title: Unconscious race and social class bias among acute care surgical clinicians and clinical treatment decisions.
abstract: OBJECTIVE
  Significant health inequities persist among minority and socially disadvantaged patients. Better understanding of how unconscious biases affect clinical decision making may help to illuminate clinicians' roles in propagating disparities.
  
  
  OBJECTIVE
  To determine whether clinicians' unconscious race and/or social class biases correlate with patient management decisions.
  
  
  METHODS
  We conducted a web-based survey among 230 physicians from surgery and related specialties at an academic, level I trauma center from December 1, 2011, through January 31, 2012.
  
  
  METHODS
  We administered clinical vignettes, each with 3 management questions. Eight vignettes assessed the relationship between unconscious bias and clinical decision making. We performed ordered logistic regression analysis on the Implicit Association Test (IAT) scores and used multivariable analysis to determine whether implicit bias was associated with the vignette responses.
  
  
  METHODS
  Differential response times (D scores) on the IAT as a surrogate for unconscious bias. Patient management vignettes varied by patient race or social class. Resulting D scores were calculated for each management decision.
  
  
  RESULTS
  In total, 215 clinicians were included and consisted of 74 attending surgeons, 32 fellows, 86 residents, 19 interns, and 4 physicians with an undetermined level of education. Specialties included surgery (32.1%), anesthesia (18.1%), emergency medicine (18.1%), orthopedics (7.9%), otolaryngology (7.0%), neurosurgery (7.0%), critical care (6.0%), and urology (2.8%); 1.9% did not report a departmental affiliation. Implicit race and social class biases were present in most respondents. Among all clinicians, mean IAT D scores for race and social class were 0.42 (95% CI, 0.37-0.48) and 0.71 (95% CI, 0.65-0.78), respectively. Race and class scores were similar across departments (general surgery, orthopedics, urology, etc), race, or age. Women demonstrated less bias concerning race (mean IAT D score, 0.39 [95% CI, 0.29-0.49]) and social class (mean IAT D score, 0.66 [95% CI, 0.57-0.75]) relative to men (mean IAT D scores, 0.44 [95% CI, 0.37-0.52] and 0.82 [95% CI, 0.75-0.89], respectively). In univariate analyses, we found an association between race/social class bias and 3 of 27 possible patient-care decisions. Multivariable analyses revealed no association between the IAT D scores and vignette-based clinical assessments.
  
  
  CONCLUSIONS
  Unconscious social class and race biases were not significantly associated with clinical decision making among acute care surgical clinicians. Further studies involving real physician-patient interactions may be warranted.
authors.affiliation: Center for Surgical Trials and Outcomes Research, Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland2now with Center for Surgery and Public Health, Department of Surgery, Brigham and Wom.
authors.forename: Adil H
authors.initials: AH
authors.lastname: Haider
authors.affiliation: Center for Surgical Trials and Outcomes Research, Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Eric B
authors.initials: EB
authors.lastname: Schneider
authors.affiliation: Department of Psychology, University of Virginia, Charlottesville.
authors.forename: N
authors.initials: N
authors.lastname: Sriram
authors.affiliation: Center for Surgical Trials and Outcomes Research, Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland4Department of Surgery, Mayo Clinic, Scottsdale, Arizona.
authors.forename: Deborah S
authors.initials: DS
authors.lastname: Dossick
authors.affiliation: Center for Surgical Trials and Outcomes Research, Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Valerie K
authors.initials: VK
authors.lastname: Scott
authors.affiliation: Center for Surgical Trials and Outcomes Research, Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Sandra M
authors.initials: SM
authors.lastname: Swoboda
authors.affiliation: Center for Surgical Trials and Outcomes Research, Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Lia
authors.initials: L
authors.lastname: Losonczy
authors.affiliation: Center for Surgical Trials and Outcomes Research, Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Elliott R
authors.initials: ER
authors.lastname: Haut
authors.affiliation: Center for Surgical Trials and Outcomes Research, Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: David T
authors.initials: DT
authors.lastname: Efron
authors.affiliation: Armstrong Institute of Patient Safety, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Pronovost
authors.affiliation: Center for Surgical Trials and Outcomes Research, Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Pamela A
authors.initials: PA
authors.lastname: Lipsett
authors.affiliation: Department of Surgery, Howard University College of Medicine, Washington, DC.
authors.forename: Edward E
authors.initials: EE
authors.lastname: Cornwell
authors.affiliation: Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
authors.forename: Ellen J
authors.initials: EJ
authors.lastname: MacKenzie
authors.affiliation: Center to Eliminate Cardiovascular Health Disparities, Johns Hopkins University School of Medicine, Baltimore, Maryland.
authors.forename: Lisa A
authors.initials: LA
authors.lastname: Cooper
authors.affiliation: Office of the Dean, University of California, Davis, School of Medicine, Sacramento.
authors.forename: Julie A
authors.initials: JA
authors.lastname: Freischlag
mesh_terms: D000328:Adult; D001291:Attitude of Health Personnel; D015142:Baltimore; D003422:Critical Care; D003430:Cross-Sectional Studies; D003657:Decision Making; D005260:Female; D005500:Follow-Up Studies; D054625:Healthcare Disparities; D006801:Humans; D008297:Male; D010817:Physician-Patient Relations / Q000941:ethics*; D010820:Physicians / Q000523:psychology*; D044469:Racial Groups; D012189:Retrospective Studies; D012923:Social Class; D011795:Surveys and Questionnaires; D014473:Unconscious, Psychology