The Associations of Clinicians’ Implicit Attitudes About Race With Medical Visit Communication and Patient Ratings of Interpersonal Care
11 Apr 2012-American Journal of Public Health (American Public Health Association)-Vol. 102, Iss: 5, pp 979-987
TL;DR: Clinician implicit race bias and race and compliance stereotyping are associated with markers of poor visit communication and poor ratings of care, particularly among Black patients.
Abstract: Objectives. We examined the associations of clinicians’ implicit attitudes about race with visit communication and patient ratings of care.Methods. In a cross-sectional study of 40 primary care clinicians and 269 patients in urban community-based practices, we measured clinicians’ implicit general race bias and race and compliance stereotyping with 2 implicit association tests and related them to audiotape measures of visit communication and patient ratings.Results. Among Black patients, general race bias was associated with more clinician verbal dominance, lower patient positive affect, and poorer ratings of interpersonal care; race and compliance stereotyping was associated with longer visits, slower speech, less patient centeredness, and poorer ratings of interpersonal care. Among White patients, bias was associated with more verbal dominance and better ratings of interpersonal care; race and compliance stereotyping was associated with less verbal dominance, shorter visits, faster speech, more patient ...
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TL;DR: Although some associations between implicit bias and health care outcomes were nonsignificant, results showed that implicit bias was significantly related to patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes.
Abstract: Background. In the United States, people of color face disparities in access to health care, the quality of care received, and health outcomes. The attitudes and behaviors of health care providers have been identified as one of many factors that contribute to health disparities. Implicit attitudes are thoughts and feelings that often exist outside of conscious awareness, and thus are difficult to consciously acknowledge and control. These attitudes are often automatically activated and can influence human behavior without conscious volition.Objectives. We investigated the extent to which implicit racial/ethnic bias exists among health care professionals and examined the relationships between health care professionals’ implicit attitudes about racial/ethnic groups and health care outcomes.Search Methods. To identify relevant studies, we searched 10 computerized bibliographic databases and used a reference harvesting technique.Selection Criteria. We assessed eligibility using double independent screening ba...
1,299 citations
Cites background from "The Associations of Clinicians’ Imp..."
...Finally, 2 studies reported moderate amounts of implicit bias among health care professionals against darker-skinned individuals compared with lighter-skinned individuals.(29,32) IAT D scores in these studies were 0....
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...They also reported longer visits and experienced their visits with the provider as being less collaborative.(32) Another study also found an association between implicit racial bias and verbal dominance by physicians during encounters with Black patients....
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TL;DR: The evidence indicates that healthcare professionals exhibit the same levels of implicit bias as the wider population, and the need for the healthcare profession to address the role of implicit biases in disparities in healthcare is highlighted.
Abstract: Implicit biases involve associations outside conscious awareness that lead to a negative evaluation of a person on the basis of irrelevant characteristics such as race or gender. This review examines the evidence that healthcare professionals display implicit biases towards patients. PubMed, PsychINFO, PsychARTICLE and CINAHL were searched for peer-reviewed articles published between 1st March 2003 and 31st March 2013. Two reviewers assessed the eligibility of the identified papers based on precise content and quality criteria. The references of eligible papers were examined to identify further eligible studies. Forty two articles were identified as eligible. Seventeen used an implicit measure (Implicit Association Test in fifteen and subliminal priming in two), to test the biases of healthcare professionals. Twenty five articles employed a between-subjects design, using vignettes to examine the influence of patient characteristics on healthcare professionals’ attitudes, diagnoses, and treatment decisions. The second method was included although it does not isolate implicit attitudes because it is recognised by psychologists who specialise in implicit cognition as a way of detecting the possible presence of implicit bias. Twenty seven studies examined racial/ethnic biases; ten other biases were investigated, including gender, age and weight. Thirty five articles found evidence of implicit bias in healthcare professionals; all the studies that investigated correlations found a significant positive relationship between level of implicit bias and lower quality of care. The evidence indicates that healthcare professionals exhibit the same levels of implicit bias as the wider population. The interactions between multiple patient characteristics and between healthcare professional and patient characteristics reveal the complexity of the phenomenon of implicit bias and its influence on clinician-patient interaction. The most convincing studies from our review are those that combine the IAT and a method measuring the quality of treatment in the actual world. Correlational evidence indicates that biases are likely to influence diagnosis and treatment decisions and levels of care in some circumstances and need to be further investigated. Our review also indicates that there may sometimes be a gap between the norm of impartiality and the extent to which it is embraced by healthcare professionals for some of the tested characteristics. Our findings highlight the need for the healthcare profession to address the role of implicit biases in disparities in healthcare. More research in actual care settings and a greater homogeneity in methods employed to test implicit biases in healthcare is needed.
