[Skip to Content]
[Skip to Content Landing]

Estimating Implicit and Explicit Gender Bias Among Health Care Professionals and Surgeons

Educational Objective
To understand the presence and extent of implicit bias among health professionals
1 Credit CME
Key Points

Question  Do surgeons and health care professionals hold implicit or explicit biases regarding gender and career roles?

Findings  A review of 42 991 Implicit Association Test records and a cross-sectional study of 131 surgeons provided evidence of implicit and explicit gender bias. Data suggest that health care professionals and surgeons hold implicit and explicit biases associating men with careers and surgery and women with family and family medicine.

Meaning  This work contributes an estimate of the extent of implicit gender bias within medicine; awareness of bias, such as through an Implicit Association Test, is an important first step toward minimizing its potential effect.


Importance  The Implicit Association Test (IAT) is a validated tool used to measure implicit biases, which are mental associations shaped by one’s environment that influence interactions with others. Direct evidence of implicit gender biases about women in medicine has yet not been reported, but existing evidence is suggestive of subtle or hidden biases that affect women in medicine.

Objectives  To use data from IATs to assess (1) how health care professionals associate men and women with career and family and (2) how surgeons associate men and women with surgery and family medicine.

Design, Setting, and Participants  This data review and cross-sectional study collected data from January 1, 2006, through December 31, 2017, from self-identified health care professionals taking the Gender-Career IAT hosted by Project Implicit to explore bias among self-identified health care professionals. A novel Gender-Specialty IAT was also tested at a national surgical meeting in October 2017. All health care professionals who completed the Gender-Career IAT were eligible for the first analysis. Surgeons of any age, gender, title, and country of origin at the meeting were eligible to participate in the second analysis. Data were analyzed from January 1, 2018, through March 31, 2019.

Main Outcomes and Measures  Measure of implicit bias derived from reaction times on the IATs and a measure of explicit bias asked directly to participants.

Results  Almost 1 million IAT records from Project Implicit were reviewed, and 131 surgeons (64.9% men; mean [SD] age, 42.3 [11.5] years) were recruited to complete the Gender-Specialty IAT. Healthcare professionals (n = 42 991; 82.0% women; mean [SD] age, 32.7 [11.8] years) held implicit (mean [SD] D score, 0.41 [0.36]; Cohen d = 1.14) and explicit (mean [SD], 1.43 [1.85]; Cohen d = 0.77) biases associating men with career and women with family. Similarly, surgeons implicitly (mean [SD] D score, 0.28 [0.37]; Cohen d = 0.76) and explicitly (men: mean [SD], 1.27 [0.39]; Cohen d = 0.93; women: mean [SD], 0.73 [0.35]; Cohen d = 0.53) associated men with surgery and women with family medicine. There was broad evidence of consensus across social groups in implicit and explicit biases with one exception. Women in healthcare (mean [SD], 1.43 [1.86]; Cohen d = 0.77) and surgery (mean [SD], 0.73 [0.35]; Cohen d = 0.53) were less likely than men to explicitly associate men with career (B coefficient, −0.10; 95% CI, −0.15 to −0.04; P < .001) and surgery (B coefficient, −0.67; 95% CI, −1.21 to −0.13; P = .001) and women with family and family medicine.

Conclusions and Relevance  The main contribution of this work is an estimate of the extent of implicit gender bias within surgery. On both the Gender-Career IAT and the novel Gender-Specialty IAT, respondents had a tendency to associate men with career and surgery and women with family and family medicine. Awareness of the existence of implicit biases is an important first step toward minimizing their potential effect.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: May 15, 2019.

Published: July 5, 2019. doi:10.1001/jamanetworkopen.2019.6545

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Salles A et al. JAMA Network Open.

Corresponding Author: Arghavan Salles, MD, PhD, Section of Minimally Invasive Surgery, Department of Surgery, Washington University in St Louis, 4901 S Euclid Ave, Ste 920, St Louis, MO 63108 (sallesa@wustl.edu).

Author Contributions: Drs Salles and Lai had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Salles, Awad, Goldin, Lai.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Salles, Goldin, Lai.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Salles, Goldin, Lai.

Administrative, technical, or material support: Salles, Lee.

Supervision: Salles, Awad.

Conflict of Interest Disclosures: Dr Salles reported receiving honoraria from Medtronic plc for consulting and speaking. Dr Lai reported serving as the director of research for Project Implicit. No other disclosures were reported.

