Association of unconscious race and social class bias with vignette-based clinical assessments by medical students

Abstract

Context: Studies involving physicians suggest that unconscious bias may be related to clinical decision making and may predict poor patient-physician interaction. The presence of unconscious race and social class bias and its association with clinical assessments or decision making among medical students is unknown.

Objective: To estimate unconscious race and social class bias among first-year medical students and investigate its relationship with assessments made during clinical vignettes.

Design, setting, and participants: A secure Web-based survey was administered to 211 medical students entering classes at Johns Hopkins School of Medicine, Baltimore, Maryland, in August 2009 and August 2010. The survey included the Implicit Association Test (IAT) to assess unconscious preferences, direct questions regarding students' explicit race and social class preferences, and 8 clinical assessment vignettes focused on pain assessment, informed consent, patient reliability, and patient trust. Adjusting for student demographics, multiple logistic regression was used to determine whether responses to the vignettes were associated with unconscious race or social class preferences.

Main outcome measures: Association of scores on an established IAT for race and a novel IAT for social class with vignette responses.

Results: Among the 202 students who completed the survey, IAT responses were consistent with an implicit preference toward white persons among 140 students (69%, 95% CI, 61%-75%). Responses were consistent with a preference toward those in the upper class among 174 students (86%, 95% CI, 80%-90%). Assessments generally did not vary by patient race or occupation, and multivariable analyses for all vignettes found no significant relationship between implicit biases and clinical assessments. Regression coefficient for the association between pain assessment and race IAT scores was -0.49 (95% CI, -1.00 to 0.03) and for social class, the coefficient was -0.04 (95% CI, -0.50 to 0.41). Adjusted odds ratios for other vignettes ranged from 0.69 to 3.03 per unit change in IAT score, but none were statistically significant. Analysis stratified by vignette patient race or class status yielded similarly negative results. Tests for interactions between patient race or class status and student IAT D scores in predicting clinical assessments were not statistically significant.

Conclusions: The majority of first-year medical students at a single school had IAT scores consistent with implicit preference for white persons and possibly for those in the upper class. However, overall vignette-based clinical assessments were not associated with patient race or occupation, and no association existed between implicit preferences and the assessments.

Figure 1

Explicit and Implicit Preference for Race and Social Class For implicit preferences, a 7-point relative preference measure derived from Implicit Association Test (IAT) D scores from 202 students was used, with no preference set in the center. Explicit preferences reflect participants’ direct response to a similar 7-point relative preference scale.

Figure 2

Responses to Clinical Vignettes by Patient Race Mean pain score for white patients was 8.0 (95% CI, 7.7–8.3) and black patients 8.2 (95% CI, 7.9–8.3; P=.23). The P values, derived by the t test, compare black with white patients.

Figure 3

Responses to Clinical Vignettes by Patient Social Class The mean pain score, a scale of 1 to 10, was 8.5 (95% CI, 8.2–8.7) for upper-class patients and 8.8 (95% CI, 8.5–9.1; P=.42) for lower-class patients. The P values, derived by the t test, compare upper-class with lower-class patients.