1,237 citations
Cites background or methods from "The Associations of Clinicians’ Imp..."
...In some studies, the attitudes of patients towards healthcare professionals were recorded and used to evaluate clinical interaction [23, 24, 44]....
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...As our review shows, there is clearer evidence for a relationship between implicit bias and negative effects on clinical interaction [23, 24, 44]....
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...Exposure to communication skills training was not associated with lower race-IAT scores for physicians [23]....
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...Implicit bias affects clinical judgement and behaviour Three studies found a significant correlation between high levels of physicians’ implicit bias against blacks on IAT scores and interaction that was negatively rated by black patients [23, 24, 44] and, in one study, also negatively rated by external observers [23]....
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...In this respect, the three studies using measures of physician-patient interaction are exemplary [22–24], in particular when using independent evaluators of the interactions [23]....
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TL;DR: An overview of the evidence linking the primary domains of racism-structural racism, cultural racism, and individual-level discrimination-to mental and physical health outcomes is provided.
Abstract: In recent decades, there has been remarkable growth in scientific research examining the multiple ways in which racism can adversely affect health. This interest has been driven in part by the stri...
962 citations
Cites background from "The Associations of Clinicians’ Imp..."
...Providers’ implicit bias is also associated with poorer quality of patient–provider communication, including the provider’s nonverbal behavior (26)....
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TL;DR: An Institute of Medicine report documents the decline in the health status of Americans relative to people in other high-income countries, concluding that “Americans are dying and suffering from illness and injury at rates that are demonstrably unnecessary.
Abstract: An Institute of Medicine report titled U.S. Health in International Perspective: Shorter Lives, Poorer Health documents the decline in the health status of Americans relative to people in other high-income countries, concluding that “Americans are dying and suffering from illness and injury at rates that are demonstrably unnecessary.”1 The report blames many factors, “adverse economic and social conditions” among them. In an editorial in Science discussing the findings of the Institute of Medicine report, Bayer et al2 call for a national commission on health “to address the social causes that have put the USA last among comparable nations.”
Although mortality from cardiovascular disease (CVD) in the United States has been on a linear decline since the 1970s, the burden remains high. It accounted for 31.9% of deaths in 2010.3
There is general agreement that the decline is the result, in equal measure, of advances in prevention and advances in treatment. These advances in turn rest on dramatic successes in efforts to understand the biology of CVD that began in the late 1940s.4,5 It has been assumed that the steady downward trend in mortality will continue into the future as further breakthroughs in biological science lead to further advances in prevention and treatment. This view of the future may not be warranted.
The prevalence of CVD in the United States is expected to rise 10% between 2010 and 2030.6 This change in the trajectory of cardiovascular burden is the result not only of an aging population but also of a dramatic rise over the past 25 years in obesity and the hypertension, diabetes mellitus, and physical inactivity that accompany weight gain. Although there is no consensus on the precise causes of the obesity epidemic, a dramatic change in the underlying biology of Americans is …
930 citations
TL;DR: It is concluded that increasing the number of African American/Black physicians could reduce the impact of implicit bias on health care disparities because they exhibit significantly less implicit race bias.
