Does unconscious bias affect patient care? A study by Green et al using the IAT tested whether physicians show implicit race bias and whether the magnitude of such bias predicts thrombolysis recommendations for black and white patients with acute coronary syndromes (ACS). Using vignettes of a patient presenting to the emergency department with ACS followed by a questionnaire and three IATs, 287 internal medicine and emergency medicine residents at four academic medical centers in Atlanta and Boston were studied. No explicit preference for white or black patients or perceived cooperativeness was found. However, the IATs demonstrated implicit preference for white patients and implicit stereotypes of black patients as less cooperative with medical procedures and less cooperative in general. As the physicians’ pro-white implicit bias increased so did their likelihood of treating white patients and not treating black patients with thrombolysis. The authors conclude that unconscious bias may contribute to racial/ethnic disparities in the use of medical procedures. While the study is a bit dated (percutaneous coronary intervention is the standard for myocardial infarction), it is the one study linking IAT results to treatment choices. A number of other studies have demonstrated the existence of implicit biases of physicians in race, obesity, gender, and age.4–6
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ACEP Now: Vol 36 – No 04 – April 2017One question that comes up with the IAT is, does it measure prejudice? Research to date has not clarified the answer. The IAT may simply be measuring the association of positive evaluations with the “in,” or majority, group and negative evaluations with the “out,” or minority, group and may not be related to a specific attribute. A study was done in which two versions of an IAT were studied. In the first, the in group was “French and me” and the out group was “North African,” and an IAT effect was found. In the second version, the two categories were “French” and “North African and me.” The IAT effect disappeared. The investigators concluded that in-group/out-group membership, and not nationality, was the important factor.7 What is the importance of the IAT? In my opinion, it is a tool that can be used to stimulate thought about one’s unconscious biases but should not be used to measure one’s prejudices. Preference for a certain group does not equal prejudice against another. Awareness of a preference allows you to consider how your bias may affect your decisions related to the other group. Remember, also, that it is a two-way street. Your patients also have their own implicit biases, and this, too, has the potential to affect decisions regarding compliance with your decisions.
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3 Responses to “How Does Bias Affect Physicians, Patients?”
April 15, 2017
Mark BuettnerThe IAT does not predict behavior of racial bias whatsoever. Is credible science not important anymore? The bias here is “Bandwagon Bias”. Perhaps we should pause before jumping on board.
It’s hard to disagree with the conclusion of Fiedler and his colleagues that it is only “fair and appropriate to treat the IAT with the same scrutiny and scientific rigour as other diagnostic procedures.” If that’s true, then between Project Implicit and cutting-edge diversity trainings, the IAT has misled potentially millions of people. Over and over and over and over, the IAT, a test whose results don’t really mean anything for an individual test-taker, has induced strong emotional responses from people who are told that it is measuring something deep and important in them. This is exactly what the norms of psychology are supposed to protect test subjects against.
May 19, 2017
Bernard L. Lopez, MD, MS, CPE, FACEP, FAAEMIn my article, I never said that the IAT predicts behavior of racial bias. Much research has been done on the IAT since it was first described. Thus, the test has undergone significant scientific scrutiny and raises questions on just exactly what it measures. One school of thought is that the IAT may simply be measuring the association of positive evaluations with the “in” or majority group and negative evaluations with the “out” or minority group and that it may not be a specific attribute effect but rather the manner in which humans behave. In my article, I describe a study that suggests that in-group/out-group membership, and not nationality, was the important factor.
Too often, people are told to take the test on their own. Therein lies the potential harm—they read the results and may assume that they are prejudiced against a group. The test may also be used by diversity educators who may suggest the existence of prejudice. In this regard, I agree with Dr. Buettner that the IAT is misleading. In my article, I gave the opinion that the IAT is a tool that can be used to stimulate thought about one’s unconscious biases but should NOT be used to measure one’s “prejudices.” Having a strong preference for a certain group does not mean that one is prejudiced against another. Knowledge of this preference is useful when dealing with someone from “the other” group as it allows you to consider how your bias may affect certain behaviors and decisions. The use of the IAT needs to be done in a controlled setting that stresses the fact that it does not measure prejudice and that it should simply stimulate thought about one’s unconscious biases.
I disagree with Dr. Buettner’s statement that the IAT is a test whose results don’t really mean anything for an individual test-taker. For the individual, the results suggest a preference. This preference, when used to stimulate thought (not measure prejudice) on potential biases, can be valuable in future interpersonal interactions.
Bernard L. Lopez, MD, MS, CPE, FACEP, FAAEM
June 2, 2017
Mark BuettnerPoint of Clarification: The opening sentence of my original response should read as follows: The IAT does not predict behavior OR racial bias whatsoever.
Mark F. Buettner DO, FACEP, FAAEM