimination in healthcare, which results in patients receiving different levels of care due to uncertainty in communication and clinical decision-making related to these biases, prejudices, and stereotyping. Implicit biases can be displayed through microaggressions. There are strategies that may be used to mitigate implicit bias; however, the evidence seems to show that interventions are not effective if they are one-time affairs but require persistent long-term strategies to maintain change.

Accreditation Statement:

RxCe.com LLC is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education.

Universal Activity Number (UAN): The ACPE Universal Activity Number assigned to this activity is

Pharmacist 0669-0000-23-003-H99-P

Pharmacy Technician 0669-0000-23-004-H99-T

Credits: 1 hour of continuing education credit

Type of Activity: Knowledge

Media: Internet Fee Information: $4.99

Estimated time to complete activity: 1 hour, including Course Test and course evaluation

Release Date: January 28, 2023 Expiration Date: January 28, 2026

Target Audience: This educational activity is for pharmacists.

How to Earn Credit: From January 28, 2023, through January 28, 2026, participants must:

Read the “learning objectives” and “author and planning team disclosures;”

Study the section entitled “educational activity;” and

Complete the Course Test and Evaluation form. The Course Test will be graded automatically. Following successful completion of the Course Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)

Learning Objectives: Upon completion of this educational activity, participants should be able to:

Describe what implicit bias is and how it can manifest in healthcare

Describe how implicit bias can affect clinical judgment and behavior in healthcare settings

Identify strategies on how to mitigate implicit bias in the pharmacy setting

Disclosures

The following individuals were involved in the development of this activity: Steve Malen, PharmD, MBA, and Susan DePasquale, MSN, PMHNP-BC. There are no financial relationships relevant to this activity to report or disclose by any of the individuals involved in the development of this activity.

Introduction

Health equity is an important concept in healthcare. It signifies a society where all members can receive quality healthcare; however, this goal has not been fully attained as health disparities are present in healthcare. Health disparities occur when there is an unequal delivery of healthcare services to patients of a specific race, ethnicity, gender, sexual orientation, or socioeconomic status. Moreover, health disparities may be due, in part, to a provider’s unconscious or implicit bias. Implicit biases are present in all areas of healthcare, including pharmacy settings. In order to confront and mitigate implicit bias, pharmacists and pharmacy staff must first understand how it can manifest in the pharmacy setting, and how it can affect clinical judgment and behavior, patient trust, and patient adherence to treatment plans. Once implicit bias is acknowledged, strategies can be developed to mitigate it.

Understanding Implicit Bias

Implicit bias, as a concept, originated in psychology many decades ago.1,2 Psychologists proposed that demographic characteristics such as race, gender, or age could influence a person’s judgment and behavior without the person being aware of the bias.1

Terminologies such as unconscious bias, systemic racism, and implicit bias, developed around this concept as ways to describe this subtle form of discrimination.1 Today, this unconscious form of bias is generally referred to as implicit bias.1

Implicit bias is also present in healthcare. In 2003, the Institute of Medicine (IOM) reported on disparities in healthcare tied to demographics.3 This disparity was partly based on implicit bias.1,3 The IOM stated that “[s]ome research suggests that differences in care may result from conscious or unconscious biases on the part of physicians and other healthcare providers.”3 By 2016, the concept of implicit bias had entered and pervaded most of society, including medical fields.4

There is a general understanding that implicit bias contributes to discrimination in healthcare.3 Discrimination in healthcare has been defined “as differences in care that emerge from biases and prejudice, [and] stereotyping” that can lead to “uncertainty in communication and clinical decision-making.”3 Implicit bias is an unconscious form of discrimination, where unconscious attitudes, stereotypes, and beliefs may influence an individual's thoughts, feelings, and behaviors.5

Studies have shown that implicit bias is pervasive, and people of all ages, races, and backgrounds hold unconscious biases.4,6,7 A person’s unconscious perceptions and attitudes toward others (implicit biases) are shaped by the person's life experiences, media exposure, and cultural influences.8

Misunderstandings or Misconceptions about Implicit Bias

A fuller understanding of implicit bias may be formed by looking at misconceptions that have developed around it. Greenwald, et al. (2022) reviewed five misunderstandings of implicit bias.1

