In Good Conscience

Everyone is guilty of unconscious bias. How can you disrupt the pattern?


In the late 20th century, orchestras had a gender problem. More specifically, in 1979 the top five orchestras in the U.S were made up of fewer than five percent women. But as time went on, female participation rose to 10 percent in the 1980s and then 25 percent in 1997.

What changed between 1979 and 1997? Orchestra leaders realized that they had fallen victim to unconscious bias, and they took steps to correct it. Beginning in the 1970s, candidates would audition behind a screen so that juries could not see them. Sometimes juries would even urge performers to remove their shoes to hide the telltale sound of high heels clicking against the floor.1,2 These blind auditions not only increased the number of women auditioning, but also led to a jump in the number of women who were hired.

“Unconscious bias, also known as implicit bias, is a bias individuals are not actively cognizant of,” says Amy K. Patel, MD, member of the ACR Commission for Women and Diversity and radiologist at Beth Israel Deaconess Medical Center in Boston. “Unconscious bias affects our decision making and perceptions.” Unconscious bias can affect anyone, from orchestra leaders to radiologists and other medical specialties.

Johnson B. Lightfoote, MD, FACR, chair of the ACR Committee for Diversity and Inclusion, provides another example: “Say you have a female African-American radiologist who has braids or dreads, and she’s youngish. She may run into an administrator who asks her, ‘How do you enjoy being a CT tech here?’ when in fact she’s chair of the department. Although the administrator meant no harm, he could have interpreted the radiologist as a technologist because of his own unconscious bias.”

Unconscious bias can also extend to the physician-patient relationship. Lightfoote describes patients who have asked female physicians when the doctor would arrive. And unconscious biases that physicians hold against patients can lead to critical health care disparities, says Patel. Studies have noted that physicians more frequently mistreat pain management in both racial minorities and women — which can lead to devastating results on the patient’s part.3,4

Although these examples illustrate why unconscious bias can be a problem, the effects can go even further, says Lightfoote. “There’s often the potential for loss of talent,” he says. “We may unintentionally prejudge a female as not being as competent as most or many males.” He adds that, in addition, teams may lose perspective on situations. If you’re discounting a new perspective because of race, gender, or other attributes, you will lose a whole side of the conversation.

And behavior like that can further lead to a loss in morale. Lightfoote says, “If a person’s opinion is consistently discounted, they may feel less inclined to contribute.” Patel agrees: “You need to acknowledge unconscious bias as an issue in order to continue building mutual respect among colleagues. If someone is being discounted, that respect isn’t there.”

What can you do about unconscious bias? Start by recognizing it in yourself, which is not such an easy task. “The key is to hold yourself accountable. Do a daily selfcheck of any situations where you may have demonstrated bias and determine what you could have done differently the next time to ensure you don’t perpetuate the pattern,” suggests Patel. She notes it’s important to remember that unconscious bias occurs in everyone, male and female. “There are stereotypes about every gender, race, and class. And even though you may be a minority, there are still biases you may hold about other individuals,” she points out. Peter Kalina, MD, FACR, member of the ACR Commission for Women and Diversity and radiologist and head of the diversity initiative at the Mayo Clinic in Rochester, Minn., also recommends teaching colleagues about unconscious bias using real-world examples — things that you have actually seen or overheard. Otherwise, he says, “The response tends to be ‘That would never happen here’ or ‘We don’t speak to each other like that.’”

Both Patel and Kalina agree that one way to combat unconscious bias is to hold other colleagues accountable and have them hold you accountable. “It can be as simple as having someone ask you about the situation or call you out if they observe you displaying such behavior,” says Patel. Adds Kalina, “Calling someone out shouldn’t be combative either. Remember that the behavior is likely unintentional. You can say something as simple as, ‘Ouch. You know, that really hurts.’ You can also say, ‘I don’t think you meant to say that.’”

Amy L. Kotsenas, MD, president of the Minnesota Radiological Society and member of the ACR Council Steering Committee, recommends taking active steps during the hiring process to address unconscious bias. “Review the various aspects of your hiring process. Is the wording in the job description friendly? Is the selection committee diverse?” she says. “These can both affect who applies to the job and who proceeds to the next step. Another action to take is to consider screening the resumes that come through. Have someone remove the names and other details that might reveal the applicant’s race or gender so that it’s not even an issue when it comes before the selection committee.”

Ultimately, Patel says that while it’s important to recognize and be knowledgeable about unconscious bias, the best way to combat it is to do something. “Acknowledgement is certainly a start, but we must also hold ourselves accountable and devise solutions that can cause meaningful change,” she says. “This is not easy and will take years of recalibrating the way we perceive others, how we make decisions, and more. However, it is necessary if we are to make any kind of progress.”

 Meghan Edwards, freelance writer for ACR Press

Rice C. How blind auditions help orchestras to eliminate gender bias. The Guardian. October 2013. Available at Accessed May 18, 2017.

Goldin C, Rouse C. Orchestrating impartiality: the impact of “blind” auditions on female musicians. Harvard Kennedy School Gender Action Portal. 2000. Available at Accessed May 18, 2017.

Hoffman KM, Trawalter S, Axt JR, Oliver MN., et al. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. PNAS. 2016;113(16): 4296–4301. Available at Accessed May 18, 2017.

 Hoffmann DE, Tarzian AJ. The girl who cried pain: a bias against women in the treatment of pain. J Law Med Ethics. 2001;29(1):13–27. Available at Accessed May 18, 2017.

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