Comparison of Physician Implicit Racial Bias Toward Adults Versus Children

Published:September 09, 2016DOI:


      Background and Objectives

      The general population and most physicians have implicit racial bias against black adults. Pediatricians also have implicit bias against black adults, albeit less than other specialties. There is no published research on the implicit racial attitudes of pediatricians or other physicians toward children. Our objectives were to compare implicit racial bias toward adults versus children among resident physicians working in a pediatric emergency department, and to assess whether bias varied by specialty (pediatrics, emergency medicine, or other), gender, race, age, and year of training.


      We measured implicit racial bias of residents before a pediatric emergency department shift using the Adult and Child Race Implicit Association Tests (IATs). Generalized linear models compared Adult and Child IAT scores and determined the association of participant demographics with Adult and Child IAT scores.


      Among 91 residents, we found moderate pro-white/anti-black bias on both the Adult (mean = 0.49, standard deviation = 0.34) and Child Race IAT (mean = 0.55, standard deviation = 0.37). There was no significant difference between Adult and Child Race IAT scores (difference = 0.06, P = .15). Implicit bias was not associated with resident demographic characteristics, including specialty.


      This is the first study demonstrating that resident physicians have implicit racial bias against black children, similar to levels of bias against black adults. Bias in our study did not vary by resident demographic characteristics, including specialty, suggesting that pediatric residents are as susceptible as other physicians to implicit bias. Future studies are needed to explore how physicians' implicit attitudes toward parents and children may impact inequities in pediatric health care.


