Race, Social Class Biases Do Not Dictate Clinical Decisions

Lara C. Pullen, PhD

March 19, 2015

The decisions made by acute care surgical clinicians in a trauma center are not significantly influenced by their unconscious social and racial biases, according to a new study. Adil H. Haider, MD, MPH, from Brigham and Women's Hospital in Boston, Massachusetts, and colleagues published the results of their web-based survey online March 18 in JAMA Surgery. They designed the survey to test the hypothesis that implicit biases may affect care decisions as divergent as analgesia-prescribing habits and the management of acute myocardial infarction.

The investigators surveyed 230 physicians (general surgery, neurosurgery, otolaryngology, orthopedic surgery, anesthesia, critical care, urology, and emergency medicine) at an academic level I trauma center between December 1, 2011, and January 31, 2012. They received responses from 215 clinicians: 74 attending surgeons, 32 fellows, 86 residents, 19 interns, and 4 physicians whose level of education was undetermined.

The researchers calculated the Implicit Association Test (IAT) differential response times (D scores) for race and social class of the responding physicians. They found that the physicians had an average IAT D score for race of 0.42 (95% confidence interval, 0.37 - 0.48), which indicated a moderate preference, and an IAT D score for social class of 0.71 (95% confidence interval, 0.65 - 0.78), which indicated a strong preference. Thus, most trauma and acute care clinician respondents had implicit biases of race and social class.

Overall, the team found evidence that clinical decisions were influenced by the biases in only 3 of 27 vignettes in the survey. Examples of decisions that did appear to be influenced included being more likely to order a magnetic resonance imaging scan of the cervical spine after a motor vehicle crash if the patient with neck tenderness appeared to be of a high socioeconomic status than if the patient were of lower socioeconomic class, and being more likely to suspect a woman had pelvic inflammatory disease rather than appendicitis if she were black than white.

The authors explained the results of their survey by suggesting that the effect of implicit bias may be mitigated by the algorithmic decision-making that underlies trauma and acute care surgery. In addition, generational differences both within specific specialties and across practitioners may also mitigate the effect of implicit bias.

Although the study did not find an association between implicit race or social bias and clinical decision-making, the investigators raise the possibility that existing biases may have an effect in real-life clinical encounters. They note that their study did not evaluate physician–patient interactions.

The results from their survey provide a small, but encouraging, data point in the much larger issue of racial bias in medicine, as discussed earlier by Medscape Medical News.

The authors have disclosed no relevant financial relationships.

JAMA Surg. Published online March 18, 2015. Abstract


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