Are we all latent bigots? The troubling and threatening implications of Implicit Bias

Last October, on an airline flight from Detroit to Houston, a passenger became seriously ill, eventually losing consciousness. The attendants asked for medical help. A doctor on the flight came forward to provide assistance. One of the flight attendants refused to allow the doctor to attend the patient without some proof of their qualifications, despite verbal reassurances and the patient’s obvious need. While this was going on, a second doctor appeared who was welcomed and permitted to examine the patient. No qualifications were either requested or offered from the second doctor.

The first doctor was a black woman. The second was a white man.

The attendant apparently had difficulty characterizing a black woman as a doctor, but had no such difficulty with the white man. As you might imagine, this has led to considerable media attention and some rather creative groveling on the part of the airline involved which has vowed to extend its diversity and inclusion training (previously provided only for corporate leaders) to frontline employees.

We’re left nonetheless to ponder how such a thing could happen. The flight attendant involved, we must assume, is neither a raving lunatic nor card-carrying bigot. She is likely a regular citizen who, in a highly stressful situation that required her to make a critical judgment, did so instinctively. In doing so, she exhibited (or made explicit) what could be termed an Implicit Bias.

The notion of Implicit Bias is rather unsettling, particularly to those who quite sincerely believe themselves to be accepting of diversity and inclusion. The concept is that we all harbour prejudicial impressions and attitudes of which we are blissfully unaware. These attitudes, apparently related to personal associations and memories, reside deep in our subconscious but are capable of influencing our decisions and actions without our intention or awareness. Fundamentally, even if we truly, even fervently believe in the principles of equality and attempt to conduct ourselves accordingly, we are all “hard-wired” to identify with and therefore feel greater affinity with those who are like us, and less so with those who differ from us in some way. It can be regarded as a developmental survival adaptation that allowed our ancient predecessors to recognize threats and react quickly to avoid them. It’s what alerts the gazelles to instantly run at the first sign of a lion without taking the time to process the decision. In terms consistent with Daniel Kahneman’s Thinking Slow and Fast approach, it’s the ultimate triumph of Type 1 over Type 2 thinking.

The concept of Implicit Bias is certainly gaining attention and being taken seriously by the scientific community. In a recent edition of Science (352:6289,1035) editor-in-chief Marcia McNutt reports on a forum of editors and publishers of prominent journals convened by the American Association for the Advancement of Science to discuss how Implicit Bias might be countered in the peer review process. Blinding reviewers as to authorship is apparently insufficient.

The Ontario Human Rights Code has, as one if its core principles, the primacy of the consequence or effect of an action over the intention that led to it, surely an acceptance of the influence of subconscious or implicit biases.

In the medical world, there have been a number of rather disturbing reports on the subject. In a study on the diagnostic approach to patients presenting with chest pain (Schulman et al, NEJM 1999;340:618) the authors prepared a series of videos of eight different patients (portrayed by actors) who described their symptoms and medical history. The descriptions and factual information were identical. The authors went to painstaking lengths to ensure the videos were also identical in all aspects, even the facial expressions, hand gestures, background and gowns worn by the patient-actors. The “patients” (pictured below in an illustration taken from the paper) differed only with respect to gender and race.


The videos were shown to 720 (mostly white) physicians who practiced either Family Medicine or Internal Medicine specialties. The results showed that the physicians were statistically more likely to suspect ischemic disease and therefore order cardiac catheterization in the men than the women, and in the white patients than blacks.


A study of 215 surgical attendings and residents at Johns Hopkins (Hader AH et al; JAMA Surg 2015:150:457) used a combination of clinical vignettes and Implicit Association Test (IAT) to assess attitudes and decision making. The instrument identified race and social class biases in most respondents, who were found more likely to suspect alcohol abuse in black patients than whites, less likely to order an MRI in a lower socioeconomic class patient with suspected cervical spine injury, and more likely to suspect pelvic inflammatory disease as a cause of right lower quadrant pain in black than white women.

