Effect of Physician Race and Gender on Simulated Patients' Ratings

Effect of Physician Race and Gender on Simulated Patients' Ratings and Confidence in Their Physicians: A Randomized Trial

The purpose of the study was to determine whether the race and gender of a simulated doctor affected analog patients' reported confidence and satisfaction in the simulated doctor's diagnosis and treatment plan. The study used two randomized patient analog experiments.

This study is complete and pre-analysis plans (PAPs) for each experiment were published prior to data collection. The PAPs are available at: http://aspredicted.org/blind.php?x=43xj25 (Study 1) and https://aspredicted.org/blind.php?x=369st7 (Study 2).

Study Overview

• Status: Completed
• Conditions: Patient Satisfaction; Bias, Racial; Physician-Patient Relations; Bias, Sex
• Intervention / Treatment: Behavioral: Simulated Black Male Physician; Behavioral: Simulated Black Female Physician; Behavioral: Simulated White Male Physician; Behavioral: Simulated White Female Physician

Detailed Description

Prior literature is unclear on whether patients display bias in their evaluations of physicians based on their race or gender. The investigators estimated the effects of physician race and gender using an online clinical vignette. Participants played the role of analog patients reporting to the Emergency Department (ED) with symptoms consistent with gastroenteritis. Participants were provided with a diagnosis of gastroenteritis by a simulated ED physician. The race (black or white) and gender (male or female) of the simulated physician was randomly assigned in a 2x2 factorial experiment. Simulated physicians provided a diagnosis of gastroenteritis and contradicted by an Online Symptom Checker. Following the physician's diagnosis and contradiction by the Online Symptom Checker, participants rated the simulated physician on survey measures of satisfaction and confidence in both the treatment plan and diagnosis. The main (null) hypothesis tested was that there were no differences across the four treatment arms (Black Female, Black Male, White Female, White Male). Participants for the first experiment (Study 1) were recruited from Amazon Mechanical Turk (MTurk) and participants for the second experiment (Study 2) were recruited from Lucid.

Primary Aim: To determine whether the race and gender of a simulated physician had a causal effect on participants' confidence and satisfaction in the physician's diagnosis and treatment plan in an ED setting.

Exploratory Aims: To determine whether the race and gender of a simulated physician had a casual effect on participants' perceptions of the warmth and competence of the physician, their willingness to sue or complain about the physician for an incorrect diagnosis, and their perceived fairness of the charge for the visit.

• Study Type: Interventional
• Enrollment (Actual): 3592
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Connecticut
    • New Haven, Connecticut, United States, 06520
      • Yale University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: Yes
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Adults over 18 years old

Exclusion Criteria:

• Participants who reported current pregnancy
• Participants who reported a current or prior diagnosis of cancer
• Participants who reported a history of abdominal surgery

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Health Services Research
• Allocation: Randomized
• Interventional Model: Factorial Assignment
• Masking: None (Open Label)

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Simulated Black Male Physician; Participants are randomized to view the clinical vignette with a simulated Black Male physician.	Behavioral: Simulated Black Male Physician; Participants in this arm of the experiment viewed one of 10 randomly selected possible images of a simulated Black Male physician. This image was paired with a written treatment and diagnosis of gastroenteritis alongside a contradictory diagnosis and treatment plan for appendicitis from an Online Symptom Checker.
Experimental: Simulated Black Female Physician; Participants are randomized to view the clinical vignette with a simulated Black Female physician.	Behavioral: Simulated Black Female Physician; Participants in this arm of the experiment viewed one of 10 randomly selected possible images of a simulated Black Female physician. This image was paired with a written treatment and diagnosis of gastroenteritis alongside a contradictory diagnosis and treatment plan for appendicitis from an Online Symptom Checker.
Experimental: Simulated White Male Physician; Participants are randomized to view the clinical vignette with a simulated White Male physician.	Behavioral: Simulated White Male Physician; Participants in this arm of the experiment viewed one of 10 randomly selected possible images of a simulated White Male physician. This image was paired with a written treatment and diagnosis of gastroenteritis alongside a contradictory diagnosis and treatment plan for appendicitis from an Online Symptom Checker.
Experimental: Simulated White Female Physician; Participants are randomized to view the clinical vignette with a simulated White Female physician.	Behavioral: Simulated White Female Physician; Participants in this arm of the experiment viewed one of 10 randomly selected possible images of a simulated White Female physician. This image was paired with a written treatment and diagnosis of gastroenteritis alongside a contradictory diagnosis and treatment plan for appendicitis from an Online Symptom Checker.

