Unconscious Race and Social Class Bias Among Acute Care Surgical Clinicians and Clinical Treatment Decisions
Unconscious Race and Social Class Bias Among Acute Care Surgical Clinicians and Clinical Treatment Decisions
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DOI：
10.1001/jamasurg.2014.4038
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发表时间：
2015-05-01
期刊：
影响因子：
16.9
通讯作者：
Freischlag, Julie A.
中科院分区：
文献类型：
--
作者：
Haider, Adil H.;Schneider, Eric B.;Freischlag, Julie A.
在少数群体和社会弱势群体患者中存在严重的卫生不平等现象。更好地理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。目的确定临床医生无意识的种族和/或社会阶层偏见是否与患者管理决策相关。设计、环境和参与者：从2011年12月1日至2012年1月31日，我们对一家学术一级创伤中心的230名外科及相关专业的医生进行了一项基于网络的调查。干预措施：我们进行临床调查，每个调查有3个管理问题。8个小插曲评估了无意识偏见与临床决策之间的关系。我们对内隐联想测验（IAT）分数进行了有序逻辑回归分析，并使用多变量分析来确定内隐偏见是否与小片段反应相关。IAT的差异反应时间（D分数）作为无意识偏见的替代。患者管理的小插曲因患者种族或社会阶层而异。计算每个管理决策的D分。结果共纳入215名临床医生，包括74名主治外科医生、32名研究员、86名住院医生、19名实习生和4名教育程度未定的医生。专科包括外科（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%）和泌尿外科（2.8%）；1.9%的人没有部门隶属关系。大多数受访者都存在隐性的种族和社会阶级偏见。在所有临床医生中，种族和社会阶层的平均IAT D评分分别为0.42 （95% CI, 0.37-0.48）和0.71 （95% CI, 0.65-0.78）。各科室（普外科、骨科、泌尿外科等）、种族或年龄的种族和班级得分相似。与男性相比，女性在种族（平均IAT D评分，0.39 [95% CI, 0.29-0.49]）和社会阶层（平均IAT D评分，0.66 [95% CI, 0.57-0.75]）方面的偏见较少（平均IAT D评分，0.44 [95% CI, 0.37-0.52]和0.82 [95% CI, 0.75-0.89]）。在单变量分析中，我们发现种族/社会阶层偏见与27个可能的患者护理决策中的3个之间存在关联。多变量分析显示，IAT D评分与基于小情节的临床评估之间没有关联。无意识的社会阶层和种族偏见与急症外科临床医生的临床决策没有显著相关。涉及真正的医患互动的进一步研究可能是有必要的。
IMPORTANCE 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.OBJECTIVE To determine whether clinicians' unconscious race and/or social class biases correlate with patient management decisions.DESIGN, SETTING, AND PARTICIPANTS We conducted aweb-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.INTERVENTIONS 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.MAIN OUTCOMES AND MEASURES 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.RESULTS 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.CONCLUSIONS AND RELEVANCE 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.