Using virtual reality to investigate bias and discrimination in clinical decision making: A proof of concept study

Background Biases held by healthcare practitioners can shape clinical interactions, leading to discrimination and poor patient outcomes. Traditional methods, such as vignettes or self-report measures, often lack ecological validity.

We evaluated a novel VR simulation designed to explore bias and discrimination in clinical decision-making.

Thirty-five healthcare practitioners across 14 NHS trusts completed an in-person VR simulation and provided feedback on realism, immersion, and usability via surveys and open-ended responses.Patients in the simulation had intersecting sociodemographic characteristics (race, gender, migration status).

Most participants rated the VR environment as at least moderately realistic (88.6%), with 42.9% rating it very or extremely realistic. Nearly half (45.7%) reported consistency with real-world experience. Open-text feedback highlighted strengths in realism, immersion, and educational potential, with suggestions to improve dialogue flexibility.

VR is a feasible, immersive, and scalable tool for investigating bias in clinical decision-making. Graphical Highlights Virtual reality (VR) is feasible for studying bias in clinical decision-making. VR simulations capture intersecting patient characteristics, including race, gender, and migration status. Participants rated the VR environment as realistic, immersive, and usable. VR provides a scalable, controlled platform for research and professional training on bias and discrimination. Competing Interest Statement The authors have declared no competing interest. Funding Statement This paper represents independent research funded by the Wellcome Trust [203380/Z/16/Z] and the Economic and Social Research Council [ES/V009931/1]. J.O. is part-funded by the NIHR Biomedical Research Centre [BRC121520018] at South London and Maudsley NHS Foundation Trust. S.L.H. and R.R. are supported by the Economic and Social Research Council Centre for Society and Mental Health at King's College London [ES/S012567/1] and by UK Research and Innovation [MR/Y030788/1] as part of Population Health Improvement UK (PHI-UK), a national research network that seeks to transform health and reduce inequalities through change at the population level. S.L.H, R.R, J.O and H.W are supported by the Wellcome Trust [308556/Z/23/Z], S.L.H. currently receives funding from Impact on Urban Health part of Guy's & St Thomas' Foundation [EIC210605 and EIC221208], the Swedish Research Council [2023-05959] and the Wellcome Trust [28117/Z/23/Z & 223486/Z/21/Z]. The funders had no involvement in study design, data collection, analysis, interpretation or the decision to submit for publication. The views expressed are those of the author(s) and not necessarily those of the funders. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The Kings College London Research Ethics Committee for Psychiatry, Nursing and Midwifery and the NHS Health Research Authority gave ethical approval for this work (KCL Ref: HR-17/18-4629; HRA Ref: 18/HRA/0368) I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes 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). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Footnotes ↵* Joint First Ethics Ethical approval was granted by the King’s College London Research Ethics Committee for Psychiatry, Nursing and Midwifery (HR-17/18-4629) and the NHS Health Research Authority (18/HRA/0368). Funding This paper represents independent research funded by the Wellcome Trust [203380/Z/16/Z] and the Economic and Social Research Council [ES/V009931/1]. J.O. is part-funded by the NIHR Biomedical Research Centre [BRC-1215–20018] at South London and Maudsley NHS Foundation Trust. S.L.H. and R.R. are supported by the Economic and Social Research Council Centre for Society and Mental Health at King’s College London [ES/S012567/1] and by UK Research and Innovation [MR/Y030788/1] as part of Population Health Improvement UK (PHI- UK), a national research network that seeks to transform health and reduce inequalities through change at the population level. S.L.H, R.R, J.O and H.W are supported by the Wellcome Trust [308556/Z/23/Z], S.L.H. currently receives funding from Impact on Urban Health part of Guy’s & St Thomas’ Foundation [EIC210605 and EIC221208], the Swedish Research Council [2023-05959] and the Wellcome Trust [28117/Z/23/Z & 223486/Z/21/Z]. The funders had no involvement in study design, data collection, analysis, interpretation or the decision to submit for publication. The views expressed are those of the author(s) and not necessarily those of the funders. Data Availability Data is available for research purposes upon request. All requests are reviewed by the study data committee. To apply for access to this data please contact care_hsc{at}kcl.ac.uk ZC prepared and submitted relevant materials for ethical approval. ZC recruited participants and drafted the manuscript alongside RR and HW with input from SH, LV, JO and LE. HW provided technical support and added necessary revisions to the manuscript in addition to acting as the corresponding author. All authors read and approved the final manuscript. Conflicts of Interest The authors have no conflicts of interest to declare. Data Availability Data is available for research purposes upon request. All requests are reviewed by the study data committee. To apply for access to this data please contact care_hsc{at}kcl.ac.uk