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An exploratory qualitative study of pharmacy student perspectives of implicit

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DOI: 10.1016/j.cptl.2023.02.006

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Research Note

An exploratory qualitative study of pharmacy student perspectives

of implicit bias in pharmacy practice
Paul Gavaza a, *, Bhaktidevi M. Rawal a, Patricia Flynn b
a
Loma Linda University School of Pharmacy, 24745 Stewart Street, Loma Linda, CA 92350, United States
b
Department of Psychology, Loma Linda University School of Behavioral Health, Department of Preventive Medicine, School of Medicine, Loma
Linda, CA 92350, United States

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Implicit biases can contribute to unfair treatment in healthcare and exacerbate
Implicit bias healthcare disparities. Little is known about the implicit biases that exist within pharmacy
Pharmacy practice and their behavioral manifestations. The purpose of this study was to explore pharmacy
Pharmacy students
student perspectives about implicit bias in pharmacy practice.
Pharmacy education
Methods: Sixty-two second-year pharmacy students attended a lecture on implicit bias in
healthcare and engaged in an assignment designed to explore their thoughts about how implicit
bias manifests or may manifest within pharmacy practice. Students' qualitative responses were
content analyzed.
Results: Students reported several examples in which implicit bias may emerge in pharmacy
practice. Various forms of potential bias were identified including bias associated with patients'
race, ethnicity, and culture, insurance/financial status, weight, age, religion, physical appearance
and language, lesbian, gay, bisexual, transgender, queer/questioning and gender identity, and
prescriptions filled. Students identified several potential implications of implicit bias in pharmacy
practice including unwelcoming non-verbal behavior on the part of providers, differences in time
devoted to interacting with patients, differences in empathy and respect, inadequate counseling,
and (un)willingness to provide services. Students also identified factors that could precipitate
biased behaviors such as fatigue, stress, burnout, and multiple demands.
Conclusions: Pharmacy students believed that implicit biases manifested in many different ways
and were potentially associated with behaviors that resulted in unequal treatment in pharmacy
practice. Future studies should explore the effectiveness of implicit bias trainings on reducing the
behavioral implications of bias in pharmacy practice.

Introduction

Implicit biases are unconscious, unintentional biases that result in a negative evaluation or judgement of another person.1 All
people have these implicit or unconscious biases that can positively or negatively influence their perceptions and behaviors.2,3 Despite
most individuals' explicit intention to treat others fairly or equally,4 people are typically unaware of these automatic negative eval­
uations that often lead to prejudiced or discriminatory behaviors.5–7
Research indicates that most healthcare professionals (HCPs) have implicit biases that may contribute to unintended prejudice and

* Corresponding author.
E-mail addresses: pgavaza@llu.edu (P. Gavaza), brawal@students.llu.edu (B.M. Rawal), pflynn@llu.edu (P. Flynn).

https://doi.org/10.1016/j.cptl.2023.02.006

1877-1297/© 2023 Elsevier Inc. All rights reserved.

Please cite this article as: Paul Gavaza et al., Currents in Pharmacy Teaching and Learning, https://doi.org/10.1016/j.cptl.2023.02.006
P. Gavaza et al. Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx

discriminatory behaviors towards patients during patient care.4,8 A previous study found that physicians were less likely to refer
women and Black patients with chest pain for cardiac catheterization than men and White patients after controlling for other important
factors, suggesting the role of bias on the part of physicians.9 In another landmark study, Green et al10 found that physicians' decisions
to give thrombolysis to White or Black patients was strongly associated with their implicit biases. HCPs' biases and prejudices have
been reported to contribute towards differences in quality of care.11 HCPs' implicit biases against vulnerable or disadvantaged groups
may exacerbate existing health and healthcare disparities.4 For example, the Agency for Healthcare Quality and Research found that
through 2013, American Indian/Alaska Native, Black, and Hispanic patients received worse care than White patients on 40% of the
quality measures assessed.12
Several studies have reported on implicit bias among healthcare trainees, mostly among medical and nursing professional
students.13–16 These studies typically utilized the implicit association test (IAT), a validated tool that is widely used to measure implicit
bias.17 The IAT measures how quickly respondents pair groups (e.g., White persons vs. Black persons) with negative or positive at­
tributes (e.g., good vs. bad) or stereotypes.17 IAT scores indicate the extent to which one has an implicit preference for one group (e.g.,
White persons) over another (e.g., Black persons).18 The IAT has been used to assess several kinds of implicit biases including race
(White vs. Black), skin tone (dark vs. light skin), and ethnicity (Hispanic vs. White) with medical and nursing students.16,19
A limited number of studies have investigated implicit bias among pharmacy students.16,19,20 Findings from these few studies
revealed that much like research with medical and nursing students, pharmacy students also have some level of preference for White
vs. Black persons and individuals with light vs. dark skin. More recently, the IAT has been used as a tool in implicit bias workshops to
help learners become more aware of their implicit biases.19 Most of these curricular interventions focus on using the race IAT with less
attention given to the other forms of implicit bias. Attributes like one's ethnicity, race, gender, weight, age, disability, sexual orien­
tation, medical condition, or others could trigger an implicit bias. Hence, it remains important to explore these other forms of implicit
bias that healthcare trainees, and in particular pharmacy students, perceive as potential barriers to providing quality healthcare.
Furthermore, identifying pharmacy students' understanding of the implications of implicit bias for pharmacy practice could provide
educators with valuable information for future efforts aimed at mitigating bias in pharmacy practice.

