Race-Based Bias as Primary Driver of Health Inequities
The Pathology of Implicit Bias in Medicine
We like to believe that good intentions are enough ~ that a caring, well-trained practitioner is, by definition, a practitioner who treats all patients equitably. The data says otherwise. Across medicine, from emergency rooms to acupuncture clinics, patients of color consistently receive less time, less pain relief, and less benefit of the doubt than white patients, even from providers who would be genuinely appalled to hear themselves described as biased. This isn’t a story about a few bad actors. It’s a story about what happens beneath conscious awareness, in the space where our intentions and our actions quietly diverge. Dayna Bowen Matthew’s Just Medicine: A Cure for Racial Inequality in American Healthcare (2015) named this gap and offered practitioners a way to begin closing it. This article takes up her work, affirms it from the front lines of clinical practice, and asks a further question:
If implicit bias operates outside conscious control, what is actually driving it?
My own work points to something underneath the intellect entirely ~ a somatic, unconscious holding pattern I call embodied racial tension (ERT) ~ and to a path for treating it that starts not in the mind, but in the body. This is the path of Internal Social Justice™.
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As a practitioner myself, I corroborate Matthew’s view that due the unconscious or implicit race based bias of individual practitioners, not exclusively systemic error, that healthcare inequities and inequalities not only exist but are one the rise. The unconscious choices and medical decision making of individual practitioners is what leads directly to inequitable access and health outcomes for patients of color.
I propose that we, as practitioners, must actively address both the systemic failure of our professional fields and actively address unconscious bias that lives within us.
Just Medicine thoroughly guides its readers to directly address just how this unconscious bias lives in our intellect. Through stereotype negation training and other pathways, Matthew does this.
Internal Social Justice™ corroborates the need for this important work, and takes it a step deeper, under the intellect and into the body. Beneath unconscious intellectual bias lives the primary causative factor ~ ERT. My work is to guide practitioners to bring consciousness to what has been hidden, to use meditative internal cultivation practices to actively unwind ERT.
If it is true the racial healthcare disparities are due to the implicit bias of individual practitioners, and Matthew’s work proves that to be true ~ and if it is true that ERT is the primary cause of implicit bias, which my work proves to be true ~ then the Internal Social Justice™ path becomes a root level treatment for racial healthcare disparities.
Through bias, the unconscious elements of ERT cause us to be less effective and more harmful in our profession. Racial healthcare disparities, in access to care, information, and education, in patient treatment, outcomes and life or death interventions, are not only our errors and poor performance, because every disparity we tolerate is a small surrender of our own humanity as healers. Elements that cause behaviors that break performance or create unusual errors are pathological. ERT, as a tension inducing internal dynamic, causes unethical medical choice-making that is dangerous for our patients, and therefore pathological.
What is the pathological pathway?
1. Moral injury and habituation
When practitioners repeatedly witness or participate in unequal care ~ undertreating pain in Black patients, dismissing symptoms in immigrant patients, spending less time with patients who don’t “advocate” fluently ~ and can’t reconcile it with their professional identity, one common psychological resolution isn’t outrage. It’s habituation. The discomfort fades not because the harm stops but because the practitioner stops registering it as harm. That numbing is the pathology: empathy becomes selectively switched off as a coping mechanism, and it tends to generalize beyond the original context.
2. Justification narratives that harden into belief
To tolerate a disparity repeatedly, people often develop explanatory stories ~ “that population doesn’t follow up,” “they have higher pain tolerance,” “cultural differences” ~ that started as post-hoc rationalizations but calcify into genuine (mis)beliefs. This is well-documented in implicit bias research: biased behavior often precedes and then reinforces biased belief, rather than the reverse.
3. Institutional diffusion of responsibility
When disparities are structural (understaffed clinics in poor neighborhoods, formulary restrictions, algorithmic risk scores calibrated on non-representative data), individual practitioners can offload moral responsibility onto “the system.” This protects the practitioner’s self-image but also severs the feedback loop that would otherwise prompt reflection or resistance ~ a kind of learned helplessness that becomes indistinguishable from indifference.
4. Burnout as an accelerant
Chronic short-staffing and time pressure ~ which themselves disproportionately affect the same overburdened, under-resourced settings where disparities are worst ~ deplete the cognitive bandwidth needed for individuated, careful judgment. Under load, people fall back on heuristics, which is a practical rule-of-thumb or mental shortcut. And heuristics are exactly where bias lives. So burnout and disparity can form a feedback loop: burnout worsens bias, biased care adds to moral distress, moral distress worsens burnout.
5. Identity protection over patient protection
Some practitioners, confronted with evidence of disparity in their own practice, experience it as a threat to their self-concept (”I’m a good doctor, therefore this can’t be bias”). Defending the self-concept can take priority over correcting the behavior ~ this is the mechanism behind why bias training alone often fails to change outcomes; it doesn’t address the identity-protective motivation.
