Association of Unconscious Race and Social Class Bias With Vignette-Based Clinical Assessments by Medical Students

Abstract

Context Studies involving physicians suggest that unconscious bias may be related to clinical decision making and may predict poor patient-physician interaction. The presence of unconscious race and social class bias and its association with clinical assessments or decision making among medical students is unknown. Objective To estimate unconscious race and social class bias among first-year medical students and investigate its relationship with assessments made during clinical vignettes. Design, Setting, and Participants A secure Web-based survey was administered to 211 medical students entering classes at Johns Hopkins School of Medicine, Baltimore, Maryland, in August 2009 and August 2010. The survey included the Implicit Association Test (IAT) to assess unconscious preferences, direct questions regarding students’ explicit race and social class preferences, and 8 clinical assessment vignettes focused on pain assessment, informed consent, patient reliability, and patient trust. Adjusting for student demographics, multiple logistic regression was used to determine whether responses to the vignettes were associated with unconscious race or social class preferences. Main Outcome Measures Association of scores on an established IAT for race and a novel IAT for social class with vignette responses. Results Among the 202 students who completed the survey, IAT responses were consistent with an implicit preference toward white persons among 140 students (69%, 95% CI, 61%–75%). Responses were consistent with a preference toward those in the upper class among 174 students (86%, 95% CI, 80%–90%). Assessments generally did not vary by patient race or occupation, and multivariable analyses for all vignettes found no significant relationship between implicit biases and clinical assessments. Regression coefficient for the association between pain assessment and race IAT scores was −0.49 (95% CI, −1.00 to 0.03) and for social class, the coefficient was −0.04 (95% CI, −0.50 to 0.41). Adjusted odds ratios for other vignettes ranged from 0.69 to 3.03 per unit change in IAT score, but none were statistically significant. Analysis stratified by vignette patient race or class status yielded similarly negative results. Tests for interactions between patient race or class status and student IAT D scores in predicting clinical assessments were not statistically significant. Conclusions The majority of first-year medical students at a single school had IAT scores consistent with implicit preference for white persons and possibly for those in the upper class. However, overall vignette-based clinical assessments were not associated with patient race or occupation, and no association existed between implicit preferences and the assessments.

The effect of socioeconomic status on access to primary care: an audit study

“…8 Most previous studies of discrimination in health care have examined the effects of patient race or ethnic back ground on treatment decisions. 9,10 These studies have typically presented physicians with clinical vignettes 11,12 or used observational databases and adjusted for confounding factors. 13 Far fewer studies have focused on discrimination on the basis of patient socioeconomic status.…”

Implicit Gender Bias and the Use of Cardiovascular Tests Among Cardiologists

“…Pilot survey participants had characteristics (82% men, 63% noninvasive cardiologists), case responses, and mean IAT scores (risk‐taking IAT score: 0.45 [SD: 0.54]; strength IAT score: 0.60 [SD: 0.42]) similar to those of the larger national sample. Among this pilot sample, internal consistency of the IATs using Pearson correlation coefficients was adequate (strong IAT: r =0.65, P <0.01, Cronbach α=0.79; risk‐taking IAT: r =0.68, P <0.01, Cronbach α=0.81) and comparable to other commonly used IATs 46. Eleven of the pilot participants repeated the IATs ≈30 days after the initial survey; test–retest reliability using Pearson correlation coefficients was high (strong IAT: r =0.68, P =0.02; risk‐taking IAT: r =0.78, P <0.01).…”

“…Our study is the first to demonstrate that >70% of the participating cardiologists associated strength and risk taking with men more than women. Prior studies have shown that the majority of physicians have implicit race/ethnicity bias at rates similar to community samples 12, 46, 51, 52, 53. Physicians may be especially vulnerable to the use of implicit biases in clinical settings characterized by time pressure, brief encounters, and the need to manage very complex situations—the type of situations in which implicit bias is more likely to be applied 17, 50.…”

Racial, Gender, and Socioeconomic Status Bias in Senior Medical Student Clinical Decision-Making: A National Survey

“…38 Haider et al studied matriculating medical students and found evidence among these students that implicit bias may exist in the absence of explicit bias. 17 Our design attempted to elicit implicit as well as explicit bias through our emphasis on rapid response to the survey questions and use of toss-up scenarios. However, it is quite possible that this effort was ineffective in evoking implicit biases.…”

“…16 On the other hand, a more recent study failed to show that student assessments of patient vignettes varied by race or social class. 17 Both of these studies, however, were based on students who were early in their medical school training and had no clinical experience, and the studies did not assess clinical decision-making. A third study used clinical-level students from a single institution to demonstrate evidence of situational gender bias in vignette patient diagnoses.…”