A similar study was carried out in Oncology programs in Detroit (Penner LA et al; J Clin Oncol 2016;34:2874) involving white oncologists and black patients. Results showed that higher implicit bias in attending physicians (as determined by the IAT survey instrument) was associated with patient interactions that were shorter and perceived to be both less supportive and less effective. Higher Implicit Bias scores were also associated with lack of patient confidence with treatment plans and perceived difficulty in completing the course of treatment.

A recent systematic review of 15 studies of health care providers using the IAT showed low to moderate levels of bias (similar to the general population) in all but one (Hall WJ et al: American Journal of Public Health 2015;105:e60-76).

Many of these studies have evoked considerable criticism. There are certainly counter arguments to be made. Survey instruments like the IAT, even if previously validated, have limitations. The diagnostic process we utilize and teach incorporates known risk factors which are known to vary among genders and racial groups, so what’s perceived to be bias, some argue, may simply be the appropriate application of epidemiological data and “real life” knowledge.

However the real and deeply disturbing concern is that the concept of individual physician judgment or intuition that the profession has valued so greatly, and both clinicians and their patients rely upon to develop effective and efficient treatment decisions, is under threat. If we’re all subject to Implicit Bias, are we capable of making valid decisions on any issue that strays from a strict guideline algorithm? Indeed, will this threaten the confidence clinicians require to make critical decisions?

Fortunately, hope springs forward in the form of several perceptive approaches that are being advanced to counter the threat of Implicit Bias. For those interested in reading further, I will list some relevant papers below, including one by Dr. Geoff Norman and colleagues at McMaster that was published just this month in Academic Medicine. Those articles describe educational, administrative or societal approaches to the issue. What seems to be missing, however, is practical advice to individual physicians and learners as to how they might approach these concerns personally. Taking the liberty to provide a personal and non-expert perspective on this, I would offer the following seat-of-my-pants prescription to combat Intrinsic Bias:

  1. Brutal honesty. It would appear from the literature that no one is immune from these influences. We are all complicated, unique individuals with our own mix of life experiences. Recognizing that these biases exist, are natural and not indicative of a disordered personality of some type, but are nonetheless capable of influencing our decision-making would seem to be the best first step.
  1. Self-awareness. A truly honest exploration of our comfort in engaging patients from various backgrounds and with personal choices or perspectives that differ from our own would seem to be a key step. There’s nothing inherently wrong with not feeling equally comfortable with everyone we encounter. Something will be very wrong if that discomfort influences the care we provide.
  1. Increasing personal diversity experiences. Personal, one-on-one experiences with people from different backgrounds is the most effective way to increase understanding, promote comfort in engaging diversity and break down the threat of intrinsic bias. We need to seek such opportunities for ourselves and, as a school, develop and promote such opportunities for our students. Our Diversity Committee, under the direction of Dr. Mala Joneja, has this goal firmly in their sights and is making considerable progress.
  1. Do the mental “double-check”. When making a clinical decision involving a patient from a diverse group or background, a helpful and simple exercise might be to imagine the same scenario being played out in a patient of your age, gender, culture and socioeconomic/social circumstances. If the decision you would make is different in anyway, there should be a valid medical reason for that different approach. If not, a second thought might be in order.

In summary, Intrinsic Bias is a distinctly uncomfortable topic, particularly for physicians. It is threatening, unsettling, humbling and personal disturbing. But it’s also probably real, and worthy of study and personal reflection on the part of both practitioners and learners.


Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education


Approaches to Implicit Bias:

Byrne A, Tanesini A. Instilling new habits: addressing implicit bias in healthcare professionals. Adv. In Heath Sci Educ 2015; 20: 1255.

Norman GR et al. The causes of errors in clinical reasoning: Cognitive biases, knowledge deficits, and dual process thinking. Academic Medicine 2017; 92: 23.

Penner LA et al. Reducing racial heath care disparities: A social psychological analysis. Policy insights from the behavioral and brain sciences. 2014; 1: 204.