Objectives

The aim of this qualitative study was to explore pharmacy students' perspectives about and experiences with implicit bias in
pharmacy practice following a didactic lecture introducing the role of implicit bias in healthcare. Specifically, objectives of this study
were (1) to identify the types of implicit biases that pharmacy students believe exist in pharmacy practice and (2) to understand
pharmacy students' perspectives concerning how implicit biases behaviorally manifest in pharmacy practice.

Methods

Implicit bias didactic lecture and assignment

Sixty-two second-year pharmacy students from Loma Linda University School of Pharmacy were enrolled in a required three-credit
unit course Social and Behavioral Aspects of Pharmacy during Spring 2021. Loma Linda University is a private university in Southern
California offering a four-year doctor of pharmacy degree program. The goal of this course is to prepare students to understand the
application of theories of health behavior to pharmacy problems and situations, key determinants of patient health behaviors, and how
to optimize patient health outcomes based on health behavior change. Furthermore, this course highlights several factors that affect
patient behaviors and subsequent health outcomes including cultural competence and health disparities, among others.
Consistent with the course objectives, a health psychology professor with expertise in implicit bias was invited to give a 90-min
guest lecture on the role of implicit bias in healthcare. The lecture was titled, “Implicit Bias: Causes, Consequences, and Solutions
for Healthcare” and was delivered synchronously via Zoom (Zoom). The didactic lecture covered aspects of implicit bias in healthcare,
broadly, without making specific reference to pharmacy practice. The guest lecturer described implicit and explicit bias, cognitive
processing errors, neuroscientific evidence for racial in-group bias, consequence and impact of implicit bias in healthcare settings, and
evidence-based strategies to combat implicit bias from the field of social psychology. During the didactic lecture students participated
in two active-learning activities consisting of one guided imagery exercise (e.g., conjure an image of an individual based on limited
information) and one race IAT.
Following the lecture, students responded to an open-ended question designed to elicit their thoughts, experiences, and under­
standing of implicit bias in pharmacy practice. The purpose of this assignment was to have students apply what they learned from the
general lecture on implicit bias in healthcare to better understand how they perceived implicit bias to manifest in pharmacy practice.
To this end, the pharmacy students were asked to “describe two scenarios or examples whereby implicit bias manifests (or may
manifest) in pharmacy practice.”
Students provided their written response via Canvas (Instructure, Inc.) as part of a larger assignment that included a total of 18
questions. Students were given 40 min for the assignment, and they received full credit for responding to the implicit bias item. It
should be noted that all students had prior clinical experience shadowing pharmacists and working in pharmacy practice through
enrollment in three introductory pharmacy practice experiences (IPPEs). IPPE Community 1 was once a week for 14 weeks, IPPE
Institutional 1 was once a week for 7 weeks, and IPPE Community 2 was daily for two consecutive weeks and specifically focused on
the Pharmacists' Patient Care Process.21

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Data analysis

Institutional review board approval was obtained to retrospectively content analyze students' responses to the implicit bias item
after the course ended. Participant responses to the question were downloaded from ExamSoft (Turnitin) to an Excel, version 2010
(Microsoft Corp.) worksheet. The de-identified data were then uploaded to NVivo, version 12 (QSR International), a qualitative
software program for content analysis. Two independent coders (PG and BR) initially read all responses to the assignment to identify
overarching themes from the data. Then a codebook was developed to represent these overarching themes and subthemes. The
codebook was subsequently used by the two coders to independently code all of the students' written responses. Consensus meetings
were held between the two coders to ensure coding consistency and resolve any coding disagreements. The inter-rater reliability of the
two coders was 96.4%. Once all student responses were coded, frequencies were computed for each code. The reported frequencies
represent the number of times the participants reported the identified code. The study adhered to the criteria established by the
standards for reporting qualitative research.22

Results

A total of 62 responses were included in the analysis. The majority of responses (68%) were from female pharmacy students. The
racial background of the students was as follows: Asian 34%, Hispanic/Latino 21%, non-Latino White/Caucasian 19%, Middle Eastern
15%, and Black 11%. There were four overarching categories that emerged from the data (see Table 1). Student reflections revealed
that they believed (1) pharmacists and pharmacy staff may have many different types of biases, (2) there are a variety of potential
behavioral and cognitive implications of implicit bias in pharmacy practice, (3) implicit bias against pharmacists and pharmacy staff,
and (4) there are factors that may precipitate biased behaviors. Results from the content analyses are presented in the Table 1.

Biases that pharmacy students believe exist in pharmacy practice

There were eight different types of biases that students believed occurred in pharmacy practice (see Table 1).

