BJA Education, 22(4): 131e137 (2022)

doi: 10.1016/j.bjae.2021.11.011
Advance Access Publication Date: 3 February 2022

Matrix codes: 1F01,

1F04, 1I05, 2H02, 3J02,
3J03

Social bias, discrimination and inequity in

healthcare: mechanisms, implications and
recommendations
C.S. Webster1,*, S. Taylor2, C. Thomas1 and J.M. Weller1
1
University of Auckland, Auckland, New Zealand and 2Auckland City Hospital, Auckland, New Zealand
*Corresponding author: [email protected]

Keywords: bias reduction; conscious and unconscious bias; equity; explicit bias; implicit bias; social bias

Learning objectives Key points

By reading this article, you should be able to:
Social bias is at the core of racism, misogyny and

Explain the central concepts underlying social other forms of discrimination based on sexual
biases and their negative effects on healthcare orientation or religion.
outcomes.
Social bias can be defined as discrimination for, or

Describe approaches to the reduction of explicit against, a person or group, or a set of ideas or
and implicit social biases and their associated beliefs, in a way that is prejudicial or unfair.
risks.
Social bias may operate consciously, which is

Apply an understanding of social biases to your known as explicit bias, and unconsciously, which
personal interactions with colleagues and patients. is known as implicit bias.

Healthcare outcomes are substantially influenced
by social biases despite many of the best in-
tentions of healthcare practitioners, as social bias
Craig Webster MSc PhD is an associate professor at the Department often operates unconsciously.
of Anaesthesiology and Centre for Medical and Health Sciences Ed-
Education can be effective against explicit social
ucation at the University of Auckland, Auckland, New Zealand. He is biases, but counteracting implicit biases requires
a psychologist with more than 20 yrs of experience in human factors a more long-term reflective approach and sup-
research and redesign projects. portive systemic structures.

Saana Taylor BDS is a senior registrar in anaesthesia at Auckland

City Hospital, Auckland, New Zealand and of Whakatohea iwi.
In high-intensity work domains, such as anaesthesia and
Courtney Thomas PGDipClinEd, FANZCA is a specialist anaesthe-
intensive care, high-quality decision-making is critical for
tist based in Christchurch, New Zealand and a Ma ori health
achieving good outcomes for patients. In a previous article in
researcher. She is currently completing doctoral research investi-
this journal, we considered how cognitive biases influence
gating Ma ori experiences of anaesthesia in the perioperative setting
clinical reasoning and decision-making during technical
and is of Ngai Tahu and Te Arawa descent.
tasks, such as diagnosis.1 In this paper, we consider social bias
Jennifer Weller MD MClinEd FANZCA FRCA is head of the Centre for and the effects of discrimination in healthcare. We define
Medical and Health Sciences Education at the University of Auck- social bias as discrimination for, or against, a person or group,
land, Auckland, New Zealand. Professor Weller is a specialist or a set of ideas or beliefs, in a way that is prejudicial or unfair.
anaesthetist at Auckland City Hospital and is on the editorial board Social bias often involves consciously or unconsciously ster-
of the British Journal of Anaesthesia. Her research encompasses eotyping others and behaving in a way that disadvantages a
medical education, patient safety and simulation-based team person or group or advantages another. Social bias, both im-
training. plicit and explicit, is at the core of racism, misogyny and

Accepted: 22 November 2021

© 2022 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
For Permissions, please email: [email protected]