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The through-line: what starts as an ethical failure (unequal care) becomes a psychological structure (numbing, rationalization, diffusion) that then reproduces the failure ~ and insulates the practitioner from noticing. But this isn’t only cognitive. Racial tension lives in the body as much as the mind: the clipped tone, the held breath, the subtle withdrawal of touch or eye contact, the racing pulse of unacknowledged discomfort in cross-racial encounters. These embodied reactions aren’t neutral background noise ~ they’re read, consciously or not, by the patient as distance or distrust, and they shape the practitioner’s own physiological state of guardedness or unease each time the encounter repeats. Over time, the body learns the pattern before the mind can question it, and that somatic conditioning fortifies the psychological structure, making it harder to interrupt. That’s the ‘pathological’ turn ~ it’s no longer episodic misjudgment, it’s a self-sustaining system braided through both cognition and the body.
Habituation, misbelief (bias), diffusion of responsibility, heuristics, and identity protection, are all elements of the intellectual pathology of bias and how individual actions lead to a self-sustaining system of harm. And what is driving them all from underneath? ERT. So remember, whenever there is a problem of the mind, a problem of decision making, behavior or action, there is something deeper there too. All 5 examples here are fueled by an internalized state of tension that is unconscious, yet creates an energetically constricting field of harm. This is felt by everything. This is the normalized energetic backdrop of medicine.
As Matthew further makes clear, the assumption that implicit bias operates without intention or conscious awareness and causes many healthcare practitioners to conclude that their unconscious racism is unavoidable, intractable, and beyond their control. It is not. Practitioners’ implicit bias, she argues, are malleable and responsive to the deliberate choices and influences of an individual. Furthermore, the ERT driving the implicit bias is also responsive to the creation of new patterning. And the Internal Social Justice™ pathway of healing.
This is a very important point. As well-meaning, well-intentioned practitioners of medicine ~ Western medicine, East Asian medicine (EAM), Naturopathic medicine, psychological medicine, and all other healing arts ~ begin to realize that we can actually treat this pathology, then we will begin. Many practitioners who have worked with me had previously felt overwhelmed and immobilized by the immensity of the problem. Many also had previously believed that because their clinics, patient populations, and colleagues were all white, that racial health disparities had nothing to do with them.
Where once white encapsulation kept practitioners distant or insulated from the problem and the potential solutions, Internal Social Justice™ presents this scenario as a symptom of the pathology ERT. White encapsulation isn’t an excuse for our complicity—it’s clear evidence of the work still ahead of us.
Let me illustrate the example of demographics. Here we have a situation where the majority of EAM practitioners, faculty, students, patients, and governing councils in the United States are white people. According to the NCCAOM’s 2013 Job Analysis Survey, 77% of EAM practitioners are of European descent, while 17% are of Asian descent and only 1.2% are of African descent (Ward-Cook, 2013). Most of our nation’s EAM practitioners operate within predominantly white clinical spaces, schools, and collegial circles (Ward-Cook, 2013). The majority of EAM patients in the U.S. are white women of average age 55 (Tournas, 2017). This mirrors the pattern in Western medicine, where the highest-paying positions ~ surgeons and specialists ~ remain predominantly white and male, even as diversity in the broader healthcare workforce slowly grows.
The fact that EAM ~ along with its medical profession counterparts ~ is practiced predominantly in white spaces is, in itself, pathological. Yet this reality has been so normalized that we do not even see it.
Upon examination of the symptomatology of ERT it will become clear how ERT inherently preserves and normalizes itself by remaining encapsulated in white spaces. It is this encapsulation that keeps EAM and healing arts practitioners from seeing exactly what needs to be treated within our professions.
This article has added to Dayna Bowen Matthew’s brilliant work showing that unconscious bias, more than explicit beliefs, drives practitioners’ behavior and fuels racial healthcare disparities. I have extended Matthew’s work by proposing that beneath this implicit bias lies a deeper root cause: “embodied racial tension” (ERT), a somatic and unconscious internal state carried within practitioners’ bodies as well as minds. Together we traced a “pathological pathway” through which ERT manifests itself into our professional lives ~ via moral injury and habituation, hardened justification narratives, diffusion of institutional responsibility, burnout, and identity protection ~ showing how these cognitive patterns become reinforced by embodied physical reactions (tone, breath, touch, eye contact) that patients perceive and that further entrench the cycle. Because these patterns are self-reinforcing rather than static, we can recognize they are also treatable: through meditative internal cultivation practices and the application of the Internal Social Justice™ path of healing. By directly addressing, treating, unwinding ERT, practitioners can interrupt the cycle at its somatic root rather than merely its intellectual symptoms. Given what this deeper diagnosis reveals, the invitation is clear: practitioners who are ready to move beyond intention alone are called to take up the Internal Social Justice™ path of healing, and begin the work of treating bias at its root.
Internal Social Justice™ is a reader-supported publication. To receive new posts and support my work, consider becoming a free or paid subscriber.
References
Matthew, D. B. (2015). Just Medicine: A Cure for Racial Inequality in American Healthcare. New York University Press.
Tournas, B. (2017). Patient demographics at an urban acupuncture teaching clinic. International Journal of Complementary & Alternative Medicine, 8(6), Article 00277. https://doi.org/10.15406/ijcam.2017.08.00277
Ward-Cook, K. (2013). Descriptive demographic and clinical practice profile of acupuncturists: An executive summary from the NCCAOM 2013 job analysis survey. National Certification Commission for Acupuncture and Oriental Medicine. https://www.nccaom.org/wp-content/uploads/pdf/Executive_Summary_Descriptive_Demographic_and_Clinical_Practice_Profile_NCCAOM_2013_Job_Analysis.pdf