Race, ethnicity, culture

Several pharmacy students indicated that implicit biases based on patients' race, ethnicity, and culture exist in pharmacy practice
(n = 34). Some students believed that patients from racial and ethnic minority backgrounds were treated differently as a result. For

Table 1
Overarching Themes and Subthemes that Emerged from Students' Reflections on Bias in Pharmacy Practice (N = 130 responses).
Overarching Themes and Subthemes Examples # of Responses
(%)

1. Pharmacists and pharmacy staff may have [79, 60.8]

many types of biases
a. Race/ethnicity & culture Black and Hispanic patients being treated poorly than White patients. 34 (26.2)
b. Physical appearance and language Patients treated differently because of how they look and dress. 14 (10.8)
c. Weight Having negative attitudes towards and passing judgement on overweight or obese 10 (7.7)
patients.
d. LGBTQ and gender identify Preference for patients of a certain gender. Not providing adequate counseling due 7 (5.4)
to patient's sexual orientation.
e. Religion Favoring patients who identified with the same religion as pharmacist or being 5 (3.8)
biased against those from different religious backgrounds.
f. Prescription filled Different treatment of patients filling certain types of medications (e.g., controlled 4 (3.1)
substances) and those filling many prescriptions
g. Insurance/financial status Assuming patients could not afford their medication, had no health insurance, or 3 (2.3)
were on Medicaid or Medical.
h. Age Older patients being treated differently than others. 2 (1.5)
2. Potential behavioral and cognitive implications 39 (30.0)
of bias in pharmacy practice
a. Time devoted to serving or interacting with Giving shorter consultations to some patients. 12 (9.2)
some patients
b. (Un)willingness to provide services Offering discounts, needles and pill counts to some patients but not others. 10 (7.7)
c. Inadequate counseling Differentially counseling patients based on their biases. 6 (4.6)
d. Showing different empathy and respect for Less attention and respect for some patients 4 (3.1)
patients
e. Provider non-verbal behaviors Avoiding eye contact, having withdrawn body language, and facial expressions. 4 (3.1)
f. Cognitive implications of bias Pharmacists not believing patients' pain and making assumptions about patients' 3 (2.3)
understanding of their medications.
3. Implicit bias against pharmacists and pharmacy staff Pharmacists and staff being unfairly treated at the workplace due to the implicit 7 (5.4)
biases of patients or their employers.
4. Factors that may precipitate biased behaviors Multi-tasking and being fatigued, overworked, stressed or under pressure. 5 (3.8)

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example, one student wrote “the pharmacy staff or pharmacists are extra cautious when a Black patient drops off a controlled substance
prescription compared to patients of other races.” Students also perceived that some pharmacists and pharmacy staff preferred and
prioritized patients of certain races and cultures over others. According to a student, “pharmacist's [have a] preference in assisting
Caucasian patients first before assisting people of other races,” while another student indicated “pharmacists unconsciously spend
more time counseling one ethnic group over another.”

Physical appearance and language

Several students noted that pharmacists may have biases based on the patient's physical appearance including their “look,”
clothing, dress, and the way that they speak (n = 14). For example, one student indicated that pharmacists may be “stereotyping a
person based on how they are dressed or how they speak.” Some students believed that when pharmacists had biases associated with
physical appearance, they treated their patients differently or made negative assumptions about their motivations. According to a
student, “we expect that someone who is dressed a certain way is of a certain social-economic class and treat them differently without
even knowing it.” Another student wrote that pharmacists may be “assuming that someone dressed in rags and comes in with a
controlled medication prescription is drug seeking.”

Weight
A number of students believed that patients' weight was a source of bias in pharmacy practice (n = 10). Interestingly, students noted
that both patients who were obese and patients who were physically fit were subject to implicit bias, although the latter was less
frequently reported. For the most part, students perceived that some pharmacists had negative attitudes towards overweight or obese
patients and passed judgement on them. For example, a student reported that “obese patients [are] seen as lazy and non-adherent to
medications.” On the other hand, biases associated with being physically fit were also perceived in pharmacy practice and had po­
tential negative implications. This is reflected by the following student's response, “athletic people don't get counsel[ed] on lifestyle
modifications.”

Gender and lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ) identity

Students also reported that some pharmacists may have biases based on the gender or LGBTQ identity of their patients (n = 7). For
example, students indicated that pharmacists may have an implicit bias against patients from the opposite gender as themselves or they
preferred patients of the same gender. A student wrote that pharmacists may be “spending more time with a female patient because she
is female just like me, compared to male patients without realizing it.” Biases associated with the LGBTQ community were also
identified by pharmacy students that had potential implications for their counseling behaviors. A student indicated that some phar­
macists are “not taking the time to properly counsel a transgender patient because the pharmacist does not want to offend the patient
and say the wrong pronoun.”

Religion
Religion was also perceived as a possible source of bias (n = 5). This was reflected by a student who indicated that bias in pharmacy
practice may emerge when staff are “treating patients based on their religion. This is very common in certain areas and it's not pro­
fessional.” Some students noted that these religious biases were both in favor of and against patients, which they perceived had
different implications for patient care. For example, a student noted that pharmacists may be “favoring a patient who is of the same
religion with you and [therefore] giving them better treatment,” while another student reported that “patients who are Muslim may
receive worse patient care.”