131
Social bias, discrimination and inequity in healthcare

discrimination based on sexual orientation or religion, and Social bias between health practitioners may mean some
such biases may operate between individuals or at the level of members of the team are privileged or disadvantaged in terms
the institution. of opportunities for leadership, gaining experience or career
‘If people are not aware of inequity and do not act to advancement. In clinical decision-making, some members of
constantly resist oppressive norms and ways of being, then the team are listened to whilst others are ignored. Within
the result is residual inequity in perpetuity’.2 A first step in teams, where effective teamwork requires mutual trust and
addressing the problem of social bias is acknowledging its respect, social bias can impede team function, for example
existence and reflecting on one’s own position and potential where some members are not heard or are discouraged from
biases. Therefore, in this overview, we consider the impact speaking up with their concerns. In extreme cases, social
and nature of social bias, with an emphasis on the aspects biases may result in workplace harassment, racist abuse or
relevant to the everyday practice of individual healthcare other overt discrimination. When such social biases become
practitioners, including strategies to manage and reduce it commonplace or normalised within an institution or work-
and thereby promote culturally safe practice.3e8 place, they comprise institutionalised bias, at which time
such biases have wider implications, influencing policy for-
mation, operational decisions and everyday institutional
Impact of social bias in healthcare functioning.
At the level of healthcare systems, structural racism has led to In the interaction between healthcare practitioners and
organisational and political constructs that have disadvan- their patients, social bias, both unconscious and conscious,
taged racial or ethnic groups both historically and in the can influence the quality and effectiveness of the care pro-
present day, creating and maintaining inequities in health.9 vided. Clinical reasoning and decision making may be influ-
At a personal practitioner level, social biases include enced by implicit racial stereotyping and prejudicial
discrimination on the grounds of ethnicity, culture, religion, assumptions. Unconscious prejudicial or negative stereotypes
gender, sexual orientation, age or body habitus.10,11 See Box 1 may be expressed as off-hand remarks, banter or casual
for examples of social and institutionalised bias. racism. To people on the receiving end, these remarks are
Social bias affects relationships and interactions at many neither unconscious nor casual and can be substantially
levels within the healthcare environment, between co- harmful. Patients who experience such discrimination are
workers in multidisciplinary healthcare teams, between likely to disengage from the healthcare system, creating
trainees and supervisors and between clinicians and patients. further barriers to access and care. The result is differential
healthcare, health inequities and poorer outcomes for certain
Box 1 groups of patients.8
Examples of discrimination relevant to healthcare.
Nature of social bias
In New Zealand, Ma  ori people experience significant in- Corresponding to the unconscious and conscious cognitive
equalities with lower life expectancy at birth, 7.3 yrs less processes of the human brain, social biases are divided into
than non-Ma  ori people. Ma ori people have less access to implicit biases and explicit biases, respectively.15 Implicit so-
and poorer care throughout all healthcare services, cial biases involve fast unconscious, emotive and automatic
which is reflected in lower levels of investigations, in- responses, often relying on pattern recognition. Although the
terventions and medicine prescriptions.8 human brain has an innate ability to differentiate similarities
Ma ori patients are less likely to get understandable an- and differences in the world, the negative associations
swers to important questions asked of health pro- involved in implicit social bias are not innate and can be
fessionals, have health conditions explained in changed by positive experiences.1 Explicit social biases
understandable terms or feel listened to by doctors or involve conscious attitudes, beliefs and knowledge, and
nurses.8 although such explicit biases may be reinforced by our expe-
A study by Files and colleagues analysed how 321 riences, we are also able to consciously resist such stereo-
speakers were introduced during grand rounds at the typical thinking.
Mayo Clinic. They found that when women introduced One well-known attempt to quantify implicit social bias is
speakers, nearly all used professional titles for both men the Implicit Association Test (IAT). Developed in 1998 by Drs
and women. However, when men introduced speakers, Mahzarin Banaji and Anthony Greenwald, the IAT is intended
there was only a 50:50 likelihood that a female speaker to provide feedback on an individual’s biases for the purposes
would be introduced as a doctor.12 of self-reflection (available from https://implicit.harvard.edu/
A survey of anaesthesia trainees in Australia and New implicit/).16 Several versions of the test are available for
Zealand showed that male trainees were more likely to different domains of implicit social bias, including mental
have performed a greater number of procedures for their illness, age and weight, but perhaps the most extensively
training level and perceived themselves as requiring only studied is the IAT on race. To determine implicit race bias, the
remote supervision compared with their female coun- IAT asks a test participant to select pairs from pictures of
terparts. This result suggests a potential bias against White and Black people and ‘good’ or ‘bad’ words, then al-
women in gaining access to procedures.13 ternates the pairings whilst measuring reaction times. For
Black and Hispanic patients are significantly less likely example, in one part of the test, participants must associate
than Whites to receive pain medications, even for acute good words with White people and bad words with Black
injuries, such as bone fractures. When they do receive people, then good words with Black people and bad words
analgesics, they are at lower dosages than White patients with White people.17 The test works by taking advantage of
despite having higher pain scores.14 the way the brain processes different information at the
conscious and unconscious levels. Pairs that are

