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The Influence of Implicit Bias on Treatment Recommendations for 4 Common Pediatric Conditions: Pain, Urinary Tract Infection, Attention Deficit Hyperactivity Disorder, and Asthma
Open accessAbstract
Objectives. We examined the association between pediatricians’ attitudes about race and treatment recommendations by patients’ race. Methods. We conducted an online survey of academic pediatricians (n = 86). We used 3 Implicit Association Tests to measure implicit attitudes and stereotypes about race. Dependent variables were recommendations for pain management, urinary tract infections, attention deficit hyperactivity disorder, and asthma, measured by case vignettes. We used correlational analysis to assess associations among measures and hierarchical multiple regression to measure the interactive effect of the attitude measures and patients’ race on treatment recommendations. Results. Pediatricians’ implicit (unconscious) attitudes and stereotypes were associated with treatment recommendations. The association between unconscious bias and patient’s race was statistically significant for prescribing a narcotic medication for pain following surgery. As pediatricians’ implicit pro-White bias increased, prescribing narcotic medication decreased for African American patients but not for the White patients. Self-reported attitudes about race were associated with some treatment recommendations. Conclusions. Pediatricians’ implicit attitudes about race affect pain management. There is a need to better understand the influence of physicians’ unconscious beliefs about race on pain and other areas of care.
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“eight articles appeared to refer to the same data collected in a single cross-country comparison study [27–32, 34, 35] and a further two articles analysed the same data [45, 47].”
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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 [42, 45–47].”
From Implicit bias in healthcare professionals: a systematic review (2017) · cites this paper as [45]
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Pediatric Fracture Epidemiology and US Emergency Department Resource Utilization
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González, C. M., Nava, S., List, J., Liguori, A., & Marantz, P. R. (2021) · MedEdPORTAL · doi:10.15766/mep_2374-8265.11162 · Cited by 23
Factors Influencing Time-to-Diagnosis of Biliary Atresia
Harpavat, S., Lupo, P., Liwanag, L., Hollier, J. M., Brandt, M., Finegold, M., & Shneider, B. (2018) · Journal of Pediatric Gastroenterology and Nutrition - JPGN · doi:10.1097/mpg.0000000000001887 · Cited by 23
“recognized in other pediatric disease, but their role in BA has not been explored (22).”
BackgroundRace and Ethnicity and Clinician Linguistic Expressions of Doubt in Hospital Admission Notes
Lee, C. R., Aysola, J., Chen, X., Addisu, E., Klein, A. Z., Weissenbacher, D., Gonzalez‐Hernandez, G., & Weissman, G. E. (2024) · JAMA Network Open · doi:10.1001/jamanetworkopen.2024.38550 · Cited by 22
Adherence to the 2017 Clinical Practice Guidelines for Pediatric Hypertension in Safety-Net Clinics
Carroll, A. J., Tedla, Y., Padilla, R., Jain, A., Segovia, E., Moin, A., Wallace, A., Sanuade, O., Langman, C., Mohanty, N., et al. (2023) · JAMA Network Open · doi:10.1001/jamanetworkopen.2023.7043 · Cited by 22
Patient Preference and Risk Assessment in Opioid Prescribing Disparities
Engel‐Rebitzer, E., Dolan, A. R., Aronowitz, S. V., Shofer, F. S., Tiako, M. J. N., Schapira, M. M., Perrone, J., Hess, E. P., Rhodes, K. V., Bellamkonda, V. R., et al. (2021) · JAMA Network Open · doi:10.1001/jamanetworkopen.2021.18801 · Cited by 29
Quigley, A., Hutton, J., Phillips, G. A., Dreise, D., Mason, T., Garvey, G., & Paradies, Y. (2020) · Emergency Medicine Australasia · doi:10.1111/1742-6723.13691 · Cited by 22
“Five studies only acquired data from a single site.(23,25,26,28,29) Comparability across studies is difficult due to known confounding variables of clinical education and experience, with only one study adequately controlling for confounding variables.”
BackgroundMethodInfluentialJindal, M., Heard-Garris, N., Empey, A., Perrin, E., Zuckerman, K., & Johnson, T. J. (2020) · Academic pediatrics · doi:10.1016/j.acap.2020.08.019 · Cited by 22
West, R., & Bartkowski, J. (2019) · Societies · doi:10.3390/soc9020045 · Cited by 22
Engaging African ancestry participants in SLE clinical trials
Anjorin, A. C., & Lipsky, P. E. (2018) · Lupus Science & Medicine · doi:10.1136/lupus-2018-000297 · Cited by 23
A Primer on the Psychology of Cognitive Bias
MacLean, C. L., & Dror, I. E. (2016) · Elsevier eBooks · doi:10.1016/b978-0-12-802460-7.00001-2 · Cited by 26
“BLINDING AND BIAS biases can subtly guide treatment choices (Sabin and Greenwald, 2012).”