Prescriptions filled
Students indicated that some pharmacists may be biased against patients filling certain types of medications, particularly controlled
substances (n = 4). This is reflected by the following student's response, “pain medications and the stigma behind them make phar­
macists have implicit prejudice for patients who seek them.” Another student indicated that “patients with controlled substance
prescriptions often face implicit bias from pharmacists deciding whether or not to fill the prescription.” Other students believed that
there may be biases against patients who filled multiple prescriptions. For example, a student indicated that some pharmacists may
believe that “because they pick up many prescriptions, they are on poor diet or they do not eat healthy.”

Insurance/financial status
Some students reported possible biases based on the type of insurance patients had and often linked this to the patient's ability to
pay for their medications (n = 3). For example, a student reported that pharmacists may be “assuming a person on Medi-Cal cannot pay
any part of a copay.” Another student's response highlighted a different assumption pharmacists may be making about their patients'
insurance status, stating “if an individual is on Medi-Cal/Medicaid they are poor or from a disadvantaged area or are getting gov­
ernment benefits.” Another student pointed out the possible intersection between race and insurance status with the following quote,
“unfortunately, race bias affects what a pharmacist subconsciously believes about a patient's insurance and ability to pay for
medication.”

Age
Some students also reported age as a possible source of bias in pharmacy practice (n = 2). Specifically, students noted that older
patients are sometimes treated differently than others, particularly when it came to counseling. A student reported that some

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pharmacists perceived that “old people won't remember all the counseling information that pharmacists give, so they give them a very
short consultation.”

Potential behavioral and cognitive implications of implicit bias in pharmacy practice

Students described how these various types of biases had potential negative behavioral and cognitive implications for pharmacy
practice and patient care (n = 39, see Table 1).

Time devoted to serving or interacting with some patients

Several students shared that biases could influence the amount of time that pharmacists devote to counseling patients on medi­
cation regimens (n = 12). For the most part, students indicated that these biases resulted in less time performing these key duties. A
student noted that there may be “shorter counseling time with Black patients vs. White patients because the pharmacists think that
Black patients are non-compliant.” At the same time, some students noted that pharmacists may spend more time with a patient who
they share similarities with. For example, a student reported that “you take more time as a pharmacist to counsel people who look like
you or can relate to you.”

(Un)willingness to offer or provide services

Students shared that some pharmacists may not help patients to the degree necessary because of potential biases (n = 10). For
example, a student wrote that some pharmacists may not be counseling homeless patients “due to most of them refusing service, we
assume that they do not need it when they actually need to be counseled.” At the same time, students indicated that services were
sometimes being offered when they may not be needed. A student pointed out that Hispanic looking patients may experience bias as
illustrated in the following statement, “without asking them [Hispanic looking patients] how may we be of service, we just saying
immediately, ‘hold on, let me get the translator.’“ Several students indicated that some pharmacists and pharmacy staff may selectively
offer discounts, pill counts, messaging services, vaccines, prescription recommendations, and needles to certain types of patients. Some
notable examples include “choosing to give vaccines only to patients who you are more familiar with at your pharmacy and allowing
your interns to give the vaccines to all other people,” and “going above and beyond and finding discounts for medications for those of
the same race as me but not doing the same for others.”

Inadequate counseling
Students reported that pharmacists and pharmacy staff may not offer adequate counseling on medication to some patients due to
biases (n = 6). A student reported that some pharmacists may be “hesitant to give full service to someone in an ‘out group,’ such as a
member of another ethnic group.” Another student indicated that bias may occur when pharmacists are “giving inadequate counseling
on medication to people that might not understand anyway.”

Provider non-verbal behaviors

Students shared that implicit biases could also manifest through the non-verbal behaviors of providers as reflected in their body
language, facial expressions, and eye contact (n = 4). For the most part students noted that these non-verbal behaviors were less
inviting with certain patients. For example, a student wrote that some pharmacists may be “showing a withdrawn body language with
overweight patients,” and another indicated that pharmacists may be “avoiding eye contact with minority patients while working.”
Students also discussed the pharmacists' warm and inviting non-verbal behaviors that occurred when interacting with a patient of the
same race, “[pharmacists] exhibit more open body language and spend more time counseling more thoroughly compared to typical
patients.”

Showing different empathy and respect for patients

Some students reported that pharmacists may give some patients less respect or attention (n = 4). A student indicated that when a
“homeless person comes in the pharmacy, they will receive less attention or less respect compared to normal or higher-class people.”
Students also shared that some pharmacists may exhibit “more empathy for a patient in pain who is of the same ingroup,” but gave
those in the out group “shorter and less empathetic consultations.”

Cognitive implications of bias

Some students reported that pharmacist and pharmacy staff may not always believe a minority patient's pain and made assumptions
about patients' ability to understand their medication regimen based on race or ethnicity (n = 3).

Implicit bias against pharmacists and pharmacy staff

Students also described scenarios whereby pharmacists and staff were unfairly treated by their employers, potentially due to their
implicit biases (n = 7, see Table 1). A student reported that biases “could be in the hiring processes. Not hiring people who belong to a
specific race. Unfortunately, I encountered that while looking for a job. HR (human resources) prefers hiring White people.” Another
student indicated that bias could occur when the “pharmacy manager/owner is giving women a lower salary wage compared to men.”
Some students reported that patients may also have biases which resulted in unfair preferences and assumptions about pharmacists.
One student indicated that patients assumed that the “Black pharmacist is a technician instead of the pharmacist,” while another

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student indicated that “people want the male pharmacist instead of a woman pharmacist.”

