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.
Center for Surgical Trials and Outcomes Research, Division of Acute Care Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.
JAMA Surg. 2015 May;150(5):457-64. doi: 10.1001/jamasurg.2014.4038.
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.
To determine whether clinicians' unconscious race and/or social class biases correlate with patient management decisions.
DESIGN, SETTING, AND PARTICIPANTS: 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.
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.
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.
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.
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.
少数民族和社会弱势群体患者中仍然存在显著的健康不平等现象。更好地了解无意识偏见如何影响临床决策，可能有助于阐明临床医生在传播差异方面的作用。
确定临床医生的无意识种族和/或社会阶级偏见是否与患者管理决策相关。
设计、地点和参与者：我们于 2011 年 12 月 1 日至 2012 年 1 月 31 日期间，在一家学术一级创伤中心的外科和相关专业的 230 名医生中进行了一项基于网络的调查。
我们提供了临床案例，每个案例有 3 个管理问题。8 个案例评估了无意识偏见与临床决策之间的关系。我们对隐性关联测试（IAT）评分进行了有序逻辑回归分析，并使用多变量分析来确定隐性偏见是否与案例反应相关。
IAT 的差异反应时间（D 分数）作为无意识偏见的替代指标。患者管理案例根据患者的种族或社会阶层而有所不同。为每个管理决策计算了相应的 D 分数。
共有 215 名临床医生参与，包括 74 名主治外科医生、32 名研究员、86 名住院医生、19 名实习医生和 4 名未确定教育程度的医生。专业包括外科（32.1%）、麻醉（18.1%）、急诊医学（18.1%）、骨科（7.9%）、耳鼻喉科（7.0%）、神经外科（7.0%）、重症监护（6.0%）和泌尿科（2.8%）；1.9%的人未报告所在部门。大多数受访者存在隐性种族和社会阶级偏见。在所有临床医生中，种族和社会阶级的 IAT D 分数平均值分别为 0.42（95%置信区间，0.37-0.48）和 0.71（95%置信区间，0.65-0.78）。部门之间（普通外科、骨科、泌尿科等）、种族或年龄的种族和阶级分数相似。与男性相比，女性在种族（IAT D 分数均值，0.39 [95%置信区间，0.29-0.49]）和社会阶级（IAT D 分数均值，0.66 [95%置信区间，0.57-0.75]）方面表现出较小的偏见，而男性的 IAT D 分数均值分别为 0.44 [95%置信区间，0.37-0.52]和 0.82 [95%置信区间，0.75-0.89]。在单变量分析中，我们发现种族/社会阶级偏见与 27 种可能的患者护理决策中的 3 种之间存在关联。多变量分析显示，IAT D 分数与基于案例的临床评估之间没有关联。
无意识的社会阶级和种族偏见与急性护理外科临床医生的临床决策没有显著关联。可能需要进行涉及真实医患互动的进一步研究。
