Unconscious race and class bias: its association with decision making by trauma and acute care surgeons

J Trauma Acute Care Surg. 2014 Sep;77(3):409-16. doi: 10.1097/TA.0000000000000392.


Background: Recent studies have found that unconscious biases may influence physicians' clinical decision making. The objective of our study was to determine, using clinical vignettes, if unconscious race and class biases exist specifically among trauma/acute care surgeons and, if so, whether those biases impact surgeons' clinical decision making.

Methods: A prospective Web-based survey was administered to active members of the Eastern Association for the Surgery of Trauma. Participants completed nine clinical vignettes, each with three trauma/acute care surgery management questions. Race Implicit Association Test (IAT) and social class IAT assessments were completed by each participant. Multivariable, ordered logistic regression analysis was then used to determine whether implicit biases reflected on the IAT tests were associated with vignette responses.

Results: In total, 248 members of the Eastern Association for the Surgery of Trauma participated. Of these, 79% explicitly stated that they had no race preferences and 55% stated they had no social class preferences. However, 73.5% of the participants had IAT scores demonstrating an unconscious preference toward white persons; 90.7% demonstrated an implicit preference toward upper social class persons. Only 2 of 27 vignette-based clinical decisions were associated with patient race or social class on univariate analyses. Multivariable analyses revealed no relationship between IAT scores and vignette-based clinical assessments.

Conclusion: Unconscious preferences for white and upper-class persons are prevalent among trauma and acute care surgeons. In this study, these biases were not statistically significantly associated with clinical decision making. Further study of the factors that may prevent implicit biases from influencing patient management is warranted.

Level of evidence: Epidemiologic study, level II.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Data Collection
  • Decision Making
  • Female
  • Healthcare Disparities / statistics & numerical data
  • Humans
  • Male
  • Prejudice / statistics & numerical data*
  • Racial Groups / statistics & numerical data
  • Racism / statistics & numerical data*
  • Social Class*
  • Surveys and Questionnaires
  • Traumatology / statistics & numerical data*
  • United States / epidemiology