132 BJA Education - Volume 22, Number 4, 2022

 Social bias, discrimination and inequity in healthcare

unconsciously associated for the participant can be rapidly disinformation, even among healthcare workers. Open
selected using the brain’s unconscious processing, whilst se- communication about the risks in a non-stigmatising way
lection of those pairs that are less well associated requires from members of the same cultural or religious group as those
slower conscious processing to complete. The participant’s members who are hesitant can be effective in improving
unconscious associations can be detected by the IAT even in vaccination rates, and it also demonstrates that overcoming
individuals who purport egalitarian views. The IAT on race hesitancy is not simply about facts but is also about group
has been completed more than 4 million times, and approxi- identity.23 The unconscious nature of implicit social biases
mately 75% of participants demonstrate a White preference, means that healthcare practitioners may be unaware that
that is, an association of White people with goodness and these biases are affecting their daily interactions with fellow
Black people with badness. The creators of the IAT are careful staff and patients, with real consequences for patient care.
to point out that a biased IAT score need not imply that the There is considerable variability in healthcare outcomes
person acts in a biased way towards others because of the across whole populations throughout the world, with some of
ability of the conscious mind to override stereotypes. How- the poorest outcomes typically occurring in minority groups.
ever, such results do appear to yield insight into why elimi- A recent large-scale study of 22 million healthcare encounters
nating bias from healthcare may be so difficult despite high across 18 states in the USA compared the top and bottom
levels of conscious motivation and egalitarian values reported deciles of a variety of healthcare outcomes. It demonstrated a
by healthcare practitioners. 2.1-fold difference in mortality rates overall and a 2.3-fold
difference in mortality rates for inpatient acute myocardial
Social bias and health outcomes infarction, after patient-based risk adjustment.24 These rates
of variability in outcome exceed the widely publicised varia-
Many current events around the world continue to be influ- tion in healthcare costs between US healthcare providers.25
enced by explicit social biases and discrimination based on Whilst such findings from the USA are some of the best
race, sex, sexual orientation or religion. Education is often known, similar results on variability and adverse events have
aimed at reducing such biases, and there is strong evidence been reported in many countries. In New Zealand, 12.9% of
that in certain domains, education has been successful in patients in hospital experience an adverse event, 35% of
reducing rates of explicit social bias, including in healthcare. which are considered highly preventable and 15% of which
For example, university medical schools are typically leaders lead to permanent disability or death.26 These figures are
in the ethical and equitable provision of healthcare, primarily concerning, but Ma  ori patients in New Zealand hospitals
through the supply of graduates instilled with these values, experience significantly higher rates of adverse events during
and at least in modern times, equity has featured as an overt their care than non-Ma  ori patients (14% vs 11%, respectively;
and strategically important element of medical school P¼0.01), and this effect persists after controlling for age and
curricula.18 Over the years, societal norms in many countries socio-demographic factors.27 However, whilst these unac-
have also become more progressive, as have the policy ceptable disparities in healthcare outcomes are widely
guidelines of professional healthcare colleges.19 A conse- acknowledged, the problem remains. Ultimately, providing
quence of such formal and informal education may be seen in equitable treatment to all patients will not only increase the
the results of surveys of US physicians, in which opposition to quality of healthcare, but also, by reducing suboptimal out-
homosexual applicants to medical school was shown to comes and the need for further treatment, improve the effi-
reduce from 30% in 1982 to 0.4% in 2017, whilst discomfort cient use of limited healthcare resources.24,28
with referring patients to homosexual physicians reduced
from 46% to 2% over the same period.20 As explicit social
Recommendations to reduce social biases in
biases involve conscious cognitive processes based on
knowledge and beliefs, it is perhaps not surprising that edu-
healthcare
cation can be effective in reducing them. Although considerable data exist that document the deficits in
However, education alone is much less effective in healthcare delivery, there is less evidence available to guide
changing implicit social biases because such biases operate remedies or to judge their effectiveness. However, drawing on
unconsciously. For example, when asked, healthcare practi- four evidence-based reviews, we have synthesised the pri-
tioners are likely to claim that they treat all their patients mary types of interventions recommended to reduce social
equally and may believe that their behaviour is unaffected by bias in healthcare (Table 1).4e7 The recommendations in
negative stereotypes.7 Despite this claim, a 2002 national Table 1 span from individual-level initiatives to policy-level
survey in the USA found that, in comparison with White initiatives. Educational initiatives do appear at the individual
Americans, Hispanics and African Americans were 14 times level, which are known to be more effective against explicit
more likely to believe that they would receive better health- social biases than implicit ones. However, it is also worth
care if they were a different ethnicity, and they were nearly noting Initiative 3 in Table 1, which suggests consciously
twice as likely to believe that they had been treated with practising egalitarian values when engaging in clinical en-
disrespect during a healthcare visit.21 Neither are the effects counters with underprivileged groups in order that these
of social bias limited to patients. A recent survey of 19,044 values become habitual. Once habitual, such a way of inter-
healthcare staff in the UK found that at the time of the survey, acting with patients could potentially counter or overwrite
71% of White staff had taken up the COVID-19 vaccination implicit social biases and counter explicit ones. Table 1 also
compared with only 37% of Black staff; this finding is despite contains some examples of how such approaches may be
the fact that healthcare staff are actively encouraged to be applied in anaesthesia and healthcare, although these ex-
vaccinated and should have few, if any, difficulties in amples are by no means exhaustive.
accessing the vaccine.22 Although the mechanisms underly- Unlearning dominant discourse or challenging the pre-
ing vaccine hesitancy are complex, evidence suggests that vailing influential views around how and why inequities exist,
hesitancy largely results from a lack of trust and the effects of and inviting input from, and partnership with, the groups

