Racial Implicit Bias and Communication Among Physicians in a Simulated Environment.

Importance: Racial implicit bias can contribute to health disparities through its negative influence on physician communication with Black patients. Interventions for physicians to address racial implicit bias in their clinical encounters are limited by a lack of high-fidelity (realistic) simulations to provide opportunities for skill development and practice. Objective: To describe the development and initial evaluation of a high-fidelity simulation of conditions under which physicians might be influenced by implicit racial bias. Design, Setting, and Participants: This cross-sectional study, performed on an online platform from March 1 to September 30, 2022, recruited a convenience sample of physician volunteers to pilot an educational simulation. Exposures: In the simulation exercise, physicians saw a 52-year-old male standardized patient (SP) (presenting as Black or White) seeking urgent care for epigastric pain, nausea, and vomiting. The case included cognitive stressors common to clinical environments, including clinical ambiguity, stress, time constraints, and interruptions. Physicians explained their diagnosis and treatment plan to the SP, wrote an assessment and management plan, completed surveys, and took the Race Implicit Association Test (IAT) and Race Medical Cooperativeness IAT. The SPs, blinded to the purpose of the study, assessed each physician's communication using skills checklists and global rating scales. Main Outcomes and Measures: Association between physicians' IAT scores and SP race with SP ratings of communication skills. Results: In 60 physicians (23 [38.3%] Asian, 4 [6.7%] Black, 23 [38.3%] White, and 10 [16.7%] other, including Latina/o/x, Middle Eastern, and multiracial; 31 [51.7%] female, 27 [45.0%] male, and 2 [3.3%] other), the interaction of physicians' Race IAT score and SP race was significant for overall communication (mean [SD] ß = -1.29 [0.41]), all subdomains of communication (mean [SD] ß = -1.17 [0.52] to -1.43 [0.59]), and overall global ratings (mean [SD] ß = -1.09 [0.39]). Black SPs rated physicians lower on communication skills for a given pro-White Race IAT score than White SPs; White SP ratings increased as physicians' pro-White bias increased. Conclusions and Relevance: In this cross-sectional study, a high-fidelity simulation calibrated with cognitive stressors common to clinical environments elicited the expected influence of racial implicit bias on physicians' communication skills. The outlined process and preliminary results can inform the development and evaluation of interventions that seek to address racial implicit bias in clinical encounters and improve physician communication with Black patients.

Don't Judge a Book by Its Cover.

Recognizing bias as the biggest hidden threat to patient safety.

Oncologist Perceptions of Racial Disparity, Racial Anxiety, and Unconscious Bias in Clinical Interactions, Treatment, and Outcomes.

BACKGROUND: Cancer spares no demographic or socioeconomic group; it is indeed the great equalizer. But its distribution is not equal; when structural discrimination concentrates poverty and race, zip code surpasses genetic code in predicting outcomes. Compared with White patients in the United States, Black patients are less likely to receive appropriate treatment and referral to clinical trials, genetic testing, or palliative care/hospice. METHODS: In 2021, we administered a survey to 369 oncologists measuring differences in perceptions surrounding racial disparity, racial anxiety, and unconscious bias and adverse influence on clinical interactions, treatment, and outcomes for non-White patients. We analyzed responses by generational age group, sex/gender, race/ethnicity, US region, and selection of "decline to respond." RESULTS: The most significant differences occurred by age group followed by race/ethnicity. Racial disparity was perceived as moderate to very high by 84% of millennial, 69% of Generation X, and 57% of baby boomer oncologists, who were also 86% more likely than millennials and 63% more likely than Generation Xers to perceive low/nonexistent levels of racial anxiety/unconscious bias. CONCLUSIONS: Most oncologists rarely or never perceived racial anxiety/unconscious bias as adversely influencing clinical treatment or survival outcomes in non-White patients, and White oncologists were 85% more likely than non-White oncologists to perceive rare/nonexistent influence on referral of non-White patients to palliative care/hospice. The discrepancy between 62% of oncologists perceiving moderate to very high levels of racial anxiety/unconscious bias and 37% associating them with adverse influence on non-White patients shows a disconnect, especially among older oncologists (baby boomers), who were also least likely to select the decline option. Together, these factors hinder effective patient-provider communication and result in differential care and outcomes. Oncologists should uncover their own perceptions surrounding racial disparity, racial anxiety, and unconscious bias and modify their behaviors accordingly. It is this simple-and this complicated. Cancer does not discriminate, and neither should cancer care.

Racial implicit bias: Perspectives of nursing students.