Abstract: Although the medical profession strives for equal treatment of all patients, disparities in health care are prevalent Cultural stereotypes may not be consciously endorsed, but their mere existence influences how information about an individual is processed and leads to unintended biases in decision-making, so called “implicit bias” All of society is susceptible to these biases, including physicians Research suggests that implicit bias may contribute to health care disparities by shaping physician behavior and producing differences in medical treatment along the lines of race, ethnicity, gender or other characteristics We review the origins of implicit bias, cite research documenting the existence of implicit bias among physicians, and describe studies that demonstrate implicit bias in clinical decision-making We then present the bias-reducing strategies of consciously taking patients’ perspectives and intentionally focusing on individual patients’ information apart from their social group We conclude that the contribution of implicit bias to health care disparities could decrease if all physicians acknowledged their susceptibility to it, and deliberately practiced perspective-taking and individuation when providing patient care We further conclude that increasing the number of African American/Black physicians could reduce the impact of implicit bias on health care disparities because they exhibit significantly less implicit race bias
889 citations
Cites background from "The Associations of Clinicians’ Imp..."
...found that physicians’ implicit pro-White bias on the IAT correlated with Black patients’ perceptions of poorer communication and lower quality care.(30) Penner et al....
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...Others have confirmed that even in the absence of explicit race bias, implicit preference for Whites among physicians is common.(29,30) The degree of implicit race bias varies by physician race and gender....
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References
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01 Dec 1969TL;DR: The concepts of power analysis are discussed in this paper, where Chi-square Tests for Goodness of Fit and Contingency Tables, t-Test for Means, and Sign Test are used.
Abstract: Contents: Prefaces. The Concepts of Power Analysis. The t-Test for Means. The Significance of a Product Moment rs (subscript s). Differences Between Correlation Coefficients. The Test That a Proportion is .50 and the Sign Test. Differences Between Proportions. Chi-Square Tests for Goodness of Fit and Contingency Tables. The Analysis of Variance and Covariance. Multiple Regression and Correlation Analysis. Set Correlation and Multivariate Methods. Some Issues in Power Analysis. Computational Procedures.
115,069 citations
TL;DR: In this article, an extension of generalized linear models to the analysis of longitudinal data is proposed, which gives consistent estimates of the regression parameters and of their variance under mild assumptions about the time dependence.
Abstract: SUMMARY This paper proposes an extension of generalized linear models to the analysis of longitudinal data. We introduce a class of estimating equations that give consistent estimates of the regression parameters and of their variance under mild assumptions about the time dependence. The estimating equations are derived without specifying the joint distribution of a subject's observations yet they reduce to the score equations for multivariate Gaussian outcomes. Asymptotic theory is presented for the general class of estimators. Specific cases in which we assume independence, m-dependence and exchangeable correlation structures from each subject are discussed. Efficiency of the proposed estimators in two simple situations is considered. The approach is closely related to quasi-likelih ood. Some key ironh: Estimating equation; Generalized linear model; Longitudinal data; Quasi-likelihood; Repeated measures.
17,111 citations
TL;DR: Twenty cross-sectional and longitudinal tests of empirical validity previously published for the 36-item short-form scales and summary measures were replicated for the 12-item Physical Component Summary and the12-item Mental Component Summary, including comparisons between patient groups known to differ or to change in terms of the presence and seriousness of physical and mental conditions.
