Effect of Socioeconomic Status Bias on Medical Student–Patient Interactions Using an Emergency Medicine Simulation

Abstract

Objectives: Implicit bias in clinical decision making has been shown to contribute to healthcare disparities and results in negative patient outcomes. Our objective was to develop a high-fidelity simulation model for assessing the effect of socioeconomic status (SES) on medical student (MS) patient care.Methods: Teams of MSs were randomly assigned to participate in a high-fidelity simulation of acute coronary syndrome. Cases were identical with the exception of patient SES, which alternated between a low-SES homeless man and a high-SES executive. Students were blinded to study objectives. Cases were recorded and scored by blinded independent raters using 24 dichotomous items in the following domains: 13 communication, six information gathering, and five clinical care. In addition, quantitative data were obtained on the number of times students performed the following patient actions: acknowledged patient by name, asked about pain, generally conversed, and touching the patient. Fisher's exact test was used to test for differences between dichotomous items. For continuous measures, group differences were tested using a mixed-effects model with a random effect for case to account for multiple observations per case.Results: Fifty-eight teams participated in an equal number of high-and low-SES cases. MSs asked about pain control more often (p = 0.04) in patients of high SES. MSs touched the low-SES patient more frequently (p = 0.01). There were no statistically significant differences in clinical care or information gathering measures.Conclusions: This study demonstrates more attention to pain control in patients with higher SES as well as a trend toward better communication. Despite the differences in interpersonal behavior, quantifiable differences in clinical care were not seen. These results may be limited by sample size, and larger cohorts will be required to identify the factors that contribute to SES bias.

Classism in Pain Care: The Role of Patient Socioeconomic Status on Nurses’ Pain Assessment and Management Practices

“…Medical students, in an emergency medicine simulation, were less likely to ask about pain control and more likely to touch a low SES patient (9). Also, low SES has been associated with less frequent opioid and non-pharmacological treatment prescriptions, greater prescription of generic pain medication and an increased recognition of the importance of psychoeducation (8)(9)(10)).…”

“…Medical students, in an emergency medicine simulation, were less likely to ask about pain control and more likely to touch a low SES patient (9). Also, low SES has been associated with less frequent opioid and non-pharmacological treatment prescriptions, greater prescription of generic pain medication and an increased recognition of the importance of psychoeducation (8)(9)(10)). On the other hand, a set of vignette studies using a novel social class implicit association test did not find significant effects of patient SES nor of implicit class biases on medical students', nurses' or physicians' pain assessment and management decisions (11)(12)(13)(14).…”

How Human Decision-making Biases Influence Health Outcomes in Patient Care

“…Evidence of implicit bias regarding race, socioeconomic status or gender varies, as some studies find biases in health professionals (Haider et al, 2015, Hall et al, 2015Johnson et al, 2017;Harris et al, 2018) while others do not (Williams et al, 2015). Another study by Pettit et al (2017) do not show any statistically significant differences in clinical care for patients with different socioeconomic status. However, they do show different behavioural patterns towards patients with a higher socioeconomic status such as a better communication or an increased attentiveness to pain control.…”

“…While there is no clear evidence that implicit bias in socioeconomic status has a direct influence on medical decision making (Haider et al, 2015;Pettit et al 2017), it is found that implicit bias is rather expressed in the behaviour towards patients. Physicians have been found to pay more attention to pain control and had a better communication with patients of a higher socioeconomic status, while the opposite has been true for patients of a lower socioeconomic status (Pettit et al, 2017). Similar results have been found for implicit racial bias.…”

Classism in pain assessment and management: the mediating role of female patient dehumanization and perceived life hardship

“…11 Lower SES patients were described as more demanding, 30 less competent to self-manage pain 19,30 but more disabled. 19,30 They were also prescribed less opioids and guideline treatments, 16,[30][31][32]48 less referred to pain specialists and multidisciplinary treatments 30 and more likely to get generic pain medication 30,32,48 and psychoeducation recommendations. 19,30,32,48 These findings generally suggest that lower SES patients' pain is more likely underassessed/undermanaged.…”