Factors that precipitate biased behaviors

A few students also shared factors that they believed exacerbated behaviors associated with implicit bias in pharmacy practice (n =
5, see Table 1). This included being fatigued and overloaded with tasks. Students wrote that bias may occur when “a pharmacist is
fatigued and worked a 12-hour day yesterday” and when “we have a high cognitive load (stressed, pressured, etc.).”

Discussion

Implicit bias is a phenomenon of interest in the pharmacy profession, yet it has been largely understudied in the context of
pharmacy practice. The present study identified several types of implicit bias that second-year pharmacy students believe existed or
may exist in pharmacy practice. This research also revealed rich insight concerning pharmacy students' awareness and understanding
of the negative behavioral and cognitive implications of implicit bias specific to pharmacy practice as well as the situations within
pharmacy practice that may exacerbate the impact of bias on clinical care. Furthermore, according to the perspective of pharmacy
students, the implications of implicit bias are not only experienced by patients especially from marginalized backgrounds but also by
pharmacists and staff from similar backgrounds. Findings from this study could provide important information necessary for the
development of effective implicit bias training programs specific to the needs and experiences of pharmacy students. This could in turn
contribute to reducing the impact of implicit bias in the clinical care of pharmacy patients. The second-year pharmacy students from
the present study, who shadow pharmacists and some of whom work as pharmacy interns, believed that some pharmacists and
pharmacy staff had implicit biases based on differing patient characteristics. These included implicit biases based on race, ethnicity,
culture, weight, age, religion, physical appearance, prescriptions, sexual orientation, gender identity, and financial status. Much of the
previous literature on implicit bias among pharmacists and pharmacy trainees has focused on race and skin tone bias.16,19,20 The
present study extends this body of work to describe a wider range of biases that may exist in pharmacy practice. Findings concerning
the identification of biases associated with physical appearance, patient prescriptions, and religious beliefs are of particular interest to
pharmacy practice and the broader medical field. To the best of our knowledge, these forms of bias have not been previously identified
among pharmacists and are also not widely researched among other HCPs. An important first step towards addressing one's implicit
biases is awareness,1 because you cannot fix a problem that you do not know you have. Considering that many pharmacy students are
not aware of their implicit biases and some are surprised to learn of them,19,23 it is particularly important that curricula designed to
enhance students' awareness of their own biases highlights the various potential forms or types of bias. To this end, pharmacy students
and other HCPs could greatly benefit from taking multiple IATs posted on the Project Implicit website (www.implicit.harvard.edu).
Furthermore, the present study findings concerning the various types of bias that were identified as relevant to pharmacy practice
could subsequently be used by pharmacy educators to develop realistic clinical vignettes when teaching about implicit bias.
There were several potential behavioral implications of implicit bias in pharmacy practice that were identified in the present study.
For example, students reported that pharmacists and pharmacy staff may unconsciously and unintentionally exhibit less empathy and
respect for some patients, devote less time to serving or interacting with certain patients, and provide poorer overall quality of care as
reflected by differential or inadequate counseling behaviors to certain patients. These findings are largely consistent with findings from
implicit bias research conducted with physicians and other medical professionals.4,24–28 For example, quantitative research reveals
that physicians with higher as compared to lower levels of implicit race bias based on the IAT have less affiliative feelings,24,25 shorter
clinical visits, and worse communication with their Black patients.4,26–28 Racial/ethnic minority populations also report that they are
treated with less respect and receive worse care than patients of other races.29 Consistent with the medical literature,30,31 it may be that
the perceived lower pharmacist expressions of warmth, empathy and respect for their patients could result in poorer patient-
pharmacist relationships, reduced patient satisfaction, and worse patient adherence to pharmaceutical recommendations.
As noted above, many of the implications of possible implicit bias identified by pharmacy students in the present study have
potential consequences for the pharmacist-patient relationship, communication, and interpersonal quality of care. In addition, some
students recognized that implicit bias may also affect pharmacists' willingness to provide pharmacy services and products to certain
patient populations. Many of the examples provided by the students are unique to pharmacy practice. For example, students indicated
that pharmacists' implicit biases may impact their willingness to offer pill counts, coupons, messaging services, vaccines, and needles.
These are all important tangible services that should be equitably provided to patients regardless of the race, ethnicity, gender, or other
patient characteristics that may differ from the pharmacist. This particular finding highlights the structural inequalities that certain
patient populations experience in accessing pharmaceutical products and care that may result from pharmacist bias.
The identified behavioral and structural implications of implicit bias may ultimately manifest as experiences of healthcare
mistreatment or discrimination for certain patient populations and exacerbate health disparities. In fact, research reveals that when
ethnic minority and low socio-economic status patients feel mistreated in healthcare (e.g. lack of respect, empathy) they are more
likely to avoid medical care, delay necessary exams, be less adherent to providers' recommendations, and have poor clinical out­
comes.32–34 Fortunately, research also reveals that when patients perceive their providers to be empathic and culturally competent,
they are less likely to avoid medical care and more likely to adhere to provider recommendations.35–37 Given the similarity between the
medical literature on implicit bias and the present study findings relevant to pharmacy practice, it is likely that interventions designed
to improve the empathy and cultural competence of pharmacists and pharmacy students could help tackle the noted implicit biases in
pharmacy practice and provide similar beneficial outcomes for patients.
This research also identified a number of situations within pharmacy practice that may exacerbate the behavioral ramifications of

