Dr Brigitte Mol is a senior registrar working in Melbourne.
The theme of International Women’s Day this year was #BreakTheBias, calling on awareness around the implications of unconscious bias on women (and men) in society. With the rise of the Teal Independents and a push for female and minority representation in government, I'm excited to say we may be making some progress.
Unconscious bias (also known as implicit bias) is the idea that we form quick assumptions about people based on demographic features like age, race or gender, that these assumptions occur outside of conscious awareness and that this stereotyping affects how we see and treat other people. This often leads to snap-judgments of someone’s character or ability. The roles and stereotypes we witnessed when we were young imprint upon us particularly strongly. For example, for many of us, we internalised an association between masculinity and authority and femininity with domesticity and care taking. Importantly, unconscious biases are universal, inherent, and normal. We all have them, and crucially, they do not represent our conscious opinions, or our moral compass. In healthcare, unconscious bias can result in unequal treatment of patients, unfair perceptions of our colleagues and when it comes to hiring and promotion: elevate some, whilst tying down others (8,11).
There is a substantial body of research linking bias with poor health outcomes, and the following are a number of studies I find fascinating.
One of the classic, early studies, The Effect of Race and Sex on Physicians Recommendations for Cardiac Catheterisation (NEJM, 1997 14) explored the impact of bias on referral rates for cardiac intervention. In the study, 720 physicians in the US watched 8 actors’ recorded interviews. These actors varied in age, gender and race, but had an identical script, wore identical gowns and the physicians received identical additional information. The outcome was that black women were referred for cardiac catheterisation less than any other group (~80% of the time, vs ~90% for each other group). The outcomes of this paper were extraordinary, and controversial, owing largely to the extensive media coverage it received and the misquoting of odds ratios as risk ratios (7). Despite the findings being overstated in the media, there was hard evidence of bias impacting on health outcomes, findings which have been supported by many studies since. For example, Colvin et al (2018) found women with heart failure are less likely to undergo heart transplantation compared with men and are 20% more likely to die waiting for a heart transplant compared with men (5).
Perhaps familiarity bias plays a role in underscoring these outcomes. WIN’s own Modra et al explored this concept in Sex Differences in Mortality of ICU Patients According to Diagnosis-Related sex Balance (2022), which looked at the relationship between ICU mortality and sex balance within a diagnostic group. The results showed that if a woman presents to ICU with a diagnosis which more commonly occurs in men (for example post cardiac surgery), she is more likely to die than a man with the same diagnosis. Of note, the inverse was also true (12).
Whilst not related to healthcare, the study by Goldin and Rouse (2000) looked into outcomes between ‘blinded’ vs ‘unblinded’ hiring in symphony orchestra auditions and found that the introduction of a concealment screen during a candidate’s audition increased the likelihood that a female would be hired by 25%! (10).
Within the fields of science and research, Wenneras and Wold (1997) looked into the delegation of postdoctoral fellowships at the Swedish Medical Research Council. They found that for peer-reviewers to equally rate male and female candidates on scientific competency, women needed approximately 3 more articles in Nature or Science, or 20 more articles in a specialist journal 15. A similar, recent paper by Witteman et al 2019, found that when the Canadian Institute of Health Research performed its funding allocation based on assessment of the scientist rather than the scientist’s project, men were 1.4 times more likely to receive funding than women (16).
Whilst I’m not entirely surprised, the findings of these studies blow me away. When I imagine the volume of work and achievement these women must attain to be on par with their male colleagues, and extend this to women everywhere, it breaks my heart and makes me angry.
In day-to-day life in the medical world, I am sure we all feel the impacts of bias. On a superficial level it is easy to spot: being mistaken for the bedside nurse, or a more junior member of the team is a common occurrence, comments on age/appearance/size are not infrequent, whilst our male colleagues are more likely to be assumed to be more senior. A particular favourite whilst looking after a patient in the ICU: “What’s a young girl like you doing running around such an important place as this??” It is the deeper impacts of bias which strikes me most, however, – the imposter syndrome which permeates amongst my female colleagues and results in self-doubt, second-guessing and deferring to male opinions; the flow-on effects demanding we work harder, be better, study more just to reassure ourselves and others that we deserve to be there. The difficulty in balancing our work and home expectations.
In Annabelle Crabb’s incredible essay Men at Work, The Parenthood Trap for The Quarterly Essay, she discusses that women’s lives have changed immeasurably over the last century, and whilst workplace opportunities are now more available than ever, the lives of men have changed very little over the same period.6 The expectations on women to manage the lion’s share of running a household and looking after children, work or no work – persists. She argues that we should look at our biases against men, the discrimination that exists around men’s rights to be an equal parent (eg abysmal father parental leave, judgemental culture around part time work, and simple lack of curiosity around how men “manage having a young family and work”) for the benefit of all of us (6).
So what can we do about it?
On an individual level, a good place to start is taking the Harvard Implicit Association Test (https://implicit.harvard.edu/implicit/takeatest.html) to increase awareness of our own biases (13). Consider doing a presentation on unconscious bias for teaching or have a conversation with your family/friends about it. Aim to amplify the voices of female/marginalised colleagues by regularly asking their opinions and suggesting they team lead critical situations/sims.