The first misunderstanding is that the IAT, and other tests for implicit bias, measure prejudice, and racism.1 This is incorrect. It is not appropriate to link implicit bias to racism or prejudice. A person may have unconscious biases toward a particular group of people, but this may not be hostile or racist toward the group. A corollary of this misunderstanding is that “good people do not possess implicit biases.”1 The opposite is true: people unavoidably acquire implicit biases from daily immersions in their culture.1

The second misunderstanding is that tests for implicit bias only measure and predict “spontaneous (automatic) behavior,” and cannot measure and predict “deliberate (controlled, rational) behavior.”1 Tests that measure implicit bias can do both. A number of studies found that implicit measures were equally effective in predicting deliberate and spontaneous behavior.1

The third misunderstanding is that explicit and implicit biases are unrelated. The reality is that implicit and explicit biases are positively correlated.1 A number of studies confirmed this correlation.1

The fourth misunderstanding is that long-established implicit biases may be modified and long-lasting or durable.1 Forscher, et al. (2017) The prejudice habit-breaking intervention remains a highly promising candidate for empowering people to reduce their own biases through awareness, concern, and effort.9 The evidence seems to say that long-lasting change is the exception and that long-established biases are not easily reduced or durably modifiable.1

The fifth misunderstanding is that group-administered antibias or diversity training effectively mitigates discriminatory bias.1 Studies have found that these methods are not effective and that they may do more harm than good.10

By correcting these misunderstandings, clinicians can have a better understanding of implicit bias. In addition, they can have realistic expectations of what can be accomplished with mitigation methods and strategies.

Microaggression as a Form of Implicit Bias

Microaggression is a subtle form of discrimination or prejudice that can have a harmful impact on the person experiencing it.11 Microaggressions are regular, daily, or common exchanges or insults intended to demean a particular group of people.11,12 This may take the form of racial or ethnic jokes.12 Microaggressions can be unintentional.13 The person making the comment or joke may even believe it was “a compliment” and become defensive when confronted.13 The use of the morpheme “micro” in the word microaggression is not intended to minimize the impact or seriousness of these exchanges but refers to the regular, ongoing nature of these encounters.11

What is the relationship between microaggressions and implicit bias? “Microaggressions are often based on implicit bias, which is the tendency to automatically associate people with stereotypical characteristics of the identity group to which they belong.”11

In the pharmacy setting, microaggression can negatively affect the patient, pharmacist, and pharmacy staff.11 Coworkers subjected to microaggressions may become disaffected or dissatisfied with their job.11 As with all forms of discrimination, microaggressions can lower a patient's quality of care.11 Implicit bias may negatively impact patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes; however, implicit bias does not appear to affect treatment processes as much as patient-provider interactions and patient outcomes.7

Healthcare Professionals have Implicit Biases

Everyone has some degree of implicit bias, and healthcare professionals, including pharmacists, and pharmacy staff, are not immune from this.7 Research has shown that healthcare providers can hold implicit biases against certain groups of patients, which can affect the quality of care that these patients receive. For example, a healthcare provider may have an implicit bias against people of a certain race or ethnicity, which could lead to a lower quality of care, such as underestimating the patient's reported pain or discomfort.5

Consequences of Implicit Bias

In healthcare, implicit bias can have significant consequences, as it can influence how healthcare providers interact with and care for their patients.6,7 Patients experiencing implicit bias also report a lower level of trust in their provider.7 It is important to remember that some studies found an insignificant correlation between healthcare outcomes and implicit bias.7 Nevertheless, a large body of research found that “racial and ethnic minorities experience a lower quality of health services, and are less likely to receive even routine medical procedures than are white Americans.”3

Implicit Bias and Clinical Judgments and Behaviors

Implicit bias can affect clinical judgment and behavior in several ways.5,14 For example, healthcare providers may have unfounded beliefs about a race of people, which can impact care.14 Hoffman, et al. (2016) reported on how beliefs about perceived biological differences between African American and White patients related to pain can lead to undertreatment of pain in African American populations.14 One of the prejudices reported in this study was that African Americans had a higher pain threshold than White patients.14 These types of generalizations are not only wrong, but they undermine the individualized care all patients are entitled to receive.

Implicit Bias, Patient Trust, and Treatment Adherence

Implicit bias causes a general lack of trust by patients in their healthcare providers, which can lead to nonadherence to treatment plans.7,15 The IOM reported on studies showing that African Americans were less likely to receive appropriate cardiac medication when compared to Whites.3 This does not appear to be tied to clinical judgment but is more likely due to nonadherence, which may be linked to implicit bias;15,16 that is, nonadherence leads to disparities in care for patients of different races, ethnicities, and other characteristics.15 Disparities in healthcare must be eliminated; therefore, it is important for healthcare professionals to be aware of their biases and to make an effort to recognize and overcome them to provide the best possible care for all of their patients.

