title: Unconscious race and class bias: its association with decision making by trauma and acute care surgeons.
abstract: BACKGROUND
  Recent studies have found that unconscious biases may influence physicians' clinical decision making. The objective of our study was to determine, using clinical vignettes, if unconscious race and class biases exist specifically among trauma/acute care surgeons and, if so, whether those biases impact surgeons' clinical decision making.
  
  
  METHODS
  A prospective Web-based survey was administered to active members of the Eastern Association for the Surgery of Trauma. Participants completed nine clinical vignettes, each with three trauma/acute care surgery management questions. Race Implicit Association Test (IAT) and social class IAT assessments were completed by each participant. Multivariable, ordered logistic regression analysis was then used to determine whether implicit biases reflected on the IAT tests were associated with vignette responses.
  
  
  RESULTS
  In total, 248 members of the Eastern Association for the Surgery of Trauma participated. Of these, 79% explicitly stated that they had no race preferences and 55% stated they had no social class preferences. However, 73.5% of the participants had IAT scores demonstrating an unconscious preference toward white persons; 90.7% demonstrated an implicit preference toward upper social class persons. Only 2 of 27 vignette-based clinical decisions were associated with patient race or social class on univariate analyses. Multivariable analyses revealed no relationship between IAT scores and vignette-based clinical assessments.
  
  
  CONCLUSIONS
  Unconscious preferences for white and upper-class persons are prevalent among trauma and acute care surgeons. In this study, these biases were not statistically significantly associated with clinical decision making. Further study of the factors that may prevent implicit biases from influencing patient management is warranted.
  
  
  METHODS
  Epidemiologic study, level II.
authors.affiliation: From the Center for Surgical Trials and Outcomes Research/Division of Acute Care Surgery (A.H.H., E.B.S., D.S.D., V.K.S., S.M.S., L.L., E.R.H., D.T.E., J.A.F., P.A.L.), Armstrong Institute of Patient Safety (P.J.P.), and Center for Elimination of Cardiovascular Disparities (L.A.C.), Johns Hopkins School of Medicine; and Department of Health Policy and Management (E.J.M.), Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Department of Psychology (N.S.), University of Virginia, Charlottesville, Virginia; Department of Surgery (E.E.C.), Howard University College of Medicine, Washington, District of Columbia; and The Mayo Clinic, Arizona.
authors.forename: Adil H
authors.initials: AH
authors.lastname: Haider
authors.forename: Eric B
authors.initials: EB
authors.lastname: Schneider
authors.forename: N
authors.initials: N
authors.lastname: Sriram
authors.forename: Deborah S
authors.initials: DS
authors.lastname: Dossick
authors.forename: Valerie K
authors.initials: VK
authors.lastname: Scott
authors.forename: Sandra M
authors.initials: SM
authors.lastname: Swoboda
authors.forename: Lia
authors.initials: L
authors.lastname: Losonczy
authors.forename: Elliott R
authors.initials: ER
authors.lastname: Haut
authors.forename: David T
authors.initials: DT
authors.lastname: Efron
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Pronovost
authors.forename: Julie A
authors.initials: JA
authors.lastname: Freischlag
authors.forename: Pamela A
authors.initials: PA
authors.lastname: Lipsett
authors.forename: Edward E
authors.initials: EE
authors.lastname: Cornwell
authors.forename: Ellen J
authors.initials: EJ
authors.lastname: MacKenzie
authors.forename: Lisa A
authors.initials: LA
authors.lastname: Cooper
mesh_terms: D000328:Adult; D003625:Data Collection; D003657:Decision Making; D005260:Female; D054625:Healthcare Disparities / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D011287:Prejudice / Q000706:statistics & numerical data*; D044469:Racial Groups / Q000706:statistics & numerical data; D063505:Racism / Q000706:statistics & numerical data*; D012923:Social Class; D011795:Surveys and Questionnaires; D014194:Traumatology / Q000706:statistics & numerical data*; D014481:United States / Q000453:epidemiology