Implicit bias among physicians and its prediction of thrombolysis decisions for Black and White patients
Open accessAbstract
CONTEXT: Studies documenting racial/ethnic disparities in health care frequently implicate physicians' unconscious biases. No study to date has measured physicians' unconscious racial bias to test whether this predicts physicians' clinical decisions. OBJECTIVE: To test 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. DESIGN, SETTING, AND PARTICIPANTS: An internet-based tool comprising a clinical vignette of a patient presenting to the emergency department with an acute coronary syndrome, followed by a questionnaire and three Implicit Association Tests (IATs). Study invitations were e-mailed to all internal medicine and emergency medicine residents at four academic medical centers in Atlanta and Boston; 287 completed the study, met inclusion criteria, and were randomized to either a black or white vignette patient. MAIN OUTCOME MEASURES: IAT scores (normal continuous variable) measuring physicians' implicit race preference and perceptions of cooperativeness. Physicians' attribution of symptoms to coronary artery disease for vignette patients with randomly assigned race, and their decisions about thrombolysis. Assessment of physicians' explicit racial biases by questionnaire. RESULTS: Physicians reported no explicit preference for white versus black patients or differences in perceived cooperativeness. In contrast, IATs revealed implicit preference favoring white Americans (mean IAT score = 0.36, P < .001, one-sample t test) and implicit stereotypes of black Americans as less cooperative with medical procedures (mean IAT score 0.22, P < .001), and less cooperative generally (mean IAT score 0.30, P < .001). As physicians' prowhite implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis (P = .009). CONCLUSIONS: This study represents the first evidence of unconscious (implicit) race bias among physicians, its dissociation from conscious (explicit) bias, and its predictive validity. Results suggest that physicians' unconscious biases may contribute to racial/ethnic disparities in use of medical procedures such as thrombolysis for myocardial infarction.
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Four studies examining the correlation between IAT scores and responses to clinical vignettes found a significant correlation between high levels of pro-white implicit bias and treatment responses that favoured patients specified as white.
“Four studies examining the correlation between IAT scores and responses to clinical vignettes found a significant correlation between high levels of pro-white implicit bias and treatment responses that favoured patients specified as white [42, 45–47].”
From Implicit bias in healthcare professionals: a systematic review (2017) · cites this paper as [46]
Implicit biases are linked to discriminatory outcomes ranging from poorer quality interactions to constrained employment opportunities and a decreased likelihood of receiving life-saving emergency medical treatments.
“accumulating evidence reveals that implicit biases are linked to discriminatory outcomes ranging from the seemingly mundane, such as poorer quality interactions (McConnell & Leibold, 2001), to the obviously consequential, such as constrained employment opportunities (Bertrand & Malainathan, 2004) and a decreased likelihood of receiving life-saving emergency medical treatments (Green et al., 2007).”
From Long-term reduction in implicit race bias: A prejudice habit-breaking intervention (2012) · cites this paper as Green et al., 2007
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- Authors
- Green, A. R., Carney, D. R., Pallin, D. J., Ngo, L. H., Raymond, K. L., Iezzoni, L. I., & Banaji, M. R.
- Affiliations
- Harvard University (US)
- Brigham and Women's Hospital (US)
- Beth Israel Deaconess Medical Center (US)
- University of North Carolina at Chapel Hill (US)
- Corresponding author
- Green, Alexander R.
- Venue
- Journal of General Internal Medicine
- Published
- 2007-06-27
- Volume
- 22
- Issue
- 9
- Pages
- 1231-1238
- ISSN
- 0884-8734 (ISSN-L)
- 1525-1497
- PMC
- PMC2219763
- OpenAlex
- W2060824655
- Cited by
- 1,460
- References
- 31
- Citations by year
- 2026: 33 · 2025: 63 · 2024: 116 · 2023: 124 · 2022: 109 · 2021: 126 · 2020: 111 · 2019: 97 · 2018: 98 · 2017: 93 · 2016: 83 · 2015: 93 · 2014: 59 · 2013: 47 · 2012: 47
- FWCI
- 125.97
- Type
- journal article
- Language
- en
- Open access
- hybrid
- doi.org
- Licence
- Locations
- Journal of General Internal Medicine (publishedVersion, cc-by-nc)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Digital Access to Scholarship at Harvard (DASH) (Harvard University) (submittedVersion, cc-by)
- DigitalGeorgetown (Georgetown University Library) (submittedVersion)
- Funders
- Brigham and Women's Hospital
- Massachusetts General Hospital
- Emory University
- Harvard University
- Mind Science Foundation
- U.S. Public Health Service (T32 HP11001-15)
- National Heart, Lung, and Blood Institute (HL-0000013)
- National Institute of Mental Health
- 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
- implicit bias, racial bias, physicians, thrombolysis, acute coronary syndrome, racial disparities, Implicit Association Test, emergency medicine residents, internal medicine residents, Black patients, myocardial infarction, stereotyping, clinical decision-making
- MeSH terms
- Adult, Black or African American, Cardiovascular Diseases, Female, Humans, Male, Physicians, Predictive Value of Tests, Prejudice, Surveys and Questionnaires, Thrombolytic Therapy, Black People, White People
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