Exploring Unconscious Bias

As regulators and health care practitioners, it is important to be aware of and acknowledge the role implicit bias can play in our professional and personal lives every day.  This article is based on a 2021 webinar presented by Jonathan Webb.

As regulators, you influence policy regulations and systems, but more importantly, you impact individual lives. While FSBPT has already done some critical work to address unconscious bias, there is still more work ahead. FSBPT should continue to engage in bold conversations that are followed by strong actions as we strive to be the catalyst for change we so desperately need.

Unconscious Bias

Bias exists everywhere and impacts our decision-making, interactions, activities, and connections. Biases are unfair prejudices in favor of or against one thing, person, or group compared with another. As a society, we are always in a perpetual state of “sizing people up”. We need to acknowledge that.

There are two types of bias: conscious and unconscious. Conscious bias is fairly straightforward. These are biases we possess that we are acutely aware of. Unconscious biases, however, are social stereotypes about certain groups of people that individuals form outside their conscious awareness. In these cases, attitudes or stereotypes unknowingly affect one’s understanding, actions, and decisions. They are not limited to race and affect several social identities, such as age, gender, physical ability, gender identity, and sexual orientation. While the focus of this article is on race, this emphasis is not intended to imply that the other forms of bias are not equally important or destructive.

Unconscious bias occurs more often than conscious bias, but it is often incompatible with one's conscious values. Therefore, many people reject the notion that they themselves are racist, as there is an acknowledgment that racist ideologies contradict our value systems. However, you'll find more people are willing to acknowledge they have some biases. Indeed, most people accept that everyone has biases.

Historically, important discussions in policy, business, and other realms have not included a diverse group of people or those who were representative of the population. The exclusion of women, people of color, and other marginalized groups from these conversations was deliberate and calculated. But have things changed? Although it may seem like there is not a current deliberate effort to keep people out, the reality is that the practices that once existed to exclude various people and groups from engaging are alive and well today, in familiar and (in some cases) new ways. Hypothetically speaking, even if those former exclusionary practices were a true thing of the past, if there has been no intentional effort to override and undo the historical damage resulting from these systemic biases, we will continue having the same conversations without bringing in new voices, thereby reinforcing the same disparate systems and perpetuating inequitable policies.

Extensive research shows that bias develops at an early age and has real-world consequences. It can affect professional decisions such as hiring practices, mentoring relationships, and compensation policies. Here are just a few examples of documented bias:

• Fictitious resumes with White-sounding names were more likely to get an interview than the same resumes with African American sounding names. (Bertrand and Mullainathan, 2004 )
• Science faculty rated male applicants as significantly more competent than female applicants. (Moss-Racusin et al., 2012)
• Among federal grant recipients, the mean salary of female researchers was $31,000 less than males. (Jagsi et al., 2013)
• Implicit bias among health care professionals can influence their behaviors and judgments. (Moskowitz et al., 2011 )
• Since 1997, more than thirty studies have found unconscious bias in clinical decision-making. (Paradies et al., 2013 )

The good news is bias is malleable; it is possible to minimize its impact. Hopefully, we have an intrinsic, moral imperative to conquer these biases and thoughtfully engage historically marginalized groups. However, there are concrete motivations for encouraging diversity that are not merely altruistic. Our country is becoming increasingly more diverse. If we neglect the opportunity to effectively embrace and include those that may differ from us, we will fail to meaningfully serve and impact the population. Our policies, practices, programs, and outreach efforts will fail if we do not adequately incorporate various perspectives and voices. We will become irrelevant.

To address this, we need to not simply strive for equality, but equity. Giving everyone the same opportunities is tone-deaf to the disparities and differences in our society. It is important to be targeted and intentional. Our focus should be placed on removing the barriers for all with a specific emphasis on the historically disenfranchised and marginalized. If we do that for those folks who are most vulnerable, we by default clear the brush for everyone.

Exploring Structural Racism and Its Impacts

As physical therapy regulators, it is essential to understand the social determinants of health. An individual's economic stability, social and community context, neighborhood environment, educational opportunities, and other factors impact their overall health and health care outcomes. These social determinants are influenced by systems. Those systems are historically rooted in racism. Bias has fueled and given life to that racism. Racism is woven into our structure and this understanding has yielded the term, ‘structural racism’. In this way, our biases and structural racism directly impact these social determinants, by influencing the policies and systems that determine the allocation of resources to individuals and communities. Additionally, the unconscious bias of today has roots in the conscious and deliberate bias of yesteryear. Connecting those dots is a key component that allow us, to properly serve patients and the public when making policies and decisions.

In a 2018 article in Health Affairs, Gabriela Alcalde articulated why racism is a root cause of inequity: "The United States intentionally structured its systems to (repeatedly) exclude certain groups of people from full participation and representation, based on their race and ethnicity. Even so-called race-neutral policies enacted in recent times (and today) have deleterious effects on communities of color because of ingrained biases and hierarchies built to favor those who are seen as White. The system is not broken—it works as it was intended. The current visible and invisible hierarchies were erected to benefit Whiteness, to the detriment of those seen as 'other.'"
Many people say our systems for health care, education, and criminal justice, are broken. However, we must be honest about what our system is if we are to find solutions. Our system has historical roots founded on racist principles, and it is intentionally functioning the way it is supposed to. Therefore, we need to be intentional about how we dismantle those systems.

