Pilot investigation into the influence of racial implicit bias on physician clinical reasoning.

Reducing Implicit Bias in Maternity Care: A Framework for Action

ContextStudies 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.ObjectiveTo 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 ParticipantsAn 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 MeasuresIAT 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.ResultsPhysicians 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).ConclusionsThis 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.

Racism in Pain Medicine: We Can and Should Do More

Racial implicit bias can contribute to health disparities through its negative influence on physician communication with Black patients. Interventions for physicians to address racial implicit bias in their clinical encounters are limited by a lack of high-fidelity (realistic) simulations to provide opportunities for skill development and practice. To describe the development and initial evaluation of a high-fidelity simulation of conditions under which physicians might be influenced by implicit racial bias. This cross-sectional study, performed on an online platform from March 1 to September 30, 2022, recruited a convenience sample of physician volunteers to pilot an educational simulation. In the simulation exercise, physicians saw a 52-year-old male standardized patient (SP) (presenting as Black or White) seeking urgent care for epigastric pain, nausea, and vomiting. The case included cognitive stressors common to clinical environments, including clinical ambiguity, stress, time constraints, and interruptions. Physicians explained their diagnosis and treatment plan to the SP, wrote an assessment and management plan, completed surveys, and took the Race Implicit Association Test (IAT) and Race Medical Cooperativeness IAT. The SPs, blinded to the purpose of the study, assessed each physician's communication using skills checklists and global rating scales. Association between physicians' IAT scores and SP race with SP ratings of communication skills. In 60 physicians (23 [38.3%] Asian, 4 [6.7%] Black, 23 [38.3%] White, and 10 [16.7%] other, including Latina/o/x, Middle Eastern, and multiracial; 31 [51.7%] female, 27 [45.0%] male, and 2 [3.3%] other), the interaction of physicians' Race IAT score and SP race was significant for overall communication (mean [SD] β = -1.29 [0.41]), all subdomains of communication (mean [SD] β = -1.17 [0.52] to -1.43 [0.59]), and overall global ratings (mean [SD] β = -1.09 [0.39]). Black SPs rated physicians lower on communication skills for a given pro-White Race IAT score than White SPs; White SP ratings increased as physicians' pro-White bias increased. In this cross-sectional study, a high-fidelity simulation calibrated with cognitive stressors common to clinical environments elicited the expected influence of racial implicit bias on physicians' communication skills. The outlined process and preliminary results can inform the development and evaluation of interventions that seek to address racial implicit bias in clinical encounters and improve physician communication with Black patients.

Postpartum Preeclampsia and Extracorporeal Membrane Oxygenation

Background: Implicit bias among clinicians is believed to contribute to health disparities. Clinicians have racial biases comparable to others in society, leading to calls for trainings in cultural awareness. However, whether such trainings improve clinician self-efficacy or reduce bias is not well known. We assessed the relationships between prior cultural awareness training, perceived efficacy in caring for African American patients, and implicit race bias. Methods: As part of a larger trial, a sample of primary care clinicians (PCPs) completed a race implicit association test (IAT) and survey regarding prior training in cultural awareness, and perceived efficacy in caring for African American patients (i.e., preparation to care for, and skill in developing positive relationships and overcoming bias). IAT d-scores measure racial implicit bias with scores &gt;+0.15 indicating “pro-White” race bias, scores &lt;-0.15 indicating “pro-Black”race bias and scores between -0.15 to +0.15 indicating “no bias”. Groups were compared using chi-squared tests for categorical variables and t-tests for continuous variables Results: Among 137 PCPs (63% female, 61% White, 51% ≤10 years in practice), 65% showed implicit pro-White race bias (mean IAT d-score = 0.34 (SD 0.44)) and 79% reported prior training in cultural awareness. Though 67% of participants felt “very prepared” to care for and 59% felt “very skilled” in developing a positive relationship with African American patients, only 26% felt “very skilled” in overcoming implicit racial bias. Prior training in cultural awareness was not associated with perceived efficacy in caring for African American patients (all p &gt;0.05). IAT scores were similar between clinicians who had training in cultural awareness and those without prior training (Mean(SD)=0.32(0.47) vs. 0.42(0.35), p=0.32). Conclusions: In this sample of PCPs, prior cultural awareness training was not associated with either implicit bias or preceived efficacy in caring for African American patients. This study suggests that cultural awareness trainings may need to be further developed and expanded to target implicit bias and improve clinician self-efficacy.

