In the Shadows of Bias

By Drew Harris, MD, FCCP
October 3, 2025 | VOLUME 3, ISSUE 3

When most of my patients who are coal miners develop black lung disease, they are frustrated by more than shortness of breath; they are often frustrated by the bias from the doctors who they meet. Let me explain.

Coal miners disabled by black lung are eligible for a federal worker’s compensation benefit that provides them with health insurance and a monthly stipend to be paid for by the coal miner’s employer. One of the ways a coal miner can qualify for this benefit is to legally prove they have severe black lung on an X-ray.

But research has shown that whether or not a doctor finds black lung on an X-ray is strongly associated with their financial conflicts of interest.

Here’s what typically happens: A coal miner gets an X-ray. Multiple doctors interpret this X-ray. Some doctors are hired by the patient to read the X-ray and some are hired by the employer. The doctors paid by the patient are more likely to read the X-ray as showing black lung, whereas the doctors hired by the employer are more likely to read the X-ray as not having black lung. Recent investigations have shown how a prestigious academic medical center’s black lung program recently exhibited this bias to very disheartening levels.

In my own black lung practice, I find myself face to face with this bias in nearly every encounter with a patient who is a coal miner. Being aware of existing bias helps me be a better doctor and a better advocate. I can help individual patients manage the frustrations of different doctors reaching different conclusions about their health.

I am forthcoming with each patient that I strive to be fair in my black lung determinations. This means I may or may not find black lung on their X-ray. But—black lung or not—I will do my best to help each patient reach the right diagnosis and get the right treatment. Striving to be fair helps build my credibility to inform politicians and policymakers who also care about issues impacting coal miners.

I am well aware than nearly everyone reading this issue of CHEST Advocates is not directly impacted by bias in black lung. Fortunately, this issue is focused on bias in many different forms, with broad applicability, as well as the research integrity and tools needed to study medicine free from these influences.

In the feature article, expert sources break down the different types of biases that are most prevalent in clinical research and the importance of diverse participant pools, publishing outlets, and funding sources. However, with the recent funding cuts seen at the federal level, many equity-focused projects have been limited. Grant recipients share how this is affecting their research—which ultimately trickles down to patient care.

Read about Judy Wawira Gichoya, MD, MS, FSIIM, Co-Director of the Healthcare AI, Innovation, and Translational Informatics Lab at Emory University, who shares practical advice on how to identify and reduce bias while utilizing artificial intelligence (AI) in scientific research and clinical applications.

Hear Heather A. Bimonte-Nelson, PhD, of Arizona State University, discuss in her own words how bias related to sex and gender presents a problematic scientific shortcoming. She also provides proof for why sex should be a critical variable studied in research.

Get to know the Rare Disease Diversity Coalition, whose mission is to fund research into the rare conditions that don’t get the most public or private sector support. Executive Director Jenifer Ngo Waldrop shares how the best way to serve all patients, especially those from historically excluded communities, is to fill knowledge gaps in medicine.

Also read about Kerry Hena, MD, the 2022 recipient of CHEST’s John R. Addrizzo, MD, FCCP, Research Grant in Sarcoidosis, another rare disease. She’s using her funding to build a database of sarcoidosis phenotypes. This research will be used to analyze how phenotypes correlate with demographic factors—with the goal of earlier disease detection and intervention.

This issue of CHEST Advocates also includes editorials from CHEST leaders. The Editor in Chief of the journal CHEST® Peter J. Mazzone, MD, FCCP, reflects on the goals and practices employed at the journal to promote trust and protect the public from misinformation. Specifically, Dr. Mazzone reflects on how the journal avoids influence and bias related to the financial relationships of the organization, journal leaders, or journal contributors. In another column, Jonathan Iaccarino, MD, Senior Director for Science and Policy, highlights CHEST’s contributions on a task force to develop a tool that can be used to adopt practices that recognize how the use and misuse of race and ethnicity in clinical guidelines and algorithms may help or harm health outcomes.

We hope this issue helps you recognize and address bias in your own practice or research efforts. Recognizing and eradicating bias is an important step we can all take when it comes to advocating for our patients and communities.