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
Explore This IssueACEP Now: Vol 36 – No 04 – April 2017
One 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.