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Cited by 274Social and Intergroup PsychologyDiversity and Career in MedicineRacial and Ethnic Identity Research

Association of Unconscious Race and Social Class Bias With Vignette-Based Clinical Assessments by Medical Students

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Haider, Adil H., Sexton, Janel, Sriram, N., Cooper, Lisa A., Efron, David T., Swoboda, Sandra, Villegas, Cassandra V., Haut, Elliott R. +5 more·2011·JAMA
DOI 10.1001/jama.2011.1248PMC PMC3684149
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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.

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  • Three of these studies reported that 90.7% of doctors (n=215), 93% of nurses (n=245) and 86% of medical students (n=211) demonstrated an implicit preference towards people with High SES.

    “Three of these studies reported that 90.7% of doctors (n=215)28, 93% of nurses (n=245)29 and 86% of medical students (n=211)27 demonstrated an implicit preference towards people with High SES.”

    From Health professionals implicit bias of patients with low socioeconomic status (SES) and its effects on clinical decision-making: a scoping review (2024) · cites this paper as [27]

    The Results report an implicit upper-class preference in 174 of 202 students with complete surveys (86%). They also say 211 students volunteered, but only 202 completed surveys, so n=211 is not the denominator for the reported 86%. The doctors and nurses figures are attached to other citations, not this paper. (LLM, conf=0.88)

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  • In these studies, the high levels of implicit SES bias were not evident in HP's decision-making.

    “However, in these studies,27–29 the high levels of implicit SES bias were not evident in HP’s decision-making.”

    From Health professionals implicit bias of patients with low socioeconomic status (SES) and its effects on clinical decision-making: a scoping review (2024) · cites this paper as [27]

  • The decision to exclude studies involving students rather than fully-trained healthcare professionals meant that a study on medical students showing no significant association between implicit bias and clinical assessments was not included.

    “our decision to exclude studies that involved students rather than fully-trained healthcare professionals meant that we did not include a study conducted on medical students that showed no significant association between implicit bias and clinical assessments [51].”

    From Implicit bias in healthcare professionals: a systematic review (2017) · cites this paper as [51]

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Research works printed but not linked: 25

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Authors
Haider, A. H., Sexton, J., Sriram, N., Cooper, L. A., Efron, D. T., Swoboda, S., Villegas, C. V., Haut, E. R., Bonds, M., Pronovost, P. J., Lipsett, P. A., Freischlag, J. A., & Cornwell, E. E.
Affiliations
  • Johns Hopkins University (US)
  • Howard University (US)
Corresponding author
Haider, Adil H.
ORCID
Venue
JAMA
Publisher
American Medical Association (AMA)
Published
2011-09-07
Volume
306
Issue
9
Pages
942-51
ISSN
  • 0002-9955 (ISSN-L)
  • 0098-7484
DOI
10.1001/jama.2011.1248
PMC
PMC3684149
OpenAlex
W2107244468
Cited by
274
References
5
Citations by year
2026: 4 · 2025: 7 · 2024: 17 · 2023: 16 · 2022: 18 · 2021: 17 · 2020: 20 · 2019: 25 · 2018: 22 · 2017: 26 · 2016: 21 · 2015: 23 · 2014: 22 · 2013: 19 · 2012: 14
FWCI
61.07
Type
journal article
Language
en
Open access
Locations
  • JAMA (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
  • eCommons - AKU (Aga Khan University) (submittedVersion)
Funders
  • National Heart, Lung, and Blood Institute (K24HL083113)
  • National Institute of General Medical Sciences (K23GM093112)
Topics
  • Social Sciences › Sociology and Political Science › Social and Intergroup Psychology
  • Social Sciences › Gender Studies › Diversity and Career in Medicine
  • Social Sciences › Sociology and Political Science › Racial and Ethnic Identity Research
Keywords
social class bias, medical students, clinical vignettes, Implicit Association Test, pain assessment, informed consent, patient trust, patient-physician interaction, medical education, racial preferences, clinical decision-making, first-year medical students, racial disparities in health care
MeSH terms
Adult, Black or African American, Cross-Sectional Studies, Data Collection, Decision Making, Female, Humans, Male, Physician-Patient Relations, Physicians, Prejudice, Schools, Medical, Social Class, Students, Medical, Unconscious, Psychology, Baltimore, Internet, Black People, White People, Young Adult

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