According to a report in the September 7 issue of JAMA, a medical education theme issue, in one medical school, most first-year students’ scores who were surveyed in regards to race and social preference, were coherent with an unconscious preference towards white people and upper social class, even though when a variety of different clinical scenarios were presented to the student’s, these biases were not linked in their decision making or clinical assessments.
In the U.S., race and socioeconomic status are predictors of worse health outcomes. According to background data in the study, the authors explain:
“Disparities may be related to where patients seek care, available resources, and the types of training physicians receive. Unconscious or implicit bias among physicians has recently been suggested as another important factor contributing to racial disparities in health care.
The presence of unconscious race and social class bias and its association with clinical assessments or decision making among medical students is unknown.”
They add that a greater understanding of the way biases might be made or reinforced during medical education and training could allow the design of interventions to address disparities in health care.
Among first-year medical students, the presence or absence of unconscious race and social bias were estimated in a study by Adil H. Haider, M.D., M.P.H., of the Johns Hopkins School of Medicine, Baltimore, and colleagues, they also researched the connection of these biases with the students clinical assessments.
Included in the investigation was a secure Web-based survey which was administered to 211 medical students at the Johns Hopkins School of Medicine entering classes in August 2009 and August 2010. The survey involved the Implicit Association Test (IAT) to evaluate unconscious preferences, direct questions about student’s explicit race and social class preferences, together with eight clinical assessment vignettes focused on pain assessment, informed consent, patient reliability and patient trust. Examinations were carried out in order to find out whether responses to the vignettes were linked with unconscious race or social class preferences.
Among the 202 medical students who completed the survey the investigators discovered, race IAT responses were coherent with no implicit preference in 34 students (17%), a white preference in 140 of students (69%), and a black preference in 28 (14%) of the students. The results indicated social class IAT responses were consistent with an implicit upper class preference in 174 students (86%), no preference in 22 students (11%), while 6 student’s preference was lower-class (3%).
For nearly all vignettes, student responses were not connected with the race of the patient they were randomly assigned. The researchers write:
“There were no significant associations between explicit preferences and responses on the clinical vignettes on multivariable analysis. Analyses for all vignettes found no significant relationship between implicit biases and clinical assessments.
Our study raises the question of why the decision-making processes of first-year medical students do not correlate with their implicit biases in the same way that may occur among more experienced physicians.
Younger students may have been more exposed to educational curricula focused on cultural competency, translating to improved awareness and management of implicit bias. Naive students who have not been exposed to the rigors of medical training might not be influenced by implicit preferences. It has been recommended that medical education curricula focus on integrating cross-cultural education to reduce disparities; however, students have noted the existence of a ‘hidden curriculum’ in which what is taught about bias in the classroom differs starkly from in-hospital training experiences.”
They conclude that more investigations are required to have an improved understanding of whether implicit preferences are linked with clinical assessments and if experiences during the students’ medical training influence social or racial bias in making decisions. “If this occurs, medical training could be an effective intervention point to decrease implicit biases and possibly mitigate physician-driven health care disparities.”
Michelle van Ryn, Ph.D., M.P.H., of the University of Minnesota Medical School, Minneapolis, and Somnath Saha, M.D., M.P.H., of the Portland VA Medical Center and Oregon Health & Science University, Portland, write in an associated report, that implicit bias among doctors might contribute to inequalities in health care:
“To evaluate this possibility, future studies should apply the lessons learned in cognitive and social psychology about the complex mechanisms by which implicit bias affects human behavior, the specific behaviors affected, and the conditions under which those behaviors are most likely to be influenced. Likewise, interventions to reduce the putative effects of implicit bias on clinical care should be informed by research about the consequences of exposing people to the results of implicit attitude tests. Implicit attitudes are both subtle and powerful. Research and education to explore and reduce their effects should be conducted thoughtfully and should build on existing knowledge to minimize unintended negative consequences and maximize the chances of eliminating physicians’ unintended contribution to racial and social inequalities in health care.”
Written by Grace Rattue