BACKGROUND: Racial implicit bias contributes to healthcare disparities. While research has been conducted on other health professionals, there is a lack of evidence about nursing students' experiences with racial implicit bias. PURPOSE: This study described the perspectives of pre-licensure nursing students regarding racial implicit bias (RIB) and its impact on patient care. METHOD: A qualitative descriptive methodology utilizing focus groups was used to describe the students' perspectives. RESULTS: Data analysis revealed three main themes: RIB may not be on purpose, but wrong is wrong; Bad nurse versus good nurse; and This is not okay. CONCLUSION: As RIB continues to contribute to health care disparities, this study reveals the need for it to be addressed in nursing education, while students prepare to be front line health care professionals.

Sports Medicine Patient Experience: Implicit Bias Mitigation and Communication Strategies.

Unconscious bias, also known as implicit bias, is the principal contributor to the perpetuation of discrimination and is a robust determinant of people's decision-making. Unconscious bias occurs despite conscious nonprejudiced intentions and interferes with the actions of the reflective and conscious side. Education and self-awareness about implicit bias and its potentially harmful effects on judgment and behavior may lead individuals to pursue corrective action and follow implicit bias mitigation communication strategies. Team physicians must follow existing communication strategies and guidelines to mitigate unconscious bias and begin an evolution toward nonbiased judgment and decision-making to improve athlete care.

Exploring implicit bias among ENT surgeons: an analysis of the implicit association test.

OBJECTIVE: This study aimed to investigate the presence of implicit bias among ENT surgeons and explore the impact of the results of the Implicit Association Test on the surgeons' behaviour towards patients. METHOD: Seven ENT surgeons who were not black, Asian or minority ethnic were asked to complete the Race Implicit Association Test. The surgeons also completed a survey about their perceptions of their implicit biases and the impact of the Race Implicit Association Test results on their behaviour towards patients. RESULTS: The mean Race Implicit Association Test score for the ENT surgeons suggested a slight bias that favoured white over black people. Furthermore, 42 per cent of the surgeons thought that they had hidden or unconscious racial bias, 42 per cent said they would change their behaviour towards patients after receiving these results and 85 per cent thought that the Race Implicit Association Test was helpful for appraisal purposes. CONCLUSION: The results suggest that ENT surgeons who are not black, Asian or minority ethnic may have implicit biases towards black patients. These findings highlight the need for interventions to reduce implicit bias among ENT surgeons and improve healthcare outcomes for marginalised populations.

Implicit Bias Toward Lesbian and Gay Persons Among Nursing Students: A Correlation Study.

AIM: The purpose of this study was to measure implicit bias among nursing students toward lesbian and gay (LG) persons. BACKGROUND: Implicit bias is identified as a contributor to the health disparities experienced by LG persons. This bias has not been studied among nursing students. METHOD: This descriptive, correlation study used the Implicit Association Test to measure implicit bias in a convenience sample of baccalaureate nursing students. Demographic information was collected to identify relevant predictor variables. RESULTS: Implicit bias in this sample ( n = 1,348) favored straight persons over LG persons ( D -score = 0.22). Participants identifying as male ( B = 0.19), straight ( B = 0.65), other sexuality ( B = 0.33), somewhat ( B = 0.09) or very religious ( B = 0.14), or enrollment in an RN-BSN program ( B = 0.11) predicted stronger bias favoring straight persons. CONCLUSION: Implicit bias toward LG persons among nursing students remains a challenge for educators.

Implicit bias in diagnosing mosaicism amongst preimplantation genetic testing providers: results from a multicenter study of 36 395 blastocysts.

