Anna Kaatz

Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health Care Disparities

ABSTRACTAlthough the medical profession strives for equal treatment of all patients, disparities in health care are prevalent. Cultural stereotypes may not be consciously endorsed, but their mere existence influences how information about an individual is processed and leads to unintended biases in decision-making, so called “implicit bias”. All of society is susceptible to these biases, including physicians. Research suggests that implicit bias may contribute to health care disparities by shaping physician behavior and producing differences in medical treatment along the lines of race, ethnicity, gender or other characteristics. We review the origins of implicit bias, cite research documenting the existence of implicit bias among physicians, and describe studies that demonstrate implicit bias in clinical decision-making. We then present the bias-reducing strategies of consciously taking patients’ perspectives and intentionally focusing on individual patients’ information apart from their social group. We conclude that the contribution of implicit bias to health care disparities could decrease if all physicians acknowledged their susceptibility to it, and deliberately practiced perspective-taking and individuation when providing patient care. We further conclude that increasing the number of African American/Black physicians could reduce the impact of implicit bias on health care disparities because they exhibit significantly less implicit race bias.

The effect of an intervention to break the gender bias habit for faculty at one institution: a cluster randomized, controlled trial.

Purpose Despite sincere commitment to egalitarian, meritocratic principles, subtle gender bias persists, constraining women’s opportunities for academic advancement. The authors implemented a pair-matched, single-blind, cluster randomized, controlled study of a gender-bias-habit-changing intervention at a large public university. Method Participants were faculty in 92 departments or divisions at the University of Wisconsin–Madison. Between September 2010 and March 2012, experimental departments were offered a gender-bias-habit-changing intervention as a 2.5-hour workshop. Surveys measured gender bias awareness; motivation, self-efficacy, and outcome expectations to reduce bias; and gender equity action. A timed word categorization task measured implicit gender/leadership bias. Faculty completed a work–life survey before and after all experimental departments received the intervention. Control departments were offered workshops after data were collected. Results Linear mixed-effects models showed significantly greater changes post intervention for faculty in experimental versus control departments on several outcome measures, including self-efficacy to engage in gender-equity-promoting behaviors (P = .013). When ≥ 25% of a department’s faculty attended the workshop (26 of 46 departments), significant increases in self-reported action to promote gender equity occurred at three months (P = .007). Post intervention, faculty in experimental departments expressed greater perceptions of fit (P = .024), valuing of their research (P = .019), and comfort in raising personal and professional conflicts (P = .025). Conclusions An intervention that facilitates intentional behavioral change can help faculty break the gender bias habit and change department climate in ways that should support the career advancement of women in academic medicine, science, and engineering.

Analysis of National Institutes of Health R01 Application Critiques, Impact, and Criteria Scores: Does the Sex of the Principal Investigator Make a Difference?

Purpose Prior text analysis of R01 critiques suggested that female applicants may be disadvantaged in National Institutes of Health (NIH) peer review, particularly for renewals. NIH altered its review format in 2009. The authors examined R01 critiques and scoring in the new format for differences due to principal investigator (PI) sex. Method The authors analyzed 739 critiques—268 from 88 unfunded and 471 from 153 funded applications for grants awarded to 125 PIs (76 males, 49 females) at the University of Wisconsin–Madison between 2010 and 2014. The authors used seven word categories for text analysis: ability, achievement, agentic, negative evaluation, positive evaluation, research, and standout adjectives. The authors used regression models to compare priority and criteria scores, and results from text analysis for differences due to PI sex and whether the application was for a new (Type 1) or renewal (Type 2) R01. Results Approach scores predicted priority scores for all PIs’ applications (P < .001), but scores and critiques differed significantly for male and female PIs’ Type 2 applications. Reviewers assigned significantly worse priority, approach, and significance scores to female than male PIs’ Type 2 applications, despite using standout adjectives (e.g., “outstanding,” “excellent”) and making references to ability in more critiques (P < .05 for all comparisons). Conclusions The authors’ analyses suggest that subtle gender bias may continue to operate in the post-2009 NIH review format in ways that could lead reviewers to implicitly hold male and female applicants to different standards of evaluation, particularly for R01 renewals.

