Black and white individuals may not receive equal health care even when insurance status, income level, and access to health care are taken into account.1 Despite psoriasis having an established standard of care, the Black race is associated with a lower likelihood of receiving biologics among Medicare beneficiaries.2 Implicit bias, which refers to subconscious beliefs that individuals have about other identity groups,3 may perpetuate disparities by influencing physicians' clinical decision-making.4 This IRB-approved feasibility study assesses the association between implicit race bias, race-compliance stereotyping, and psoriasis patient management in dermatology residents.
A confidential online survey with a single, randomized vignette describing either a black or white 33-year-old male patient with severe plaque psoriasis was distributed to current US dermatology residents via the Association of Professors of Dermatology (APD) listserv from October 2021 to January 2022. Residents selected the best patient management option, rated their attitudes toward implicit bias using a Likert scale, and completed two Implicit Association Tests (IAT): Race and Race-Compliance.5
Data were analyzed using either Student t-tests or one-way ANOVA for normally distributed continuous variables when comparing two or more groups, and chi-square/Fisher exact tests for categorical variables, respectively; all tests were two-sided. The IAT d-scores range from -2 to +2, with positive d-score indicating implicit preference for white race relative to black race; a negative d-score indicates the converse.
Overall, 30 residents completed the survey (Table 1). Four dropped out before completing the Race IAT (n=26), and nine more dropped out before completing the Race-Compliance IAT (n=17). Residents assigned to either the white or black patient vignette were similar demographically (Table 1) and in their race and compliance IAT d-scores (Table 2).
Residents selected systemic, topical, and phototherapy at similar rates for both patient vignettes (P=0.99; Table 1). Though not statistically significant, biologics were chosen more often for the black patient (n=8, 50%) compared to the white patient (n=4, 28.6%, P=0.23; Table 1). Furthermore, Race IAT d-scores of residents assigned to the black patient show greater pro-white bias in residents who chose biologics (mean 0.32 plus/minus 0.25) compared to non-biologics (0.03 plus/minus 0.60, P=0.22) (Table 3). This difference is more pronounced when comparing the Race-Compliance IAT d-score between residents who chose biologics (0.23 plus/minus 0.31) versus non-biologics (-0.21 plus/minus 0.30) in the same group (P=0.06; Table 3).
Majority of residents agree that implicit bias may affect their management decisions (n=19, 63.3%), knowledge of their implicit biases may improve their clinical management (n=26, 86.7%), and formal training on implicit bias should be included in the residency curriculum (n=26, 86.7%; Table 1).
Our study demonstrated no statistically significant difference in dermatology residents' management of severe psoriasis between two different skin types. Additionally, residents were open to implicit bias education during residency training. Interestingly, biologics were chosen more often for the black patient compared to the white patient. This could be due to increased awareness of implicit bias and hypercorrection, perceived differences in disease severity from patient photos despite identical provided history, or study limitations: small sample size, risk of response and social desirability bias, and inability to determine response rate. Given the unexpected direction of implicit bias and associated clinical decision-making, as well as the limitations of vignette studies, future research in actual or simulated clinical settings could better advance our understanding of the role of implicit bias in clinical decision-making within dermatology.
