Implicit Bias in the Pediatric Cardiac Intensive Care Unit


“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”
– Martin Luther King, Jr

As we cross the 1-year mark of living through the COVID-19 pandemic, it is hard not to mourn everything and everyone we have lost this past year. This global pandemic has affected all of our lives, though the increased toll on minority communities has been repeatedly demonstrated. While much of the past year will be defined by its hardships, many people and organizations took time to reflect on their own privilege, and the consequences of systematic racism and inequality. This year also sparked conversations on our critical care work force, equity and disparities. The pandemic brought to light the fragility and fragmentation of our healthcare system and of health care workers on the whole.

One of the first (and most uncomfortable) steps in this personal reflective process is to look at our own implicit bias. Implicit bias refers to the unconscious thoughts and stereotypes we have about people or groups that can unknowingly affect our behavior and attitudes. One of the ways to evaluate implicit bias is through the Implicit Association Test, which in video game format asks us to sort categories of pictures and words in order to test our implicit biases on a variety of topics: race, gender, weight and religion. I highly suggest that everyone take these tests, as the results are often surprising and unnerving.

After I took these tests, I looked at the cardiac intensive care unit (ICU) where I practice and the care we provide with a different perspective. How much do our own biases affect how we interact, communicate and care for our patients and their families? Do we spend more time with those who look like us and talk like us? Do we use language interpretation services as often as we should? Does it affect how much pain medicine we prescribe or how quickly it is given? It is in stressful situations (just like a cardiac ICU) when our implicit biases manifest as assumptions, behaviors and actions. On review of racial and ethnic outcome data in pediatric critical care, we unfortunately find that we come up short[1-2]. I know we can do better.

It is important also to consider how our own implicit bias affects our interactions with our learners. Do we only recruit, mentor and sponsor those who look like us? Or are we reaching out to under-represented minorities to promote inclusivity in our training programs? Policies that improve racial and ethnic diversity of physicians, nurses and allied health professionals are an important step to reduce bias and its impact on patient care.

A lot of people often say “I can’t wait to get back to normal.” In some ways, I do not want to go back to what we were a year ago. The racial and social justice movements of the past year have changed the way we look at our lives, our society and our institutions, including healthcare. We can and we must do better. Let us not go back, but look forward and move forward.


1. Leimanis Laurens, M et al. Racial/Ethnic Minority Children With Cancer Experience Higher Mortality on Admission to the ICU in the United States, Pediatric Critical Care Medicine: October 2020 – Volume 21 – Issue 10 – p 859-868 doi: 10.1097/PCC.0000000000002375.

2. Jacobs, C et al. Racial and Ethnic Disparities in Postcardiac Arrest Targeted Temperature Management Outcomes, Critical Care Medicine: January 2020 – Volume 48 – Issue 1 – p 56-63 doi: 10.1097/CCM.0000000000004001.


Natasha Afonso, MD, MPH

Assistant Professor, Department of Pediatrics
Section of Critical Care
Baylor College of Medicine and Texas Children’s Hospital
Houston, TX