In the new study, published July 2020 in JAMA Network Open, researchers showed 46 clinicians attending an international heart transplant conference vignettes for 1 in 4 patients with identical medical and social histories: a white woman, a white man, an African American woman, and an African American man. Then researchers asked clinicians to share their thoughts about the patient and explain whether they thought each person was a suitable candidate for a heart transplant or a ventricular assist device. They found several indications of implicit bias in clinicians’ impressions of these patients, such as:
Clinicians critiqued the appearance of women more harshly than men.African American men were perceived as having more severe illness.Clinicians worried more about appropriateness of care for African American women than white women.Clinicians questioned whether patients had support at home more for women than men.Children were considered liabilities for women, particularly African American women.Family dynamics were seen as a bigger problem for African American women.Spouses were seen as inadequate support for women, not men.
“This matters for patients and for doctors and broadly for healthcare systems and as a society — it is uncomfortable to speak about bias and it is hard to acknowledge that this is happening,” says Sadiya Khan, MD, an assistant professor at Northwestern University Feinberg School of Medicine in Chicago, who wasn’t involved in the study. “But it is. And we have to call it out to identify solutions.” “It is well-established that disparities exist by race and gender in medical care broadly, and particularly in heart-failure care,” Dr. Khan says. “Often studies will cite socioeconomic factors at the individual and neighborhood level as key contributors to disparities,” Khan says. “However, this study helps disentangle the complex interactions between race, place, and socioeconomics by focusing on bias through hypothetical scenarios.” RELATED: Heart Failure Deaths Climb in Younger Adults, Study Says
Bias May Keep Patients From Reaching Specialists
One limitation of the study is that it looked at what might happen when patients are evaluated by specialists who can offer them advanced therapies for heart failure. But implicit bias might prevent women or people of color from ever getting referred for evaluation, says Prateeti Khazanie, MD, MPH, a specialist in advanced heart failure, transplant and ventricular assist devices at the University of Colorado in Aurora. “This is the first step of the leaky pipeline where biases can affect who is and who is not referred for higher levels of care, and we currently have no idea how many patients are lost in that process,” Dr. Khazanie says. When patients do get evaluated for a transplant or VAD, they are assessed by a dizzying array of physicians, surgeons, nurses, social workers, psychologists, and financial analysts, Khazanie says. Every part of patients’ lives gets scrutinized to determine if they are a candidate for a heart transplant or VAD, or if they should instead receive palliative care and eventually, hospice. Ventricular assist devices can improve survival and quality of life for many heart failure patients who can’t get a transplant because a matched donor heart isn’t available, Khan says. Heart failure develops when the heart muscle is no longer strong enough to pump blood through the body. Symptoms can include fluid retention, weight gain, fatigue, shortness of breath, and coughing or wheezing.
Other Studies Show Bias Impacts Treatment Options
While the current study showed how bias impacts clinicians’ impressions of patients, some previous research has found that bias can also influence what treatment patients ultimately receive. One study published in 2019 in the Journal of the American Heart Association asked clinicians to review vignettes of white and Black men who had identical social and medical histories and then discuss with researchers whether patients should receive a heart transplant or ventricular assist device. Clinicians believed the Black men were sicker and less able to follow treatment regimens, and race appeared to influence white men receiving transplants while Black men got ventricular assist devices. Another study published in 2019 in the American Journal of Transplantation examined data on U.S. patients who received heart transplants or got added to waiting lists for transplants between 2006 and 2018. Women received less than one-quarter of heart transplants, and women and nonwhite patients were far less likely to get on waiting lists for transplants than white or male patients. While the medical community clearly has work to do on addressing implicit bias, there is one thing patients and families can do to minimize the potential for this to negatively impact the care they receive: a second opinion. “I always encourage my patients to obtain second opinions whenever possible,” Khan advises.