STUDY QUESTION: Does the diagnosis of mosaicism affect ploidy rates across different providers offering preimplantation genetic testing for aneuploidies (PGT-A)? SUMMARY ANSWER: Our analysis of 36 395 blastocyst biopsies across eight genetic testing laboratories revealed that euploidy rates were significantly higher in providers reporting low rates of mosaicism. WHAT IS KNOWN ALREADY: Diagnoses consistent with chromosomal mosaicism have emerged as a third category of possible embryo ploidy outcomes following PGT-A. However, in the era of mosaicism, embryo selection has become increasingly complex. Biological, technical, analytical, and clinical complexities in interpreting such results have led to substantial variability in mosaicism rates across PGT-A providers and clinics. Critically, it remains unknown whether these differences impact the number of euploid embryos available for transfer. Ultimately, this may significantly affect clinical outcomes, with important implications for PGT-A patients. STUDY DESIGN, SIZE, DURATION: In this international, multicenter cohort study, we reviewed 36 395 consecutive PGT-A results, obtained from 10 035 patients across 11 867 treatment cycles, conducted between October 2015 and October 2021. A total of 17 IVF centers, across eight PGT-A providers, five countries and three continents participated in the study. All blastocysts were tested using trophectoderm biopsy and next-generation sequencing. Both autologous and donation cycles were assessed. Cycles using preimplantation genetic testing for structural rearrangements were excluded from the analysis. PARTICIPANTS/MATERIALS, SETTING, METHODS: The PGT-A providers were randomly categorized (A to H). Providers B, C, D, E, F, G, and H all reported mosaicism, whereas Provider A reported embryos as either euploid or aneuploid. Ploidy rates were analyzed using multilevel mixed linear regression. Analyses were adjusted for maternal age, paternal age, oocyte source, number of embryos biopsied, day of biopsy, and PGT-A provider, as appropriate. We compared associations between genetic testing providers and PGT-A outcomes, including the number of chromosomally normal (euploid) embryos determined to be suitable for transfer. MAIN RESULTS AND THE ROLE OF CHANCE: The mean maternal age (±SD) across all providers was 36.2 (±5.2). Our findings reveal a strong association between PGT-A provider and the diagnosis of euploidy and mosaicism. Amongst the seven providers that reported mosaicism, the rates varied from 3.1% to 25.0%. After adjusting for confounders, we observed a significant difference in the likelihood of diagnosing mosaicism across providers (P < 0.001), ranging from 6.5% (95% CI: 5.2-7.4%) for Provider B to 35.6% (95% CI: 32.6-38.7%) for Provider E. Notably, adjusted euploidy rates were highest for providers that reported the lowest rates of mosaicism (Provider B: euploidy, 55.7% (95% CI: 54.1-57.4%), mosaicism, 6.5% (95% CI: 5.2-7.4%); Provider H: euploidy, 44.5% (95% CI: 43.6-45.4%), mosaicism, 9.9% (95% CI: 9.2-10.6%)); and Provider D: euploidy, 43.8% (95% CI: 39.2-48.4%), mosaicism, 11.0% (95% CI: 7.5-14.5%)). Moreover, the overall chance of having at least one euploid blastocyst available for transfer was significantly higher when mosaicism was not reported, when we compared Provider A to all other providers (OR = 1.30, 95% CI: 1.13-1.50). Differences in diagnosing and interpreting mosaic results across PGT-A laboratories raise further concerns regarding the accuracy and relevance of mosaicism predictions. While we confirmed equivalent clinical outcomes following the transfer of mosaic and euploid blastocysts, we found that a significant proportion of mosaic embryos are not used for IVF treatment. LIMITATIONS, REASONS FOR CAUTION: Due to the retrospective nature of the study, associations can be ascertained, however, causality cannot be established. Certain parameters such as blastocyst grade were not available in the dataset. Furthermore, certain platform-related and clinic-specific factors may not be readily quantifiable or explicitly captured in our dataset. As such, a full elucidation of all potential confounders accounting for variability may not be possible. WIDER IMPLICATIONS OF THE FINDINGS: Our findings highlight the strong need for standardization and quality assurance in the industry. The decision not to transfer mosaic embryos may ultimately reduce the chance of success of a PGT-A cycle by limiting the pool of available embryos. Until we can be certain that mosaic diagnoses accurately reflect biological variability, reporting mosaicism warrants utmost caution. A prudent approach is imperative, as it may determine the difference between success or failure for some patients. STUDY FUNDING/COMPETING INTEREST(S): This work was supported by the Torres Quevedo Grant, awarded to M.P. (PTQ2019-010494) by the Spanish State Research Agency, Ministry of Science and Innovation, Spain. M.P., L.B., A.R.L., A.L.R.d.C.L., N.P.P., M.P., D.S., F.A., A.P., B.M., L.D., F.V.M., D.S., M.R., E.P.d.l.B., A.R., and R.V. have no competing interests to declare. B.L., R.M., and J.A.O. are full time employees of IB Biotech, the genetics company of the Instituto Bernabeu group, which performs preimplantation genetic testing. M.G. is a full time employee of Novagen, the genetics company of Cegyr, which performs preimplantation genetic testing. TRIAL REGISTRATION NUMBER: N/A.

Implicit Bias in Nursing: Student Reflections.

ABSTRACT: Implicit bias can lead to health disparities related to a patient's race, religion, sexual identity, and mental illness. Students responded to the Implicit Association Test for race followed by a structured reflection. Student reflections were evaluated qualitatively. Results hold a key to future educational interventions/training to help nursing students become consciously aware of implicit biases and choose behaviors that are non-biased.

A scoping review of research on potential impact of implicit bias in healthcare settings for children with acquired brain injuries.