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implicit bias such as pharmacist fatigue and overwork. The retail pharmacy working environment is characterized by time pressures,
stress, competing demands, and clinically ambiguous situations (e.g., pain management and assessment), all of which may increase
pharmacists' susceptibility to the behavioral manifestations of bias when interacting with patients different from themselves. Previous
studies have found that similar features in the healthcare setting such as fatigue, pressure, limited time, and increased cognitive load
may lead to biases in medical decision making.38,39 In fact, a previous study conducted with emergency department physicians found
that overcrowding and patient load were associated with increased physician bias.40 Collectively, these findings suggest the need for
policies that protect pharmacists' work conditions in order to create an environment that shields patients from unfair treatment
associated with pharmacist bias. At the same time, pharmacists and students could be taught skills such as mindfulness and stress
reduction techniques to help manage difficult work situations and conditions.
The following limitations should be considered when interpreting the study findings. First, this study included second year
pharmacy students from a private religious university in a culturally diverse region of Southern California. As such, participants re­
flected a highly diverse population of pharmacy students, which may not be representative of the general population of pharmacy
students in the United States (US) or pharmacists in general. Future studies should be conducted in public schools of pharmacy as well
as with practicing pharmacists in various regions of the US to confirm these findings. Second, participants from this study attended a
general didactic lecture on implicit bias in healthcare and completed the race IAT prior to answering the open-ended question relevant
to implicit bias in pharmacy practice. As such, they may have been primed to the broad range of behavioral manifestations of implicit
bias in healthcare as well as primed to think about biases associated with race. Nevertheless, the present study revealed various types of
bias and several unique behavioral manifestations of implicit bias specific to pharmacy practice. Third, there are inherent limitations in
data obtained primarily from one open-ended question. Still, the qualitative nature of this study provided contextual richness to the
data that could not be obtained from multiple quantitative items. Fourth, given the wording of the implicit bias item, it was not
possible to identify if the biases reported by students were based on situations they witnessed in pharmacy practice or if they reflect
what students believe could occur in pharmacy practice. Fifth, it is possible that some students were responding to the question in a
desirable manner given that this was a class assignment. Students had an option to give a hypothetical example instead of a real
example if they so chose. Some students gave hypothetical examples. Sixth, the process of content coding qualitative data is subjective
in nature. Still, two researchers conducted an independent thematic analysis of the data and achieved an inter-rater reliability of 96%
suggesting strong consistency in the study findings. Finally, the pharmacy students' perspectives appeared to be largely informed by
experiences and interactions in the community/retail pharmacy setting. It is possible that these responses may overlap with inpatient,
industry, or other pharmaceutical practice settings, but these areas warrant future investigation.
Despite the noted limitations, there are several strengths of the research including the large sample size for qualitative research, the
diversity of participants in terms of race/ethnicity, and the richness that qualitative data provides in terms of understanding pharmacy
students' experiences and beliefs about implicit bias in pharmacy practice. Collectively, the study findings revealed that pharmacy
students believe there are a variety of implicit biases which impact pharmacists' clinical interactions, communication, and quality of
care. Implicit biases may contribute to patient experiences of healthcare discrimination and exacerbate health disparities resulting
from poor quality of care. Observational studies are needed to advance the present study findings and confirm the impact of implicit
bias on pharmacists' behaviors. Namely, future research could be conducted to examine the role of pharmacists' implicit bias, as
measured by the implicit association test, and test its impact on patient-pharmacist clinical interactions, communication, medication
adherence, and patient health outcomes.

Conclusions

There is a great need to address and mitigate the cognitive and behavioral manifestations of pharmacy professionals' implicit biases.
Organizations such as the Institute of Medicine and the Joint Commission have highlighted the importance of addressing implicit
biases to reduce health disparities.5 Education can go a long way through raising awareness of implicit biases and the impact that
biases have on patients.19 Cultural competence and implicit bias training and education should be required of all pharmacy students in
the didactic and experiential portions of their curriculum.19 While schools and colleges of pharmacy offer trainings aimed at mitigating
bias and microaggressions and increasing student and faculty awareness of implicit bias,6,23,41,42 such trainings should be mandatory
for all pharmacy students and professionals. Furthermore, research efforts should be directed at testing the impact of such trainings on
reducing the behavioral manifestations of implicit bias in pharmacy practice.

CRediT authorship contribution statement

Paul Gavaza: Conceptualization, Methodology, Formal analysis, Funding acquisition, Investigation, Writing – original draft,
Resources. Bhaktidevi M. Rawal: Conceptualization, Validation, Writing – review & editing. Patricia Flynn: Conceptualization,
Methodology, Validation, Writing – review & editing.

Declaration of Competing Interest

None.