Further, structural change is a fundamental piece of the puzzle to level the playing field and counter the effects of unconscious bias. Gender and minority targets within work places, blinded job applications (no name, gender, age visible) and avoiding hiring on merit alone (which has been shown to actually amplify the effect of implicit biases (2)), are all important to create diverse workforces which represent the communities they serve (1,3,17). I am excited to say that both CICM and ANZICS have recently committed to gender equal targets in leadership roles which is a great start (4).
I believe female trainee nomination, elevation and sponsorship in leadership and academic roles is as important as ever to generate the next class of female role models. Our attitudes towards our male colleagues must shift as well: we must encourage flexible working arrangements, parental leave and curiosity around family structures and balancing work loads.
Lastly, unconscious bias training is a tool we could build into our training. Traditional tick-box ‘mandatory training modules’ for implicit bias aren’t effective, and a 2019 meta-analysis with 490 studies and 80,000 participants showed that they did not change behaviour (9, 17). However, studies which have utilised structured, longer term approaches which provide guidance on how to change behaviour, have resulted in improved recognition of bias, more balanced hiring practices, and increased feelings of inclusivity and belonging (9).
So what does the future look like?
I am hopeful for a future where we are all more aware of how our unconscious biases impact others, where there is inspiring leadership to enact cultural change, where flexible, varied and freeing workplace arrangements are the norm and where there is equal modelling of positions of power, caretaking roles, heads of department and prime ministers, such that future generations might interact with one another as equals. #Breakthebias
References and Further Reading:
Besley TJ, Folke O, Persson T, Rickne J. Gender Quotas and the Crisis of the Mediocre Man: Theory and Evidence from Sweden. SSRN Electronic Journal. 2013;
Castilla EJ, Benard S. The Paradox of Meritocracy in Organizations. Administrative Science Quarterly. 2010 Dec;55(4):543–676.
Coe IR, Wiley R, Bekker L-G. Organisational best practices towards gender equality in science and medicine. The Lancet. 2019 Feb;393(10171):587–93.
College of Intensive Care Medicine of Australia and New Zealand [Internet]. [cited 2022 Nov 10]. Available from: https://www.cicm.org.au/CICM_Media/CICMSite/CICM-Website/Resources/Professional%20Documents/IC28-Statement-On-Gender-Balance-Within-The-College-Of-Intensive-Care-Medicine.pdf?fbclid=IwAR3toamZjMBDUaOzKw9FAbjbshg4qCmS6S89xJslbf4B8ddqlQ0DUjqe054
Colvin M, Smith JM, Hadley N, Skeans MA, Carrico R, Uccellini K, et al. OPTN/SRTR 2016 Annual Data Report: Heart. American Journal of Transplantation. 2018 Jan;18:291–362.
Crabb, A. Men at Work: Australia’s Parenthood Trap. Quarterly Essay. 2019; Issue 75
Fisher, S. Race in cardiac care: DMS researchers warn that statistics can lie. Dartmouth Medicine Website. https://dartmed.dartmouth.edu/winter99/html/vs_race.shtml. Date accessed June 1st 2022
FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC medical ethics [Internet]. 2017 Mar 1;18(1):19. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28249596
Gino F, Coffman K. Unconscious Bias Training That Works [Internet]. Harvard Business Review. 2021. Available from: https://hbr.org/2021/09/unconscious-bias-training-that-works
Goldin C, Rouse C. Orchestrating Impartiality: The Impact of “Blind” Auditions on Female Musicians. American Economic Review [Internet]. 2000 Sep;90(4):715–41. Available from: https://www.aeaweb.org/articles?id=10.1257/aer.90.4.715
Marcelin JR, Siraj DS, Victor R, Kotadia S, Maldonado YA. The impact of unconscious bias in healthcare: How to recognize and mitigate it. The Journal of Infectious Diseases [Internet]. 2019;220(2):62–73. Available from: https://academic.oup.com/jid/article-abstract/220/Supplement_2/S62/5552356
Modra LJ, Higgins AM, Pilcher DV, Bailey MJ, Bellomo R. Sex Differences in Mortality of ICU Patients According to Diagnosis-Related sex Balance. American Journal of Respiratory and Critical Care Medicine. 2022 Jul 18;
Project Implicit. Take a Test [Internet]. Harvard. Project Implicit; 2011. Available from: https://implicit.harvard.edu/implicit/takeatest.html
Schulman KA, Berlin JA, Harless W, Kerner JF, Sistrunk S, Gersh BJ, et al. The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization. New England Journal of Medicine. 1999 Feb 25;340(8):618–26.
Wennerås C, Wold A. Nepotism and sexism in peer-review. Nature [Internet]. 1997 May;387(6631):341–3. Available from: https://www.nature.com/articles/387341a0
Witteman HO, Hendricks M, Straus S, Tannenbaum C. Are gender gaps due to evaluations of the applicant or the science? A natural experiment at a national funding agency. The Lancet. 2019 Feb;393(10171):531–40.
Yong SA, Moore CL, Lussier SM. Towards gender equity in intensive care medicine: ten practical strategies for improving diversity. Critical Care and Resuscitation. 2021 Jun 7;23(2):132–6.