Stone J, Moskowitz GB. Non-conscious bias in medical decision making: what can be done to reduce it. Medical Education 2011; 45: 768.


Many thanks to Sarah Wickett, Health Informatics Librarian, Bracken Library, for her valuable assistance in the compilation of information for this article.

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When your objective is to write learning objectives…

Several times over the last few weeks, I’ve had conversations with course directors and instructors about writing learning objectives.

Many people – from award-winning educators to rookies and everyone in between – find writing learning objectives a challenge. The typical advice of write out who will do what under what conditions is vague, so it’s often not very helpful.

“General” learning objectives – from our UGME Competency Framework, aka the Red Book* – are already assigned to your course, and possibly to your session by your course director.

The key task for instructors is to take these general objectives and annotate them with specific objectives for their sessions, including what level of learning, such as comprehension, application or analysis. (This is from something called “Bloom’s Taxonomy”, if you’re interested in the research behind this).

A natural starting point is: What do you want your learners to take away from your session?

Frequently the response is:

  •  “I want them to know….”
  •  “I want them to understand….”
  •  “I want them to be able to…”

Once you’ve wrestled something like this into sentences, I realize it’s disheartening to have someone like me come along and say, “Uh, no, that’s not up to scratch.”

What’s wrong with “know” and “understand”? Isn’t that exactly what we’d like our students to walk away with – knowledge, understanding, skills? Absolutely. The challenge with these so-called “bad objective verbs” is that we can’t measure them through assessment. How do we know they know?

That’s the starting point for writing a better learning objective. If you want to assess that students know something, how will you assess that?

For example, while we can’t readily assess if a learner “understands” a concept, we can assess whether they can “define”, “describe”, “analyze”, or “summarize” material.

Here’s my “secret” that I use all the time to write learning objectives – I can’t memorize anything to save my life, so I rely on what I informally call my Verb Cheat Sheet. The one I’ve used for many years was published by Washington Hospital Centre, Office of Continuing Medical Education. It list cognitive domains (levels) and suggests verbs for each one. There are many such lists available on the Internet if you search “learning objectives” (here’s another one that’s more colourful than my basic chart, below).

Screen shot 2017-01-16 at 2.43.06 PM

Well-written learning objectives can help learners focus on what material they need to learn and what level of mastery is expected. Well-written objectives can assist instructors in creating assessment questions by reminding you of the skills you want students to demonstrate.

Here’s my quick three step method to annotating your assigned objectives on your MEdTech Learning Event page with your learning-event specific objectives:

  1. Start with writing your know or understand statements: what do you want learners to know or understand after your session?
  2. Think about what level of understanding you want students to demonstrate and how you would measure that (scan the verb chart for ideas)
  3. Write a declarative sentence of your expectation of students’ abilities following your session. In your draft, start it off with “The learner will”. For example: The learner will identify the bones of the hand on a reference diagram. Your objective would be: “Identify the bones of the hand on a reference diagram.”

As a fourth step, feel free to email your draft objectives to me at for review and assistance (if needed). I’m happy to help.


Table excerpted from Washington Hospital Center, Office of Continuing Medical Education’s “Behavioral Verbs for Writing Objectives in the Cognitive, Affective and Psychomotor Domains” (no date).

* The “Red Book” got its name because for the first edition (we’re now on the fourth), the card stock used for the cover was red. Over time, everyone started calling it the “Red Book”.

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Our hospital and institutional problems are formidable, but not unprecedented: Finding lessons (and validation) in the past.

“The study of history is an antidote to the hubris of the present – the idea that everything we have, everything we do and everything we think is the ultimate, the best.”

David McCullough


Mr. McCullough’s wise words can also serve as a reminder that the various challenges we find so troublesome today almost always have parallels in the past. Learning how previous generations dealt with the dilemmas of their time can be instructive, encouraging, and often rather humbling.