Purpose: Implicit bias contributes to health disparities through physician communication behaviors. 1 Research in clinical encounters suggests certain nonverbal and verbal communication is associated with racial implicit bias. 2 To date, there are no published simulations that can be used for teaching or assessment purposes in implicit bias recognition and management (IBRM). We developed a high-fidelity simulation 3 and adapted existing checklists and global rating scales to include communication behaviors known to be associated with racial implicit bias. 2 Approach: This case involved a 52-year-old man presenting to the urgent care center with nausea, vomiting, and epigastric pain. Epigastric pain was chosen as the clinical presentation given the demonstrated racial disparities in acute coronary syndrome (ACS). 4 Cognitive stressors included time constraints, clinical ambiguity (epigastric pain, a normal EKG, asymptomatic on exam), and an interruption from a standardized nurse. We have complete data for N = 15 physician volunteers (PV) over 3 pilots. We pursued an exploratory approach investigating the associations between racial implicit bias as measured on race and race-compliance implicit association tests (IAT) and communication skills of internal/family medicine PVs. We explored the associations between IATs and communication skills of internal/family medicine PV as rated by a highly trained SP and monitor. For each communication domain and subdomain, the mean score was computed comparing the scores on SPs that were Black vs White. Communication checklist items were rated on a 3-point scale, while the entrustment items were rated on a 4-point scale. A mean score was then computed for reach domain and subdomain, and linear regression was conducted with race of the SP and race of the Physician (model 1) as independent variables, followed by race IAT (model 2). Correlation analysis was also conducted to determine if significant relationship existed between the domain/subdomain scores and IAT scores. Outcomes: Mean IAT scores for PVs were in the neutral range. A total of 11 Black SPs/monitors and 9 White SPs/monitors rated physician skills. A significant negative relationship was found between “Elicits all patient’s concerns” item from information gathering with race IAT (r = −0.68, P = .01) and compliance IAT (r = −0.72, r = 0.02). A significant main effect was found on PV race and overall mean global entrustment scores (P = .01), with non-Black physicians receiving a higher score (m = 2.43, SD = 0.35) than Black physicians (m = 1.82, SD = 0.48) when race IAT was not included (model 1). When race IAT was included, no significant differences were found. No other significant differences were found in the other competencies. Significance: We developed a high-fidelity simulation and accompanying checklists and global rating scales that were able to elicit variability in communication skills scores among practicing PVs. A significant difference was found between the Black and non-Black physicians in their overall global entrustment scores when race IAT was not controlled for. When we controlled for race IAT scores (implicit bias impact), differences were no longer present suggesting the impact of implicit bias can be measured through the use of this case and global entrustment measures rather than communication competencies. This study suggests the use of high-fidelity simulations over vignettes may be better in understanding the impact of implicit bias in the patient experience. Medical educators implementing curricula in IBRM infrequently provide learners opportunities for skill development and practice, or assessment of those skills. 5 Our simulation provides a model for skill development in IBRM as it relates to ACS. In addition, given the racial disparities treatment decisions in ACS, this simulation is timely and relevant both for its assessment of communication behaviors associated with IBRM and for its clinical content. Next steps include finalizing simulations with community member input, revisions as informed by data analysis, and assessing medical decision making.

Implicit racial bias has been well studied in adults, including among orthopaedic surgeons, through the Implicit Association Test (IAT). Recent studies suggest implicit race bias is also present among children. Explicit racial preference has been studied in children through The Clark Doll Test since the 1930s. The purpose of this study was to determine whether implicit and explicit racial biases are present among pediatric orthopaedic patients. A prospective, cross-sectional survey was administered to pediatric orthopaedic patients aged 7 to 18 years at clinics in a tertiary pediatric hospital setting. The survey included a Clark Doll Test to determine whether pediatric patients expressed explicit bias, followed by a race IAT to determine whether pediatric patients expressed implicit bias. Preference and magnitude of implicit bias as demonstrated on the IAT was calculated using standard D-scores. A total of 96 patients were consented and included in this study. Overall, pediatric patients demonstrated a slight pro-White implicit bias (M = 0.22) on IAT testing. Pediatric patients who identified as White or European American and Hispanic or Latinx both had the strongest pro-White implicit bias (M = 0.35). Patients who identified as Black or African American demonstrated no implicit racial bias (M = -0.13) on IAT testing. No notable explicit bias was observed in participants of any racial background. This study contributes evidence that pediatric orthopaedic patients express implicit racial bias on IAT testing, with an overall slight pro-White bias. It also provides insight into the dissociation of implicit and explicit racial bias in childhood and adolescence. We encourage future research on implicit bias among pediatric patients in the orthopaedic community to provide a better understanding and possible solutions to bias-related challenges in health care.