Association of American Medical Colleges. Table 1: medical students, selected years, 1965-2015. https://www.aamc.org/download/481178/data/2015table1.pdf. Published 2015. Accessed March 1, 2018.
Association of American Medical Colleges. More women than men enrolled in US medical schools in 2017. https://news.aamc.org/press-releases/article/applicant-enrollment-2017/. Published December 18, 2017. Accessed December 20, 2017.
Association of American Medical Colleges. Table 13: US medical school faculty by sex, rank, and department, 2017. https://www.aamc.org/download/486102/data/17table13.pdf. Published 2018. Accessed February 1, 2019.
Association of American Medical Colleges. Table C: department chairs by department, sex, and race/ethnicity, 2017. https://www.aamc.org/download/486590/data/supplementaltablec.pdf. Published 2018. Accessed February 1, 2019.
Greenwald  AG, Banaji  MR.  Implicit social cognition: attitudes, self-esteem, and stereotypes.  Psychol Rev. 1995;102(1):4-27. doi:10.1037/0033-295X.102.1.4PubMedGoogle ScholarCrossref
Santry  HP, Wren  SM.  The role of unconscious bias in surgical safety and outcomes.  Surg Clin North Am. 2012;92(1):137-151. doi:10.1016/j.suc.2011.11.006PubMedGoogle ScholarCrossref
Greenwald  AG, Poehlman  TA, Uhlmann  EL, Banaji  MR.  Understanding and using the Implicit Association Test, III: meta-analysis of predictive validity.  J Pers Soc Psychol. 2009;97(1):17-41. doi:10.1037/a0015575PubMedGoogle ScholarCrossref
Dovidio  JF, Kawakami  K, Gaertner  SL.  Implicit and explicit prejudice and interracial interaction.  J Pers Soc Psychol. 2002;82(1):62-68. doi:10.1037/0022-3514.82.1.62PubMedGoogle ScholarCrossref
Files  JA, Mayer  AP, Ko  MG,  et al.  Speaker introductions at internal medicine grand rounds: forms of address reveal gender bias.  J Womens Health (Larchmt). 2017;26(5):413-419. doi:10.1089/jwh.2016.6044PubMedGoogle ScholarCrossref
Desai  T, Ali  S, Fang  X, Thompson  W, Jawa  P, Vachharajani  T.  Equal work for unequal pay: the gender reimbursement gap for healthcare providers in the United States.  Postgrad Med J. 2016;92(1092):571-575. doi:10.1136/postgradmedj-2016-134094PubMedGoogle ScholarCrossref
Silver  JK, Slocum  CS, Bank  AM,  et al.  Where are the women? the underrepresentation of women physicians among recognition award recipients from medical specialty societies.  PM R. 2017;9(8):804-815. doi:10.1016/j.pmrj.2017.06.001PubMedGoogle ScholarCrossref
Boiko  JR, Anderson  AJM, Gordon  RA.  Representation of women among academic grand rounds speakers.  JAMA Intern Med. 2017;177(5):722-724. doi:10.1001/jamainternmed.2016.9646PubMedGoogle ScholarCrossref
Moss-Racusin  CA, Dovidio  JF, Brescoll  VL, Graham  MJ, Handelsman  J.  Science faculty’s subtle gender biases favor male students.  Proc Natl Acad Sci U S A. 2012;109(41):16474-16479. doi:10.1073/pnas.1211286109PubMedGoogle ScholarCrossref
Greenwald  AG, McGhee  DE, Schwartz  JL.  Measuring individual differences in implicit cognition: the Implicit Association Test.  J Pers Soc Psychol. 1998;74(6):1464-1480. doi:10.1037/0022-3514.74.6.1464PubMedGoogle ScholarCrossref
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. doi:10.1037/0022-3514.85.2.197PubMedGoogle ScholarCrossref
Bar-Anan  Y, Nosek  BA.  A comparative investigation of seven indirect attitude measures.  Behav Res Methods. 2014;46(3):668-688. doi:10.3758/s13428-013-0410-6PubMedGoogle ScholarCrossref
Schwartz  MB, Chambliss  HON, Brownell  KD, Blair  SN, Billington  C.  Weight bias among health professionals specializing in obesity.  Obes Res. 2003;11(9):1033-1039. doi:10.1038/oby.2003.142PubMedGoogle ScholarCrossref
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. doi:10.1007/s11606-007-0258-5PubMedGoogle ScholarCrossref
Abelson  JS, Chartrand  G, Moo  TA, Moore  M, Yeo  H.  The climb to break the glass ceiling in surgery: trends in women progressing from medical school to surgical training and academic leadership from 1994 to 2015.  Am J Surg. 2016;212(4):566-572.e1. doi:10.1016/j.amjsurg.2016.06.012PubMedGoogle ScholarCrossref
