Patient Representation in Medical Literature: Are We Appropriately Depicting Diversity?

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Abstract

Background:

Racial disparities exist in the accessibility, delivery, and quality of healthcare. Clinical images are central to plastic surgery, but choice of images in the literature is susceptible to implicit biases. The objective of this study was to determine if published images reflect the racial demographic of patients.

Methods:

A search for color photographs and rendered graphics depicting human skin was completed in 6 plastic surgery journals and the New England Journal of Medicine Images in Clinical Medicine for each decade between 1992 and 2017. For each article, images were categorized as white or nonwhite based on Fitzpatrick Scale (1–3 versus 4–6). Additionally, the authors’ geographic region was documented. Proportional data and average number of nonwhite images per article were compared. Regression analyses were performed to assess the correlation of time and geographic region on nonwhite images.

Results:

In total, 24,209 color photographs and 1,671 color graphics were analyzed. In plastic surgery journals, 22% of photographs were nonwhite and the average number of photographs per article with white skin was 5.4 compared with 1.6 with nonwhite skin ( P < 0.0001). There was a significant increase in nonwhite photographs over time ( r = 0.086, P < 0.001) and association of nonwhite photographs with international authors ( r = 0.12, P < 0.001).

Conclusions:

Roughly 60%–70% of the world population and 30% of US cosmetic patients are nonwhite. Images in plastic surgery literature reflect neither racial demographics by global region nor the patient population seeking surgery. To advance equitable care, images should better represent the racial composition of the populations served.

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Most cited references 14

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Implicit Bias among Physicians and its Prediction of Thrombolysis Decisions for Black and White Patients

Alexander R Green, Dana R. Carney, Daniel J Pallin … (2007)

Context Studies documenting racial/ethnic disparities in health care frequently implicate physicians’ unconscious biases. No study to date has measured physicians’ unconscious racial bias to test whether this predicts physicians’ clinical decisions. Objective To test whether physicians show implicit race bias and whether the magnitude of such bias predicts thrombolysis recommendations for black and white patients with acute coronary syndromes. Design, Setting, and Participants An internet-based tool comprising a clinical vignette of a patient presenting to the emergency department with an acute coronary syndrome, followed by a questionnaire and three Implicit Association Tests (IATs). Study invitations were e-mailed to all internal medicine and emergency medicine residents at four academic medical centers in Atlanta and Boston; 287 completed the study, met inclusion criteria, and were randomized to either a black or white vignette patient. Main Outcome Measures IAT scores (normal continuous variable) measuring physicians’ implicit race preference and perceptions of cooperativeness. Physicians’ attribution of symptoms to coronary artery disease for vignette patients with randomly assigned race, and their decisions about thrombolysis. Assessment of physicians’ explicit racial biases by questionnaire. Results Physicians reported no explicit preference for white versus black patients or differences in perceived cooperativeness. In contrast, IATs revealed implicit preference favoring white Americans (mean IAT score = 0.36, P < .001, one-sample t test) and implicit stereotypes of black Americans as less cooperative with medical procedures (mean IAT score 0.22, P < .001), and less cooperative generally (mean IAT score 0.30, P < .001). As physicians’ prowhite implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis (P = .009). Conclusions This study represents the first evidence of unconscious (implicit) race bias among physicians, its dissociation from conscious (explicit) bias, and its predictive validity. Results suggest that physicians’ unconscious biases may contribute to racial/ethnic disparities in use of medical procedures such as thrombolysis for myocardial infarction.

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The associations of clinicians' implicit attitudes about race with medical visit communication and patient ratings of interpersonal care.

K Carson, Caroline Sabin, Mary Beach … (2012)

We examined the associations of clinicians' implicit attitudes about race with visit communication and patient ratings of care. In a cross-sectional study of 40 primary care clinicians and 269 patients in urban community-based practices, we measured clinicians' implicit general race bias and race and compliance stereotyping with 2 implicit association tests and related them to audiotape measures of visit communication and patient ratings. Among Black patients, general race bias was associated with more clinician verbal dominance, lower patient positive affect, and poorer ratings of interpersonal care; race and compliance stereotyping was associated with longer visits, slower speech, less patient centeredness, and poorer ratings of interpersonal care. Among White patients, bias was associated with more verbal dominance and better ratings of interpersonal care; race and compliance stereotyping was associated with less verbal dominance, shorter visits, faster speech, more patient centeredness, higher clinician positive affect, and lower ratings of some aspects of interpersonal care. Clinician implicit race bias and race and compliance stereotyping are associated with markers of poor visit communication and poor ratings of care, particularly among Black patients.

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The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma.

Ester Sabin, Anthony Greenwald (2012)

We examined the association between pediatricians' attitudes about race and treatment recommendations by patients' race. We conducted an online survey of academic pediatricians (n = 86). We used 3 Implicit Association Tests to measure implicit attitudes and stereotypes about race. Dependent variables were recommendations for pain management, urinary tract infections, attention deficit hyperactivity disorder, and asthma, measured by case vignettes. We used correlational analysis to assess associations among measures and hierarchical multiple regression to measure the interactive effect of the attitude measures and patients' race on treatment recommendations. Pediatricians' implicit (unconscious) attitudes and stereotypes were associated with treatment recommendations. The association between unconscious bias and patient's race was statistically significant for prescribing a narcotic medication for pain following surgery. As pediatricians' implicit pro-White bias increased, prescribing narcotic medication decreased for African American patients but not for the White patients. Self-reported attitudes about race were associated with some treatment recommendations. Pediatricians' implicit attitudes about race affect pain management. There is a need to better understand the influence of physicians' unconscious beliefs about race on pain and other areas of care.

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Author and article information

Journal

Journal ID (nlm-ta): Plast Reconstr Surg Glob Open

Journal ID (iso-abbrev): Plast Reconstr Surg Glob Open

Journal ID (publisher-id): GOX

Title: Plastic and Reconstructive Surgery Global Open

Publisher: Wolters Kluwer Health

ISSN (Electronic): 2169-7574

Publication date Collection: December 2019

Publication date (Electronic): 26 December 2019

Volume: 7

Issue: 12

Electronic Location Identifier: e2563

Affiliations

From the [* ]Division of Plastic Surgery, Department of Surgery, Feinberg School of Medicine at Northwestern University, Chicago, Illinois

[† ]Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine. Seattle, Washington

[‡ ]Department of Surgery, University of California Davis Medical Center, Sacramento, California

[§ ]Section of Plastic Surgery, Department of Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan

[¶ ]Division of Plastic Surgery, Department of Surgery, University of Chicago Medicine. Chicago, Illinois

[‖ ]Department of Biomedical Informatics and Medical Education, Center for Health Equity, Diversity, and Inclusion, University of Washington, Seattle, Washington

[** ]Hansjörg Wyss Department of Plastic Surgery, New York University School of Medicine, New York, New York

[†† ]Align Surgical Associates, San Francisco, California.

Author notes

Shane D. Morrison, MD, MS, Division of Plastic Surgery, University of Washington Department of Surgery, 7CT73.1 Harborview Medicine Center, 325 9th Avenue, Mailstop #359796, Seattle, WA 98104, E-mail: shanedm@ 123456uw.edu

Article

Accession ID: 00024

DOI: 10.1097/GOX.0000000000002563

PMC ID: 6964926

PubMed ID: 32042543

SO-VID: 6ee8d031-f255-42bc-90a4-6a9929d2aabf

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

History

Date received : 30 August 2019

Date accepted : 16 October 2019

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