Trevor Noah of “The Daily Show” and Democratic presidential nominee Hillary Clinton  have recently invoked the notion of “implicit bias” and its effects on our society. Implicit bias lives beneath the surface of our unconscious and yet it shapes our attitudes and actions toward others.

Recently, I asked a group of medical residents at our hospital to journal their experiences and observations in clinical settings and to describe how those implicit biases impacted patient care.

I received the following examples:

  • A Caucasian boy with an abscess was nearly discharged from the ER with a less-effective medication because his parents were young and not well dressed, leading physicians to assume he was on Medicaid. It turned out he had private insurance and could afford the right drug for his condition.
  • In another instance, a young African American woman was considered a “drug seeker” because of multiple trips to the emergency department complaining of headaches. Residents believed there was nothing really wrong with her but an attending physician suggested a full neurologic work up; an MRI revealed a brain tumor. Indeed, the woman had a physiologic cause for her headaches.

As these medical examples illustrate, implicit bias can be a life or death issue. Just as it can mean life or death in the streets of our cities, it is also critical in health care settings that implicit bias be recognized for entrenching health disparities and sustaining inequities.

Also known as “implicit social cognition,” Implicit bias reminds me of the term “pentimento,” a notion derived from the Italian word ”pentirsi,” which means to repent or change one’s mind. It is also used to refer to a “painter’s repentance” such as when an artist begins to paint something, then changes his or her mind and paints over the original image with something completely new. Over time, the top layer of paint fades, becomes transparent. and the original image that was once hidden is revealed.


My career has focused on the social and economic factors affecting our urban communities. Now a long look at individual bias at the personal level complements that work. The implicit associations we harbor in our subconscious cause us to have feelings and attitudes about other people based on superficial characteristics of race, ethnicity, age, and appearance.  These associations develop over the course of a lifetime beginning very early through exposure to direct and indirect messages.  In addition to early life experiences, in later life media and news programming are often-cited origins of implicit associations.


So, implicit bias, like pentimento, lives beneath the surface of our unconscious and yet very definitively shapes our attitudes and our actions toward others.

Clinton and Noah admit they own their implicit biases, and they challenge the rest of us to do the same. Comedians, politicians, and even our doctors show how us how critical it is to look beneath the surface in order to fully see and comprehend the people with whom we interact; the surface simply does not tell us enough. It is only by seeing beyond the surface that the full story becomes apparent. Only by recognizing our own implicit bias can we begin to address it.


Lynn Todman, PhD, is Executive Director for Population Health at Lakeland Health System in St. Joseph, Michigan. In her role, Lynn is responsible for helping to establish the strategic direction of the hospital system to improve the health of the regional population and to reduce health disparities. Lynn’s career has focused on identifying and addressing the social and economic factors that undermine the welfare of urban communities. Her most recent research examines the relationship between urban food deserts and community violence. She was born and grew up in Chicago.