title: The Impact of Cognitive Stressors in the Emergency Department on Physician Implicit Racial Bias.
abstract: OBJECTIVE
  The emergency department (ED) is characterized by stressors (e.g., fatigue, stress, time pressure, and complex decision-making) that can pose challenges to delivering high-quality, equitable care. Although it has been suggested that characteristics of the ED may exacerbate reliance on cognitive heuristics, no research has directly investigated whether stressors in the ED impact physician racial bias, a common heuristic. We seek to determine if physicians have different levels of implicit racial bias post-ED shift versus preshift and to examine associations between demographics and cognitive stressors with bias.
  
  
  METHODS
  This repeated-measures study of resident physicians in a pediatric ED used electronic pre- and postshift assessments of implicit racial bias, demographics, and cognitive stressors. Implicit bias was measured using the Race Implicit Association Test (IAT). Linear regression models compared differences in IAT scores pre- to postshift and determined associations between participant demographics and cognitive stressors with postshift IAT and pre- to postshift difference scores.
  
  
  RESULTS
  Participants (n = 91) displayed moderate prowhite/antiblack bias on preshift (mean ± SD = 0.50 ± 0.34, d = 1.48) and postshift (mean ± SD = 0.55 ± 0.39, d = 1.40) IAT scores. Overall, IAT scores did not differ preshift to postshift (mean increase = 0.05, 95% CI = -0.02 to 0.14, d = 0.13). Subanalyses revealed increased pre- to postshift bias among participants working when the ED was more overcrowded (mean increase = 0.09, 95% CI = 0.01 to 0.17, d = 0.24) and among those caring for >10 patients (mean increase = 0.17, 95% CI = 0.05 to 0.27, d = 0.47). Residents' demographics (including specialty), fatigue, busyness, stressfulness, and number of shifts were not associated with postshift IAT or difference scores. In multivariable models, ED overcrowding was associated with greater postshift bias (coefficient = 0.11 per 1 unit of NEDOCS score, SE = 0.05, 95% CI = 0.00 to 0.21).
  
  
  CONCLUSIONS
  While resident implicit bias remained stable overall preshift to postshift, cognitive stressors (overcrowding and patient load) were associated with increased implicit bias. Physicians in the ED should be aware of how cognitive stressors may exacerbate implicit racial bias.
authors.affiliation: Division of Pediatric Emergency Medicine, PolicyLab, and Center for Perinatal and Pediatric Health Disparities Research, Children's Hospital of Philadelphia, and the Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA.
authors.forename: Tiffani J
authors.initials: TJ
authors.lastname: Johnson
authors.affiliation: Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Hickey
authors.affiliation: Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA.|Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA.
authors.forename: Galen E
authors.initials: GE
authors.lastname: Switzer
authors.affiliation: Division of Adolescent and Young Adult Medicine, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Miller
authors.affiliation: Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA.
authors.forename: Daniel G
authors.initials: DG
authors.lastname: Winger
authors.affiliation: Department of Emergency Medicine, Rady Children's Hospital San Diego, San Diego, CA.
authors.forename: Margaret
authors.initials: M
authors.lastname: Nguyen
authors.affiliation: Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Saladino
authors.affiliation: Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA.|Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, Pittsburgh, PA.
authors.forename: Leslie R M
authors.initials: LR
authors.lastname: Hausmann
mesh_terms: D000328:Adult; D003071:Cognition; D003657:Decision Making; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008511:Medicine; D010820:Physicians / Q000523:psychology*; D044469:Racial Groups; D063505:Racism / Q000523:psychology*; D012959:Socioeconomic Factors; D013315:Stress, Psychological / Q000523:psychology*