Unconscious Bias
With Dr. Mary Brandt & Dr. Julie Freischlag & Dr. Quinn Capers IV · hosted by Dr. Alex Cassar & Dr. Todd Ponsky
Chapter 1 of 9 · Fundamentals
Introduction
Introduction and Context: Recognizing Unconscious Bias
Expert statements on this page
No expert statements were drawn from this page.
Host summaries · secondary, not cited in answers
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Video
Female Fertility Cryopreservation Outcomes in Childhood Cancer: A Systematic Review
59 s · Published May 2024
Video
Dr. Ramy Shaaban - Best of the Best in Pediatric Surgery 2025
Dr. Todd Ponsky · 9 min · Published Mar 2025
Video
Keys to Building a Successful Interdisciplinary Program-Creating the...
10 min · Published Jul 2017
Video
Off the grid: how I got off the grid & you can too | Lee Ponsky | TEDxCLE
Dr. Lee Ponsky · 20 min · Published Jul 2015
Video
Dr. Timothy B. Lautz - Best of the Best in Pediatric Surgery 2025
Dr. Todd Ponsky · 10 min · Published Mar 2025
Video
Best of the Best Gen Surg - Limited Health Literacy is Associated with Reduced Adherence to ERP Components. - Dr. Shao
9 min · Published Sep 2022
Only a few other public items share this expert — go deeper there →
What the experts said
No one recognizes they have implicit bias, yet everyone has it to different degrees and about different things (groups, religions, gender, sexual preference).
Every woman in surgery or medicine has experienced implicit bias; colleagues from underrepresented minorities or with gender differences experience it even more profoundly.
Microaggressions (micro-insults) are very small 'paper cuts'—not blatant prejudice but repeated tiny slights such as men talking over women or minorities, 'mansplaining,' and the 'hepeat' (a woman's idea ignored until a man repeats it).
People in dominant positions (e.g., white, male, Protestant, cisgender) are responsible for calling out microaggressions and bias when they occur.
Once implicit bias is pointed out, one notices it constantly in meetings and interactions (e.g., women being talked over by men).
Implicit bias testing at Hopkins in 2005–2006 demonstrated that people have bias based on institutional affiliation (Hopkins vs. Harvard) and that there is typically a white preference because white individuals receive more recognition and opportunities.
Julie Freischlag learned 20 years after her residency match that the UCSF surgery chair had decided not to rank any of the three women applicants, meaning she was excluded not for lack of merit but due to explicit gender bias.
Many people believe women cannot lead or serve on executive teams; this perception is improving but percentages remain very low.
All search committees at Wake Forest must now undergo implicit bias testing and examination so that hiring decisions are made with awareness of potential bias.
Unconscious bias consists of associations, likes, or dislikes occurring outside of awareness and control; hearing the word 'bias' often causes an initial recoil because people think it means they are bad.
Unconscious biases can influence clinical decision-making so that even pure-hearted, egalitarian clinicians may treat patients differently based on gender, race, age, height, or weight.
In a cancer case, an outside oncologist attributed a patient's relapse to noncompliance with outpatient chemotherapy for several months; genetic testing later revealed the cancer had mutated, and therapy was switched too late. The patient was an underrepresented minority, and physicians unconsciously associate minorities with noncompliance.
If you are in a dominant group (white, male, Protestant, cisgender), your social identity and associated privilege never cross your mind during interactions—analogous to fish not knowing what water is.
There is not a single person who does not have implicit bias; it is a matter of recognizing it and deciding what to do about it.
Social identity bias extends beyond gender to professional roles: assumptions that doctors are male and nurses are female, or that surgeons are too narcissistic to lead organizations.
A panel composed purely of white males will attract fewer listeners and less credibility; diversity in gender, ethnicity, and age makes panels more interesting and popular.
When organizing panels, people typically default to their existing social network ('my buddies') rather than intentionally seeking the most qualified and diverse experts.
To diversify a panel, one can contact colleagues outside one's immediate circle (e.g., a woman dean in a related field) and ask for recommendations of experts from underrepresented groups.
Implicit bias arises from upbringing, community, and media exposure; one should not feel shame but rather surprise and motivation to take action.
Appreciative inquiry—asking 'why?' and 'tell me more'—helps one understand others' perspectives and reduces implicit bias through education and empathy.
Implicit bias exists in 100% of people; it is not one's fault (it comes from societal messages and media), but individuals are responsible for how they behave once they recognize it.