This became very apparent to me recently as I read a copy of Margaret Angus’ “Kingston General Hospital: A Social and Institutional History” which I came upon while browsing in the angushistorykghbook section of a local antique market (actually, while killing time waiting for my wife to complete her browsing). In it, Ms. Angus documents the trials and tribulations faced by those who originally planned, built and operated KGH. Despite the vastly different cultural context and technology, what comes through are accounts of determined and community-minded people coming together to overcome challenges and improve the health care available to their families and fellow citizens. A brief summary of that early history as recorded by Ms. Angus is illuminating.


The first petition for the establishment of a public hospital in Kingston came in 1809 from a group of 44 residents and was made to Governor Sir James Craig. Fully nine years later, land for a hospital site was granted by an 1818 Order in Council by the Lieutenant Governor, but no funds were provided for building. A number of public subscription programs resulted in pledges amounting to about £1,000 for the purpose, and led the 11th Parliament of 1832 to finally grant £3,000 for the erection of a Kingston hospital. Drs. James Sampson and Edmund Armstrong were appointed “commissioners for superintending and managing the erection and completion of the said hospital, and for the purchasing or otherwise obtaining, choosing and determining the site thereof”. After much negotiation and consideration, they purchased six acres of a farm lot from Rev. G.O. Stuart between the present-day Barrie Street and Lower University Avenue.


At this point the population of the town was 3,500 with an additional 1,000 in the military garrison, and considerable growth was anticipated with the development of the Rideau Canal. Local architect Thomas Rogers was engaged, plans developed, tenders for work awarded. However, work on the hospital was delayed by the tragic cholera epidemic of 1834 and competition for workmen from two other major local building projects, the Kingston Penitentiary and rebuilding of Fort Henry. In response to a request from government for a progress report, Dr. Sampson exhibits a rather cheeky eloquence in his December 1834 report:


“and first with respect to the ‘period in which it has existed’ we beg to remark that the establishment which was the object of the address presented to His Majesty by the House of Assembly last session, and in which His Excellency has been pleased to take a warm and very gratifying interest, cannot yet be said to ‘exist’.”


Nonetheless, work was finally completed in 1835, now 26 years after the initial request. Ms. Angus reports the following description from the Upper Canada Herald:


“The Kingston Hospital, which has been in the course of erection for almost two years, is now nearly completed. It presents a fine appearance. Eighty-nine feet four inches long fifty-three feet four inches wide, four stories high, rooms lofty and well ventilated: can accommodate about 120 patients. It has two fronts and is approached by a handsome flight of stone steps.”


Unfortunately, it was far from complete. The interiors had not been completed. It was unpainted, no baths or washrooms, no furnishing and large mounds of excavated earth had been left impeding access to the hospital. The funds provided were practically depleted (although not exceeded). The commissioners went back to government asking for an additional £500 pounds to finish the project. The request was initially denied, but was followed by a more direct petition to the legislature, which, in 1837, eventually provided the funds. By this time, that amount was inadequate due to damage that had occurred in the unused, unheated building.


Social problems now intervened and led to further delays. Rebellions were breaking out in Upper Canada and resources now had to be concentrated on military defense. Dr. Sampson, the chief commissioner and champion of the hospital, was appointed Chief Magistrate, in charge of organizing military patrols for protection and defense of the town. He was nonetheless able to eventually report on the hospital, explaining how the £500 pounds had been used to purchase beds and linen, as well as a large stove in the basement to heat the building. With the hospital now in reasonable working order, operating funds were required. He made a request for ongoing support of the hospital:


“(we) take this opportunity to state to Your Excellency, that they are not aware that any provision has yet been made to meet the expenses, which must unavoidably be increased in order to carry the benevolent intention of the Legislature, and private donors, into effective operation, and that without such provision the building must necessarily remain useless and the just expectations of the public disappointed, all of which is most respectfully submitted.”