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References

1 Blair IV, Steiner JF, Havranek EP. Unconscious (implicit) bias and health disparities: where do we go from here? Perm J. 2011;15(2):71–78. https://doi.org/
10.7812/tpp/11.979.
2 Greenwald AG, Banaji MR. Implicit social cognition: attitudes, self-esteem, and stereotypes. Psychol Rev. Jan 1995;102(1):4–27. https://doi.org/10.1037/0033-
295x.102.1.4.
3 Staats C, Capatosto K, Wright RA, Contractor D. State of the Science: Implicit Bias Review 2015. Kirwin Institute; 2015. Accessed 23 February 2023 https://
kirwaninstitute.osu.edu/sites/default/files/pdf/2015-implicit-bias-review.pdf.
4 FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18(1):19. https://doi.org/10.1186/s12910-017-0179-
8.
5 Arif S, Schlofeldt J. Gaps in measuring and mitigating implicit bias in healthcare. Front Pharmacol. 2021;12, 633565. https://doi.org/10.3389/
fphar.2021.633565.
6 Okorie-Awé C, Crawford SY, Sharp LK, Jaki BU, Kachlic MD. A faculty and staff workshop on microaggression and implicit bias: knowledge and awareness of
student, faculty, and staff experiences. Curr Pharm Teach Learn. 2021;13(9):1200–1209. https://doi.org/10.1016/j.cptl.2021.06.031.
7 Hagiwara N, Kron FW, Scerbo MW, Watson GS. A call for grounding implicit bias training in clinical and translational frameworks. Lancet. 2020;395(10234):
1457–1460. https://doi.org/10.1016/S0140-6736(20)30846-1.
8 Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review.
Am J Public Health. 2015;105(12):e60–e76. https://doi.org/10.2105/AJPH.2015.302903.
9 Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians’ recommendations for cardiac catheterization. N Engl J Med. 1999;340(8):
618–626. https://doi.org/10.1056/NEJM199902253400806.
10 Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med.
2007;22(9):1231–1238. https://doi.org/10.1007/s11606-007-0258-5.
11 Institute of Medicine. In the Nation's Compelling Interest: Ensuring Diversity in the Health-Care Workforce. National Academies Press; 2004. https://doi.org/10.17226/
10885.
12 2015 National Healthcare Quality and disparities report and 5th anniversary update on the National Quality Strategy. Agency for Healthcare Research and Quality; May
2016. Reviewed June 2018. Accessed 23 February 2023 https://archive.ahrq.gov/research/findings/nhqrdr/nhqdr15/quality.html.
13 Byrne A, Tanesini A. Instilling new habits: addressing implicit bias in healthcare professionals. Adv Health Sci Educ Theory Pract. 2015;20(5):1255–1262. https://
doi.org/10.1007/s10459-015-9600-6.
14 Gonzalez CM, Kim MY, Marantz PR. Implicit bias and its relation to health disparities: a teaching program and survey of medical students. Teach Learn Med. 2014;
26(1):64–71. https://doi.org/10.1080/10401334.2013.857341.
15 Hernandez RA, Haidet P, Gill AC, Teal CR. Fostering students’ reflection about bias in healthcare: cognitive dissonance and the role of personal and normative
standards. Med Teach. 2013;35(4):e1082–e1089. https://doi.org/10.3109/0142159X.2012.733453.
16 White-Means S, Dong Z, Hufstader M, Brown LT. Cultural competency, race, and skin tone bias among pharmacy, nursing, and medical students: implications for
addressing health disparities. Med Care Res Rev. 2009;66(4):436–455. https://doi.org/10.1177/1077558709333995.
17 Greenwald AG, McGhee DE, Schwartz JL. Measuring individual differences in implicit cognition: the implicit association test. P Pers Soc Psychol. 1998;74(6):
1464–1480. https://doi.org/10.1037//0022-3514.74.6.1464.
18 Greenwald AG, Nosek BA, Banaji MR. Understanding and using the implicit association test: I. an improved scoring algorithm. J Pers Soc Psychol. 2003;85(2):
197–216. https://doi.org/10.1037/0022-3514.85.2.197.
19 Avant ND, Weed E, Connelly C, Hincapie AL, Penm J. Qualitative analysis of student pharmacists’ reflections of Harvard’s race implicit association test. Curr
Pharm Teach Learn. 2018;10(5):611–617. https://doi.org/10.1016/j.cptl.2018.02.002.
20 Collins JC, MacKenzie M, Schneider CR, Chaar BB, Moles RJ. A mixed-method simulated patient approach to explore implicit bias in health care: a feasibility study
in community pharmacy. Res Soc Adm Pharm. 2021;17(3):553–559. https://doi.org/10.1016/j.sapharm.2020.05.003.
21 The Pharmacists' Patient Care Process. Joint Commission of Pharmacy Practitioners. Accessed 7 October 2022 https://jcpp.net/patient-care-process/; 29 May
2014.
22 O’Brien BC, Harris IB, Beckman TJ, Reed DA, Cook DA. Standards for reporting qualitative research: a synthesis of recommendations. Acad Med. 2014;89(9):
1245–1251. https://doi.org/10.1097/ACM.0000000000000388.
23 Prasad-Reddy L, Fina P, Kerner D, Daisy-Bell B. The impact of implicit biases in pharmacy education. Am J Pharm Educ. 2022;86(1):8518. https://doi.org/
