1. Health care disparities Stereotyping and unconscious bias Harry Pomeranz Mercy College October 2008

2. Do you think the average African American is better off, worse off, or just about as well off as the average white person in terms of access to health care?

3. Black and White Differences in Specialty Procedure Utilization Among Medicare Beneficiaries Age 65 and Older, 1993

5. What are potential sources of disparities in care? Health systems-level factors – financing, structure of care; cultural and linguistic barriers Health systems-level factors – financing, structure of care; cultural and linguistic barriers Patient-level factors – including patient preferences, refusal of treatment, poor adherence, biological differences Patient-level factors – including patient preferences, refusal of treatment, poor adherence, biological differences Disparities arising from the clinical encounter Disparities arising from the clinical encounter

6. Potential Sources of Racial and Ethnic Healthcare Disparities – Healthcare Systems-level Factors Lack of stable relationships with primary care providers –-- minority patients, even when insured at the same level as whites, are more likely to receive care in emergency rooms and have less access to private physicians Lack of stable relationships with primary care providers –-- minority patients, even when insured at the same level as whites, are more likely to receive care in emergency rooms and have less access to private physicians

7. Disparities in the Clinical Encounter: The Core Paradox How could well-meaning and highly educated health professionals, working in their usual circumstances with diverse populations of patients, create a pattern of care that appears to be discriminatory?

8. Perceptions of Disparities in Health Care What their race or ethnic background is How well they speak English Whether they are male or female Whether or not they have insurance 27% 15% 47% 29% 58% 43% 70% 72% Generally speaking, how often do you think our health care system treats people unfairly based on… DoctorsThe Public Percent Saying “Very/Somewhat Often” Source: Kaiser Family Foundation, National Survey of Physicians, March 2002 (conducted March-October 2001); Survey of Race, Ethnicity and Medical Care: Public Perceptions and Experiences, October 1999 (Conducted July – Sept., 1999) Figure 18

9. Disparities in the Clinical Encounter: The Core Paradox Uncertainty – a plausible hypothesis, particularly when providers treat patients that are dissimilar in cultural or linguistic background Uncertainty – a plausible hypothesis, particularly when providers treat patients that are dissimilar in cultural or linguistic background

10. Disparities in the Clinical Encounter: The Core Paradox Stereotyping – evidence suggests that physicians, like everyone else, use these ‘cognitive shortcuts’ Stereotyping – evidence suggests that physicians, like everyone else, use these ‘cognitive shortcuts’

11. Stereotyping: A Definition Stereotyping can be defined as the process by which people use social categories (e.g. race, sex) in acquiring, processing, and recalling information about others. Stereotyping can be defined as the process by which people use social categories (e.g. race, sex) in acquiring, processing, and recalling information about others.

12. Stereotyping: A Definition Stereotyping beliefs may serve important functions - organizing and simplifying complex situations and giving people greater confidence in their ability to understand, predict, and potentially control situations and people. Stereotyping beliefs may serve important functions - organizing and simplifying complex situations and giving people greater confidence in their ability to understand, predict, and potentially control situations and people.

13. Stereotyping: Risks Can exert powerful effects on thinking and actions at an implicit, unconscious level, even among well-meaning, well-educated persons who are not overtly biased. Can exert powerful effects on thinking and actions at an implicit, unconscious level, even among well-meaning, well-educated persons who are not overtly biased. Can influence how information is processed and recalled. Can influence how information is processed and recalled.

14. Stereotyping: Risks Can exert “self-fulfilling” effects, as patients’ behavior may be affected by providers’ overt or subtle attitudes and behaviors. Can exert “self-fulfilling” effects, as patients’ behavior may be affected by providers’ overt or subtle attitudes and behaviors.

15. Stereotyping: When Is It in Action? Situations characterized by time pressure, resource constraints, and high cognitive demand promote stereotyping due to the need for cognitive ‘shortcuts’ and lack of full information. Situations characterized by time pressure, resource constraints, and high cognitive demand promote stereotyping due to the need for cognitive ‘shortcuts’ and lack of full information.

16. What is the Evidence that Physician Biases and Stereotypes May Influence the Clinical Encounter? study conducted in actual clinical settings found that doctors are more likely to ascribe negative racial stereotypes to their minority patients. study conducted in actual clinical settings found that doctors are more likely to ascribe negative racial stereotypes to their minority patients. These stereotypes were ascribed to patients even when differences in minority and non-minority patients’ education, income, and personality characteristics were considered. These stereotypes were ascribed to patients even when differences in minority and non-minority patients’ education, income, and personality characteristics were considered. van Ryn and Burke (2000)

17. What is the Evidence that Physician Biases and Stereotypes may Influence the Clinical Encounter? medical students were more likely to evaluate a white male “patient” with symptoms of cardiac disease as having “definite” or “probable” angina, relative to a black female “patient” with objectively similar symptoms. Rathore et al. (2000) medical students were more likely to evaluate a white male “patient” with symptoms of cardiac disease as having “definite” or “probable” angina, relative to a black female “patient” with objectively similar symptoms. Rathore et al. (2000)

18. What is the Evidence that Physician Biases and Stereotypes may Influence the Clinical Encounter? mental health professionals and trainees were more likely to evaluate a hypothetical patient more negatively after being “primed” with words associated with African American stereotypes. Abreu (1999) mental health professionals and trainees were more likely to evaluate a hypothetical patient more negatively after being “primed” with words associated with African American stereotypes. Abreu (1999)

19. The Elimination of Health Care Disparities In 2002, the Institute of Medicine (IOM) published Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, In 2002, the Institute of Medicine (IOM) published Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, it reported that racial and ethnic minorities experience a lower quality of health care than non-minorities, even when the patient's insurance status and income are controlled. it reported that racial and ethnic minorities experience a lower quality of health care than non-minorities, even when the patient's insurance status and income are controlled.

