Recognizing Implicit Bias and Ways to Overcome It

A gleaming, luxury vehicle approaches a medical office and a patient—a woman in a smart blazer aided by a gentleman, presumably her husband—emerges from the passenger side. The clinic’s financial counselor observes the couple’s arrival from a breakroom window, bemused, and before he has even had a conversation with the patient on the financial aspects of her treatment plan, he has formed an impression about his patient and her lifestyle.  

After meeting with the patient who displays serious distress at the financial costs of her treatment, the financial counselor vents to a co-worker over the seeming dissonance between the patient’s affluent presentation and her plea for a more flexible payment arrangement. “I talk with people every day that are just struggling to survive,” he says. “And then she rolls up in this fancy car [with] her rich husband, and she says she can’t afford to pay her bills.” However, as the video later reveals, his disdain is misplaced. His co-worker informs him that the patient—a widow with no family nearby—was driven to the appointment by a friend from her church since she doesn’t have a car, and after multiple rounds of treatment and exhausting her savings and maxing out her health insurance’s lifetime benefit, she is barely scraping by financially.

This scenario is depicted in Beyond Bias: Promote Equity in Care, the second of three vignettes featured in the Association of Cancer Care Centers' (ACCC) Personalizing Care Video Series, which uses dramatization to reflect real-world experiences often observed in the community care setting.

The conversation that unfolds in the video represents the experiences of 20% of patients surveyed by ACCC in 2022 who did not feel their identity, lifestyle, or circumstances were understood by providers and may have encountered implicit bias as a result during their care.

Care Delivery and Research

Implicit bias—the subconscious feelings, attitudes, prejudices, and stereotypes developed from prior influences or experiences, which occur automatically and unintentionally, and affect judgment, decision, and behaviors—can often result in inconsistent or inadequate provision of support for patients. Implicit bias can be based on race, ethnicity, ability, gender identity, income, education, age, sexual orientation, national origin, and other personal characteristics. Studies have shown that it can be associated with diagnostic uncertainty, negative clinical interactions, less patient-centeredness, poor provider communication, and undertreatment of pain.

Predicated upon snap judgments akin to the video’s financial counselor’s assumption, implicit bias has contributed to the historical underrepresentation of African American patients, Hispanic and Latinx patients, and other underserved patient populations in clinical trials. To counter this, ACCC partnered with the American Society of Clinical Oncology (ASCO) to develop the Just Ask Training Program, which aims to increase diversity in cancer clinical research. The program outlines key diversity, equity, and inclusion concepts and includes vignettes that provide real-world examples of implicit bias from the perspective of community-based cancer programs as well as guidance for mitigating disparities in cancer research settings.

Ask Questions to Detect Financial Toxicity

After the financial counselor depicted in the video acknowledges his mistake in making assumptions about the patient, he shares an insight that dovetails with best practices to personalize care and overcome implicit bias: “This is why we have to ask all of our patients the same questions.” Asking questions rather than making assumptions and, crucially, asking each patient the same set of questions helps ensure that all patients are provided with the same information about available resources, as providers are not attempting to differentiate between patients who may or may not need additional support.

In addition to mitigating assumptions about patients’ level of need, initiating conversations around patient identity helps personalize care and promote equity. Asking about personal preferences such as name and language goes a long way in building patient-provider rapport and imbuing more agency in patients during treatment decision-making.

To avoid breakdown in communication, providers are also encouraged to be attentive to patients’ nonverbal cues such as body language, use simple language in favor of complex medical jargon, and continuously ensure patient understanding when discussing support services available. Doing so makes the patients more likely to utilize services such as clinical trials, genetic counseling, and transportation assistance, and builds confidence and trust in their provider.

For providers and multidisciplinary care teams, ACCC has curated a resource library of publications, tools, videos, and other assets that address health equity and social determinants of health, among other topics, to help identify and mitigate implicit bias.

Later in the video, back in the financial counselor’s office, he listens as the patient details her cancer journey. “Cancer had taken everything from her, and it was back for the interest,” the counselor says, with empathy, before devising a solution that preserves the patient’s financial security along with the clinic’s, based on the insight he gleaned by simply listening to the patient. The video’s most compelling takeaway for providers, though, might be this:

“We never really know what’s going on in someone’s life until we ask.”

To view the full video series and for more tools and resources to help providers personalize care for patients of all backgrounds, please visit the ACCC website.

Funding and support for ACCC’s Personalizing Care for Patients of All Backgrounds education program is provided by Pfizer Oncology.