Implicit bias may be unconscious, but patients often feel it. As mentioned above, this may or may not affect the treatment process, but it significantly impacts patient trust and treatment adherence. Casanova-Perez, et al. (2022) reported how many LGBTQ+ patients described biased healthcare experiences when visiting their healthcare provider.17

Assessing Implicit Bias

The Implicit Association Test (IAT) was developed in 1998 by Greenwald, McGhee, and Schwartz.18 It is currently implemented through the Harvard Project Implicit, assessing implicit bias in healthcare toward people based on race, ethnicity, sex, gender identity, sexual orientation, weight, and age.19 The IAT is generally accepted as the most effective tool for measuring implicit bias, and it is in common use.20 Pharmacists and pharmacy staff can consider utilizing the IAT to help assess and identify unconscious biases.

Strategies for Mitigating Implicit Bias in the Pharmacy Setting

Eliminating implicit bias entirely is the goal, but it may be more of an ideal than a reality; nevertheless, it is important to take steps to reduce its impact and attain long-lasting change,21 if possible.1 Strategies to mitigate should be viewed realistically. Evidence-based support for the effectiveness of mitigation strategies may be thin.22 FitzGerald, et al. (2019) state starkly that “[c]urrent data do not allow the identification of reliably effective interventions to reduce implicit biases. As our systematic review reveals, many interventions have no effect, or may even increase implicit biases.”22 This expresses the serious approach professionals must take when confronting implicit bias. They should not approach this topic flippantly and “check the box” that they have completed diversity training. In addition, this highlights the importance of continual training and education to combat this complex but important issue.

Implicit bias training and education can be done at the individual or organizational levels.12,13 Education and training aim to create more inclusive and equitable environments.12,13 By acknowledging and addressing implicit bias, individuals and organizations can work to create a more fair and equitable healthcare system. As FitzGerald, et al. (2017) said, “A patient should not expect to receive a lower standard of care because of her race, age, or any other irrelevant characteristic.”5

There are also specific strategies that pharmacies may use for their pharmacists and pharmacy staff to deal with implicit bias. They include increased awareness of implicit bias, learning to control automatic responses, creating an inclusive work and learning environment, using objective decision- making, seeking feedback, encouraging open and honest communication, and monitoring and evaluating progress toward mitigating implicit biases. These may be implemented at the individual or organizational levels.

Increased Awareness

The first step in addressing implicit bias is to become aware of its existence.6 This can be accomplished through “self-reflection activities,” which can help people challenge the views they have about themselves and help them become aware of biases they may not know they have.6 Pharmacists and pharmacy staff can educate themselves about the ways that implicit bias can affect patient outcomes and seek out training and resources to help them become more aware of their biases.

Controlling Automatic Responses

Once a person is aware of implicit biases, it is essential to provide the person with strategies to control his or her “automatic responses” toward patients within a stigmatized group.6 This may include “affirming egalitarian goals, seeking common-group identities, perspective-taking, and individuation via counter-stereotyping.”6 A powerful way to identify with a person from a different race, ethnicity, etc., is to engage in perspective- taking.22,23 Perspective-taking is the “ability to understand how a situation appears to another person and how that person is reacting cognitively and emotionally to the situation.”23 Pharmacists and pharmacy staff can use this strategy to put themselves in the place of a co-worker or patient to help control their “automatic responses.”

Creating an Inclusive Work and Learning Environment

Creating a welcoming and inclusive environment for all patients and coworkers can help reduce the impact of implicit bias.10,24 This can include using inclusive language, actively listening to patients, and trying to understand their unique needs and concerns.10,24

Using Objective Decision-making

When making treatment recommendations or decisions, pharmacists and pharmacy staff should strive to use objective criteria rather than relying on subjective opinions or stereotypes.25 This can help to ensure that patients receive the best possible care, regardless of their background or identity.25

Seeking Feedback

Pharmacists can ask for feedback from staff and patients about their experiences in the pharmacy and use this information to identify areas where implicit bias may impact patient care.6 This can help pharmacists to make necessary changes and improve the quality of care they provide. However, this must be done without awakening a defensive or resistant response to the issue.6

Encouraging Open and Honest Communication

Encouraging open and honest communication among employees can help create a culture in which people feel comfortable speaking up about instances of bias or discrimination.26 This can include providing anonymous reporting mechanisms or setting up regular check-ins to discuss diversity and inclusion issues.

