Race and Gender Bias May Sway Decisions in Advanced HF Care

An eye-opening study shows just how harshly some physicians judge patients with advanced heart failure when deciding whether to recommend a heart transplant or a bridge to transplant. Free to speak their minds, physicians appeared to focus on inappropriate and irrelevant criteria when thinking through decisions for women in general, and for black women in particular, including things like unkempt appearance or being burdened by what they view as too many children.

Lead author Khadijah Breathett, MD (University of Arizona, Tucson), said the findings show that regardless of how removed people claim to be from racist and sexist bias, their thinking processes often show otherwise.

“This is a national study . . . and the chances are it does happen at your center, and chances are you are also a part of the problem,” she told TCTMD.

Breathett and colleagues used interviews and surveys to examine how physicians made decisions based on clinical vignettes that contained a fictional patient history and photo. All patients in the vignettes had end-stage heart failure with complex history and contraindications for advanced therapies, and they varied only by gender and race. Interviews regarding the patients in the vignettes were conducted in a “think-aloud” format that allowed the investigators unique insights on the thoughts that were going into physician decisions.

This is a critical area where we're talking about life and death types of therapies. There's no room for bias to enter. Khadijah Breathett

In an accompanying editorial, Bessie A. Young, MD, MPH (VA Puget Sound Health Care System, Seattle, WA), notes that the study paints a wide swath of bias among physicians—the group consisted of a mix of white and minority men and women—“implying that clinicians may be taught certain biases that are internalized, whether they are from majority or minority populations.”

The study and editorial were published online today in JAMA Network Open.

Thinking Processes on Display

Overall, 46 physicians attending an annual transplantation scientific session participated in the interview and surveys. Most participants were women (52%), and racial minorities were well-represented (43%). According to Breathett and colleagues, some did not welcome the photos, paying less attention to them when forming their decision. Others had strong visceral reactions to the images, particularly the ones of women, critiquing them on their weight, age, hair, makeup, and facial expressions. Among the thoughts that were expressed about women’s photos were “unfriendly,” “unkempt,” “tired,” “scared,” and “looks like she’s never been petite.” Clinical vignettes of African-American or white men did not elicit the same types of comments.

“These are real people, not mannequins or models. Although the vignette is fictitious, the photos are real people, and it is disturbing to realize how much appearance matters to people in clinical situations,” Breathett observed. “It's fairly well recognized that appearance dictates different levels of privilege and access in general, but it shouldn't exist in medicine.”

Women also were critiqued on their family life, as perceived by the viewers. Participants expressed concern that among both African-American and white women, children could be a liability in terms of not being able to care for themselves or could create additional burdens on their already sick mothers.

Participants also questioned women’s family dynamics and social support systems, especially those who were African-American. Based on the photos and history, they voiced concerns about the women’s finances, whether a spouse could help out with care and doctor’s appointments, and how many vehicles the family owned. In one case, a white male physician found it concerning that a black woman had given birth at age 53 and now had a 10-year-old child.

Internal Bias ‘Pops Out’

Ultimately, all the physicians made the same treatment decisions regardless of their gender or race, and all patients received the same recommendation regardless of their gender or race.  All were recommended for a ventricular assist device (VAD) rather than heart transplants.

“It's a form of cognitive dissonance, where I think people mean to do well but that's not exactly how their behavior lines up,” Breathett said about reconciling the things physicians said versus their ultimate decisions. She added that the study shows how internal bias that people may not even be aware they possess “pops out” in random places.

“This is a critical area where we're talking about life and death types of therapies. There's no room for bias to enter,” she said.

In her editorial, Young notes that sex/gender and race bias has been “a longstanding issue in medicine” with regard to assessing CVD. “Women are less likely to undergo heart transplantation compared with men and are 20% more likely to die waiting for a heart transplant compared with men,” she writes. Young also points out that when VADs are used as a bridge to heart transplantation, Black patients have higher odds than white patients of graft failure and death.

According to Young, real-life harsh judgement of women could lead to delays in their referral for transplantation.

Chances are it does happen at your center, and chances are you are also a part of the problem. Khadijah Breathett

“Additional research regarding which biases exist against women is needed to decrease disparities in heart transplantation, given that women are more likely to donate an organ but less likely to undergo transplantation than men, despite having similar survival after transplantation,” she writes.

To TCTMD, Breathett concluded that “we need to take the subjectivity out of the process.” She added that reliable evidence-based methods exist; instead of making decisions based on what physicians and others think they know about a patient and their individual circumstances, these should be used to reduce bias. Lastly, Breathett said, the team-based decision-making that is used to determine who gets advanced therapies and what type of therapy they get needs to be made more equitable.

“We have a broken system, and caring about our patients as we do, we must  take the next structural steps to change the system,” she added.