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Social bias, discrimination and inequity in healthcare

Table 1 Interventions intended to reduce social bias at multiple levels within healthcare. Synthesised from reviews by authors Hassen
and colleagues,4 Zestcott and colleagues,5 Byrne and Tanesini6 and Marcelin and colleagues.7 *These examples are not exhaustive.

Level of Strategy Examples relevant to anaesthesia and intensive care*

intervention

Individual Ongoing training on cultural safety, minimisation of Sit down with patients to flatten hierarchies before
stereotyping and implicit bias; critical reflection on engaging in respectful communication and practised
knowledge, attitudes, beliefs and practice as it listening
pertains to diverse patient care

Interpersonal Take opportunities during clinical encounters with Checking whether patients have understood care
underprivileged or stereotyped groups to practise instructions should go beyond simply asking if they
egalitarian values such that these values become understand; it should also consider whether, in their
habitual; intentionally diversify experiences with particular circumstances, the patient is happy and
cultural humility and curiosity; develop and able to follow instructions; if difficulties are
implement guidelines on how to address racist or discovered, care may need to be negotiated
prejudicial comments; seek mentorship and
collaboration with underprivileged or stereotyped
groups

Community Develop ongoing, meaningful collaborations with Arrange visits to the hospital for local high school
underprivileged or stereotyped groups in the students who may not have considered a career in
community; strengthen links for such groups to anaesthesia or healthcare, to introduce them to
primary and further care facilities clinical roles and technology and to provide an
opportunity to participate in simulation

