Does stress produce racialized patterns in clinical decisions? - A vignette study among physicians in Germany

Healthcare systems increasingly operate under conditions of staff shortages, time pressure, and growing economic pressures. While a growing body of research documents racialized inequalities in healthcare, less is known about how these organizational conditions shape clinical decision-making and potentially contribute to unequal treatment. Situating stress within the broader political economy of healthcare economization, this study examines whether experimentally induced stress affects physicians' clinical judgements and whether these effects differ by racialization. A quasi-experimental factorial survey design was implemented with physicians in German emergency care. Stress cues were manipulated to examine their effects on clinical decision-making for an otherwise identical BIPoC (Black, Indigenous and People of Colour) person wearing hijab versus White vignette patient. Ordinal logistic regression analyses of the 2 (stress vs. no stress) × 2 (BIPoC vs. White patient) between-subjects design, based on data from 828 physicians collected in an online survey in autumn 2023, revealed that stress was significantly associated with systematically lower assessments of disease seriousness and diagnostic likelihood of angina pectoris. Although the interaction was not statistically significant, the reduction in clinical assessments was more pronounced for the BIPoC vignette, suggesting a potentially racialized pattern in how stress shapes clinical judgement. Experimental findings are discussed alongside physicians' perceptions of resource scarcity, healthcare equity, and cost-containment policies in physician's real-life healthcare facilities. The findings highlight the importance of understanding clinical decision-making within the organizational and political-economic conditions of healthcare. Ensuring equitable access and fair treatment in healthcare requires attention to the institutional conditions under which care is delivered while simultaneously addressing structural racism within healthcare organizations.