Journal of General Internal Medicine

, Volume 33, Issue 12, pp 2056–2064 | Cite as

Racial/Gender Biases in Student Clinical Decision-Making: a Mixed-Method Study of Medical School Attributes Associated with Lower Incidence of Biases

  • Robert L. WilliamsEmail author
  • Cirila Estela Vasquez
  • Christina M. Getrich
  • Miria Kano
  • Blake Boursaw
  • Crystal Krabbenhoft
  • Andrew L. Sussman
Original Research



Accumulating evidence suggests that clinician racial/gender decision-making biases in some instances contribute to health disparities. Previous work has produced evidence of such biases in medical students.


To identify contextual attributes in medical schools associated on average with low levels of racial/gender clinical decision-making biases.


A mixed-method design using comparison case studies of 15 medical schools selected based on results of a previous survey of student decision-making bias: 7 schools whose students collectively had, and 8 schools whose students had not shown evidence of such biases.


Purposively sampled faculty, staff, underrepresented minority medical students, and clinical-level medical students at each school.

Main Measures

Quantitative descriptive data and qualitative interview and focus group data assessing 32 school attributes theorized in the literature to be associated with formation of decision-making and biases. We used a mixed-method analytic design with standard qualitative analysis and fuzzy set qualitative comparative analysis.

Key Results

Across the 15 schools, a total of 104 faculty, administrators and staff and 21 students participated in individual interviews, and 196 students participated in 29 focus groups. While no single attribute or group of attributes distinguished the two clusters of schools, analysis showed some contextual attributes were seen more commonly in schools whose students had not demonstrated biases: longitudinal reflective small group sessions; non-accusatory approach to training in diversity; longitudinal, integrated diversity curriculum; admissions priorities and action steps toward a diverse student body; and school service orientation to the community.


We identified several potentially modifiable elements of the training environment that are more common in schools whose students do not show evidence of racial and gender biases.


students medical decision-making healthcare disparities 



The authors wish to thank Lee Green, MD, MPH, for consultation with the fuzzy set qualitative comparative analysis, and Denise Ruybal for untiring and unflappable administrative support.


Research reported in this paper was supported by the National Institute on Minority Health and Health Disparities of the National Institutes of Health under Award Numbers R01MD006073 and P20MD004811.

Compliance with Ethical Standards

Prior Presentations

The findings of this study have been presented in part or in whole at the following conferences: (1) 13th Annual AAMC Health Workforce Research Conference. Arlington, VA, May 2017; (2) Society of General Internal Medicine Annual Meeting. Washington DC, April 2017; (3) Society of Teachers of Family Medicine Conference on Medical Student Education. Anaheim, CA, February 2017; (4) 43rd Annual meeting of North American Primary Care Research Group, Cancun, Mexico, November 2015.

Conflict of Interest

The authors declare that they do not have a conflict of interest.


The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Supplementary material

11606_2018_4543_MOESM1_ESM.docx (26 kb)
ESM 1 (DOCX 26 kb)


