Do Physicians' Implicit Views of African Americans Affect Clinical Decision Making?

M. Norman Oliver, MD, MA; Kristen M. Wells, MPH, PhD; Jennifer A. Joy-Gaba, PhD; Carlee Beth Hawkins, MA; Brian A. Nosek, PhD


J Am Board Fam Med. 2014;27(2):177-188. 

In This Article


Patient race did not affect the decision to recommend TKR for severe OA in the clinical vignette. However, physicians demonstrated implicit pro-white bias, reported an explicit preference for white people, had beliefs that blacks were less medically cooperative than whites, and believed that subconscious biases could influence their clinical decision making.

Although our study showed no main effect for race on clinicians' decision to recommend TKR, we found a suggestive 3-way interaction. When participants were presented with the clinical vignette before the IAT or with a white patient, or both of these conditions, they were more likely not to recommend TKR. When they were presented with the IAT first and a black patient, or both of these conditions, they were more likely to recommend TKR. One possible explanation for this finding is that the clinicians in the study felt that a medically cooperative or "good" patient would be able to manage their arthritis with conservative treatment—analgesic medication and physical therapy—rather than surgery. Patients thought to be medically uncooperative or "bad" patients would not do as well with conservative therapy and, therefore, should receive a recommendation for the more aggressive surgical option.

Another possible explanation for the lack of a main effect of patient race on TKR recommendation is that the study population may be uniquely different from physicians included in prior studies. Our participants see a large proportion of black patients, with more than half of the participants reporting that 30% or more of their patients are African American. The proportion of blacks in the US population is 12%, and the proportion in the catchment area of the practices of the physicians in our study is even less. Moreover, we found that the participants who were randomly assigned the black patient believed that they would feel more comfortable and confident working with him than those who were randomly assigned the white patient. Perhaps the fact that our physician participants see such a disproportionately high number of African American patients has led to effective compensatory strategies that mitigate effects of implicit and explicit biases when treating African Americans.

Alternatively, our clinical vignette may not have been sensitive enough to detect a racial difference. It was a single scenario and may not have sufficiently captured the realities of racial bias in clinical practice to detect an effect. An additional limitation is the inability to study the effect of sex on racial differences. However, adding a female vignette would require controlling for sex bias, and our study lacked sufficient power to examine both sex and racial biases simultaneously.

Another conclusion to be drawn from this research is the role of the IAT as an educational intervention to help physicians manage implicit racial bias. In the educational debriefing that followed the study, our participants felt that unconscious biases could affect clinical decision making. They also agreed that learning about such implicit biases could improve the care they provide to their patients.