Introduction

As early as 1888, Mary Putnam Jacobi noticed differences in treatment between male and female hysteria diagnosis, saying: “if this be a female, and notably selfish, the case is pronounced hysteria. If a man, or though a woman, amiable and unselfish, the case is called neurasthenia” (Wells 2012). This notable difference in treatment has been encountered countless times and “throughout history, a woman in pain was presumed to be lying” (Norman). Although there have been many modern changes in healthcare which attempt to avoid explicit biases, this issue is still internally present. A modern example of this perpetuation is the story of Abby Norman, where she was not given trust from her physicians. Among Norman’s first patient-provider interactions in her book Ask Me About My Uterus, even though she is crying, completely in distress and telling her doctor she is in pain, she noted that her “doctor seemed completely unsurprised” and immediately “assumed that her issue was of a sexual nature” (Norman 2018). With all the advances of training and knowledge in modern healthcare, why was her doctor still unable to trust her and give her the treatment she needed?

This brings us to the notion that healthcare still is not equitable. Patients frequently face various barriers that lower the quality of care and worsen health outcomes, such as socioeconomic disparities, differences in cultural background and racial bias. While these barriers appear distinct, many are propagated through the same underlying concept: implicit bias. The term “implicit bias” refers to the attitude or internalized stereotypes that unconsciously affect our perceptions, actions, and decisions (Shah 2023). Just as cultural barriers, socioeconomic disparities and racial bias create tangible obstacles in healthcare, implicit biases create a more subtle, but similarly potent, form of harm. Implicit biases affect both sides in the patient-provider relationship, which accounts for most interactions in the healthcare system.

Implicit Bias from Provider Perspective

The most typical form of implicit bias comes from a provider perspective in the form of subtle racial, gender or weight biases. Researchers Chapman et al. have found that medical practitioners sway treatment decisions based on patient characteristics due to implicit bias. Some examples include the fact that women are three times less likely than men to receive knee arthroplasty when clinically appropriate, Black and Hispanic patients are seven times less likely to receive analgesics or painkillers compared to white patients with similar injuries, and that women are more likely to be diagnosed with asthma or a non-respiratory problem while identical male patients are more likely to be diagnosed with chronic obstructive pulmonary disease (Chapman et al. 2013). These distinctions suggest that implicit bias shapes medical decisions by distorting the way providers perceive pain tolerance, symptom credibility, or the likelihood of certain conditions based on a patient’s group membership. Rather than relying solely on clinical data, providers may unconsciously fall back on stereotypes such as thinking women exaggerate pain, Black patients are more pain tolerant, or respiratory issues are less serious in women, which can lead to unfair and often inferior care. Similar research demonstrates evidence of providers having unconscious biases regarding race, gender, age, weight and/or other characteristics according to the standard Implicit Association Test (Gopal et al. 2021). This noted disparity in treatment due to implicit bias only perpetuates health care disparities between diverse people and can be noticed and/or picked up by patients.

An example of a patient who was able to perceive implicit biases is Terry Alston Jones, an educator at North Carolina Wesleyan College, who gave an interview with the University of North Carolina at Chapel Hill’s Southern Oral History Program. In this interview, Jones talks about her family’s medical history and eventually talks about her pregnancy and how the healthcare system seems to be regressing:

TAJ: I never knew of anybody, any of my friends or anyone in my age group who died in childbirth, and now I hear of people all the time who die in childbirth, and it seems just like we’re regressing.
SP: Why do you think that is?
TAJ: Well, I still think that it is prejudices, and a perfect example, I know a young lady who is white and she just got pregnant, and she’s been out of work half a day, if not a whole day, for the last two weeks. She just says, “Oh, not feeling well today… I know of another young lady who’s African American and she was pregnant, never missed a day, and it would have been looked at differently. So I just think that as Black women and Black people, sometimes we’re not seen or heard. (Penman 2019)

In this brief portion of the interview, it is clear that Jones is worried for the future state of healthcare, especially for women in pregnancy and maternal health, as she thinks that it could possibly be regressing due to racial biases and health inequity. Jones has a deep concern for the state of maternal healthcare in the future and highlights a racial double standard in how women are perceived and treated during pregnancy. She points out that Black women are often expected to endure more and are judged harshly by taking time off even if it is medically necessary. The specific observation that Black women and Black people are not seen and heard brings up the idea of medical dismissal which is rooted in implicit bias. For Jones, implicit bias isn’t just a concept, it is a lived experience that for her signals a troubling decline in healthcare and health outcomes for Black patients.

