Tests of ER trainees find signs of race bias in care*

*Study seeks root of known disparity*

By Stephen Smith, Boston Globe Staff | July 20, 2007



Deeply imbedded attitudes about race influence the way doctors care for
their African- American patients, according to a Harvard study that for the
first time details how unconscious bias contributes to inferior care.



Researchers have known for years that African-Americans in the midst of a
heart attack are far less likely than white patients to receive potentially
life-saving treatments such as clot-busting drugs, a dramatic illustration
of America's persistent healthcare disparities. But the reasons behind such
stark gaps in care for heart disease, as well as cancer and other serious
illnesses, have remained murky, with blame fixed on doctors, hospitals, and
insurance plans.



In the new study, trainee doctors in Boston and Atlanta took a 20-minute
computer survey designed to detect overt and implicit prejudice. They were
also presented with the hypothetical case of a 50-year-old man stricken with
sharp chest pain; in some scenarios the man was white, while in others he
was black.



"We found that as doctors' unconscious biases against blacks increased,
their likelihood of giving [clot-busting] treatment decreased," said the
lead author of the study, Dr. Alexander R. Green of Massachusetts General
Hospital. "It's not a matter of you being a racist. It's really a matter
of the way your brain processes information is influenced by things you've
seen, things you've experienced, the way media has presented things."



Specialists predict that the novel study, appearing on the website of the
Journal of General Internal Medicine, will result in considerable
soul-searching in the medical profession, rethinking of medical school
curriculum, and refresher courses for veteran doctors.



"Years of advanced education and egalitarian intentions are no protection
against the effect of implicit attitudes," said Dr. Thomas Inui, president
of the Regenstrief Institute Inc. in Indianapolis, which studies vulnerable
patient groups. "When do they surface? When we're involved with
high-pressure, high-stakes decision-making, when there's a lot riding on our
decisions but there isn't a lot of time to make them, that's when the
implicit attitudes that are not scientific rise up and grab us."



Green said he cannot explain why implicit bias would cause doctors to
deprive patients of potentially life-saving therapy, and other researchers
said they do not know how big a factor unconscious prejudice is in the
far-reaching problem of disparities.



The best way to combat those impulses is by acknowledging them, specialists
said, suggesting that medical personnel take a test to measure unconscious
bias, such as one at implicit.harvard.edu.



"The great advantage of being human, of having the privilege of awareness,
of being able to recognize the stuff that is hidden, is that we can beat the
bias," said Mahzarin R. Banaji, a Harvard psychologist who helped design a
widely used bias test.



Dr. JudyAnn Bigby, Massachusetts secretary of health and human services and
a specialist in healthcare disparities, said the study demonstrates the
importance of monitoring how hospitals and large physician practices provide
care to patients of different races.



But Inui and other specialists said that even conquering doctor bias will
not be enough to eliminate healthcare disparities.



A succession of studies during the past decade has demonstrated graphically
the scope of disparities and the complexity of the problem, which touches on
issues from poverty to geography to genetics.



Black patients in the process of having a heart attack, for example, are
only half as likely as whites to get clot-busting medication, and they are
much less likely to undergo open-heart surgery. Similarly, African-American
women receive breast-cancer screenings at a rate substantially lower than
white women. Fewer black babies live to celebrate their first birthdays: In
Massachusetts, the mortality rate for black infants is more than double the
rate for white babies.



Healthcare disparities emerged as a national issue with the 2002 release of
a landmark study titled "Unequal Treatment" that was commissioned by
Congress and produced by the Institute of Medicine. In Boston, the city
health department released a sweeping blueprint for addressing disparities
two years ago, with Mayor Thomas M. Menino describing the issue as the most
pressing health problem confronting the city.



"Most physicians are now willing to acknowledge that important disparities
exist in the healthcare system," said Dr. John Ayanian, a healthcare policy
specialist at Brigham and Women's Hospital who was not involved with the new
research. "There's still a barrier, though, to many physicians
acknowledging that disparities may exist in the care of their own patients."



It was during a lecture three years ago by Banaji that Green came up with
the idea of measuring the unconscious bias of physicians by using a test
Banaji had helped develop .



Green and his colleagues decided to test residents at Massachusetts General,
the Brigham, and Beth Israel Deaconess Medical Center in Boston, as well as
at an Atlanta hospital. Residents were told that the study was evaluating
the use of heart attack drugs in the emergency room, but not that it was
also examining racial bias; 220 trainee doctors were counted in the results.



The residents were first given a narrative describing a male patient who
shows up in the emergency room complaining of chest pains. Accompanying the
narrative was a computer-generated image of the patient, either a black or
white man shown in a hospital gown from the chest up, wearing a neutral
facial expression.



The doctors were asked if, based on the information provided, they would
diagnose the man as having a heart attack and, if so, whether they would
prescribe clot-busting drugs called thrombolytics, commonly used in
community hospitals to stabilize patients having heart attacks, and how
likely they were to give those drugs.



Study participants were also asked questions designed to determine if they
were overtly biased. Answers showed they were not.



Last, the residents took Banaji's "implicit association test," which is
based on the concept that the more strongly test-takers associate a picture
of a white or black patient with a particular concept, say cooperativeness,
the faster they will make a match. White, Asian, and Hispanic doctors were
faster to make matches between blacks and negative concepts and slower to
make matches between blacks and positive ones. The small number of African-
American physicians in the study were as likely to show bias against blacks
as against whites.



The researchers then compared the implicit association test scores with the
decisions about whether to provide the clot- busting medicine and found that
doctors whose ratings of African-Americans were most negative were also the
least likely to prescribe the drug to blacks.



Another study, scheduled to be presented by a Johns Hopkins medical
researcher in October, reaches similar results.



"At the end of the day, even among very well-intentioned people, implicit
biases can be both prevalent and in some situations can impact clinical
decisions," said Dr. Amal Trivedi, a healthcare disparities specialist at
Brown Medical School who was not involved in the study. "What this study
can do is raise awareness of that finding."



Stephen Smith can be reached at stsmith@globe.com.

And folks come on this board and say that how Blacks are portrayed in the media is not really a big deal.