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        • Flores G.
        Technical report—racial and ethnic disparities in the health and health care of children.
        Pediatrics. 2010; 125: e979-e1020
        • Greenwald A.
        • Banaji M.R.
        Implicit social cognition: attitudes, self-esteem, and stereotypes.
        Psychol Rev. 1995; 102: 4-27
        • Greenwald A.G.
        • Poehlman T.A.
        • Uhlmann E.L.
        • et al.
        Understanding and using the Implicit Association Test. III. Meta-analysis of predictive validity.
        J Pers Soc Psychol. 2009; 97: 17-41
        • Wittenbrink B.
        • Schwarz N.
        Implicit Measures of Attitudes.
        Guilford Press, New York, NY2007
        • Lane K.A.
        • Banaji M.R.
        • Nosek B.A.
        • et al.
        Understanding and using the Implicit Association Test. IV. What we know (so far) about the method.
        in: Wittenbrink B. Schwarz N. Implicit Measures of Attitudes. Guilford Press, New York, NY2007: 59-102
        • Nosek B.A.
        • Greenwald A.G.
        • Banaji M.R.
        The Implicit Association Test at age 7: a methodological and conceptual review.
        in: Bargh J.A. Automatic Processes in Social Thinking and Behavior. Psychology Press, New York, NY2007: 265-292
        • Green A.R.
        • Carney D.R.
        • Pallin D.J.
        • et al.
        Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients.
        J Gen Intern Med. 2007; 22: 1231-1238
        • Sabin J.A.
        • Rivara F.P.
        • Greenwald A.G.
        Physician implicit attitudes and stereotypes about race and quality of medical care.
        Med Care. 2008; 46: 678-685
        • Sabin J.
        • Nosek B.A.
        • Greenwald A.
        • et al.
        Physicians' implicit and explicit attitudes about race by MD race, ethnicity, and gender.
        J Health Care Poor Underserved. 2009; 20: 896-913
        • White-Means S.
        • Zhiyong D.
        • Hufstader M.
        • et al.
        Cultural competency, race, and skin tone bias among pharmacy, nursing, and medical students: implications for addressing health disparities.
        Med Care Res Rev. 2009; 66: 436-455
        • Haider A.H.
        • Sexton J.
        • Sriram N.
        • et al.
        Association of unconscious race and social class bias with vignette-based clinical assessments by medical students.
        JAMA. 2011; 306: 942-951
        • Cooper L.A.
        • Roter D.L.
        • Carson K.A.
        • et al.
        The associations of clinicians' implicit attitudes about race with medical visit communication and patient ratings of interpersonal care.
        Am J Public Health. 2012; 102: 979-987
        • Blair I.V.
        • Havranek E.P.
        • Price D.W.
        • et al.
        Assessment of biases against Latinos and African Americans among primary care providers and community members.
        Am J Public Health. 2013; 103: 92-98
        • Oliver M.N.
        • Wells K.M.
        • Joy-Gaba J.A.
        • et al.
        Do physicians' implicit views of African Americans affect clinical decision making?.
        J Am Board Fam Med. 2014; 27: 177-188
        • Hausmann L.R.
        • Myaskovsky L.
        • Niyonkuru C.
        • et al.
        Examining implicit bias of physicians who care for individuals with spinal cord injury: a pilot study and future directions.
        J Spinal Cord Med. 2015; 38: 102-110
        • Haider A.H.
        • Schneider E.B.
        • Sriram N.
        • et al.
        Unconscious race and class bias: its association with decision making by trauma and acute care surgeons.
        J Trauma Acute Care Surg. 2014; 77: 409-416
        • Penner L.A.
        • Dovidio J.F.
        • West T.V.
        • et al.
        Aversive racism and medical interactions with black patients: a field study.
        J Exp Soc Psychol. 2010; 46: 436-440
        • Sabin J.A.
        • Greenwald A.G.
        The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma.
        Am J Public Health. 2012; 102: 988-995
        • Johnson T.J.
        • Hickey R.W.
        • Switzer G.E.
        • et al.
        The impact of cognitive stressors in the emergency department on physician implicit racial bias.
        Acad Emerg Med. 2016; 23: 297-305
        • Baron A.S.
        • Banaji M.R.
        The development of implicit attitudes. Evidence of race evaluations from ages 6 and 10 and adulthood.
        Psychol Sci. 2006; 17: 53-58
        • Greenwald A.G.
        • McGhee D.E.
        • Schwartz J.L.
        Measuring individual differences in implicit cognition: the Implicit Association Test.
        J Pers Soc Psychol. 1998; 74: 1464-1480
        • Nosek B.A.
        • Smyth F.L.
        A multitrait-multimethod validation of the Implicit Association Test: implicit and explicit attitudes are related but distinct constructs.
        Exp Psychol. 2007; 54: 14-29
        • Nosek B.A.
        • Greenwald A.G.
        • Banaji M.R.
        Understanding and using the Implicit Association Test. II. Method variables and construct validity.
        Pers Soc Psychol Bull. 2005; 31: 166-180
        • Greenwald A.G.
        • Nosek B.A.
        • Banaji M.R.
        Understanding and using the Implicit Association Test. I. An improved scoring algorithm.
        J Pers Soc Psychol. 2003; 85: 197-216
        • Newheiser A.K.
        • Olson K.R.
        White and black American children's implicit intergroup bias.
        J Exp Soc Psychol. 2012; 48: 264-270
      1. Smedley B.D. Stith A.Y. Nelson A.R. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. National Academies Press, Washington, DC2002
        • Blair I.V.
        • Steiner J.F.
        • Fairclough D.L.
        • et al.
        Clinicians' implicit ethnic/racial bias and perceptions of care among black and Latino patients.
        Ann Fam Med. 2013; 11: 43-52
        • van Ryn M.
        • Hardeman R.
        • Phelan S.M.
        • et al.
        Medical school experiences associated with change in implicit racial bias among 3547 students: a medical student CHANGES Study report.
        J Gen Intern Med. 2015; 30: 1748-1756
        • Stivers T.
        • Majid A.
        Questioning children: interactional evidence of implicit bias in medical interviews.
        Soc Psychol Q. 2007; 70: 424-441
        • Bottoms B.L.
        • Davis S.L.
        • Epstein M.A.
        Effects of victim and defender race on jurors' decisions in child sexual abuse cases.
        J Appl Soc Psychol. 2004; 34: 1-33
        • Goff P.A.
        • Jackson M.C.
        • Di Leone B.A.
        • et al.
        The essence of innocence: consequences of dehumanizing Black children.
        J Pers Soc Psychol. 2014; 106: 526-545
        • Devine P.G.
        • Forscher P.S.
        • Austin A.J.
        • et al.
        Long-term reduction in implicit race bias: a prejudice habit-breaking intervention.
        J Exp Soc Psychol. 2012; 48: 1267-1278
        • Blair I.V.
        • Steiner J.F.
        • Havranek E.P.
        Unconscious (implicit) bias and health disparities: where do we go from here?.
        Perm J. 2011; 15: 71-78
        • Blair I.V.
        • Ma J.E.
        • Lenton A.P.
        Imagining stereotypes away: the moderation of implicit stereotypes through mental imagery.
        J Pers Soc Psychol. 2001; 81: 828-841
        • Dasgupta N.
        • Greenwald A.G.
        On the malleability of automatic attitudes: combating automatic prejudice with images of admired and disliked individuals.
        J Pers Soc Psychol. 2001; 81: 800-814
        • Burgess D.J.
        • Warren J.
        • Phelan S.
        • et al.
        Stereotype threat and health disparities: what medical educators and future physicians need to know.
        J Gen Intern Med. 2010; 25: S169-S177
        • Cohen G.L.
        • Garcia J.
        • Apfel N.
        • et al.
        Reducing the racial achievement gap: a social-psychological intervention.
        Science. 2006; 313: 1307-1310
        • Cohen G.L.
        • Garcia J.
        • Purdie-Vaughns V.
        • et al.
        Recursive processes in self-affirmation: intervening to close the minority achievement gap.
        Science. 2009; 324: 400-403
        • Miyake A.
        • Kost-Smith L.E.
        • Finkelstein N.D.
        • et al.
        Reducing the gender achievement gap in college science: a classroom study of values affirmation.
        Science. 2010; 330: 1234-1237
        • Plant E.A.
        • Devine P.G.
        The active control of prejudice: unpacking the intentions guiding control efforts.
        J Pers Soc Psychol. 2009; 96: 640-652
        • Chapman E.N.
        • Kaatz A.
        • Carnes M.
        Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities.
        J Gen Intern Med. 2013; 28: 1504-1510