We created a web-based survey instrument that randomly assigned participants to see a picture of a black or white patient while reading a clinical vignette. From hundreds of shareware photographs, we chose 58 whose facial expressions appeared neutral. We created new patient images by morphing together these photographs using Photo Morpher Software (Morpheus Software, LLC, Santa Barbara, Calif, USA). The 21 best quality images were chosen and 19 independent evaluators (physicians, research assistants, and graduate students of various racial/ethnic backgrounds and not involved in the study) reviewed these. We chose four (two black and two white) that were most closely matched on apparent age (approximately 50 years) and attractiveness (7-point scale). The vignette (see Appendix ) describes a 50-year-old male presenting to the emergency department with chest pain and an electrocardiogram suggestive of anterior myocardial infarction. It is stated that primary angioplasty is not an option and no absolute contraindications to thrombolysis are evident.
We asked participants to rate the likelihood that the chest pain was because of coronary artery disease (CAD) (5-point scale, very unlikely to very likely), whether they would give the patient thrombolysis (yes/no), and the strength of their recommendation (5-point scale, definitely to definitely not). To assess explicit bias, the software then asked participants several questions about whether they preferred white or black Americans (5-point scale with preference expressed as somewhat or slightly prefer black or white Americans, and 10-point thermometer scale of warm feelings toward each group separately). We also asked about their beliefs about patients’ cooperativeness in general and with regard to medical procedures such as thrombolysis (5-point scale—black patients somewhat less cooperative, slightly less cooperative, equally cooperative; white patients slightly less cooperative or somewhat less cooperative). Finally, the online survey included queries about respondent demographics, effectiveness of thrombolysis, and pre- and posttest opinions on unconscious bias and IATs. The vignettes and survey are available upon request.
Participants also completed three IATs corresponding to the explicit bias questions. The Race Preference IAT measured implicit association of white and black race with good and bad terms. We created the next two IATs specifically for this study. The Race Cooperativeness IAT measured implicit associations between race and general cooperativeness. The Race Medical Cooperativeness IAT measured implicit associations between race and cooperativeness with medical recommendations. All IAT scores are expressed as normally distributed continuous variables. For efficiency we used a 5-block structure for the IATs, with the specific pairing received first (e.g., black-bad/white-good) counterbalanced across participants. We scored IATs according to published guidelines with zero representing no racial bias, positive values representing prowhite bias, and negative scores representing problack bias (range typically −0.6 to 1.2).21 (link) Figure1 shows the faces representing white or black race and the terms used as stimuli for the concepts of good/bad and cooperativeness/uncooperativeness.
We asked participants to rate the likelihood that the chest pain was because of coronary artery disease (CAD) (5-point scale, very unlikely to very likely), whether they would give the patient thrombolysis (yes/no), and the strength of their recommendation (5-point scale, definitely to definitely not). To assess explicit bias, the software then asked participants several questions about whether they preferred white or black Americans (5-point scale with preference expressed as somewhat or slightly prefer black or white Americans, and 10-point thermometer scale of warm feelings toward each group separately). We also asked about their beliefs about patients’ cooperativeness in general and with regard to medical procedures such as thrombolysis (5-point scale—black patients somewhat less cooperative, slightly less cooperative, equally cooperative; white patients slightly less cooperative or somewhat less cooperative). Finally, the online survey included queries about respondent demographics, effectiveness of thrombolysis, and pre- and posttest opinions on unconscious bias and IATs. The vignettes and survey are available upon request.
Participants also completed three IATs corresponding to the explicit bias questions. The Race Preference IAT measured implicit association of white and black race with good and bad terms. We created the next two IATs specifically for this study. The Race Cooperativeness IAT measured implicit associations between race and general cooperativeness. The Race Medical Cooperativeness IAT measured implicit associations between race and cooperativeness with medical recommendations. All IAT scores are expressed as normally distributed continuous variables. For efficiency we used a 5-block structure for the IATs, with the specific pairing received first (e.g., black-bad/white-good) counterbalanced across participants. We scored IATs according to published guidelines with zero representing no racial bias, positive values representing prowhite bias, and negative scores representing problack bias (range typically −0.6 to 1.2).21 (link) Figure
