The Impact of Cognitive Stressors in the Emergency Department on Physician Implicit Racial Bias

Abstract

Objectives The emergency department (ED) is characterized by stressors (e.g. fatigue, stress, time-pressure, and complex decision-making) that can pose challenges to delivering high quality, equitable care. Although it has been suggested that characteristics of the ED may exacerbate reliance on cognitive heuristics, no research has directly investigated whether stressors in the ED impact physician racial bias, a common heuristic. We seek to determine if physicians have different levels of implicit racial bias post-ED shift versus pre-shift, and to examine associations between demographics and cognitive stressors with bias. Methods This repeated measures study of resident physicians in a pediatric ED used electronic pre- and post-shift assessments of implicit racial bias, demographics, and cognitive stressors. Implicit bias was measured using the Race Implicit Association Test (IAT). Linear regression models compared differences in IAT scores pre- to post-shift, and determined associations between participant demographics and cognitive stressors with post-shift IAT and pre- to post-shift difference scores. Results Participants (n=91) displayed moderate pro-white/anti-black bias on pre-shift (M=0.50, SD=0.34, d=1.48) and post-shift (M=0.55, SD=0.39, d=1.40) IAT scores. Overall, IAT scores did not differ pre-shift to post-shift (mean increase=0.05, 95% CI −0.02,0.14, d=0.13). Sub-analyses revealed increased pre- to post-shift bias among participants working when the ED was more overcrowded (mean increase=0.09, 95% CI 0.01,0.17, d=0.24) and among those caring for >10 patients (mean increase=0.17, 95% CI 0.05,0.27, d=0.47). Residents’ demographics (including specialty), fatigue, busyness, stressfulness, and number of shifts were not associated with post-shift IAT or difference scores. In multivariable models, ED overcrowding was associated with greater post-shift bias (coefficient=0.11 per 1 unit of NEDOCS score, SE=0.05, 95% CI 0.00,0.21). Conclusions While resident implicit bias remained stable overall pre-shift to post-shift, cognitive stressors (overcrowding and patient load) were associated with increased implicit bias. Physicians in the ED should be aware of how cognitive stressors may exacerbate implicit racial bias.

Comparison of Physician Implicit Racial Bias Toward Adults Versus Children

“…This was a planned secondary analysis of data from an original study examining the impact of cognitive stressors during an ED shift on levels of physician implicit bias. 19 We collected data for the original study from 91 of 106 residents rotating in the ED between April and June 2013. The study was conducted in an urban academic pediatric ED with over 70,000 annual visits, of which 61.5% involve patients who are non-Hispanic white, 33.5% non-Hispanic black, 0.9% Asian, and 0.6% Hispanic.…”

“…24 Linear models were used to analyze Adult Race, Child Race, and Difference (calculated by subtracting Adult from Child) IAT scores. To take into account potential IAT practice effects based on the repeated measures design of the original study, 19 linear models were adjusted for whether residents completed their pre-shift assessments first (N=47) or second (N=44). We also examined the association of resident demographic characteristics (race/ethnicity, age, gender, specialty, and training year) with Adult, Child, and Difference IAT scores using separate linear models, each adjusted for practice effect.…”

“…5,6 Research conducted on over 4,000 healthcare students, trainees, and attending physicians using the Adult Race IAT demonstrates that most healthcare providers also have pro-white/anti-black implicit racial bias, similar to the general population. 7-18 While studies show that pediatricians are among those who have implicit bias against black adults, 8,19 one study found lower levels of bias among pediatricians compared to other physicians or the general population. 8 …”

When the Aberrant Becomes the Accepted: The Rise of Hallway Care in Emergency Medicine

“…[9][10][11][12][13][14][15] There is evidence that leaving without being seen does create a risk to patients resulting from delayed care that can lead to serious morbidity and mortality, although the risk of adverse outcomes has differed by country and population studied. [9][10][11][12][13][14][15][16] One systematic review in 2008 reported that "reports of adverse outcomes appear very rare in the (LWBS) literature." 9 The authors concluded that, "With the exception of these instances, no other article reports deaths or serious adverse events.…”

Shared Decision Making With Vulnerable Populations in the Emergency Department

“…Implicit bias has been documented across a wide range of healthcare settings, 19 including the ED. 20 Implicit bias "occurs without conscious awareness and is frequently at odds with one's personal beliefs," 21 but may still result in stereotyping. 19 This bias could affect communication and interaction across all three domains of SDM: information sharing, deliberation/recommendation, and decision making.…”