Background Implicit bias can influence behavior and decision-making. In clinical settings, implicit bias may influence treatment decisions and contribute to health disparities. Given documented Black-White disparities in vascular care, the purpose of this study was to examine the prevalence and degree of unconscious bias and awareness of bias among vascular surgeons treating peripheral artery disease (PAD).

Methods The sampling frame included all vascular surgeons who participate in the Vascular Quality Initiative (VQI). Participants completed a survey which included demographic questions, the race implicit association test (IAT) to measure magnitude of unconscious bias, and six bias awareness questions to measure conscious bias. The magnitude of unconscious bias was no preference; or slight, moderate, or strong in the direction of pro-White or pro-Black. Data from participants were weighted to account for nonresponse bias and known differences in the characteristics of surgeons who chose to participate compared to the full registry. We stratified unconscious and conscious findings by physician race/ethnicity, physician sex, and years of experience. Finally, we examined the relationship between unconscious and conscious bias.

Results There were 2,512 surgeons in the VQI registry, 304 of whom completed the survey, including getting IAT results. Most participants (71.6%) showed a pro-White bias with 73.0% of this group in the moderate and strong categories. While 77.5% of respondents showed conscious awareness of bias, of those whose conscious results showed lack of awareness, 67.8% had moderate or strong bias, compared to 55.7% for those with awareness. Bias magnitude varied based on physician race/ethnicity and years of experience. Women were more likely than men to report awareness of biases and potential impact of bias on decision-making.

Conclusions Most people have some level of unconscious bias, developed from early life reinforcements, social stereotypes, and learned experiences. Regarding health disparities, however, these are important findings in a profession that takes care of patients with PAD due to heavy burden of comorbid conditions and high proportion of individuals from structurally vulnerable groups. Given the lack of association between unconscious and conscious awareness of biases, awareness may be an important first step in mitigation to minimize racial disparities in healthcare.

What is new?

This is the first study to examine unconscious and conscious bias in vascular surgeons, an important population for treating peripheral artery disease which disproportionately affects structurally vulnerable groups.

We found that the majority of vascular surgeons show a pro-White bias, there is a lack of association between unconscious bias and conscious awareness of bias, and those who do not report conscious awareness of bias may also show greater magnitude of unconscious bias.

What are the clinical implications?

These findings offer important considerations for attentiveness to both unconscious biases and enhancement of awareness of the existence of biases among a surgery community that provides care to a diverse population of patients with PAD and disparities in health outcomes.

Incorporating information on the awareness of biases and structural changes to facilitate behavior change based on these findings may be helpful within training programs for vascular surgeons.

With awareness as an important first step in mitigation, cognizance of the existence of biases, as identified by this study, can aid in efforts to minimize racial disparities in health care.

The authors have declared no competing interest.

CAK was funded for this work by Career Development Awards from the American Heart Association (19CDA34760135) and National Institute of Health/National Heart Lung and Blood Institute (K01HL146900).

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The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The Institutional Review Boards at Clemson University (IRB 2020-096) and Indiana University (IRB 16325) approved this study.

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I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

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I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

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Because of the sensitive nature of the data collected for this study, requests to access the dataset from qualified researchers trained in human subject confidentiality protocols may be sent to the Vascular Quality Initiative.