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Clinical Vignettes Inadequate to Assess Impact of Implicit Bias: Concerning Limitations of a Systematic Review

2017; Wiley; Volume: 24; Issue: 12 Linguagem: Inglês

10.1111/acem.13317

1553-2712

Elizabeth A. Samuels, Dowin Boatright, León D. Sánchez, Sheryl Heron, Aisha T. Liferidge, Taneisha Wilson, Ava Pierce, Alden Landry, Lisa Moreno‐Walton, Jeffrey Druck, J.L. Moll, Bernard L. Lopez,

Emergency and Acute Care Studies

To the Editor: We are writing in response to the article by Dehon et al.,1 "A Systematic Review of the Impact of Physician Implicit Racial Bias on Clinical Decision Making," in the August 2017 issue of Academic Emergency Medicine. As members of SAEM's Academy of Diversity and Inclusion in Emergency Medicine, we believe that it is imperative to pursue research on the impact of bias and discrimination on clinical practice and healthcare outcomes. While we commend Dehon and colleagues for their effort to assess the impact of implicit bias on clinical decision making, we do not think that the evidence reviewed supports the breadth of their conclusions. Systematic reviews are significantly impacted by the quality of reviewed studies. The absence of quality research evidence impedes researchers' ability to draw meaningful conclusions.2 The source articles reviewed by Dehon et al. suffers from this limitation. Most reviewed studies (8/9) utilized artificial clinical vignettes. While clinical vignettes may test fund of knowledge, there is no high-quality evidence that suggests that vignettes accurately measure real-world clinical decision making.3 In fact, given susceptibility to social desirability bias, they may overestimate clinical performance.4 Although Dehon et al. acknowledge the limitations of clinical vignettes, they conclude that "the current state of the evidence suggests that physicians' implicit biases do not impact their clinical decision making." An overall lack of an association is not equivalent to concluding there is no impact on clinical decision making. Concluding that implicit bias has no impact on clinical decision making without high-quality evidence is potentially dangerous. It suggests that we can ignore our unconscious biases, thus potentially increasing the health disparities that are well documented in the literature and described by Dr. Dehon. We agree with Meisel's narrative summary that "Without conducting ethnography (observing providers in their real work environments) we can't know how their implicit biases translate into differential care for patients." Research outside of medicine has demonstrated that implicit bias impacts real-world decision making.5 Given the "widely documented evidence of an association between race and differential treatment decisions across clinical settings,"1 there is no reason to believe that physicians are immune to this phenomenon. The differential between real-world racial disparities and the findings of the reviewed studies should lead the authors not to a conclusion about implicit bias and clinical decision making, but rather to one about the accuracy of vignettes to assess real-world clinical decision making. Implicit bias has the potential to cause significant harm in our clinical practice, which is subject to cognitive overload and requires snap-judgment decision making. This could lead to complacency in holding ourselves accountable when bias becomes a part of the physician–patient and health systems encounters. We agree with Dr. Dehon that there is significant work to be done to eliminate racial health inequalities and, to that end, understand the role of implicit bias in clinical decision making. We look forward to partnering in this pursuit.