Threats to objectivity in peer review: the case of gender

Scientists strive to be objective in their peer review of grant applications and manuscript submissions. Nevertheless, all humans are susceptible to biases in decision-making. To illustrate how cognitive bias unrelated to the merit of the science could influence scientific peer review we describe the potential impact of applicant gender on the judgment of reviewers. Table 1 describes some different types of cognitive biases and Table 2 describes conditions that might facilitate the operation of cognitive biases in peer review.

A quantitative linguistic analysis of National Institutes of Health R01 application critiques from investigators at one institution.

Purpose Career advancement in academic medicine often hinges on the ability to garner research funds. The National Institutes of Health’s (NIH’s) R01 award is the “gold standard” of an independent research program. Studies show inconsistencies in R01 reviewers’ scoring and in award outcomes for certain applicant groups. Consistent with the NIH recommendation to examine potential bias in R01 peer review, the authors performed a text analysis of R01 reviewers’ critiques. Method The authors collected 454 critiques (262 from 91 unfunded and 192 from 67 funded applications) from 67 of 76 (88%) R01 investigators at the University of Wisconsin–Madison with initially unfunded applications subsequently funded between December 2007 and May 2009. To analyze critiques, the authors developed positive and negative grant application evaluation word categories and selected five existing categories relevant to grant review. They analyzed results with linear mixed-effects models for differences due to applicant and application characteristics. Results Critiques of funded applications contained more positive descriptors and superlatives and fewer negative evaluation words than critiques of unfunded applications. Experienced investigators’ critiques contained more references to competence. Critiques showed differences due to applicant sex despite similar application scores or funding outcomes: more praise for applications from female investigators, greater reference to competence/ability for funded applications from female experienced investigators, and more negative evaluation words for applications from male investigators (all P < .05). Conclusions Results suggest that text analysis is a promising tool for assessing consistency in R01 reviewers’ judgments, and gender stereotypes may operate in R01 review.

An Educational Intervention Designed to Increase Women's Leadership Self-Efficacy

Women are sparsely represented in leadership in academic science, technology, engineering, mathematics, and medicine (STEMM). Cultural stereotypes about men, women, and leaders influence the attitudes, judgments, and decisions that others make about women and the choices women make for themselves. Multilevel interventions are needed to counteract the impact of these pervasive and easily activated stereotypes, which conspire in multiple ways to constrain womens entry, persistence, and advancement in academic STEMM. We describe an individual-level educational intervention. Using the transtheoretical model of behavioral change as a framework, we assessed the success of a semester course on increasing womens leadership self-efficacy for the first three cohorts of course participants (n = 30). Pre/post questionnaires showed gains in leadership self-efficacy, personal mastery, and self-esteem, and decreases in perceived constraints. Qualitative text analysis of weekly journals indicated increasing leadership self-efficacy as course participants applied course information and integrated strategies to mitigate the impact of societal stereotypes into their own leadership practices. Follow-up queries of the first two cohorts supported the enduring value of course participation. We conclude that providing strategies to recognize and mitigate the impact of gender stereotypes is effective in increasing leadership self-efficacy in women at early stages of academic STEMM careers.

A qualitative study of work-life choices in academic internal medicine

The high attrition rate of female physicians pursuing an academic medicine research career has not been examined in the context of career development theory. We explored how internal medicine residents and faculty experience their work within the context of their broader life domain in order to identify strategies for facilitating career advancement. Semi-structured interviews were conducted with a purposeful sample of 18 residents and 34 faculty members representing male and female physicians at different career stages. Using thematic analysis, three themes emerged: (1) the love of being a physician (“Raison d’être”), (2) family obligations (“2nd Shift”), and (3) balancing work demands with non-work life (“Negotiating Academic Medicine”). Female researchers and educators reported more strategies for multiple role planning and management than female practitioners. Interventions aimed at enhancing academic internists’ planning and self-efficacy for multiple role management should be investigated as a potential means for increasing participation and facilitate advancement.