BackgroundTajeu, G., Halanych, J., Juarez, L., Stone, J., Stepanikova, I., Green, A., & Cherrington, A. (2018) · Journal of the National Medical Association · doi:10.1016/j.jnma.2017.12.001 · Cited by 21
Outcomes Following Surgical Management of Cauda Equina Syndrome: Does Race Matter?
Jain, A., Menga, E. N., & Mesfin, A. (2018) · Journal of Racial and Ethnic Health Disparities · doi:10.1007/s40615-017-0369-6 · Cited by 21
“Implicit bias has been attributed to decreased rates of thrombolysis for AfricanAmerican patients compared to Caucasian patients as well as decrease pain medication administration for AfricanAmerican children compared to Caucasian children [33, 34].”
BackgroundTrends and Disparities in Postpartum Sterilization after Cesarean Section, 2000 through 2008.
Garcia, G., Richardson, D., Gonzales, K. L., & Cuevas, A. (2015) · Women's health issues · doi:10.1016/j.whi.2015.07.006 · Cited by 21
“In fact, studies have increasingly shown that providers manifest negative stereotypes of minority patients, which influence decision making (Chapman, Kaatz, & Carnes, 2013; Sabin & Greenwald, 2012; Shavers et al., 2012; Smedley et al., 2009).”
Counting the lives lost: how many black trauma deaths are attributable to disparities?
Scott, V. K., Hashmi, Z. G., Schneider, E. B., Hui, X., Efron, D. T., Cornwell, E. E., Cooper, L. A., & Haider, A. H. (2013) · Journal of Surgical Research · doi:10.1016/j.jss.2013.04.080 · Cited by 22
Racial color blindness and Black-White health care disparities.
Penner, L., & Dovidio, J. (2016) · American Psychological Association eBooks · doi:10.1037/14754-017 · Cited by 21
Beni, C., Rice-Townsend, S. E., Esangbedo, I. D., Jancelewicz, T., Vogel, A., Newton, C. R., Boomer, L. A., & Rothstein, D. (2023) · Pediatric Critical Care Medicine · doi:10.1097/pcc.0000000000003322 · Cited by 20
“It is also not limited to the care of adult patients, with studies demonstrating implicit bias in the care of pediatric patients across different clinical settings (39, 40).”
BackgroundPain sensitivity differs between dog breeds but not in the way veterinarians believe
Caddiell, R. M. P., Cunningham, R. M., White, P. A., Lascelles, B. D. X., & Gruen, M. E. (2023) · Frontiers in Pain Research · doi:10.3389/fpain.2023.1165340 · Cited by 20
González, C. M., Onumah, C. M., Walker, S. A., Karp, E., Schwartz, R., & Lypson, M. L. (2022) · Advances in Health Sciences Education · doi:10.1007/s10459-022-10168-w · Cited by 22
“…medical decision-making (Blair et al., 2013; Colon-Emeric et al., 2017; Cooper et al., 2012; Daugherty et al., 2017; Green et al., 2007; Hagiwara et al., 2017; Hausmann et al., 2015; Penner et al., 2016; Sabin & Greenwald, 2012; Sabin et al., 2008; Stepanikova, 2012; Zestcott et al., 2016).”
Hagiwara, N., Duffy, C., & Quillin, J. M. (2022) · Journal of Genetic Counseling · doi:10.1002/jgc4.1648 · Cited by 20
“Likewise, the variability in implicit racial stereotyping in our overall sample of genetic counselors (SD = 0.37) was similar to that in two samples of physicians (SDs = 0.39– 0.42; Green et al., 2007; Sabin & Greenwald, 2012).”
BackgroundMethodResultInfluentialAcosta, D. A., & Skorton, D. J. (2021) · The American Journal of Medicine · doi:10.1016/j.amjmed.2021.04.034 · Cited by 28
Odonkor, C. A., Leitner, B. P., Taraben, S., Adekoya, P., Orhurhu, V., Hirani, S., Ike, K., Lee, R., Vanterpool, S. G., Goree, J. H., et al. (2021) · Pain Medicine · doi:10.1093/pm/pnab004 · Cited by 22
“Other reports suggest that implicit bias affects the care received by ethnic and racial minorities [12, 13].”