Abstract: Regression methods were used to select and score 12 items from the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36) to reproduce the Physical Component Summary and Mental Component Summary scales in the general US population (n=2,333). The resulting 12-item short-form (SF-12) achieved multiple R squares of 0.911 and 0.918 in predictions of the SF-36 Physical Component Summary and SF-36 Mental Component Summary scores, respectively. Scoring algorithms from the general population used to score 12-item versions of the two components (Physical Components Summary and Mental Component Summary) achieved R squares of 0.905 with the SF-36 Physical Component Summary and 0.938 with SF-36 Mental Component Summary when cross-validated in the Medical Outcomes Study. Test-retest (2-week)correlations of 0.89 and 0.76 were observed for the 12-item Physical Component Summary and the 12-item Mental Component Summary, respectively, in the general US population (n=232). Twenty cross-sectional and longitudinal tests of empirical validity previously published for the 36-item short-form scales and summary measures were replicated for the 12-item Physical Component Summary and the 12-item Mental Component Summary, including comparisons between patient groups known to differ or to change in terms of the presence and seriousness of physical and mental conditions, acute symptoms, age and aging, self-reported 1-year changes in health, and recovery for depression. In 14 validity tests involving physical criteria, relative validity estimates for the 12-item Physical Component Summary ranged from 0.43 to 0.93 (median=0.67) in comparison with the best 36-item short-form scale. Relative validity estimates for the 12-item Mental Component Summary in 6 tests involving mental criteria ranged from 0.60 to 107 (median=0.97) in relation to the best 36-item short-form scale. Average scores for the 2 summary measures, and those for most scales in the 8-scale profile based on the 12-item short-form, closely mirrored those for the 36-item short-form, although standard errors were nearly always larger for the 12-item short-form.
14,793 citations
TL;DR: An implicit association test (IAT) measures differential association of 2 target concepts with an attribute when instructions oblige highly associated categories to share a response key, and performance is faster than when less associated categories share a key.
Abstract: An implicit association test (IAT) measures differential association of 2 target concepts with an attribute. The 2 concepts appear in a 2-choice task (e.g., flower vs. insect names), and the attribute in a 2nd task (e.g., pleasant vs. unpleasant words for an evaluation attribute). When instructions oblige highly associated categories (e.g., flower + pleasant) to share a response key, performance is faster than when less associated categories (e.g., insect + pleasant) share a key. This performance difference implicitly measures differential association of the 2 concepts with the attribute. In 3 experiments, the IAT was sensitive to (a) near-universal evaluative differences (e.g., flower vs. insect), (b) expected individual differences in evaluative associations (Japanese + pleasant vs. Korean + pleasant for Japanese vs. Korean subjects), and (c) consciously disavowed evaluative differences (Black + pleasant vs. White + pleasant for self-described unprejudiced White subjects).
9,731 citations
TL;DR: The role of stereotype vulnerability in the standardized test performance of ability-stigmatized groups is discussed and mere salience of the stereotype could impair Blacks' performance even when the test was not ability diagnostic.
Abstract: Stereotype threat is being at risk of confirming, as self-characte ristic, a negative stereotype about one's group. Studies 1 and 2 varied the stereotype vulnerability of Black participants taking a difficult verbal test by varying whether or not their performance was ostensibly diagnostic of ability, and thus, whether or not they were at risk of fulfilling the racial stereotype about their intellectual ability. Reflecting the pressure of this vulnerability, Blacks underperformed in relation to Whites in the ability-diagnostic condition but not in the nondiagnostic condition (with Scholastic Aptitude Tests controlled). Study 3 validated that ability-diagnosticity cognitively activated the racial stereotype in these participants and motivated them not to conform to it, or to be judged by it. Study 4 showed that mere salience of the stereotype could impair Blacks' performance even when the test was not ability diagnostic. The role of stereotype vulnerability in the standardized test performance of ability-stigmatized groups is discussed. Not long ago, in explaining his career-long preoccupation with the American Jewish experience, the novelist Philip Roth said that it was not Jewish culture or religion per se that fascinated him, it was what he called the Jewish "predicament." This is an apt term for the perspective taken in the present research. It focuses on a social-psychological predicament that can arise from widely-known negative stereotypes about one's group. It is this: the existence of such a stereotype means that anything one does or any of one's features that conform to it make the stereotype more plausible as a self-characterization in the eyes of others, and perhaps even in one's own eyes. We call this predicament stereotype threat and argue that it is experienced, essentially, as a self-evaluative threat. In form, it is a predicament that can beset the members of any group about whom negative stereotypes exist. Consider the stereotypes elicited by the terms yuppie, feminist, liberal, or White male. Their prevalence in society raises the possibility for potential targets that the stereotype is true of them and, also, that other people will see them that way. When the allegations of the stereotype are importantly
7,282 citations