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

Adil H. Haider, Eric B. Schneider, N. Sriram, Deborah S. Dossick, Valerie K. Scott, Sandra M. Swoboda, Lia Losonczy, Elliott R. Haut, David Thomas Efron, Peter J Pronovost, Julie A Freischlag, Pamela A. Lipsett, Edward E. Cornwell, Ellen J. Mackenzie, Lisa A. Cooper

Research output: Contribution to journalArticlepeer-review


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.

Original languageEnglish (US)
Pages (from-to)409-416
Number of pages8
JournalJournal of Trauma and Acute Care Surgery
Issue number3
StatePublished - Sep 2014


  • Implicit Association Test
  • Trauma
  • disparities
  • surgeon
  • unconscious bias

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine


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