Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients
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Alexander R Green1, Dana R Carney, Daniel J Pallin
1The Disparities Solutions Center, Massachusetts General Hospital, Harvard Medical School, 50 Staniford Street, Suite 901, Boston, MA 02114, USA. argreen@partners.org
Context:
Studies documenting racial/ethnic disparities in health care frequently implicate physicians' unconscious biases. No study to date has measured physicians' unconscious racial bias to test whether this predicts physicians' clinical decisions.
Objective:
To test whether physicians show implicit race bias and whether the magnitude of such bias predicts thrombolysis recommendations for black and white patients with acute coronary syndromes.
Design, Setting, And Participants:
An internet-based tool comprising a clinical vignette of a patient presenting to the emergency department with an acute coronary syndrome, followed by a questionnaire and three Implicit Association Tests (IATs). Study invitations were e-mailed to all internal medicine and emergency medicine residents at four academic medical centers in Atlanta and Boston; 287 completed the study, met inclusion criteria, and were randomized to either a black or white vignette patient.
Main Outcome Measures:
IAT scores (normal continuous variable) measuring physicians' implicit race preference and perceptions of cooperativeness. Physicians' attribution of symptoms to coronary artery disease for vignette patients with randomly assigned race, and their decisions about thrombolysis. Assessment of physicians' explicit racial biases by questionnaire.
Results:
Physicians reported no explicit preference for white versus black patients or differences in perceived cooperativeness. In contrast, IATs revealed implicit preference favoring white Americans (mean IAT score = 0.36, P < .001, one-sample t test) and implicit stereotypes of black Americans as less cooperative with medical procedures (mean IAT score 0.22, P < .001), and less cooperative generally (mean IAT score 0.30, P < .001). As physicians' prowhite implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis (P = .009).
Conclusions:
This study represents the first evidence of unconscious (implicit) race bias among physicians, its dissociation from conscious (explicit) bias, and its predictive validity. Results suggest that physicians' unconscious biases may contribute to racial/ethnic disparities in use of medical procedures such as thrombolysis for myocardial infarction.
Insights
Physicians exhibit unconscious racial bias, favoring white patients. This implicit bias influences clinical decisions, impacting treatment recommendations for conditions like acute coronary syndromes, potentially widening health disparities.
Area of Science:
- Medical Ethics
- Health Disparities Research
- Psychology of Healthcare
Background:
- Racial and ethnic disparities in healthcare are often linked to physicians' unconscious biases.
- Previous research has not quantitatively assessed physicians' unconscious racial bias to determine its impact on clinical decisions.
Purpose of the Study:
- To investigate the presence of implicit race bias in physicians.
- To determine if the magnitude of implicit bias predicts thrombolysis recommendations for Black and White patients presenting with acute coronary syndromes.
Main Methods:
- An internet-based study involving clinical vignettes and Implicit Association Tests (IATs) was administered to internal medicine and emergency medicine residents.
- Participants (n=287) were randomized to vignettes featuring either a Black or White patient with acute coronary syndrome.
- IAT scores measured implicit race preference and perceived cooperativeness, alongside explicit bias assessments and thrombolysis decision-making.
Main Results:
- Physicians reported no explicit racial bias or differences in perceived patient cooperativeness.
- IATs revealed significant implicit preference for White Americans and negative stereotypes regarding Black Americans' cooperativeness.
- Increased pro-White implicit bias correlated with a higher likelihood of recommending thrombolysis for White patients and not for Black patients.
Conclusions:
- This study provides the first empirical evidence of unconscious (implicit) race bias in physicians and demonstrates its predictive validity for clinical decisions.
- The findings suggest that physicians' implicit biases, distinct from explicit biases, may contribute to racial disparities in the utilization of critical medical procedures like thrombolysis for myocardial infarction.
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