Abstract
Women and black physicians encounter workplace challenges because of their gender and race. It is unclear whether these individuals are assessed with lower patient satisfaction or confidence ratings compared with white male physicians. To examine whether physician gender and race affect participant ratings in scenarios in which physician competence is challenged. This randomized trial enrolled a geographically diverse sample of 3592 online respondents in the United States who were recruited from 2 crowdsourcing platforms: Amazon Mechanical Turk (n = 1741) and Lucid (n = 1851). A 2 × 2 factorial design for the gender and race of simulated physicians was conducted between March 9 and July 25, 2018. Participants were excluded before intervention if they were younger than 18 years, were pregnant, or had a history of cancer or abdominal surgical procedures. A clinical vignette was presented to the participant with a picture of the emergency department physician. Participants were randomly assigned to physicians with different gender and race, with 823 assigned to black women, 791 to black men, 828 to white women, and 835 to white men. A contradictory diagnosis from an online symptom checker introduced doubt about the clinical diagnosis. A composite outcome (range, 0-100, with 0 representing low patient confidence and satisfaction and 100 representing the maximum on the composite scale) measured participant (1) confidence in the physician, (2) satisfaction with care, (3) likelihood to recommend the physician, (4) trust in the physician's diagnosis, and (5) likelihood to request additional tests. Among 3277 adult participants, complete data were available for 3215 (median age, 49 years [range, 18-89 years]; 1667 [52%] female; 2433 [76%] white). No significant differences were observed in participant satisfaction and physician confidence for the white male physician control physicians (mean composite score, 66.13 [95% CI, 64.76-67.51]) compared with white female (mean composite score, 66.50 [95% CI, 65.19-67.82]), black female (mean composite score, 67.36 [95% CI, 66.03-68.69]), and black male (mean composite score, 66.96 [95% CI, 65.55-68.36]) physicians. Machine learning with bayesian additive regression trees revealed no evidence of treatment effect heterogeneity as a function of participants' race, gender, racial prejudice, or sexism. No significant differences were observed for simulated patients' evaluations of female or black physicians, suggesting that bias in favor of white male physicians is negligible in survey-based measures of patient satisfaction. ClinicalTrials.gov Identifier: NCT04190901.
Highlights
IntroductionWomen and minority group physicians have steadily become a larger proportion of the health care workforce during the past few decades.[1,2] the same groups report experiencing workplace bias from their institutions, superiors, and colleagues in the form of unfair treatment, leading to unequal compensation and career advancement.[3,4,5,6,7] They report discrimination from patients; minority group physicians experience repeated microaggressions and sometimes glaring instances of racism, with patients refusing care, whereas female physicians have reported cases of gender harassment from patients.[8,9,10,11,12] Such treatment devalues underrepresented physician groups and negatively influences their career trajectories, professional attainment, and retention in medicine.[13,14,15]Whether physicians’ experience of discrimination from patients represents occasional but offensive anecdotes or signals broader systemic bias that could influence ratings of physicians remains an open question
No significant differences were observed in participant satisfaction and physician confidence for the white male physician control physicians compared with white female, black female, and black male physicians
No significant differences were observed for simulated patients’ evaluations of female or black physicians, suggesting that bias in favor of white male physicians is negligible in survey-based measures of patient satisfaction
Summary
Women and minority group physicians have steadily become a larger proportion of the health care workforce during the past few decades.[1,2] the same groups report experiencing workplace bias from their institutions, superiors, and colleagues in the form of unfair treatment, leading to unequal compensation and career advancement.[3,4,5,6,7] They report discrimination from patients; minority group physicians experience repeated microaggressions and sometimes glaring instances of racism, with patients refusing care, whereas female physicians have reported cases of gender harassment from patients.[8,9,10,11,12] Such treatment devalues underrepresented physician groups and negatively influences their career trajectories, professional attainment, and retention in medicine.[13,14,15]Whether physicians’ experience of discrimination from patients represents occasional but offensive anecdotes or signals broader systemic bias that could influence ratings of physicians remains an open question. A meta-analysis of 45 studies,[16] mostly from the primary care setting, that pooled evaluations from more than 100 000 patients for more than 4000 physicians (one-third female) found negligible differences in patient preferences for physician gender. Some studies[23,24] have examined the benefits of racial concordance in patient-physician relationships, there is little evidence about the causal effect of a physician’s race or gender on patient-based evaluations.[23,24] It is unclear whether the discrepancy in patients’ preferences for race-concordant physicians is caused by differences in communication styles or choice of outpatient practice setting where patients have an opportunity to exercise their preferences. Average Patient Evaluation Scores on Composite Index of Primary Outcomes eTable 5. Estimated Treatment Effects on Primary Outcomes in Study 2 eTable 8. Estimated Treatment Effects on Secondary Outcomes in Study 1 eTable 10. Estimated Treatment Effects on Secondary Outcomes in Study 2 eReferences
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