A gender bias habit-breaking intervention led to increased hiring of female faculty in STEMM departments

Addressing the underrepresentation of women in science is a top priority for many institutions, but the majority of efforts to increase representation of women are neither evidence-based nor rigorously assessed. One exception is the gender bias habit-breaking intervention (Carnes et al., 2015), which, in a cluster-randomized trial involving all but two departmental clusters (N = 92) in the 6 STEMM focused schools/colleges at the University of Wisconsin - Madison, led to increases in gender bias awareness and self-efficacy to promote gender equity in academic science departments. Following this initial success, the present study compares, in a preregistered analysis, hiring rates of new female faculty pre- and post-manipulation. Whereas the proportion of women hired by control departments remained stable over time, the proportion of women hired by intervention departments increased by an estimated 18 percentage points (OR = 2.23, dOR = 0.34). Though the preregistered analysis did not achieve conventional levels of statistical significance (p < 0.07), our study has a hard upper limit on statistical power, as the cluster-randomized trial has a maximum sample size of 92 departmental clusters. These patterns have undeniable practical significance for the advancement of women in science, and provide promising evidence that psychological interventions can facilitate gender equity and diversity.

Are Men More Likely than Women To Commit Scientific Misconduct? Maybe, Maybe Not

ABSTRACT In their study published in January 2013 in mBio, Fang et al. reviewed records from the Office of Research Integrity (ORI) and found more cases of scientific misconduct committed by men than women, particularly by faculty (F. C. Fang, J. W. Bennett, and A. Casadevall, mBio 4:1–3, 2013). Powerful social norms shape the way men and women behave, and implicit gender schemas can lead to different evaluation standards for men and women for tasks stereotypically linked to one gender. It is possible that norms for acceptable male and female behavior could lead to a lower threshold for men than women to engage in the risky behavior of scientific misconduct. It is also possible that women and men commit scientific fraud at the same rate but that, because crime is a male-gendered domain, evaluators require more proof of the criminal “competence” of women for an investigation to rise to the level of an ORI case or that female gender norms for likeability and a lower apology threshold more often prevent escalation of women’s fraud beyond a local level. Male scientists also have more opportunity to commit fraud than female scientists because they receive more NIH research funding—a finding that may also be influenced by gender schemas. We cannot conclude from the ORI data that men are more likely than women to risk the consequences of committing scientific misconduct simply because risk taking aligns with male gender stereotypes. Neither can we conclude that because men are more likely than women to commit fraud in other contexts, men are also more likely than women to commit scientific fraud. We can conclude, however, that scientific misconduct, regardless of who commits it, diminishes all who contribute to the scientific enterprise.

Low agreement among reviewers evaluating the same NIH grant applications

Significance Scientific grant peer reviewers must differentiate the very best applications from comparatively weaker ones. Despite the importance of this determination in allocating funding, little research has explored how reviewers derive their assigned ratings for the applications they review or whether this assessment is consistent when the same application is evaluated by different sets of reviewers. We replicated the NIH peer-review process to examine the qualitative and quantitative judgments of different reviewers examining the same grant application. We found no agreement among reviewers in evaluating the same application. These findings highlight the subjectivity in reviewers’ evaluations of grant applications and underscore the difficulty in comparing the evaluations of different applications from different reviewers—which is how peer review actually unfolds. Obtaining grant funding from the National Institutes of Health (NIH) is increasingly competitive, as funding success rates have declined over the past decade. To allocate relatively scarce funds, scientific peer reviewers must differentiate the very best applications from comparatively weaker ones. Despite the importance of this determination, little research has explored how reviewers assign ratings to the applications they review and whether there is consistency in the reviewers’ evaluation of the same application. Replicating all aspects of the NIH peer-review process, we examined 43 individual reviewers’ ratings and written critiques of the same group of 25 NIH grant applications. Results showed no agreement among reviewers regarding the quality of the applications in either their qualitative or quantitative evaluations. Although all reviewers received the same instructions on how to rate applications and format their written critiques, we also found no agreement in how reviewers “translated” a given number of strengths and weaknesses into a numeric rating. It appeared that the outcome of the grant review depended more on the reviewer to whom the grant was assigned than the research proposed in the grant. This research replicates the NIH peer-review process to examine in detail the qualitative and quantitative judgments of different reviewers examining the same application, and our results have broad relevance for scientific grant peer review.