Checking Our Bias: An Examination of Implicit Racial Attitudes Amongst Pediatric Orthopedic Surgeons

Background: Racial and ethnic minority patients continue to experience disparities in healthcare. It is critical to understand provider-level factors that may contribute to these inequities. Many factors likely contribute to variation in treatment and healthcare quality; however, evidence suggests that a provider’s implicit bias, or unconscious/involuntary beliefs and attitudes, may play a role. Despite investigations into the presence and impact of implicit racial bias in other specialties, research among pediatric orthopedic surgeons is nonexistent. This study aims to evaluate the presence of implicit racial bias among pediatric orthopedic surgeons and determine the relationship between bias and clinical decision making with regards to common pediatric fractures.

Methods: A web-based survey was distributed to 415 pediatric orthopedic surgeons. The first section consisted of clinical vignettes with associated questions. For each vignette, surgeons were randomly assigned a single race-version, white or black. Vignette questions were grouped into an opioid recommendation, management decision, or patient perception category for analysis based on subject tested. The second section measured implicit racial bias using a child-race implicit association test (IAT). IAT scores were compared to U.S. physicians and the U.S. general population using publicly available data. Vignette answers from surgeons with IAT scores that were concordant with their randomized vignette race-version (i.e., surgeon with pro-white score assigned white vignette version) were compared to those that were discordant (i.e., surgeon with pro-white score assigned black vignette version) using bivariate analysis.

Results: IAT results were obtained from 119 surveyed surgeons (28.7% response rate). Overall, respondents showed a minor pro-white implicit bias (p < 0.001) (Figure 1). Implicit bias of any strength towards either race was present among 103/119 (86.6%) surgeons. The proportion of pediatric orthopedic surgeons with a strong pro-white implicit bias (29.4%) was greater than that of U.S. physicians (21.3%, p = 0.032) and the U.S. general population (19.1%, p = 0.004) (Figure 2). No differences were found in overall opioid recommendations, management decisions, or patient perceptions between concordant and discordant groups.

Conclusion: Most pediatric orthopedic surgeons demonstrate implicit racial bias on IAT testing, with a large proportion exhibiting strong pro-white bias. This is the first study dedicated to implicit racial attitudes among pediatric orthopedic surgeons, which is especially important as the broader field of orthopedics continues to lag behind the level of diversity seen among other specialties and in the patient population it serves. Despite an established association between implicit bias and clinical decision making in the literature, our study was unable to demonstrate the role of implicit racial bias in the management of pediatric fractures. However, bias in the live clinical setting may present far differently than in answering clinical vignettes. Providers should make a consistent effort to recognize their own implicit bias and mitigate its potential impact in practice.