BackgroundLloyd, E. P., Lloyd, A. R., Mcconnell, A. R., & Hugenberg, K. (2021) · Social Psychology and Personality Science · doi:10.1177/19485506211045887 · Cited by 19
“…several mechanisms underlying racial disparities in pain treatment (and medical care more broadly), including prejudice (Penner et al., 2010; Sabin et al., 2008), stereotyping (Hoffman et al., 2016; Moskowitz et al., 2012), empathy gaps (Drwecki et al., 2011), and differential health care…”
BackgroundWolsiefer, K. J., Mehl, M., Moskowitz, G., Cagno, C. K., Zestcott, C. A., Tejeda-Padron, A., & Stone, J. (2021) · Health Communication · doi:10.1080/10410236.2021.1936756 · Cited by 19
Triage Accuracy in Pediatrics Using the Emergency Severity Index
Frankenberger, W. D., Zorc, J. J., Have, E. D. T., Brodecki, D., & Faig, W. G. (2023) · Journal of Emergency Nursing · doi:10.1016/j.jen.2023.11.009 · Cited by 20
Harrington, Y., Rauch, D. A. A., & Leary, J. C. (2023) · Hospital Pediatrics · doi:10.1542/hpeds.2021-006471 · Cited by 20
Caring for providers to improve patient experience (CPIPE): intervention development process
Afulani, P. A., Oboke, E. N., Ogolla, B. A., Getahun, M., Kinyua, J., Oluoch, I., Odour, J., & Ongeri, L. (2022) · Global Health Action · doi:10.1080/16549716.2022.2147289 · Cited by 19
Clarke, G., Chapman, E., Crooks, J., Koffman, J., Ahmed, S., & Bennett, M. (2022) · BMC Palliative Care · doi:10.1186/s12904-022-00923-6 · Cited by 23
“The wider literature outside of palliative care has also shown that some clinicians hold false beliefs about biological differences in pain experience between Black people and White people (such as “Black peoples’ nerve endings are less sensitive than white peoples’ nerve endings”), and these beliefs have been shown t…”
BackgroundGraetz, D., Madni, A., Gossett, J., Kang, G., Sabin, J., Santana, V., & Russo, C. (2020) · Cancer · doi:10.1002/cncr.33268 · Cited by 18
“Although CVs are constrained in their ability to represent or convey nuances of real-life clinical care, they are a tool used to study medical decision making and have been used in similar studies.(12) Our vignettes were designed specifically for the current study and thus were not previously used or pretested, which…”
BackgroundMethodSelf-citationWilliams, R. L., Vasquez, C. E., Getrich, C. M., Kano, M. A., Boursaw, B., Krabbenhoft, C., & Sussman, A. L. (2018) · Journal of General Internal Medicine · doi:10.1007/s11606-018-4543-2 · Cited by 21
When Bad News Isn’t Necessarily Bad: Recognizing Provider Bias When Sharing Unexpected News
Carroll, C., Carroll, C., Goloff, N., & Pitt, M. B. (2018) · Pediatrics · doi:10.1542/peds.2018-0503 · Cited by 18
Calling Out Implicit Racial Bias as a Harm in Pediatric Care
Lang, K. R., Dupree, C. Y., Kon, A. A., & Dudzinski, D. M. (2016) · Cambridge Quarterly of Healthcare Ethics · doi:10.1017/s0963180116000190 · Cited by 21
Public Health Perspectives on Depressive Disorders
Cohen, N. L. (2017) · Johns Hopkins University Press eBooks · doi:10.1353/book.52762 · Cited by 15
Metadata
- Authors
- Sabin, J. A., & Greenwald, A. G.
- Affiliations
- University of Washington (US)
- Venue
- American Journal of Public Health
- Publisher
- American Public Health Association
- Published
- 2012-05
- Volume
- 102
- Issue
- 5
- Pages
- 988-995
- ISSN
- 0090-0036 (ISSN-L)
- 1541-0048
- PMC
- PMC3483921
- OpenAlex
- W2078029714
- Cited by
- 525
- References
- 0
- Citations by year
- 2026: 21 · 2025: 32 · 2024: 46 · 2023: 48 · 2022: 78 · 2021: 54 · 2020: 53 · 2019: 37 · 2018: 37 · 2017: 34 · 2016: 25 · 2015: 26 · 2014: 19 · 2013: 11 · 2012: 2
- FWCI
- 61.18
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- American Journal of Public Health (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- RePEc: Research Papers in Economics (submittedVersion)
- American Journal of Public Health
- Funders
- University of Washington
- Agency for Healthcare Research and Quality (R36 HS015676, 1-R36HS1576-01)
- National Institute of Mental Health (T32MH20010, T32MH020010)
- Topics
- Social Sciences › Sociology and Political Science › Racial and Ethnic Identity Research
- Social Sciences › Gender Studies › Diversity and Career in Medicine
- Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Cultural Competency in Health Care
- Keywords
- implicit bias, racial bias in medicine, pediatricians, treatment guidelines, pain management, urinary tract infection, attention deficit hyperactivity disorder, asthma, racial disparities, African American patients, opioid prescribing, Implicit Association Test, racial stereotypes
- MeSH terms
- Central Nervous System Stimulants, Analgesics, Opioid, Asthma, Attention Deficit Disorder with Hyperactivity, Attitude of Health Personnel, Black or African American, Counseling, Female, Health Services Research, Humans, Male, Pediatrics, Prejudice, Referral and Consultation, Stereotyping, Urinary Tract Infections, White People, Healthcare Disparities, Pain Management
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