Research ObjectiveClinicians’ implicit bias can affect quality of healthcare delivery and contribute to healthcare disparities. How to design an educational intervention to equip clinicians with skills to mitigate implicit bias without inducing defensiveness is unclear. COmmuNity‐engaged SimULation Training for Blood Pressure Control (CONSULT‐BP) Trial is a 5‐year clinical trial educational intervention designed in collaboration with racial, ethnic, and socioeconomically diverse representatives of the local patient community. CONSULT evaluates clinician trainee awareness of and defensiveness about implicit bias pre‐ and postexposure to a face‐to‐face simulation training with standardized patients (SPs) from local racial and ethnic communities.Study DesignPre‐post analysis of trainee bias awareness and defensiveness in the context of a clinical trial that evaluates the impact of an educational intervention to improve clinicians’ interaction skills with diverse populations. Participants completed two, in‐person educational sessions, 5 weeks apart. Learning components included the following: online modules on health disparities, implicit bias, and patient‐centered care; and face‐to‐face simulation encounters with diverse SPs. Four Implicit Association Tests (IATs) were used to measure implicit and explicit bias, and to promote self‐reflection. We measured pre/post bias awareness using a 7‐item Bias Awareness Scale and defensiveness using a 3‐item pre/post measure of reaction to feedback on implicit bias scores. We also collected trainee feedback about the educational experience.Population StudiedGraduate medical and nurse practitioner trainees, including internal medicine, family medicine residents, and nurse practitioner students. We present preliminary findings from CONSULT year 1 cohort (N = 86).Principal FindingsBoth before and after, the intervention participants slightly agreed that they are objective that bias does not affect their decision‐making, disagreed that society treats all groups equally, and that all people have equal opportunity. After the intervention, participants were significantly more likely to disagree with the statement that bias is no longer a problem in patient care (P = .00). In response to feedback on their IAT scores, participants were more likely to agree that the IAT reflects “something about my thoughts or feelings, unconscious or otherwise” (48% pre, 54%, post). Preintervention, 76% agreed that “the IAT captures something important about me” but only 58% agreed postintervention. When asked if the IAT reflects something about their “automatic thoughts and feelings” concerning racial/ethnic bias, 75% agreed preintervention and 65% agreed postintervention. Qualitative feedback from trainees reported that the intervention was a burden on their, taking numerous IATs was redundant, and identified an unmet need to address patient bias toward medical providers.ConclusionsDefensiveness about implicit bias scores increased after exposure to our educational program to mitigate implicit bias. Trainees identified challenges with our educational approach and study design.Implications for Policy or PracticeWe learned of the need to include trainee participants during the design phase of this type of training experience and refined our educational intervention for subsequent cohorts. Without sacrificing essential elements of education, investigators amended the study for years 2‐5 to a single session, one IAT per participant, streamlined content in educational modules and included more in‐person education by an educator with the experience and skills needed to facilitate discussion on this highly charged and complicated topic.Primary Funding SourceNational Institutes of Health.

An Institute of Medicine report titled U.S. Health in International Perspective: Shorter Lives, Poorer Health documents the decline in the health status of Americans relative to people in other high-income countries, concluding that “Americans are dying and suffering from illness and injury at rates that are demonstrably unnecessary.”1 The report blames many factors, “adverse economic and social conditions” among them. In an editorial in Science discussing the findings of the Institute of Medicine report, Bayer et al2 call for a national commission on health “to address the social causes that have put the USA last among comparable nations.” Although mortality from cardiovascular disease (CVD) in the United States has been on a linear decline since the 1970s, the burden remains high. It accounted for 31.9% of deaths in 2010.3 There is general agreement that the decline is the result, in equal measure, of advances in prevention and advances in treatment. These advances in turn rest on dramatic successes in efforts to understand the biology of CVD that began in the late 1940s.4,5 It has been assumed that the steady downward trend in mortality will continue into the future as further breakthroughs in biological science lead to further advances in prevention and treatment. This view of the future may not be warranted. The prevalence of CVD in the United States is expected to rise 10% between 2010 and 2030.6 This change in the trajectory of cardiovascular burden is the result not only of an aging population but also of a dramatic rise over the past 25 years in obesity and the hypertension, diabetes mellitus, and physical inactivity that accompany weight gain. Although there is no consensus on the precise causes of the obesity epidemic, a dramatic change in the underlying biology of Americans is …

