First-year medical students show an unconscious preference toward the white race and the upper class on two tests that measure automatic responses to racial and social visual cues, according to a report in the Sept. 7 issue of JAMA.
But surprisingly, these preferences did not influence the students’ clinical assessments or decision making in a series of hypothetical medical vignettes, said the researchers, led by Dr. Adil H. Haider, codirector of the Center for Surgical Trials and Outcomes Research at the Johns Hopkins University, Baltimore.
Previous studies among older physicians have shown that such unconscious biases influence their clinical decisions, the researchers noted. For example, physicians typically prescribe fewer analgesics for black or Hispanic patients than they do for white patients, despite identical self-reported assessments of pain. In turn, these implicit preferences could be the source of some of the race- and class-based disparities in American health care, the team said.
"Unconscious biases are normal and rooted in stereotyping, a cognitive process in which individuals use a social category to acquire, process, and recall information about people," Dr. Haider and his colleagues explained.
To assess unconscious race and class biases, the team did a Web-based survey of two cohorts of 202 first-year medical students at a single institution. The study subjects responded to eight written clinical vignettes that involved assessing pain, obtaining consent for a procedure, judging the reliability of a patient or family, and assessing the trustworthiness of hypothetical patients representing two races (black and white) and two social classes (upper and lower class).
The students also took the validated, race-focused Implicit Association Test (IAT), which assesses unconscious attitudes toward racial groups by measuring reaction times to visual and language cues, and a similar but not yet validated social class–focused IAT. The study subjects also answered direct questions about their explicit racial and class biases and provided demographic information, including their own ethnicity.
As in the general population, most of the medical students reported that they had no conscious racial preferences. Only 39% said they explicitly preferred white people and 7% said they explicitly preferred black people. The subjects appeared less guarded in their self-reports of class bias, with 51% saying they explicitly preferred upper-class individuals and 12% saying they explicitly preferred lower-class individuals.
However, the IATs revealed that these conscious preferences did not correlate well with subjects’ implicit (unconscious) preferences. The IAT results showed that unconsciously, 69% of medical students preferred white people and 86% preferred upper-class individuals, which are numbers similar to those in studies of the general population.
Yet, the medical students’ responses to the medical vignettes did not reflect either their unconscious or conscious preferences. There was no association between the hypothetical patients’ race or class and the students’ responses to the clinical situations. Similarly, there was no association between the hypothetical patients’ race or class and the students’ IAT scores, the investigators said (JAMA 2011;306:942-51).
In further analyses, the researchers continued to find no impact of the students’ biases on clinical decision making. These analyses included categorizing the students’ clinical responses according to their races and self-reported social classes. Even in the subgroup of students who admitted to having explicit racial (93 students) and class (125 students) biases, no clinical–decision making effect appeared.
The findings among medical students stand in stark contrast to results among practicing physicians, where "implicit race and social class biases ... are increasingly recognized as potential factors contributing to disparities in health care," Dr. Haider and his colleagues said.
They deemed the reasons for this discrepancy between students and physicians unknown. Possibly, because the students are younger, they "have been more exposed to educational curricula focused on cultural competency, translating to improved awareness and management of implicit bias," the team said.
It also is possible that students who "have not yet been exposed to the rigors of medical training" might not yet be influenced by implicit biases, the researchers suggested.
They called for further study of whether experiences during medical training influence social or racial bias in clinical decision making. If so, "medical training could be an effective intervention point to decrease implicit biases and possibly mitigate physician-driven health care disparities," they added.
The study was supported by the National Institute of General Medical Sciences, the National Institutes of Health, the American College of Surgeons, and the National Heart, Lung, and Blood Institute. The authors reported no financial conflict of interest.