PURPOSE/OBJECTIVE: Acquired brain injury (ABI) is a leading cause of disability in children and adolescents. Implicit biases within pediatric ABI healthcare settings may exert negative effects on clinical interactions and medical decision-making processes. This study aimed to conduct a scoping review of current research that examines the potential impact of implicit biases in such healthcare settings for children with ABI. RESEARCH METHOD/DESIGN: Following PRISMA-ScR guidelines, a search among five databases (CINAHL, Cochrane CENTRAL, PubMed, PsycArticles, and PsycInfo) was conducted, followed by abstract/full-text screening and data extraction. Main characteristics of the included studies, including research design, relevance to implicit biases, and public health impact were synthesized. The risk of bias of included studies was assessed. RESULTS: Out of the 203 articles returned from the literature search, a total of three studies met the inclusion criteria for the present review. All studies examined the relevance of racial/ethnic biases for evaluating abusive head trauma or nonaccidental trauma. The included studies had an overall unclear to low risk of biases. CONCLUSIONS/IMPLICATIONS: This scoping review identified scarce but emerging evidence of the presence and detrimental impact of potential implicit biases on the access and quality of care received by children with ABI. More research is needed to examine the causes, process mechanisms, and consequences of implicit biases in pediatric ABI healthcare settings. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Elephant in the Room: Racial Microaggressions and Implicit Bias in Surgical Training.

OBJECTIVE: The aim of this study was to examine the association between race, experience of microaggressions, and implicit bias in surgical training. BACKGROUND: There is persistent underrepresentation of specific racial and ethnic groups in the field of surgery. Prior research has demonstrated significant sex differences among those who experience microaggressions during training. However, little research has been conducted on the association between race and experiences of microaggressions and implicit bias among surgical trainees. METHODS: A 46-item survey was distributed to general surgery residents and residents of surgical subspecialties through the Association of Program Directors in Surgery listserv and social media platforms. The questions included general information/demographic data and information about experiencing, witnessing, and responding to microaggressions during surgical training. The primary outcome was the prevalence of microaggressions during surgical training by self-disclosed race. Secondary outcomes were predictors of and adverse effects of microaggressions. RESULTS: A total of 1624 resident responses were obtained. General surgery residents comprised 825 (50.8%) responses. The female-to-male ratio was nearly equal (815:809). The majority of respondents identified as non-Hispanic White (63.4%), of which 5.3% of residents identified as non-Hispanic Black, and 9.5% identified as Hispanic. Notably, 91.9% of non-Hispanic Black residents (n=79) experienced microaggressions. After adjustment for other demographics, non-Hispanic Black residents were more likely than non-Hispanic White residents to experience microaggressions [odds ratio (OR): 8.81, P <0.001]. Similar findings were observed among Asian/Pacific Islanders (OR: 5.77, P <0.001) and Hispanic residents (OR: 3.35, P <0.001). CONCLUSIONS: Race plays an important role in experiencing microaggressions and implicit bias. As the future of our specialty relies on the well-being of the pipeline, it is crucial that training programs and institutions are proactive in developing formal methods to address the bias experienced by residents.

Does it work? Resident selection and implicit bias training for postgraduate program directors.

One element to address health disparities and historical injustices of systemically excluded groups is to examine selection processes. Implicit association testing for selection committees is suggested as one intervention to address bias in selection and is used for Undergraduate Medical Education at the University of Manitoba. Our study demonstrated that implicit bias training for PDs in isolation has minimal impact on addressing bias within resident selection. This training must occur as part of a systemic institutional approach to address bias in resident selection. Programs should consider a multipronged and sustained approach when committing to diversifying postgraduate medical education programs.

Le processus de sélection est un des éléments à revoir pour lutter contre les inégalités en matière de santé et les injustices historiques dont souffrent les populations victimes d'exclusion systémique. Une des mesures suggérées pour contrer le biais de sélection est de soumettre les membres des comités de sélection à des tests d'association implicite. Ils sont utilisés à l'Université du Manitoba au programme d'études médicales de premier cycle. Or, notre étude montre qu'une formation en matière de biais implicites, lorsqu'elle est offerte de manière isolée aux directeurs de programme, a peu d'impact sur l'élimination des préjugés dans la sélection des résidents. Les programmes qui désirent favoriser la diversité doivent envisager une approche multidimensionnelle et soutenue.

Reducing implicit bias in the neurosurgery application and interview process: a single-institution experience.

