Training doctors in implicit bias could save black mothers’ lives

St. David’s HealthCare, which acquired Austin Diagnostic Clinic, said it couldn’t comment on Rivera-Clemente’s experience but said the hospital is committed to “providing exceptional care to every patient every day.” All of the hospital’s employees receive diversity training, and the hospital recently added more training for the nursing staff, it said.

Dr. Raymond Cox, a former OB-GYN who is now the medical and clinical director at the Hilton Head, South Carolina, branch of Volunteers in Medicine, a free clinic network, said that throughout his career, he has witnessed patients treated differently based on race.

“Doctors tend to spend less time and tend to assume that the black or Latino patient isn’t going to understand what we’re talking about, and as a consequence, have a tendency to make decisions for that patient,” said Cox, who is black.

Training doctors in implicit bias could save black mothers’ lives
Training doctors in implicit bias could save black mothers’ lives

“With implicit bias, it’s tasteless, odorless, to everybody except the victim,” he added. “It is related to institutional racism, and that’s something that’s very difficult to parse out.”


In the past several years, implicit bias training has gained popularity in a variety of industries as a way of confronting prejudices. Police departments have used it in the wake of high-profile shootings of unarmed black men. Facebook has trained all of its employees in it, and at the end of this month, Starbucks is closing some 8,000 stores for an afternoon of employee implicit-bias training.

But it’s a newer idea in medicine, where such training is just beginning to catch on.

Bias training typically starts with taking the Harvard Implicit Association Test, which measures automatic associations between categories of people and value judgments through a series of multiple-choice questions. (Take the test here.) The test measures not just biases on race, but also religion and ethnicity.

The results can be stunning — particularly for those who think they are unbiased.

“The Implicit Association Tests are humbling. I have every bias in the book,” said Dr. Molly Carnes, director of the Center for Women’s Health Research at the University of Wisconsin School of Medicine and Public Health and an internal medicine doctor.

Carnes has developed workshops for the university’s faculty that increase awareness about bias by teaching participants how to recognize it. They also get specific strategies, like putting themselves in the shoes of others, and practicing seeing people as individuals rather than as part of a group.

The Mayo medical schools in Arizona and Rochester, Minn., recently started offering training for their students. All first-years entering in the fall will read “Blindspot: Hidden Biases of Good People,” a book that examines perceptions of social groups written by the two psychology professors who co-created the Implicit Association Test.

Then at the start of school, students will take the test, said Dr. Sharonne Hayes, the cardiology and medical director of the Office of Diversity and Inclusion at the Mayo Clinic in Minnesota. Hayes has led an institution-wide effort to train all 63,000 Mayo Clinic employees in implicit bias.

“There’s really no evidence that you can get rid of implicit bias,” Hayes said. “So what our approach has been is to use some of the evidence-based things that can help us as health care providers not be hijacked by those implicit biases.”

This includes having providers follow checklists for each patient so they don’t accidentally skip over something, and reminding providers that it’s important to take care of themselves — getting more sleep and eating better may make doctors less vulnerable to falling victim to their own stereotypes, Hayes said.

Mount Sinai, the New York City hospital where McCants delivered, has also implemented implicit bias training.

But implicit bias training is not without controversy. While the Implicit Association Test is the most widely used way of measuring ingrained prejudice, critics say its methodology — testing how quickly a user associates certain words with certain groups — may not be reliable.

Those touting it acknowledge this. Carnes said raising awareness of biases can backfire by normalizing them, and while the training can help, it must be done properly.

“Saying it will improve maternal-fetal outcomes is a stretch,” she said. “It all depends on how you do it.”


The risks black women face in childbirth came into the spotlight last year when tennis pro Serena Williams nearly died after giving birth to her daughter. Williams told Vogue magazine that a day after her emergency C-section, she felt short of breath. Given her history of blood clots, she knew something was wrong. But she struggled to convince doctors, and when they finally checked her, it turned out she had several clots in her lungs. Her insistence likely saved her life.

Advocates fear that the disregard Williams’ doctors initially showed is playing out in hospital rooms across the country — and even more so for women who are not wealthy and famous.

“How many other women has that happened to that we don’t know about where they’re telling their providers that there’s something wrong, you need to help me, and yet no help is offered?” asked Elizabeth Dawes Gay, the steering committee chair of the Black Mamas Matter Alliance, a network of partners across the United States that is raising awareness about black maternal health.

That toll is beyond anything that an individual has control over.

That toll is beyond anything that an individual has control over.

Black women face an uphill battle before even getting pregnant. In 1992, Arline Geronimus, a professor in health behavior and education at the University of Michigan School of Public Health, coined the term “weathering” to describe how the stress of gender and racial discrimination wears down the body over a lifetime.

“That toll is beyond anything that an individual has control over,” Geronimus said. “It’s not something as simple as smoking, or poor diet, or get more exercise.”

As evidence, Geronimus points to her 2010 study, which found that telomeres — chromosomal markers of aging — of middle-age black women were on average seven and a half years older than those of white women. In other words, Geronimus said, the chronic stress of being a black woman in America has a physical effect.

Implicit bias training is an important part of a larger strategy in recognizing bias in health care, Geronimus said. “But on its own, it will not change weathering.”


In 2015, the American College of Obstetricians and Gynecologists wrote a series of recommendations for combating racial and ethnic disparities, which included recruiting racial minorities to become OB-GYNs. (Just 11 percent are black.)

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