Implicit Bias from Patient Perspective

Implicit bias not only comes from the provider perspective, but can also come from the patient perspective. An example of implicit bias from a patient perspective is pertinent in Stephanie Atkinson’s observations in her interview with the University of North Carolina at Chapel Hill’s Southern Oral History Program. As a nurse, Atkinson notices that many of her Black male patients exhibit a reluctance in trusting healthcare professionals. Atkinson links this directly to the lasting effects of the Tuskegee Syphilis Study, which is infamous for its unethical conduct that withheld treatment from African-American men:

“Guess who did this? The CDC. Guess who this targeted? Black males of a certain age. Guess who some of your hardest patients to get to trust physicians are? Black males of a certain age” (Kameny 2018)

This historical trauma fosters a form of inherited distrust, which may not always be conscious, but still influences how patients approach healthcare. While the bias stems from this explicitly harmful study, this bias now operates in a way that resembles implicit bias. This study has led to the development of unconscious, subtle biases that now affect how people make healthcare decisions. This can be in the form of automatic behaviors like rejecting medical advice, second-guessing diagnoses or avoiding care altogether. These behaviors can erode the trust needed for effective treatment in the patient-provider relationship.

Atkinson relates this skepticism to the reluctance of patients towards getting flu shots or vaccinations:

“So that’s why I see a mistrust in flu vaccinations, because guess who does it? The CDC. And they’re like, ‘Well, the CDC wouldn’t give them the penicillin that they needed so they’d be better’” (Kameny 2018)

While Atkinson focuses on Black males, this reluctance towards vaccination extends to other communities as well where many factors such as historical injustices, misinformation and/or inequitable access to care can contribute to a distrust in the patient-provider relationship (Etowa et al.). In these cases, implicit biases from the patient perspective can contribute just as significantly to the formation of distrust in the patient-provider relationship as the implicit biases from the provider perspective.

Conclusion

Implicit bias in the patient-provider relationship is a prominent issue that needs addressing. It determines whether or not a patient is safe, whether they follow treatment, and whether they survive. It operates behind the scenes, out of sight, but its effects are broad and enduring. This essay has illustrated how implicit bias exists both in patients—inherited distrust—and providers—inherent biases and biased interactions. In both cases, the result is the same: damaged communication, painful trust, and imbalanced care.

The live accounts of Stephanie Atkinson and Terry Alston Jones give voice to the lived reality of these dynamics. They demonstrate how history, culture, and personal experience meet in the clinical encounter. As opposed to statistics standing alone, these individual accounts bring depth to the conversation and necessitate a response—not simply academic acknowledgment, but action.

In order to push healthcare progress, especially with at-risk groups, we must begin by exploring the role of implicit bias. Medical training must transcend the pages and actively deal with the social contexts that make up patient experience. Providers must not only be taught how to treat disease, but how to be trusted. Only by addressing the invisible assumptions that shape our behavior can we move toward a more just and equitable healthcare system.

Works Cited

Chapman, Elizabeth N., et al. “Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health Care Disparities.” Journal of General Internal Medicine, vol. 28, no. 11, 2013, pp. 1504–1510. https://doi.org/10.1007/s11606-013-2441-1.

Etowa, Josephine, et al. “Understanding Low Vaccine Uptake in the Context of Public Health in High-Income Countries: A Scoping Review.” Vaccines, vol. 12, no. 3, 2024, p. 269. https://doi.org/10.3390/vaccines12030269.

Gopal, Dhruti P., et al. “Implicit Bias in Healthcare: Clinical Practice, Research and Decision Making.” Future Healthcare Journal, vol. 8, no. 1, 2021, pp. 40–48. https://doi.org/10.7861/fhj.2020-0233.

Kameny, Maddy. Interview with Atkinson, Stephanie. 25 June 2018. Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.

Norman, Abby. Ask Me About My Uterus. Nation Books, 2018.

Penman, Susie. Interview with Terry Alston Jones. 11 June 2019. Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.

Shah, Huma S. “Implicit Bias.” StatPearls [Internet], 4 Mar. 2023, https://www.ncbi.nlm.nih.gov/books/NBK589697/.

Wells, Susan. Out of the Dead House: Nineteenth-Century Women Physicians and the Writing of Medicine. University of Wisconsin Press, 2012.