Research In Action

Racism, bias, and discrimination are unfortunate facts of life in the United States, even in health care where providers' mission is to help those in need. From the years I spent as a child growing up in Trenton, N.J., to working at the New Jersey Department of Health as a summer intern in medical school, I saw first-hand how race and other social determinants can have an impact on health outcomes.

I'm leading a research team that is dedicated to improving the equity of care for children in the emergency department. We are approaching this work through three sequential phases of research that involves identifying pediatric health care disparities, understanding the sources of those disparities, and developing interventions to reduce avoidable inequities in care. Part of our research portfolio includes exploring the implicit racial bias of physicians. We have investigated the impact of cognitive stressors in the emergency department on implicit bias, as well as the bias that resident physicians have against black children – the first study of its kind.

Our findings indicate black children are as vulnerable to implicit racial bias from their health care providers as black adults are, with more than 90 percent of the physicians assessed expressing an unconscious preference for white children.

What is Implicit Bias?

Bias refers to attitudes, positive or negative, that we have towards a person, group, or idea. Those biases may exist on an explicit level, meaning they are conscious and can be self-reported, or on an implicit level, meaning attitudes that we are not conscious of, but which may still influence our behaviors. Implicit racial biases in clinical health care settings may negatively affect communication between providers and patients, disparities in treatment, patient and family satisfaction with the care provided, and compliance with the treatment recommended.

Similar to the attitudes of the general public, most physicians have unconscious biases against black adults. Healthcare providers' racial biases have been identified as a contributing factor in healthcare inequities in the U.S. However, little research has focused on bias against children in the healthcare setting. Understanding how such implicit biases affect providers' care of black versus white children will help address pediatric healthcare disparities and improve services for all children, particularly in emergency departments, where providers have no time to develop long-term relationships with patients and their families.

Due to the nature of our implicit biases being unconscious and involuntarily activated, measuring providers' implicit racial biases can be a challenge. So, we used a widely accepted tool called the Implicit Association Test (IAT), which requires participants to quickly pair two social groups with either positive or negative attributes to see if the user has an automatic preference for one group or another.

For our research, we administered Child and Adult Race IATs to 91 physicians working in a large, busy urban pediatric emergency department at a hospital in western Pennsylvania. The tests required study subjects to pair black and white faces with pleasant or unpleasant words, such as "joy","love", "wonderful", "pleasure", "laughter", and "happy" versus "terrible", "horrible", "evil", "awful", and "hurt".

Our results indicated the physicians clearly had pro-white/anti-black biases for both adults and children. Specifically, we found that 85 percent of participants had bias against black adults and 91 percent of participants had bias against black children. We also discovered that participants had similar scores on the Adult and Child Race IATs, revealing comparable levels of bias against black adults and children alike. Further, we found participants' scores didn't vary significantly according to their specialties; pediatric residents' implicit racial biases were similar to those of emergency medicine and family medicine residents, for example.

Research to Action: Next Steps

We plan to build on our findings by investigating the impact that this implicit racial bias against black children has on disparities in pediatric health care. We hope our research will contribute to the development of strategies to reduce physicians' racial biases, increase the effectiveness of clinical encounters, and improve health care outcomes for black children.

Educating healthcare providers and trainees about their unconscious attitudes is an important first step to help reduce the impact of bias on the clinical encounter. I am therefore working with CHOP's pediatric residency program leadership to help develop a curriculum focused on recognizing and combating implicit biases. We have also established an Advanced Skills in Health Equity program for pediatric residents to train the next generation of pediatricians to advance child health equity through their clinical practice, community service, and research. In addition to my research with PolicyLab and CHOP residency program educational efforts, I'm working with a phenomenal group of leaders in the American Academy of Pediatrics on the Taskforce on Addressing Bias and Discrimination to develop policy and practice recommendations.

Complete findings on our research were published earlier this year in Academic Pediatrics as well as in Social Science and Medicine.