Salles  A, Mueller  CM, Cohen  GL.  Exploring the relationship between stereotype perception and residents’ well-being.  J Am Coll Surg. 2016;222(1):52-58. doi:10.1016/j.jamcollsurg.2015.10.004PubMedGoogle ScholarCrossref
Project Implicit website. https://implicit.harvard.edu/implicit/. Accessed September 5, 2017.
Nosek  BA, Smyth  FL, Hansen  JJ,  et al.  Pervasiveness and correlates of implicit attitudes and stereotypes.  Eur Rev Soc Psychol. 2007;18(1):36-88. doi:10.1080/10463280701489053Google ScholarCrossref
Project Implicit Demo Website Datasets. Gender-Career IAT 2005-2018. Center for Open Science website. https://osf.io/abxq7/. Accessed December 1, 2017.
Nosek  BA, Greenwald  AG, Banaji  MR. The Implicit Association Test at age 7: a methodological and conceptual review. In: Bargh J, ed.  Social Psychology and the Unconscious: The Automaticity of Higher Mental Processes. New York, NY: Psychology Press; 2007:265-292.
Cohen  J.  A power primer.  Psychol Bull. 1992;112(1):155-159. doi:10.1037/0033-2909.112.1.155PubMedGoogle ScholarCrossref
Bergen  PC, Turnage  RH, Carrico  CJ.  Gender-related attrition in a general surgery training program.  J Surg Res. 1998;77(1):59-62. doi:10.1006/jsre.1998.5335PubMedGoogle ScholarCrossref
Lynch  G, Nieto  K, Puthenveettil  S,  et al.  Attrition rates in neurosurgery residency: analysis of 1361 consecutive residents matched from 1990 to 1999.  J Neurosurg. 2015;122(2):240-249. doi:10.3171/2014.10.JNS132436PubMedGoogle ScholarCrossref
Walker  JL, Janssen  H, Hubbard  D.  Gender differences in attrition from orthopaedic surgery residency.  J Am Med Womens Assoc (1972). 1993;48(6):182-184, 193.PubMedGoogle Scholar
Girod  S, Fassiotto  M, Grewal  D,  et al.  Reducing implicit gender leadership bias in academic medicine with an educational intervention.  Acad Med. 2016;91(8):1143-1150. doi:10.1097/ACM.0000000000001099PubMedGoogle ScholarCrossref
Hunt  V, Layton  D, Prince  S. Why diversity matters. https://www.mckinsey.com/business-functions/organization/our-insights/why-diversity-matters. Published January 2015. Accessed February 1, 2019.
Association of American Medical Colleges. Data-driven diversity and inclusion change. http://www.aamcdiversityfactsandfigures2016.org/report-section/section-2/. Published 2016. Accessed February 1, 2019.
Cooper  LA, Powe  NR. Disparities in Patient Experiences, Health Care Processes, and Outcomes: The Role of Patient-Provider Racial, Ethnic, and Language Concordance. New York, NY: Commonwealth Fund. http://citeseerx.ist.psu.edu/viewdoc/download?doi= Published July 2004. Accessed February 1, 2019.
Butler  PD, Longaker  MT, Britt  LD.  Major deficit in the number of underrepresented minority academic surgeons persists.  Ann Surg. 2008;248(5):704-711. doi:10.1097/SLA.0b013e31817f2c30PubMedGoogle ScholarCrossref
Dobbin  F, Schrage  D, Kalev  A.  Rage against the iron cage: the varied effects of bureaucratic personnel reforms on diversity.  Am Sociol Rev. 2015;80(5):1014-1044. doi:10.1177/0003122415596416Google ScholarCrossref
Monteith  MJ, Ashburn-Nardo  L, Voils  CI, Czopp  AM.  Putting the brakes on prejudice: on the development and operation of cues for control.  J Pers Soc Psychol. 2002;83(5):1029-1050. doi:10.1037/0022-3514.83.5.1029PubMedGoogle ScholarCrossref
Krivkovich  A, Robinson  K, Starikova  K, Valentino  R, Yee  L. Women in the workplace 2017. https://www.mckinsey.com/featured-insights/gender-equality/women-in-the-workplace-2017. Published October 2017. Accessed December 13, 2017.
Leslie  K, Hopf  HW, Houston  P, O’Sullivan  E.  Women, minorities, and leadership in anesthesiology: take the pledge.  Anesth Analg. 2017;124(5):1394-1396. doi:10.1213/ANE.0000000000001967PubMedGoogle ScholarCrossref
Carnes  M, Morrissey  C, Geller  SE.  Women’s health and women’s leadership in academic medicine: hitting the same glass ceiling?  J Womens Health (Larchmt). 2008;17(9):1453-1462. doi:10.1089/jwh.2007.0688PubMedGoogle ScholarCrossref
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience

Lookup An Activity


My Saved Searches

You currently have no searches saved.


My Saved Courses

You currently have no courses saved.