Is physician implicit bias associated with differences in care by patient race for metastatic cancer-related pain?

Kevin Fiscella,Jennifer J Griggs,Mary M Marshall,Ronald M Epstein,Cleveland G Shields,Juan F Orueta

doi:10.1371/journal.pone.0257794

Abstract

RationaleImplicit racial bias affects many human interactions including patient-physician encounters. Its impact, however, varies between studies. We assessed the effects of physician implicit, racial bias on their management of cancer-related pain using a randomized field experiment.MethodsWe conducted an analysis of a randomized field experiment between 2012 and 2016 with 96 primary care physicians and oncologists using unannounced, Black and White standardized patients (SPs)who reported uncontrolled bone pain from metastatic lung cancer. We assessed implicit bias using a pain-adaptation of the race Implicit Association Test. We assessed clinical care by reviewing medical records and prescriptions, and we assessed communication from coded transcripts and covert audiotapes of the unannounced standardized patient office visits. We assessed effects of interactions of physicians’ implicit bias and SP race with clinical care and communication outcomes. We conducted a slopes analysis to examine the nature of significant interactions.ResultsAs hypothesized, physicians with greater implicit bias provided lower quality care to Black SPs, including fewer renewals for an indicated opioid prescription and less patient-centered pain communication, but similar routine pain assessment. In contrast to our other hypotheses, physician implicit bias did not interact with SP race for prognostic communication or verbal dominance. Analysis of the slopes for the cross-over interactions showed that greater physician bias was manifested by more frequent opioid prescribing and greater discussion of pain for White SPs and slightly less frequent prescribing and pain talk for Black SPs with the opposite effect among physicians with lower implicit bias. Findings are limited by use of an unvalidated, pain-adapted IAT.ConclusionUsing SP methodology, physicians’ implicit bias was associated with clinically meaningful, racial differences in management of uncontrolled pain related to metastatic lung cancer. There is favorable treatment of White or Black SPs, depending on the level of implicit bias.

Highlights

There is evidence that implicit racial bias affects many human interactions including patientphysician encounters [1]
University of Rochester Office of Human Subject Protection will require that shared data associated with the publication be restricted to broad age categories (55 years) and all data be stripped of race, ethnicity, specialty and study site identifier
We conducted an analysis of a randomized field experiment in 2012 through 2016 on the association of physician implicit attitudes on care provided to Black and White patients

Summary

Introduction

There is evidence that implicit racial bias affects many human interactions including patientphysician encounters [1]. Implicit bias may undermine health care provided to minority patients [2,3]. These effects may be mediated through verbal and non-verbal communication and clinical decision-making [3]. Studies of physician implicit bias involving experimental vignette studies have often shown no effect on clinical decisions [9]. With the exception of audit studies for new patient appointments [11], we are not aware of real world experimental studies involving Black and White SPs; such studies have been used to assess racial bias outside of health care, for example, in hiring decisions [12,13]

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