By 1837, a building was in place, but lacked the ongoing support or organizational structure to function as a hospital. However, it didn’t go unused. Over the next several years, it was used intermittently as a military barracks. The first “patients” treated at the site were 20 wounded American soldiers captured in November 1838 at the Battle of the Windmill near Cornwall, two of whom died of their wounds (making our first case mortality rate 10%). In 1840, permission was granted by the Lieutenant Governor to lease the building to the Presbyterian community in Kingston for the housing of a theological college that would eventually become Queen’s University. Dr. Sampson who, in addition to his medical practice and responsibilities as hospital commissioner, was now serving as Mayor of Kingston and negotiated the lease. However, the Queen’s College Trustees, decided to decline the offer, finding the £150 pounds per year cost excessive. The first attempt to develop a working hospital-university partnership therefore failed miserably.


By 1841, Kingston had been selected as the site for the capital of the United Provinces of Upper and Lower Canada, and construction on parliament buildings on Ontario Street (currently our city hall) was underway. The hospital building, still empty, was available and selected to serve as the temporary accommodation of the legislature. This decision not only provided a source of income (£300 pounds per year), but also required the completion and expansion of building facilities. The interior was re-configured into two large rooms, for the House of Assembly and Legislative Council, as well as a number of smaller offices and a library. In addition, a number of government buildings and private homes were constructed nearby to accommodate services and officials.


Kingston remained capital only two years, but during that time the economy and population boomed, expanding even further the need for a hospital. By the time the capital was moved to Montreal in 1843, most patient care took place in private homes or boarding houses provided by the Ladies Benevolent Society, and was greatly aided by the arrival of the Religious Hospitalers of Saint Joseph who began to admit patients to their Brock Street facility (eventually Hotel Dieu Hospital) in 1845.


The building now needed to be re-converted to its original purpose. Dr. Sampson, having been re-elected as Mayor, was again instrumental in leading the charge to re-possess the building for the city and securing funding for the conversion, all of which took considerable legal and political activity. Finally, in 1845, the hospital commissioners and Ladies Benevolent Society formed a successful collaboration that resulted in the building finally being opened for the admission of patients. The following notice appeared in the Kingston Chronicle and Gazette on November 12, 1845:


“The Hospital for the use of the town of Kingston, under the superintendence of the Ladies of the Female Benevolent Society, is open in the building lately occupied by the Provincial Parliament and patients will, on the certificate of a medical man that they are proper recipients for public charity, be admitted on the order of one of the following ladies who have consented to act as Directresses of the Society.”


And so, the hospital initially conceived and petitioned for 39 years previously, began to admit those in need of medical care under the direction of local physicians and care of volunteer citizens.


The problems faced by our hospitals and providers today are certainly daunting, but no more so than those faced by our dedicated predecessors. They needed to make valid cases for resources despite competing societal needs, while simultaneously delivering the best care possible for those in need. Sound familiar? Doing so required ingenuity, patience, perception and the political savvy to take advantage of opportunities that arose, often in times of crisis. It also required forging strong collaborative links to community members and organizations with common values and goals.


With regard to the later, the recent move to amalgamate our hospitals seems a highly sensible and effective initiative. It’s again a little humbling to read the following excerpt from the Foreword to Ms. Angus’s book, written by Mr. Harvey L. Millman, President of the KGH Board of Governors in 1971:


“Today the Kingston General Hospital stands at the beginning of a new era. We are moving into closer association with the Hotel Dieu Hospital, St. Mary’s of the Lake Hospital, Kingston Psychiatric Hospital, Ongwanada Hospital, Queen’s University, and the St. Lawrence College of Applied Arts and Technology to form the Kingston Health Science Complex, an integrated system of health care delivery to meet today’s community needs.”


Forty-six years later, we find ourselves taking tentative steps toward realizing at least a portion of that grand vision. That shouldn’t be seen as an indictment, but rather encouragement that we’re on the right path. Sensible and worthy ideas usually find their way to full realization, not always when we think they should, but when concept and opportunity converge.


Examining the past can indeed counter our “hubris of the present”. It provides perspective, illuminates the future and keeps us humble.



Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education

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