10.5688/ajpe8518.
24 van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians’ perceptions of patients. Soc Sci Med. 2000;50(6):813–828. https://doi.org/
10.1016/s0277-9536(99)00338-x.
25 Maina IW, Belton TD, Ginzberg S, Singh A, Johnson TJ. A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test.
Soc Sci Med. 2018;199:219–229. https://doi.org/10.1016/j.socscimed.2017.05.009.
26 Cooper LA, Roter DL, Carson KA, et al. The associations of clinicians’ implicit attitudes about race with medical visit communication and patient ratings of
interpersonal care. Am J Public Health. 2012;102(5):979–987. https://doi.org/10.2105/AJPH.2011.300558.
27 Lorié Á, Reinero DA, Phillips M, Zhang L, Riess H. Culture and nonverbal expressions of empathy in clinical settings: a systematic review. Patient Educ Couns. 2017;
100(3):411–424. https://doi.org/10.1016/j.pec.2016.09.018.
28 Dovidio JF, Fiske ST. Under the radar: how unexamined biases in decision-making processes in clinical interactions can contribute to health care disparities. Am J
Public Health. 2012;102(5):945–952. https://doi.org/10.2105/AJPH.2011.300601.
29 Johnson RL, Saha S, Arbelaez JJ, Beach MC, Cooper LA. Racial and ethnic differences in patient perceptions of bias and cultural competence in health care. J Gen
Intern Med. 2004;19(2):101–110. https://doi.org/10.1111/j.1525-1497.2004.30262.x.
30 Roter DL, Frankel RM, Hall JA, Sluyter D. The expression of emotion through nonverbal behavior in medical visits. J Gen Intern Med. 2006;21(suppl 1):28–34.
https://doi.org/10.1111/j.1525-1497.2006.00306.x.
31 Penner LA, Dovidio JF, Gonzalez R, et al. The effects of oncologist implicit racial bias in racially discordant oncology interactions. J Clin Oncol. 2016;34(24):
2874–2880. https://doi.org/10.1200/JCO.2015.66.3658.
32 Flynn PM, Betancourt H, Garberoglio C, Regts GJ, Kinworthy KM, Northington DJ. Attributions and emotions regarding health care mistreatment impact
continuity of care among Latino and Anglo American women. Cult Divers Ethn Minor Psychol. 2015;21(4):593–603. https://doi.org/10.1037/cdp0000019.
33 Betancourt H, Flynn PM, Ormseth SR. Healthcare mistreatment and continuity of cancer screening among Latino and Anglo American women in southern
California. Women Health. 2011;51(1):1–24. https://doi.org/10.1080/03630242.2011.541853.
34 Betancourt H, Flynn PM. Healthcare mistreatment and cultural beliefs impact HbA1c in patients with type 2 diabetes mellitus. Acta Investig Psicol. 2019;9(2):5–13.
https://doi.org/10.22201/fpsi.20074719e.2019.2.258.
35 Ortiz MS, Baeza-Rivera MJ, Salinas-Onate N, Flynn P, Betancourt H. Healthcare mistreatment attributed to discrimination among mapuche patients and
discontinuation of diabetes care. Article Spanish Rev Med Chil. 2016;144(10):1270–1276. https://doi.org/10.4067/s0034-98872016001000006.
36 Amador JA, Flynn PM, Betancourt H. Cultural beliefs about health professionals and perceived empathy influence continuity of cancer screening following a
negative encounter. J Behav Med. 2015;38(5):798–808. https://doi.org/10.1007/s10865-015-9646-1.
37 Flynn PM, Betancourt H, Emerson ND, Nunez EI, Nance CM. Health professional cultural competence reduces the psychological and behavioral impact of negative
healthcare encounters. Cult Divers Ethn Minor Psychol. 2020;26(3):271–279. https://doi.org/10.1037/cdp0000295.
38 Burgess DJ. Are providers more likely to contribute to healthcare disparities under high levels of cognitive load? How features of the healthcare setting may lead
to biases in medical decision making. Med Decis Mak. 2010;30(2):246–257. https://doi.org/10.1177/0272989x09341751.

8
P. Gavaza et al. Currents in Pharmacy Teaching and Learning xxx (xxxx) xxx

39 van Ryn M, Saha S. Exploring unconscious bias in disparities research and medical education. JAMA. 2011;306(9):995–996. https://doi.org/10.1001/
jama.2011.1275.
40 Johnson TJ, Hickey RW, Switzer GE, et al. The impact of cognitive stressors in the emergency department on physician implicit racial bias. Acad Emerg Med. 2016;
23(3):297–305. https://doi.org/10.1111/acem.12901.
41 Avant ND, Penm J, Hincapie AL, Huynh VW, Gillespie GL. “Not to exclude you, but…”: characterization of pharmacy student microaggressions and
recommendations for academic pharmacy. Curr Pharm Teach Learn. 2020;12(10):1171–1179. https://doi.org/10.1016/j.cptl.2020.05.007.
42 Avant ND, Gillespie GL. Pushing for health equity through structural competency and implicit bias education: a qualitative evaluation of a racial/ethnic health
disparities elective course for pharmacy learners. Curr Pharm Teach Learn. 2019;11(4):382–393. https://doi.org/10.1016/j.cptl.2019.01.013.

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