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Patient Confidence	"How confident are you that this doctor made the correct diagnosis?" Study 1: [not at all confident (0) to completely confident (100)] Study 2: [not at all confident (1) to completely confident (5)]*; "How confident are you that this doctor made the correct treatment plan?" Study 1: [not at all confident (0) to completely confident (100)] Study 2: [not at all confident (1) to completely confident (5)]*The Patient Confidence outcome for each study participant was the unweighted average of their ratings on questions a and b. In Study 1, this item was measured using 0-100 point scales. In Study 2, this outcome was measured using 5 point scales. For all analyses, these Patient Confidence outcomes from a and b were rescaled to match the 1-5 point range from Study 2.	Approximately 10 minutes
Believed Symptom Checker over Doctor	"Which diagnosis do you think is more likely to be correct?" [the doctor's diagnosis (0); online symptom checker (1)]	Approximately 10 minutes
Likelihood of Requesting more Tests	"Would you ask the doctor to perform additional diagnostic tests? (Such as the CT scan recommended by the Symptom Checker)." [definitely not (1); probably not (2); might or might not (3); probably (4); definitely (5)]	Approximately 10 minutes
Patient Satisfaction: scale	"What number would you use to rate your care during this emergency room visit?" Study 1: [0 (worse possible care) to 100 (best possible care)] Study 2: [0 (worse possible care) to 10 (best possible care)]* *In Study 1, the Patient Satisfaction was measured using a 0-100 point scale. In Study 2, this was measured using a 10 point scale. For all analyses, this Patient Satisfaction outcome from Study 1 was rescaled to match the 0-10 point range in Study 2.	Approximately 10 minutes
Likelihood to Recommend	"Would you recommend this doctor to your friends and family?" [definitely not (1); probably not (2); might or might not (3); probably (4); definitely (5)]	Approximately 10 minutes

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Warmth and Competence	Study 1: "How do you imagine this doctor would be in a real interaction?". 7-item scale: Tolerant, Warm, Sincere, Good-natured, Intelligent, Competent, Confident.; Study 2: "Based on the doctor's diagnosis, to what extent do you find [him/her]". 6-item scale: Kind, Qualified, Intelligent, Competent, Open-minded, Trustworthy.Warmth and Competence were measured in Study 1 (7-item scale) and Study 2 (6-item scale).	Approximately 10 minutes
Willingness to sue or complain	"You take the doctor's advice and go home. Over the next few days, the pain in your abdomen got worse and you returned to the hospital where you were diagnosed with appendicitis. Your appendix had burst and you developed a serious infection. This required emergency surgery and an extended stay in the hospital's intensive Care Unit"*; "Would you file a complaint against this doctor?" [5 = "Definitely"; 4 = "Probably"; 3 = "Might or might not"; 2 = "Probably not"; 1 = "Definitely not"]; "Would you consider suing this doctors?" [5 = "Definitely"; 4 = "Probably"; 3 = "Might or might not"; 2 = "Probably not"; 1 = "Definitely not"]Willingness to sue or complain was only measured in Study 2.	Approximately 10 minutes
Fairness of the cost	"You would be charged about $350 for this emergency department visit. How fair do you think this charge is?" [0 = "Completely unfair" to 100 = "Completely Fair"]* *Fairness of the cost was only measured in Study 1.	Approximately 10 minutes

Collaborators and Investigators

• Sponsor: Yale University

Publications and helpful links

General Publications

• Solnick RE, Peyton K, Kraft-Todd G, Safdar B. Effect of Physician Gender and Race on Simulated Patients' Ratings and Confidence in Their Physicians: A Randomized Trial. JAMA Netw Open. 2020 Feb 5;3(2):e1920511. doi: 10.1001/jamanetworkopen.2019.20511.

Study record dates

Study Major Dates

• Study Start (Actual): March 9, 2018
• Primary Completion (Actual): July 31, 2018
• Study Completion (Actual): July 31, 2018

Study Registration Dates

• First Submitted: November 18, 2019
• First Submitted That Met QC Criteria: December 5, 2019
• First Posted (Actual): December 9, 2019

Study Record Updates

• Last Update Posted (Actual): July 21, 2020
• Last Update Submitted That Met QC Criteria: July 18, 2020
• Last Verified: July 1, 2020

More Information

Terms related to this study

• Other Study ID Numbers: 2000022317; 12916 (AsPredicted.org); 9068 (Other Identifier: AsPredicted.org)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: YES
• IPD Plan Description: We will make the data available upon individual request.
• IPD Sharing Time Frame: All data and replication code will be posted on an open-source website after the manuscript is accepted.
• IPD Sharing Access Criteria: We have no restrictions on access. All data and replication code will be posted on an open-source website after the manuscript is accepted.
• IPD Sharing Supporting Information Type: STUDY_PROTOCOL; SAP; ICF; ANALYTIC_CODE

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No