Addressing implicit bias is hard work that will make one extremely uncomfortable; discomfort signals progress.
When first confronted about bias, a common defensive reaction is to deny it ('I am not biased'); overcoming this defensiveness is the hardest but most critical step.
Physicians are good-hearted and want to do the right thing, but unconscious biases can 'hijack' good intentions and lead to inequitable care.
Research-proven strategies to reduce unconscious bias include: (1) finding common group identities with patients or interviewees (shared background, hobbies, etc.), which inhibits bias; (2) perspective-taking and developing empathy (imagining the patient's day, stressors); empathy actively opposes unconscious bias.
Ohio State's admissions committee (140 members) took three IATs (sexuality, male-career stereotype, black-white race), reviewed aggregate results, and received training on bias-reduction strategies; the following cycle, the college admitted its most diverse class in history.
Ohio State now holds a mandatory annual admissions-committee workshop with vignette-based exercises on implicit bias reduction; members are recommended to retake several IATs each year.
Implicit biases hurt individuals and the profession by preventing the hiring and retention of diverse, talented people and by weakening the 'mosaic' that makes teams stronger.
Addressing implicit bias requires courage; people in positions of power must call out microaggressions and racist or sexist comments in real time.
In medicine's hierarchy, younger and more diverse individuals often do not feel comfortable calling out bias; senior leaders must be public and proactive in addressing it.
When someone reports an offensive comment or behavior, leaders must listen with an open mind, because implicit bias may cause the leader to have heard the same event differently than the person affected.
Leaders will make mistakes when addressing bias; public apologies ('I didn't mean it that way; thank you for bringing it to my attention') are essential.
Forgiveness and kindness are necessary as people learn to address bias; most people want to improve, and fear of making mistakes should not prevent normal interactions (e.g., mentoring women, having one-on-one meetings).
In a 'wrestling match' between conscious and unconscious mind, the conscious mind wins every time; if we know our unconscious biases and when we are at highest risk (high cognitive load, time pressure, sleep deprivation), we can overcome them.
The 'consider the opposite' strategy: before finalizing a decision, force yourself to re-examine the data looking for evidence that supports the opposite conclusion (e.g., that a student with a D in chemistry will succeed in medical school, or that a patient with a history of noncompliance will be a good transplant candidate). This blunts unconscious bias.
Implicit bias tests should not be used to screen out job or committee applicants, because unconscious associations do not reflect conscious intent; instead, use test results to guide education and professional development.
Julie Freischlag tolerated harassment and bias for 20 years (starting at age 17) before raising her hand as an associate professor, illustrating how long women in surgery have historically remained silent.
True leaders now want to listen, understand, and help when bias is reported; most institutions have resources (faculty affairs, DIO, ombudsman) for trainees to seek support.
Women comprise about 30% of practicing surgeons but face pay differentials and leadership gaps: only 22 women chair general surgery departments, about 20 women are medical school deans, and Julie Freischlag believes she is the only woman CEO in the southeastern United States.
Younger physicians (current trainees) have been raised in more diverse teams and are more comfortable with women and underrepresented minorities in leadership, offering hope for generational change.
Programs or leaders unwilling to engage with inclusion and bias are not worth joining; speaking publicly about bias will help trainees find the right training environment.
There is nothing radical about trying to do the right thing and being inclusive; if someone views you as radical for teaching about implicit bias, politely walk away.
Wake Forest's theme for the year is inclusion, following a prior year focused on health and wellness; there is widespread enthusiasm because everyone wants to feel included, connected, and respected regardless of appearance, identity, or role.
Implicit bias is defined by the Kirwan Institute as 'the attitudes or stereotypes that affect our understanding, actions and decisions in an unconscious manner.'
A study showed that in a diverse group of doctors, minority children were consistently given less pain medicine than white children, with no reason other than implicit bias and stereotypes.
Social identity is the portion of self-concept derived from perceived membership in a relevant social group (gender, sexual orientation, race, religion, etc.).
When building a panel or team, choosing a diverse mosaic has been proven in business to increase innovation, revenue, and audience engagement.
Taking the Harvard Implicit Association Tests (IATs) for sexuality, male-career stereotype, and race can reveal unconscious preferences (e.g., moderate preference for straight over gay people) that the test-taker did not expect.
Robin DiAngelo's book 'White Fragility' explains how pervasive race issues are in society and how white people often respond irrationally or defensively ('fragility') when confronted about bias.