Organisational Leadership commitment to culture change within Whether the institution is performing adequately in
organisation, including appropriate resources; terms of serving the community should be judged by
develop guidelines on how to address racist or representatives of the community, not by hospital
prejudicial comments, and implement throughout committees or management; consider equity during
organisation; ensure core leadership demonstrates quality and safety reviews e how can the larger
and supports diversity; meaningful engagement and negative effects in minority groups be actively
training for change; incorporate anti-bias efforts into countered?
quality improvement initiatives

Policy Recruit and retain diverse staff; involve diverse staff in Assure racial and sex (and other) diversity on
policy and decision-making; develop a long-term plan anaesthesia trainee selection committees; reducing
for change bias, this approach will provide role models for new
applicants

against whom social biases are perpetuated may help to process, largely because being a member of a dominant cul-
navigate pathways forward together. Individuals may be ture can effectively blind you to the privileges and power
powerless to deliver equitable care if all the systems they differentials that are part of that cultural group. Jowsey has
work in are designed for and advantage the dominant cul- described this reflective process in terms of a journey through
ture.29 For initiatives at the individual and interpersonal levels three distinct zones of increasing depth (Table 2).3 The first,
to be maximally successful and sustainable, they need to surface-level zone, is where individuals and healthcare orga-
operate within a system that supports and reinforces them at nisations typically start, and it is also the zone most consis-
the community, organisational and policy levels. tent with a cultural competence approach. Failing to consider
In recent years, the approaches outlined in Table 1 have what lies beyond the first zone risks reinforcing stereotypes,
become known collectively as the ‘cultural safety’ approach, as the first zone may focus on superficial differences and may
which attempts to promote healthcare in a way that does not do so without examining the underlying causes of inequity.3,8
bias against minority groups. Cultural safety in healthcare Cultural safety asks us to continue the journey into the deeper
requires clinicians to examine their own biases and to zones. However, it does not require practitioners to become
deconstruct the power differentials that exist between clini- ‘competent’ in the culture of others, as in a cultural safety
cians and patients that may undermine genuine connection approach the concept of competence is not defined by those in
and engagement.30 Importantly, cultural safety should be power but by those in the minority group in question. Table 2
seen as distinct from the earlier concept of cultural com- describes the remaining stages along the journey of cultural
petencedthe primary distinction being that when using cul- safety in healthcare and may be used as a kind of road map for
tural safety, the adequacy (or competence) of care is this process. Table 2 also contains the common risks at each
determined by people who receive the care, not by the people stage of this journey, which should be considered pitfalls to
who provide it.8 ‘Cultural safety is an outcome of health avoid. Although much work to develop and promote cultural
practice and education that enables safe service to be defined safety has taken place in Australia and New Zealand, its
by those who receive the service’.19 Becoming aware of per- concept and lessons are applicable to the reduction of
sonal biases and addressing them in terms of the way you healthcare inequities in any country. Therefore, in Table 3, we
interact with others can be a lengthy and ongoing reflective include a list of helpful courses, instructive videos and other

134 BJA Education - Volume 22, Number 4, 2022

 Social bias, discrimination and inequity in healthcare

Table 2 Journey through the three zones of cultural safety, adapted from Jowsey.3

Depth of cultural safety Definition Examples Risks

Surface cultural safety zone Deployment of culturally Provision of culturally May lead to overly simplistic
specific knowledge appropriate services, such as interpretations of culture and
an interpreter or prayer spaces in fact perpetuate stereotypes,
in hospitals; greeting people in hence reducing trust; surface-
their native language; and level approaches often do not
being aware of certain taboos examine underlying causes of
and cultural practices, for inequity
example, in the drawing and
use of a patient’s blood

