bias study method
Dr. Alexander Green came up with the idea of measuring unconscious bias among physicians three years ago during a lecture by Harvard pscyhologist Mahzarin Banaji.
A test Banaji helped develop had never been applied to physicians and their treatment practices.
Green and his colleagues decided to test residents at Massachusetts General, the Brigham, and Beth Israel Deaconess Medical Center in Boston, as well as at an Atlanta hospital.
The results included 220 trainee doctors, who were told that the study was evaluating the use of heart attack drugs in the emergency room, but not that it was also examining racial bias.
The residents were first given a narrative describing a male patient who shows up in the emergency room complaining of chest pains, along with a computer- generated image of the patient that was either a black or a white man.
The doctors were asked if, based on the information provided, they would diagnose the man as having a heart attack and, if so, whether they would prescribe clot-busting drugs.
Study participants were also asked questions designed to determine if they were overtly biased. Their answers showed they were not.
Last, the residents took Banaji's "implicit association test," which is based on the concept that the more strongly test-takers associate a picture of a white or black patient with a particular concept, say cooperativeness, the faster they will make a match.
White, Asian and Hispanic doctors were faster to make matches between blacks and negative concepts and slower to make matches between blacks and positive ones.
The small number of African-American physicians in the study were as likely to show bias against blacks as against whites.
The researchers then compared the implicit association test scores with the decisions about whether to provide the clot-busting medicine and found that doctors whose ratings of African-Americans were most negative were also the least likely to prescribe the drug to blacks.
"The great advantage of being human, of having the privilege of awareness, of being able to recognize the stuff that is hidden, is that we can beat the bias."
Deeply imbedded attitudes about race influence the way doctors care for their African-American patients, according to a Harvard study that for the first time details how unconscious bias contributes to inferior care.
Researchers have known for years that African-Americans in the midst of a heart attack are far less likely than white patients to receive potentially life-saving treatments such as clot-busting drugs, a dramatic illustration of America's persistent healthcare disparities. But the reasons behind such stark gaps in care for heart disease, as well as cancer and other serious illnesses, have remained murky, with blame fixed on doctors, hospitals and insurance plans.
In the new study, trainee doctors in Boston and Atlanta took a 20-minute computer survey designed to detect overt and implicit prejudice. They were also presented with the hypothetical case of a 50-year-old man stricken with sharp chest pain; in some scenarios the man was white, while in others he was black.
"We found that as doctors' unconscious biases against blacks increased, their likelihood of giving (clot-busting) treatment decreased," said the lead author of the study, Dr. Alexander Green of Massachusetts General Hospital.
"It's not a matter of you being a racist. It's really a matter of the way your brain processes information is influenced by things you've seen, things you've experienced, the way media has presented things."
Specialists predict that the novel study, appearing on the Web site of the Journal of General Internal Medicine, will result in considerable soul-searching in the medical profession, rethinking of medical school curriculum, and refresher courses for veteran doctors.
"Years of advanced education and egalitarian intentions are no protection against the effect of implicit attitudes," said Dr. Thomas Inui, president of the Regenstrief Institute Inc. in Indianapolis, which studies vulnerable patient groups.
"When do they surface? When we're involved with high-pressure, high-stakes decision-making, when there's a lot riding on our decisions but there isn't a lot of time to make them, that's when the implicit attitudes that are not scientific rise up and grab us."
Green said he cannot explain why implicit bias would cause doctors to deprive patients of potentially life-saving therapy, and other researchers said they do not know how big a factor unconscious prejudice is in the far-reaching problem of disparities.
The best way to combat those impulses is by acknowledging them, specialists said, suggesting that medical personnel take a test to measure unconscious bias, such as one at implicit.harvard.edu.
"The great advantage of being human, of having the privilege of awareness, of being able to recognize the stuff that is hidden, is that we can beat the bias," said Mahzarin Banaji, a Harvard psychologist who helped design a widely used bias test.
Dr. JudyAnn Bigby, Massachusetts secretary of health and human services and a specialist in healthcare disparities, said the study demonstrates the importance of monitoring how hospitals and large physician practices provide care to patients of different races.
But Inui and other specialists said that even conquering doctor bias will not be enough to eliminate healthcare disparities.
Black patients in the process of having a heart attack, for example, are only half as likely as whites to get clot-busting medication, and they are much less likely to undergo open-heart surgery.
Similarly, African-American women receive breast-cancer screenings at a rate substantially lower than white women. And fewer black babies live to celebrate their first birthdays.
"Most physicians are now willing to acknowledge that important disparities exist in the healthcare system," said Dr. John Ayanian, a healthcare policy specialist at Brigham and Women's Hospital who was not involved with the new research.
"There's still a barrier, though, to many physicians acknowledging that disparities may exist in the care of their own patients."