Monitoring and Evaluating Progress

Regularly monitoring and evaluating progress on diversity and inclusion efforts can help organizations identify areas where implicit bias may impact

employee experiences and make necessary changes.27 This can include collecting and analyzing data on employee demographics, retention rates, and promotion rates and soliciting employee feedback through surveys or focus groups.

Long-lasting Mitigation of Implicit Bias

When speaking of long-lasting changes that reduce or eliminate implicit biases, it is important to recall Greenwald, et al. (2022)’s assertion that long- established implicit biases are usually not modifiable over the long term.1 If they are correct, and the evidence seems to say they are, then education, training, and efforts to create more inclusive and equitable environments cannot be one-time affairs. Long-term education and training are needed. As FitzGerald, et al. (2019) points out, “[i]f change is really to be produced, a commitment to more in-depth training is necessary.”22 It is not enough to provide “short, one-shot sessions that can be completed and the requisite diversity boxes ticked.”22

Healthcare organizations are working to address implicit bias through training and education for their employees. As stated above, this cannot be a one-time affair. This education and training must be ongoing. This can help raise awareness of how implicit bias can affect patient care and can provide tools and strategies for reducing its impact. It is essential for healthcare providers to be aware of their biases and to take steps to ensure that they are providing the best possible care to all their patients, regardless of their background or identity.

Summary

Implicit bias is the unconscious attitudes, stereotypes, and beliefs that can influence an individual's thoughts, feelings, and behaviors. Differences in care may result from conscious or unconscious biases on the part of healthcare providers, pharmacists, and pharmacy staff.

Microaggressions are regular, daily, or common exchanges or insults intended to demean a particular group of people. Microaggressions can be unintentional, in which case, they fall within the concept of implicit bias.

Training and education on implicit bias are used to mitigate its effects on healthcare. This training and education can be done at the individual or organizational levels. Education and training aim to create more inclusive and equitable environments. By acknowledging and addressing implicit bias, individuals and organizations can work to create a more fair and just healthcare system.

There are specific strategies that pharmacies may use for their pharmacists and pharmacy staff to deal with implicit bias. They include increased awareness of implicit bias, learning to control automatic responses, creating an inclusive work and learning environment, using objective decision- making, seeking feedback, encouraging open and honest communication, and monitoring and evaluating progress toward mitigating implicit biases. These may be implemented at the individual or organizational levels.

Long-lasting changes that mitigate implicit bias require a commitment to in-depth training. It is not enough to provide one-time sessions. Healthcare organizations that use training and education for their employees must commit to ongoing, regular interventions.

References

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Greenwald AG, Banaji MR. The implicit revolution: Reconceiving the relation between conscious and unconscious. Am Psychol. 2017;72(9):861-871. doi:10.1037/amp0000238

Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care; Smedley BD, Stith AY, Nelson AR, editors. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington (DC): National Academies Press (US); 2003. 4, Assessing Potential Sources of Racial and Ethnic Disparities in Care: The Clinical Encounter. https://www.ncbi.nlm.nih.gov/books/NBK220340/. Accessed January 24, 2023.

Staats C, Capatosto K, Tenney L, Mamo S. State of Science: Implict Bias Review. Ohio State University. Kirwan Institute for the Study of Race and Ethnicity. 2017. https://kirwaninstitute.osu.edu/sites/default/files/pdf/2017-implicit- bias-review.pdf. Accessed January 24, 2023.

FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18(1):19. Published 2017 Mar

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Zestcott CA, Blair IV, Stone J. Examining the Presence, Consequences, and Reduction of Implicit Bias in Health Care: A Narrative Review. Group Process Intergroup Relat. 2016;19(4):528-542. doi:10.1177/1368430216642029

Hall WJ, Chapman MV, Lee KM, et al. Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. Am J Public Health. 2015;105(12):e60-e76. doi:10.2105/AJPH.2015.302903

Okoro for contrary view that “Race is not biological” Okoro ON, Arya V, Gaither CA, Tarfa A. Examining the Inclusion of Race and Ethnicity in Patient Cases. Am J Pharm Educ. 2021;85(9):8583. doi:10.5688/ajpe8583

Forscher PS, Mitamura C, Dix EL, Cox WTL, Devine PG. Breaking the prejudice habit: Mechanisms, timecourse, and longevity. J Exp Soc Psychol. 2017;72:133-146. doi:10.1016/j.jesp.2017.04.009

Gonzalez CM, Lypson ML, Sukhera J. Twelve tips for teaching implicit bias recognition and management. Med Teach. 2021;43(12):1368- 1373. doi:10.1080/0142159X.2021.1879378

Brown C, Daniel R, Addo N, Knight S. The experiences of medical students, residents, fellows, and attendings in the emergency department: Implicit bias to microaggressions. AEM Educ Train. 2021;5(Suppl 1):S49-S56. Published 2021 Sep 29. doi:10.1002/aet2.10670

Dale SK, Safren SA. Gendered racial microaggressions predict posttraumatic stress disorder symptoms and cognitions among Black women living with HIV. Psychol Trauma. 2019;11(7):685-694. doi:10.1037/tra0000467

Avant ND, Davis RD. Navigating and Supporting Marginalized Identities in Dominant Pharmacy Spaces. Innov Pharm. 2018;9(4):10.24926/iip.v9i4.1033. Published 2018 Nov 30. doi:10.24926/iip.v9i4.1033

Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S

A. 2016;113(16):4296-4301. doi:10.1073/pnas.1516047113

Daugherty SL, Helmkamp L, Vupputuri S, et al. Effect of Values Affirmation on Reducing Racial Differences in Adherence to Hypertension Medication: The HYVALUE Randomized Clinical Trial. JAMA Netw Open. 2021;4(12):e2139533. Published 2021 Dec 1. doi:10.1001/jamanetworkopen.2021.39533

Blair IV, Steiner JF, Hanratty R, et al. An investigation of associations between clinicians' ethnic or racial bias and hypertension treatment, medication adherence and blood pressure control. J Gen Intern Med. 2014;29(7):987-995. doi:10.1007/s11606-014-2795-z

Casanova-Perez R, Apodaca C, Bascom E, et al. Broken down by bias: Healthcare biases experienced by BIPOC and LGBTQ+ patients. AMIA Annu Symp Proc. 2022;2021:275-284. Published 2022 Feb 21.

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Marini M, Waterman PD, Breedlove E, et al. The target/perpetrator brief-implicit association test (B-IAT): an implicit instrument for efficiently measuring discrimination based on race/ethnicity, sex,

gender identity, sexual orientation, weight, and age. BMC Public Health. 2021;21(1):158. Published 2021 Jan 19. doi:10.1186/s12889-021-

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Prasad-Reddy L, Fina P, Kerner D, Daisy-Bell B. The Impact of Implicit Biases in Pharmacy Education. Am J Pharm Educ. 2022;86(1):8518. doi:10.5688/ajpe8518

Devine PG, Forscher PS, Austin AJ, Cox WT. Long-term reduction in implicit race bias: A prejudice habit-breaking intervention. J Exp Soc Psychol. 2012;48(6):1267-1278. doi:10.1016/j.jesp.2012.06.003

FitzGerald C, Martin A, Berner D, Hurst S. Interventions designed to reduce implicit prejudices and implicit stereotypes in real world contexts: a systematic review. BMC Psychol. 2019;7(1):29. Published 2019 May 16. doi:10.1186/s40359-019-0299-7

Johnson DW. Cooperativeness and social perspective taking. J Pers Soc Psychol. 1975;31(2):241-244.

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DISCLAIMER

The information provided in this course is general in nature, and it is solely designed to provide participants with continuing education credit(s). This course and materials are not meant to substitute for the independent, professional judgment of any participant regarding that participant’s professional practice, including but not limited to patient assessment, diagnosis, treatment, and/or health management. Medical and pharmacy practices, rules, and laws vary from state to state, and this course does not cover the laws of each state; therefore, participants must consult the laws of their state as they relate to their professional practice.

Healthcare professionals, including pharmacists and pharmacy technicians, must consult with their employer, healthcare facility, hospital, or other organization, for guidelines, protocols, and procedures they are to follow. The information provided in this course does not replace those guidelines, protocols, and procedures but is for academic purposes only, and this course’s limited purpose is for the completion of continuing education credits.

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