Bias twilight zone Supporting people to increase Moves away from learning With increasing ethnic and
self-awareness of their own specific cultural traits and cultural diversity, biases and
biases with a view to uses more reflective strategies racism move beyond non-
addressing health disparities to understand the impact that indigenous and indigenous
individuals have on others; paradigms; important to avoid
uses collaborative tokenistic engagement with
partnerships with indigenous cultural groups
people

Confronting midnight zone Realising that individuals live Slow development of an Minority groups may find
in relationships with others in awareness of cultural safety, attempts at communication
the larger world and reflecting which allows an by those members in power to
on the power, privilege and understanding of existing be meaningless or
inequities in those power structures, including disingenuous; the realisations
relationships healthcare providers, and the of cultural safety may also be
effects of such power threatening to those people in
structures on the status quo power
and marginalisation of
minority groups

Table 3 Training courses, instructive videos and other resources on equity and cultural safety in anaesthesia and healthcare. *All links
as accessed on November 7, 2021.

Resource title Organisation Resource link*

Building a culture of health equity at the National Academy of Medicine, US states https://nam.edu/building-a-culture-of-
federal level health-equity-at-the-federal-level/
Equality, diversity and inclusion Royal College of Anaesthetists https://rcoa.ac.uk/about-college/
strategy-vision/equality-diversity-
inclusion
Report on health equity in England Public Health England https://www.gov.uk/government/
focusing on inequality between ethnic publications/health-equity-in-england
groups
Series of reports on achieving healthcare Institute of Health Equity https://www.instituteofhealthequity.
equity in ethnic groups in the UK org/home
Providing patients with culturally safe Australian and New Zealand College of https://www.anzca.edu.au/safety-
care Anaesthetists advocacy/indigenous-health/providing-
patients-with-culturally-competent-
care
Cultural safety and cultural competence Health Quality & Safety Commission https://www.hqsc.govt.nz/our-
New Zealand programmes/patient-safety-day/
previous-psw-campaigns/psw-2019/
cultural-safety-and-cultural-
competence/
Health equity and cultural safety Royal New Zealand College of General https://www.rnzcgp.org.nz/RNZCGP/
Practitioners Dashboard/Resources/CPD_Resources/
Health_equity_and_cultural_safety_?
WebsiteKey¼4105e6d5-9ad4-4cbf-b3d4-
8a1df183be9d
Cultural safety and equity resources Royal New Zealand College of Urgent https://rnzcuc.org.nz/publications/
Care cultural-safety-and-equity-resources/
Cultural safety training Aboriginal Health Council of Western https://www.ahcwa.org.au/cst
Australia
Cultural responsiveness training Indigenous Allied Health Australia https://iaha.com.au/iaha-consulting/
cultural-responsiveness-training/

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Social bias, discrimination and inequity in healthcare

