Physician gender as a source of implicit bias affecting clinical decision-making processes: a scoping review

Champagne-Langabeer and Hedges BMC Medical Education https://doi.org/10.1186/s12909-021-02601-2 (2021) 21:171 RESEARCH ARTICLE Open Access Physician gender as a source of implicit bias affecting clinical decision-making processes: a scoping review Tiffany Champagne-Langabeer* and Andrew L. Hedges Abstract Background: The demographic profile of practicing physicians is changing as more female medical students are graduating and practicing in the field. While the education received may not differ by gender, studies have shown that physician practice outcomes vary by provider gender. Various factors could contribute to these differences, including culture and explicit biases which may lead to implicit bias. This study aims to identify the available evidence of gender-based implicit bias throughout the delivery process of medicine. Methods: This scoping review evaluated published literature within the PubMed, Ovid MEDLINE, PsychINFO, Web of Science, and BioMed Central databases pertaining to physician’s gender as a factor in the delivery of medicine. Arksey and O’Malley’s six-stage methodology was used as a framework and reported using the updated Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Searches occurred between May 2020 and June 2020, and the timeframe was not limited. Included articles had gender as a factor in the delivery of medicine and implicit bias. Articles were excluded if they did not include the gender of the physician. After screening by reviewers and a medical librarian, study characteristics were charted and analyzed. Results: The initial search resulted in 2420 records. After screening, 162 of the records were selected based on title and keyword relevance. After additional screening, 15 records were ultimately included in the review based on fulltext evaluation. Records were organized into sub-topics post hoc focused on clinical qualities, diagnostics, treatment, and outcomes. Conclusion: This scoping review found that gender-based implicit bias may be inadvertently acquired from culture and education. Although implicit bias is highly researched, much of the current literature focuses on the gender of the patient. This study found important gaps in the available literature regarding race and gender of the physician. Further studies could explore outcome differences between recent graduates and career physicians, for both female and male physicians. Keywords: Implicit bias, Gender medicine, Provider characteristics, Medical education * Correspondence: School of Biomedical Informatics, The University of Texas Health Science Center, 7000 Fannin Street, Suite 600, Houston, TX, USA © The Author(s). 2021 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Champagne-Langabeer and Hedges BMC Medical Education (2021) 21:171 Introduction Undergraduate medical education has experienced a plethora of new challenges which pose a significant social impact on the practice of medicine. Society places an unspoken moral contract on the profession of physicians, and the concept of medicine as both art and science further emphasizes the subjective nuances of care delivery [1]. Undergraduate medical education intertwines this sentiment defining medicine as “… a profession that incorporates science and the scientific method with the art of being a physician” [2]. There is a qualitative component of expertise which is indicated by the social skills involved in physician-patient interactions, and an intuitive sense involved in diagnostic decision-making. Within the modern healthcare environment, good medical practitioners understand how crucial and inseparable both aspects can be in patient outcomes [3]. Initiatives to demonstrate patient-centeredness require that physicians exercise their artistic capabilities while maintaining evidence-based practice guidelines [4]. This is partially in hopes of lowering health disparities affecting disenfranchised patients; however, evidence shows that many disparities persist today [5, 6]. Several factors contribute to the presence and persistence of these disparities; however, it remains a challenge to promote awareness of bias while not assigning blame [7]. While it is the rigor of science and research that develops clinical practice guidelines, it is the art and judgment of an individual physician which impacts the patient. Within the context of healthcare, the concept of prejudice, or perceived feelings regarding a patient based upon certain characteristics such as race, gender, ethnicity, sexual orientation, or other variables, is considered negative and is discouraged within the medical profession [8, 9]. However, implicit bias–defined as preferential associations that exist subconsciously—is subtle and harder to detect [10]. In psychological terms, implicit bias can be viewed as a latent or subconscious construct. In this way, a physician with an (unrealized) implicit bias against patients who use heroin may create preconceived judgments about the patient’s ability to adhere to medication. This may or may not change their behavior towards the patient. Thus, implicit bias may be described in terms of the resultant behavior: the decision made by the physician [11]. There are assessments for measuring implicit bias such as the Implicit Assessment Test (IAT); however, this assessment intends to measure the deeply held beliefs which do not necessarily translate into action [12, 13]. The IAT in vignette-based studies has shown mixed results, with implicit bias correlating to action or having no relationship to outcomes [14]. The definition by De Houwer and colleagues of implicit bias as a “behavioral phenomenon” may prove more useful, as measuring a subconscious and often unrealized construct in the absence of action proves challenging and often unreliable [11]. Page 2 of 9 Implicit bias may be observed through the actions of physicians as well as patients. Prior studie (...truncated)