#KeyLIMEPodcast 273: Why do you test?

Reference

Sukhera et. al., The Implicit Association Test in health professions education: A meta-narrative review. Perspect Med Educ. 2019 Oct; 8(5): 267–275.

Reviewer

Lara Varpio (@LaraVarpio)

Background

• The paper defines implicit bias as attitudes that form through experiences and operate outside an individual’s awareness
• Research has shown that implicit bias in healthcare contributes to disparities in patient care and inequitable treatment. Research has also indicated that implicit biases are a unique type of prejudice that is inherently complex and more challenging to address that more explicit prejudices.
• Researchers have relied heavily on the Implicit Association Test (IAT). The individual’s response latency is calculated and used as a proxy for the strength of implicit associations between categories.
• The IAT has some strong evidence behind it suggesting that it is a robust tool — BUT there is also criticism of the test.

Purpose

• The authors set out to synthesize existing knowledge about the IAT, about how and why it is used for teaching and learning in HPE. They set out to understand the assumptions and theoretical positions that inform those assumptions

Key Points on the Methods

• The authors engaged in a meta-narrative literature review which is a review designed for topics that have been differently conceptualized and studied by different groups of researchers. It was developed by Trish Greenhalgh in 2005. A meta-narrative review looks historically at how particular research traditions have unfolded over time and shaped the kind of questions being asked and the methods used to answer them.
• There are a series of steps and processes to follow, and I won’t go into them here, but it is important to know the core principles that underpin the meta-narrative review process and those are: pragmatism, pluralism, historicity, contestation, reflexivity, and peer review. I should also point out that in 2013 Greenhalgh was part of a team that developed publication standards for meta-narratives
• Sukhera et al. followed those standards in their paper. They searched for literature in a broad set of databases so that they would capture the breadth of literature on the IAT but only included in their review those papers that described the IAT as part of or related to an educational activity. After removing duplicates, and screening for applicability to the research question, 38 articles were included in this review.
• Analysis started by focusing on the main goals, aims of the study, the research design, setting, the type of bias studied, and how the IAT was used in relation to the educational activity. The authors also tracked citations and references in the papers to trace how the IAT was used to build an understanding of how research unfolded from previous work.

Key Outcomes

• The results from this meta-narrative review are fascinating. The IAT was used in two different ways: to measure an individual’s implicit bias, or to encourage discussion and reflection
• When the IAT was used to measure bias, the test was used to calculate the degree of implicit bias in relation to a specific educational intervention. In most of these studies, the IAT was given before and then after the educational intervention. If a decrease in implicit bias was revealed, the intervention was deemed a success. Now, interestingly, only 5 of the 24 articles demonstrated a significant change in implicit attitudes after the intervention, and 10 clearly demonstrated so significant change at all. In these studies, the IAT was like a gauge that objectively measured the TRUE existence of a person’s implicit biases. Here, implicit bias is conceived of as an observable phenomenon that can be measured and it can be changed through education. So this has positivist underpinnings
• In contrast, when the IAT was used to stimulate reflection and discussion, the test was often used to demonstrate bias before the start of a learning activity or as a way of framing an understanding of implicit bias. Sometimes the IAT was used to enhance participants’ knowledge about implicit bias, and enhance the design of the intervention. Most of these studies coupled the IAT with facilitated discussion and debriefing. These studies delved deeper into how implicit bias influences an individual’s thinking, behavior and emotions. They used the IAT to help identify strategies to reduce implicit bias, while ALSO drawing attention to systemic and pervasive injustices faced by marginalized or underserved populations. These studies are underpinned by interpretivist or critical theory orientations that emphasize the varying interpretations and implications of implicit bias for the individual, while also highlighting the broader power relations involved in society.

Key Conclusions

• The authors conclude that we must analyze the assumptions underpinning our use of the IAT before implementing it.
• The authors ask: What are the implications of these two ways of thinking about and using the IAT? Are they complementary or are they competing? Can we use it to do both?

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