20. The Elimination of Health Care Disparities The study committee also found evidence that stereotyping, biases, and uncertainty on the part of health care providers contribute to unequal treatment. The study committee also found evidence that stereotyping, biases, and uncertainty on the part of health care providers contribute to unequal treatment.

21. The Elimination of Health Care Disparities Clinicians may order fewer tests for racial and ethnic minorities if they do not understand the patient's description of symptoms. Clinicians may order fewer tests for racial and ethnic minorities if they do not understand the patient's description of symptoms.

22. The Elimination of Health Care Disparities Alternatively, clinicians may order more diagnostic tests to compensate for not understanding what their patients are saying. Alternatively, clinicians may order more diagnostic tests to compensate for not understanding what their patients are saying.

23. Race was noted in 16 of 18 case presentations by residents, but only 19 of 36 cases involving white patients. Race was noted in 16 of 18 case presentations by residents, but only 19 of 36 cases involving white patients. Race was mentioned in 10 of 10 cases when the resident described black patient's unflattering characteristics, but only four of nine cases where the resident described unflattering characteristics in white patients. Race was mentioned in 10 of 10 cases when the resident described black patient's unflattering characteristics, but only four of nine cases where the resident described unflattering characteristics in white patients.

24. African American patients were viewed by physicians as less intelligent, less educated, less likely to comply with their advice and more likely to have problems with alcohol and drugs. African American patients were viewed by physicians as less intelligent, less educated, less likely to comply with their advice and more likely to have problems with alcohol and drugs. Physicians also rated African American patients as less likely to be the kind of person whom the physician could have as a friend. Physicians also rated African American patients as less likely to be the kind of person whom the physician could have as a friend.

25. Using pain-management vignettes in patients who differed only in race, male physicians prescribed higher doses of hydrocodone to whites than to blacks, while female physicians did the opposite Using pain-management vignettes in patients who differed only in race, male physicians prescribed higher doses of hydrocodone to whites than to blacks, while female physicians did the opposite

29. “Implicit Bias” and “Unconscious Stereotyping” Research indicates: Implicit biases are pervasive. Implicit biases are pervasive. People are often unaware of their implicit biases People are often unaware of their implicit biases Ordinary people harbor negative associations in relation to various groups Ordinary people harbor negative associations in relation to various groups

30. “Implicit Bias” and “Unconscious Stereotyping” Implicit biases predict behavior Implicit biases predict behavior People differ in levels of implicit bias People differ in levels of implicit bias

31. Implicit Bias and Clinical Outcomes Physicians reported no explicit preference for white versus black patients Physicians reported no explicit preference for white versus black patients Implicit Association Test (IAT) revealed implicit preference favoring white Americans Implicit Association Test (IAT) revealed implicit preference favoring white Americans

32. Implicit Bias and Clinical Outcomes IAT revealed implicit stereotypes of black Americans as less cooperative with medical procedures and less cooperative generally IAT revealed implicit stereotypes of black Americans as less cooperative with medical procedures and less cooperative generally As physicians’ pro-white implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis As physicians’ pro-white implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis

33. Dual Process Stereotyping Two distinct methods of stereotyping: 1. Automatic stereotyping 2. Goal modified stereotyping Burgess and van Ryn: Understanding the provider contribution to race/ethnicity disparities in pain treatment; Pain Med. 2006

34. Automatic Stereotyping occurs when stereotypes are automatically activated and influence judgments/behaviors outside of consciousness occurs when stereotypes are automatically activated and influence judgments/behaviors outside of consciousness Occur regardless of their relevance to the perceivers’ goals Occur regardless of their relevance to the perceivers’ goals Burgess and van Ryn: Understanding the provider contribution to race/ethnicity disparities in pain treatment; Pain Med. 2006

35. Goal Modified Stereotyping More conscious process, done when specific needs of clinician arise (time constraints, filling in gaps in information needed to make complex decisions More conscious process, done when specific needs of clinician arise (time constraints, filling in gaps in information needed to make complex decisions Burgess and van Ryn: Understanding the provider contribution to race/ethnicity disparities in pain treatment; Pain Med. 2006

36. Function of Stereotyping Providers are likely to apply information contained in racial/ethnic stereotypes to interpret symptoms and make decisions Providers are likely to apply information contained in racial/ethnic stereotypes to interpret symptoms and make decisions Stereotypes likely to be used when stereotypic information is perceived as clinically relevant, and the decision is complex Stereotypes likely to be used when stereotypic information is perceived as clinically relevant, and the decision is complex Burgess and van Ryn: Understanding the provider contribution to race/ethnicity disparities in pain treatment; Pain Med. 2006 Burgess and van Ryn: Understanding the provider contribution to race/ethnicity disparities in pain treatment; Pain Med. 2006

37. Web and Other Resources “Heads Up!” Website: http://www.stop-disparities.org/RESOURCES.html

39. Web and Other Resources Implicit Association Test: https://implicit.harvard.edu/implicit/ https://implicit.harvard.edu/implicit/ Project Implicit Information Page: http://projectimplicit.net/ (Recommended Tests: Race, Arab-Muslim, Gender, Sexuality) http://projectimplicit.net/ (Recommended Tests: Race, Arab-Muslim, Gender, Sexuality) "The Police Officer's Dilemma" http://home.uchicago.edu/~jcorrell/TPOD.html and then click on the very bottom link http://backhand.uchicago.edu/Center/ShooterEffect/