In order to better understand structural racism, it is important to start with slavery. Slavery was a business, built on the backs of people who were unwillingly ripped from their homelands and families. The value of US slave labor in 2009 dollars is estimated to be $5.9-$14.2 trillion. The slave trade had a real and long-lasting impact on families. African Americans can and should be proud of their history of resilience, but there is still an honest understanding that that tradition also involves a loss of cultural identity. Many African Americans have difficulty tracing their history back beyond the slave trade. Families were broken apart; babies were taken away from mothers. Women and people of color were treated as property. This detachment affects social and community context, families, maternal-child health, and overall health outcomes. Additionally, Black people were often used as guinea pigs to advance medical science; they were dehumanized. These past atrocities still influence our lives today.

As it relates to medical training and the perception of the biological differences between Black and White individuals, a University of Virginia research study examined the perception of these differences among several groups: the general population, medical students, and residents. They tested what percentage of each group believed in various statements. The statements reflected certain discrepancies between Black and White people, for example, Black people have thicker skin, White people have a better sense of hearing, or Black people are more fertile. In reality, all the statements were false. Unfortunately, many medical residents believed some of these false statements. Surprisingly, this study is not decades old, but was conducted in 2016. Medical biases are still alive and well in our medical education system.

Biases also still impact our criminal justice system. Historically, lynchable offenses included actions such as arguing with a White man, flirting with a White woman, or attempting to vote. After emancipation, there were "Black codes" set up to easily arrest Black workers and force them into work on plantations. Between 1884 and 1928, state-run prisons profited from contracting with private parties to provide them with convict labor. Versions of this are still happening today. Sadly, there are still minor offenses (or no offense at all) that can result in lost life. Additionally, it is well documented that our legal system issues harsher penalties for Black defendants than White ones for the same or similar crimes.

This historical existence of racism and bias was also present in housing, as well. Many African Americans fleeing the post-emancipation south headed north looking for a better opportunity, only to find more of the same discrimination and injustice through policies such as redlining. While World War II veterans received many benefits, Black veterans weren't able to take advantage of the GI bill benefits in the same way White veterans were. These policies had a deleterious effect on educational opportunities and homeownership, which have continued effects on intergenerational wealth. Redlining also had indirect effects on community schools. There was a trickle-down impact on wealth, health outcomes, and social determinants.

While this is a historical look back, we have not advanced as far as many would like. Black people still do not have that same mortgage approval rates as their White counterparts. Mass incarceration is still a problem. While one in nine men are incarcerated, that reflects one in seventeen White men, one in six Latino men, and one in three Black men.

The higher incarceration rate may suggest that the latter groups commit crimes at a higher rate, but this is frankly, not true. Black people are nearly four times more likely than White people to be arrested for marijuana, although commitment of the crime is similar. Today, there are more African Americans in prison than there were enslaved people. In fact, largely because of the mass incarceration of Black fathers, a Black child born today is less likely to be raised by both parents than a Black child born during slavery.

Some people have said education can make up for the gaps created by history and lopsided policies with racist roots. While education is tremendously valuable and can increase a family's net worth, unfortunately, according to the Federal Reserve, it does not make up the difference between races. Therefore, education alone is not the cure. We have other challenges. Discrimination in hiring practices continues to depress opportunities, pay equity is still nonexistent, opportunities for advancement are harder to come by for people of color, and the standards for performance are often higher for communities of color versus their White counterparts. A 2003 American Journal of Sociology article highlighted that White individuals with a criminal record get interviews at a higher percentage than Black individuals without a criminal record.

Intentional Efforts and Antiracism

So why does this history matter for physical therapy regulators? It's important to understand these circumstances because your job is to protect the public, which includes communicating with patients, interviewing complainants, disciplining practitioners, and generally serving the public. Hopefully, this provides a different lens for how you may view and engage with those impacted populations. This understanding of bias has implications for policies, communications, and programs, including programs concerning encouraging pipeline development.

When championing these types of efforts, however, it is important to do so with humility and a genuine interest in understanding through partnership with the impacted communities. This approach avoids a potential savior mentality that sees people as victims. Individuals who have been impacted by these systems are resilient. There's value in their experiences, and there's an opportunity for you to see them as partners, not projects. Understanding this history helps target your solution and make it productive versus something that may feel good to do, but barely scratches the surface. Zooming out to see how you can impact the system also helps the individual.

As Lyndon Johnson said, “You do not take a person who, for years, has been hobbled by chains and liberate him, bring him up to the starting line of a race and then say, 'you are free to compete with all the others,' and still justly believe that you have been completely fair.

To properly address unconscious bias and structural racism, we must do more than simply “not be racist.” We must embrace the notion of being antiracist. Ibram Kendi defines antiracists as people who support antiracist policies through their actions and by expressing antiracist ideas: we all have value. People are not broken; the system creates inequality. An antiracist mentality searches for opportunities to challenge and undo structures and policies that benefit one group at the detriment of another. Antiracism is an active effort for change.

Accomplishing this will require bold efforts because these ideas may not always sit well with others. They may make some people uncomfortable. We need to stay intentional and keep focused, though. First, address your own bias:

• Take a hard look at instances you may have been in that may not have been equitable.
• Interrogate the policies around you through an equity lens and examine them for their impact
• Be self-aware of your decision-making; challenge your assumptions and even your values.
• Seek out educational opportunities and engage in honest conversations.
• Be mindful about how you engage with others.

Next, be a leader on your board. Organizations like ours have more power than we often think. Encourage your organization to do an equity audit that takes a critical look at your policies, including your policies on certification and remediation. Are these systems equitable, or are they just inherited policies from previous eras? Getting an outside opinion can be vital as sometimes our blinders can prevent us from seeing problematic issues.

It's essential to have a strategic road map to understand how each milestone moves us closer to our goal. This issue is too big for just one organization, so we need to find partners to impact the change we want to see. Challenge yourself to see your role as a regulator through an antiracist lens to better fulfill your mission: protecting the public.