OBJECTIVE: The neurosurgical match is a challenging process for applicants and programs alike. Programs must narrow a wide field of applicants to interview and then determine how to rank them after limited interaction. To streamline this, programs commonly screen applicants using United States Medical Licensing Examination (USMLE) Step scores. However, this approach removes nuance from a consequential decision and exacerbates existing biases. The primary objective of this study was to demonstrate the feasibility of effecting minor modifications to the residency application process, as the authors have done at their institution, specifically by reducing the prominence of USMLE board scores and Alpha Omega Alpha (AΩA) status, both of which have been identified as bearing racial biases. METHODS: At the authors' institution, residents and attendings holistically reviewed applications with intentional redundancy so that every file was reviewed by two individuals. Reviewers were blinded to applicants' photographs and test scores. On interview day, the applicant was evaluated for their strength in three domains: knowledge, commitment to neurosurgery, and integrity. For rank discussions, applicants were reviewed in the order of their domain scores, and USMLE scores were unblinded. A regression analysis of the authors' rank list was made by regressing the rank list by AΩA status, Step 1 score, Step 2 score, subinternship, and total interview score. RESULTS: No variables had a significant effect on the rank list except total interview score, for which a single-point increase corresponded to a 15-position increase in rank list when holding all other variables constant (p < 0.05). CONCLUSIONS: The goal of this holistic review and domain-based interview process is to mitigate bias by shifting the focus to selected core qualities in lieu of traditional metrics. Since implementation, the authors' final rank lists have closely reflected the total interview score but were not significantly affected by board scores or AΩA status. This system allows for the removal of known sources of bias early in the process, with the aim of reducing potential downstream effects and ultimately promoting a final list that is more reflective of stated values.

Overlooked and Damaging Impact of Structural Racism and Implicit Bias on US Health Care: Overarching Policy Implications.

ABSTRACT: Marginalized populations, including racial and ethnic minorities, have historically faced significant barriers to accessing quality health care because of structural racism and implicit bias. A brief review and analysis of past and historic and current policies demonstrate that structural racism and implicit bias continue to underscore a health system characterized by unequal access and distribution of health care resources. Although advances in cancer care have led to decreased incidence and mortality, not all populations benefit. New policies must explicitly seek to eliminate disparities and drive equity for historically marginalized populations to improve access and outcomes.

Perceptions of healthcare professionals and students about interventions addressing implicit bias and microaggression: A mixed-studies systematic review.

AIM: To consolidate and appraise available evidence on the experiences and perceptions of healthcare professionals and students about the interventions addressing implicit bias and microaggression in the clinical setting. BACKGROUND: Patient-perpetrated acts of implicit bias and microaggression have profound effects on healthcare professionals' and students' mental health. However, the efficacy of interventions targeted at addressing implicit bias and microaggression requires further scrutiny. DESIGN: Mixed-studies systematic review. METHODS: A comprehensive search was conducted on PubMed, EMBASE, CINAHL, Scopus, Web of Science, PsycINFO, Cochrane Library, ProQuest (Social Science Premium Collection Database), ProQuest (Dissertations and Theses Global), and ClinicalTrials.gov. Study selection, quality appraisal using the mixed methods appraisal tool, and data extraction were performed. Narrative and thematic synthesis were used to analyze quantitative and qualitative findings respectively. A results-based convergent approach was employed to integrate findings from both research designs. RESULTS: A total of 23 studies were included, involving 4667 healthcare professionals and students. There were 17 quantitative studies and six mixed-method studies of varying methodological quality. This review presented findings on healthcare professionals' and students' experiences and perceptions of the efficacy of the interventions targeted at addressing implicit bias and microaggression. Two themes were identified: 1) A safe space leading to enhanced confidence, and 2) what and why the interventions worked. CONCLUSION: Our review findings found that healthcare professionals and students generally had a positive view of implicit bias and microaggression interventions in the realm of helping them gain knowledge and confidence to identify and respond to biased clinical encounters. This review could provide insights for administrators and institutions to provide such interventions in mitigating the impact of implicit bias and microaggression on healthcare staff and students. Future research should focus on comparing the views of participants from varied geographical and cultural backgrounds, and those with different healthcare disciplines.

Language Frames and Shapes the Response to Obesity.

Because the scientific understanding of obesity has grown, explicit expressions of weight bias have steadily become less acceptable. However, implicit weight bias and stigma remain common impediments to health. Language frames the public perception of obesity. It is problematic when public discourse or scientific publications reflect misinformation or bias against people with obesity because this can promote stigma and barriers to health. Examples of stigmatizing language include descriptions of obesity as an identity rather than a disease, language that describes obesity as a crisis or a cause for panic, and excessive focus on weight or appearance rather than health outcomes.