  1. 1.
    Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academies Press, 2003.Google Scholar
  2. 2.
    Agency for Healthcare Research and Quality. 2016 National Healthcare Quality and Disparities Report. Available at: Accessed April 24, 2018.
  3. 3.
    Fiscella K, Sanders MR. Racial and ethnic disparities in the quality of health care. Ann Rev Public Health 2016; 37:375–94.CrossRefGoogle Scholar
  4. 4.
    Centers for Medicare and Medicaid Services, Office of Minority Health and RAND Corporation. Racial and ethnic disparities by gender in health care in Medicare Advantage. Available at: Accessed April 24, 2018.
  5. 5.
    Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health. 2015;105:e60–76.CrossRefGoogle Scholar
  6. 6.
    Dovidio JF, Fiske ST. Under the radar: how unexamined biases in decision-making processes in clinical interactions can contribute to health care disparities. Am J Public Health. 2012;102: 945–952.CrossRefGoogle Scholar
  7. 7.
    van Ryn M. Research on the provider contribution to race/ethnicity disparities in medical care. Med Care. 2002;40:I140–51.PubMedGoogle Scholar
  8. 8.
    Fincher C, Williams JE, MacLean V, Allison JJ, Kiefe CI, Canto J. Racial disparities in coronary heart disease: a sociological view of the medical literature on physician bias. Ethn Dis. 2004;14:360–371.PubMedGoogle Scholar
  9. 9.
    Blair IV, Steiner JF,Fairclough DL, et al. Clinicians’ implicit ethnic/racial bias predicts patients’ perceptions of care among Black but not Latino patients. Ann Fam Med. 2013;11:43–52.CrossRefGoogle Scholar
  10. 10.
    Maserejian NN, Link CL, Lutfey KL, Marceau LD, McKinlay JB. Disparities in physicians’ interpretations of heart disease symptoms by patient gender: results of a video vignette factorial experiment. J Womens Health (Larchmt). 2009;18:1661–7.CrossRefGoogle Scholar
  11. 11.
    Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for Black and White patients. J Gen Intern Med. 2007;22:1231–1238.CrossRefGoogle Scholar
  12. 12.
    Cooper LA, Roter DL, Carson KA, et al. The associations of clinicians’ implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. Am J Public Health. 2012;102:979–987.CrossRefGoogle Scholar
  13. 13.
    Sabin JA, Greenwald AG. The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: pain, urinary tract infection, attendtion deficit hyperactivity disorder, and asthma. Am J Public Health. 2012;102:988–995.CrossRefGoogle Scholar
  14. 14.
    Paradies Y, Truong M, Priest N. A systematic review of the extent and measurement of healthcare provider racism. J Gen Intern Med. 2013;29:364–87.CrossRefGoogle Scholar
  15. 15.
    Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities. J Gen Intern Med. 2013;28:1504–10.CrossRefGoogle Scholar
  16. 16.
    Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians' recommendations for cardiac catheterization. N Engl J Med. 1999; 340:618–25.CrossRefGoogle Scholar
  17. 17.
    Van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians’ perceptions of patients. Soc Sci Med. 2000;50:813–28.CrossRefGoogle Scholar
  18. 18.
    Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA. 1993;269:1537–9.CrossRefGoogle Scholar
  19. 19.
    Rathore SS, Lenert LA, Weinfurt KP, et al. The effects of patient sex and race on medical students' ratings of quality of life. Am J Med. 2000;108:561–6.CrossRefGoogle Scholar
  20. 20.
    Haider AH, Sexton J, Sriram N, et al. Association of unconscious race and social class bias with vignette-based clinical assessments by medical students. JAMA. 2011;306:942–51.PubMedPubMedCentralGoogle Scholar
  21. 21.
    Chiaramonte GR, Friend R. Medical students’ and residents’ gender bias in the diagnosis, treatment, and interpretation of coronary heart disease symptoms. Health Psychol. 2006;25:255–66.CrossRefGoogle Scholar
  22. 22.
    Williams RL, Romney C, Kano M, et al. Racial, gender, and socioeconomic status bias in senior medical student clinical decision-making: a national survey. J Gen Intern Med. 2015;30:758–67.CrossRefGoogle Scholar
  23. 23.
    Liaison Committee on Medical Education. Functions and Structure of a medical school: standards for accreditation of medical education programs leading to the MD degree. Standard 7.6 Cultural competence and health care Disparities. Available at: Accessed April 24, 2018.
  24. 24.
    Association of American Medical Colleges. Assessing Change: Evaluating Cultural Competence Education and Training. Available at: . Accessed April 24, 2018.
  25. 25.
    Addison RB. A grounded hermeneutic editing approach. In: Crabtree BF, Miller WL, editors. Doing Qualitative Research. 2nd Ed. Thousand Hills, CA: Sage; 1999:145–61.Google Scholar
  26. 26.
    Burgess D, van Ryn M, Dovidio J, Saha S. Reducing racial bias among health care providers: lessons from social-cognitive psychology. J Gen Intern Med. 2007;22:882–7.CrossRefGoogle Scholar
  27. 27.
    Project Implicit. Implicit Association Test. Available at: Accessed April 24, 2018.
  28. 28.
    Burgess DJ, Burke SE, Cunningham BA, et al. Medical students’ learning orientation regarding interracial interactions affects preparedness to care for minority patients: a report from Medical Student CHANGES. BMC Med Educ. 2016;29:254.CrossRefGoogle Scholar
  29. 29.
    van Ryn M, Hardeman R, Phelan SM, et al. Medical school experiences associated with change in implicit racial bias among 3547 students: a medical student CHANGES study report. J Gen Intern Med. 2015;30:1748–5.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2018

Authors and Affiliations

  • Robert L. Williams
    • 1
    Email author
  • Cirila Estela Vasquez
    • 2
  • Christina M. Getrich
    • 3
  • Miria Kano
    • 4
  • Blake Boursaw
    • 5
  • Crystal Krabbenhoft
    • 1
  • Andrew L. Sussman
    • 1
  1. 1.Department of Family and Community Medicine; MSC09-5060 University of New MexicoAlbuquerqueUSA
  2. 2.Morehouse School of MedicineAtlantaUSA
  3. 3.Department of AnthropologyUniversity of MarylandCollege ParkUSA
  4. 4.Cancer Research and Treatment CenterUniversity of New MexicoAlbuquerqueUSA
  5. 5.College of NursingUniversity of New MexicoAlbuquerqueUSA

Personalised recommendations