A Medical Science Educator Article Review From Dr. Louis B. Justement

This review was written by Louis B Justement, PhD, a member of the IAMSE Publications Committee, and was first published online on August 14th, 2020 in Medical Science Educator. The article is titled “Addressing Implicit Bias in First-Year Medical Students: a Longitudinal, Multidisciplinary Training Program” and was written by Megan Ruben and Norma S. Saks, Medical Science Educator (2020) 30:1419-1426.

Implicit bias continues to present a significant challenge with respect to the practice of medicine and contributes to decision-making on the part of physicians that in turn contributes to health disparities experienced by individuals from diverse backgrounds. This problem has been recognized in the medical community and calls have been made to address implicit bias in medical education. However, many efforts to address implicit bias fall short in terms of not only raising awareness of implicit bias by trainees, but in terms of actually changing the degree of implicit bias that individuals experience. This is in part due to the fact that, although efforts may be relatively successful in terms of raising an individual’s awareness of implicit bias, it is extremely difficult to impact in a meaningful way the level of implicit bias that any given individual has towards those from different groups/backgrounds.  This is likely a reflection that changing one’s level of implicit bias requires a long-term, sustained set of interventions in which one’s awareness of implicit bias is constantly being raised through a diverse array of activities/experiences. 

Although the issue of implicit bias has been raised in medical education and is an issue that is of great significance with respect to addressing health disparities, the inclusion of implicit bias training as a single unit or class in the curriculum is most likely not sufficient to change the overall impact that implicit bias has on the practice of medicine. In the study by Ruben and Saks a multidisciplinary, longitudinal intervention was created to reduce implicit bias towards skin tone, to raise awareness of implicit bias and to determine whether exposure to the intervention, which took place during the first year of medical school would result in changes in implicit bias among the participants. The program used a multidisciplinary approach in which students were expected to visit an art museum and then participate in a medical anthropology lecture followed by a sociological discussion pertaining to implicit bias in medicine. In parallel, the investigators assessed implicit bias in a control group that did not participate in the program.  The investigators took the Harvard Implicit Association Test for Skin Tone and took a survey to assess awareness of implicit bias before and after the program.

The study demonstrated that both the experimental and control group of students exhibited a clear bias towards light skin and that this bias was not significantly impacted by participating in the program. Although, a power analysis supported the conclusion that those in the experimental group were trending towards a decrease in their implicit bias towards light skin. All participants indicated that they were aware of implicit bias, but importantly, the results suggest that those who demonstrate a stronger bias tend to be less willing to recognize implicit bias in themselves. A promising result of the study was that those who were in the experimental group expressed a much more developed and complex understanding of what implicit bias is and how it affects health care than those in the control group.

In conclusion, this study demonstrates that medical students are aware of implicit bias, but that individuals may not necessarily be willing to acknowledge their own implicit bias. The study further demonstrates that even with a year-long, multidisciplinary program, it is difficult to alter the degree of implicit bias on an individual basis, but with a sustained approach, it is possible to begin to impact the degree to which individuals understand how implicit bias plays a role in their decision making and that of the medical community at-large. This study supports the conclusion that isolated classes or units offered once within the overall medical curriculum are not likely to significantly impact implicit bias and its contribution to health disparities. Rather, there needs to be a focus on integrating implicit bias training throughout the curriculum and to utilize a range of approaches to foster student exploration of their own implicit biases.

Louis B. Justement, PhD
Professor, Department of Microbiology
Director, GBS Immunology Theme
Director, Undergraduate Immunology Program
University of Alabama at Birmingham