resources, including from the USA and the UK, to promote 3. Jowsey T. Three zones of cultural competency: surface
healthcare equity and cultural safety in anaesthesia and competency, bias twilight, and the confronting midnight
healthcare. zone. BMC Med Educ 2019; 19: 306
Although cultural safety primarily involves the way clini- 4. Hassen N, Lofters A, Michael S et al. Implementing anti-
cians interact with patients, achieving equity and diversity in racism interventions in healthcare settings: a scoping
clinical teams requires a related concept known as psycho- review. Int J Environ Res Public Health 2021; 18: 2993
logical safety. Psychological safety may be defined as a state, 5. Zestcott CA, Blair IV, Stone J. Examining the presence,
where team members believe it is safe to take risks in inter- consequences, and reduction of implicit bias in health
personal communications without the fear of negative con- care: a narrative review. Group Process Intergroup Relat
sequences to self-image or career.31 Rather than authoritarian 2016; 19: 528e42
leadership, psychological safety in the workplace promotes 6. Byrne A, Tanesini A. Instilling new habits: addressing
inclusive leadership, where diverse team members are invited implicit bias in healthcare professionals. Adv Health Sci
to provide information and contribute to team decision- Educ Theory Pract 2015; 20: 1255e62
making, where the team leader need not know everything 7. Marcelin JR, Siraj DS, Victor R et al. The impact of un-
and where team performance is collaborative. In the context conscious bias in healthcare: how to recognize and miti-
of modern, complex and multidisciplinary teamwork, inclu- gate it. J Infect Dis 2019; 220: S62e73
sive leadership typically leads to better team engagement, 8. Curtis E, Jones R, Tipene-Leach D et al. Why cultural safety
better team performance and better patient outcomes. Psy- rather than cultural competency is required to achieve
chological safety and inclusive leadership are also consistent health equity: a literature review and recommended
with the initiatives in Table 1, but in particular, those at the definition. Int J Equity Health 2019; 18: 174
organisational and policy levels in terms of the recruitment 9. Talamaivao N, Harris R, Cormack D et al. Racism and
and retention of diverse staff. health in Aotearoa New Zealand: a systematic review of
quantitative studies. N Z Med J 2020; 133: 55e68
Conclusions 10. Hall WJ, Chapman MV, Lee KM et al. Implicit racial/ethnic
bias among health care professionals and its influence on
Social bias and discrimination influence healthcare delivery at health care outcomes: a systematic review. Am J Public
the levels of interpersonal relationships, teamwork and Health 2015; 105: e60e76
healthcare system design. The effects can be the cause of 11. Helzer EG, Myers CG, Fahim C et al. Gender bias in
widespread discriminatory practices and embedded health collaborative medical decision making: emergent evi-
inequities. Education may be effective over time to reduce the dence. Acad Med 2020; 95: 1524e8
negative impact of explicit bias and discrimination. However, 12. Files JA, Mayer AP, Ko MG et al. Speaker introductions at
the effects of implicit bias and discrimination are more diffi- Internal Medicine Grand Rounds: forms of address reveal
cult to counteract. Tests, such as the IAT, may allow personal gender bias. J Womens Health (Larchmt) 2017; 26: 413e9
insight into implicit biases, and practical steps are known, 13. Pearce G, Sidhu N, Cavadino A et al. Gender effects in
which can assist with reducing bias. However, the journey to anaesthesia training in Australia and New Zealand. Br J
understanding biases and their consequences is typically a Anaesth 2020; 124: e70e6
long one, which should be supported at the organisational, 14. Mossey JM. Defining racial and ethnic disparities in pain
policy and governmental levels. More fundamental ap- management. Clin Ortho Relat Res 2011; 469: 1859e70
proaches are needed in healthcare at multiple levels to un- 15. Amodio DM. The neuroscience of prejudice and stereo-
pack and address existing health inequities arising from typing. Nat Rev 2014; 15: 670e82
implicit discrimination at the interpersonal level and at the 16. Greenwald AG, Banaji MR, Nosek BA. Statistically small
level of embedded discriminatory practices in the healthcare effects of the Implicit Association Test can have societally
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Declaration of interests vidual differences in implicit cognition: the Implicit As-
sociation Test. J Pers Soc Psychol 1998; 74: 1464e80
CSW is a minor shareholder in SAFERsleep LLC, a company
that manufactures an anaesthesia record system. JMW is a 18. University of Auckland. Taumata Teiteidvision 2030 and
strategic plan 2025. the University of Auckland; 2020.
member of the editorial board of the British Journal of Anaes-
thesia. ST and CT declare no conflicts of interest. Available from: https://www.auckland.ac.nz/en/about-
us/about-the-university/the-university/official-
publications/strategic-plan.html. [Accessed 7 November
MCQs 2021]
The associated MCQs (to support CME/CPD activity) will be 19. Royal Australasian College of General Practitioners. Cul-
accessible at www.bjaed.org/cme/home by subscribers to BJA tural awareness education and cultural safety training. 2011.
Education. Available from: https://www.racgp.org.au/download/
Documents/AHU/cabooklet.pdf. [Accessed 7 November
2021]
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