Implicit Bias and Philosophy: Metaphysics and Epistemology, Volume 1

Physician explicit and implicit biases involving race and sexual orientation (SO) affect patient and provider experiences in healthcare settings. An anonymous survey was disseminated nationally to graduating medical students, residents, and practicing physicians to evaluate SO and racial biases across medical specialties. SO explicit and implicit bias were measured with the Attitudes toward Lesbians and Gay Men Scale, short form (ATLG-S) and Gay-Straight Implicit Association Test (IAT). Racial explicit and implicit bias were measured with the Quick Discrimination Index (QDI) and the Black-White IAT. Medical specialty was associated with racial explicit bias and specialty prestige with Black-White IAT score. Medical specialty and specialty prestige were not associated with SO bias. Female sex, sexual and gender minority (SGM) identity, and decreased religiosity were associated with reduced SO and racial bias. Provider race was associated with racial implicit and explicit bias.

Implicit Bias Among Physicians

Implicit bias is common and is thought to drive discriminatory behaviour. Having previously demonstrated discrimination against specific applicant demographics by academic radiology departments in a simulated resident selection process, the authors sought to better understand the relationship between implicit bias and discrimination, as well as the potential and mechanisms for their mitigation. A total of 51 faculty reviewers at three academic radiology departments, who had participated in a 2017 audit study in which they were shown to treat applicants differently based on race or ethnicity and physical appearance, were invited to complete testing for implicit racial and weight bias using the Implicit Association Test in 2019. Respondents were also surveyed regarding awareness of their own personal racial and weight biases, as well as any prior participation in formal diversity training. Comparisons were made between implicit bias scores and applicant ratings, as well as between diversity training and self-awareness of bias. A total of 31 out of 51 faculty reviewers (61%) completed and submitted results of race and weight Implicit Association Tests. A total of 74% (23/31) reported implicit anti-obese bias, concordant with discrimination demonstrated in the resident selection simulation, in which obese applicants were rated 0.40 standard deviations (SDs) lower than non-obese applicants (P<.001). A total of 71% (22/31) reported implicit anti-Black bias, discordant with application ratings, which were 0.47 SDs higher for Black than for White applicants (P<.001). A total of 84% (26/31) of participants reported feeling self-aware of potential racial bias at the time of application review, significantly higher than the 23% (7/31) reporting self-awareness of potential anti-obese bias (P<.001). Participation in formal diversity training was not associated with implicit anti-Black or anti-fat bias, nor with self-reported awareness of potential racial or weight-based bias (all P>.2). These findings suggest that implicit bias, as measured by the Implicit Association Test, does not inevitably lead to discrimination, and that personal awareness of implicit biases may allow their mitigation.

In recent years, there has been a surge of discussion, debate, and research on the topic of implicit bias. Implicit bias has become the go-to form of racial bias that many academics, practitioners, and policy makers have identified as important and timely to study (Eberhardt et al., 2004; Levinson and Smith, 2017). Interventions to address implicit racial bias in policing have been particularly popular (Fridell 2008). Arguably, combatting implicit racial bias presents itself as a tool for protecting civil rights. This essay examines the emergence of the implicit bias paradigm as a way to address racial bias in justice system outcomes. The first part provides an overview of implicit bias, including how it is defined, how it is measured, and how it impacts the justice system. The second part examines the term “implicit bias.” This section assesses implicit bias as a social problem and considers whether the label illuminates or obscures the reality of racial bias in the criminal justice system. The discussion considers whether “implicit bias” is viewed as a more appealing approach for dealing with racial bias because it does not assign racial blame. The third part considers the contours of the relationship between implicit bias and explicit bias. The discussion highlights the interconnectedness between the two forms of racial bias. Is the implicit bias approach a signal of racial retrenchment? The final section considers how elementary and secondary education could be used as a proactive strategy for addressing implicit racial bias.