Showing papers on "Peer group published in 2021"

Effects of Social Media on Adolescents’ Willingness and Intention to Use E-Cigarettes: An Experimental Investigation

Abstract: Introduction This study examined the effects of experimentally manipulated social media exposure on adolescents' willingness and intention to use e-cigarettes. Aims and methods Participants were 135 adolescents of age 13-18 (52.6% female, mean age = 15.3) in California. Participants viewed six social media posts online in a 2 (post source: peer or advertisement) × 2 (e-cigarette content exposure: heavy or light) between-subjects design. Analyses were weighted to population benchmarks. We examined adolescents' beliefs, willingness, and intention to use e-cigarettes in association with social media use intensity in daily life and with experimentally manipulated exposure to social media posts that varied by source (peer or advertisement) and content (e-cigarette heavy or light). Results Greater social media use in daily life was associated with greater willingness and intention to use e-cigarettes and more positive attitudes, greater perceived norms, and lower perceived danger of e-cigarette use (all p-values .529). Conclusions Greater social media use and heavier exposure to advertisements and e-cigarette content in social media posts are associated with a greater risk for e-cigarette use among adolescents. Regulatory action is needed to prohibit sponsored e-cigarette content on social media platforms used by youth. Implications Adolescents who use social media intensely may be at higher risk for e-cigarette use. Even brief exposure to e-cigarette content on social media was associated with greater intention to use and more positive attitudes toward e-cigarettes. Regulatory action should be taken to prohibit sponsored e-cigarette content on social media used by young people, including posts by influencers who appeal to young people.

Toward understanding the functions of peer influence: A summary and synthesis of recent empirical research.

Abstract: Compelling evidence demonstrates that peer influence is a pervasive force during adolescence, one that shapes adaptive and maladaptive attitudes and behaviors. This literature review focuses on factors that make adolescence a period of special vulnerability to peer influence. Herein, we advance the Influence-Compatibility Model, which integrates converging views about early adolescence as a period of increased conformity with evidence that peer influence functions to increase affiliate similarity. Together, these developmental forces smooth the establishment of friendships and integration into the peer group, promote interpersonal and intragroup compatibility, and eliminate differences that might result in social exclusion.

The Impact of Peer Personality on Academic Achievement

Abstract: This paper provides evidence of a novel facet of peer effects by showing that peer personality influences academic achievement. We exploit random assignment of students to university sections and find that students perform better in the presence of persistent peers. The impact of peer persistence is enduring, as students exposed to persistent peers at the beginning of their studies continue to achieve higher grades in subsequent periods. The personality peer effects that we document are distinct from other observable peer characteristics and suggest that peer personality traits affect human capital accumulation.

Adolescent Peer Influence on Eating Behaviors via Social Media: Scoping Review.

Abstract: Background: The influence of social media among adolescent peer groups can be a powerful change agent. Objective: Our scoping review aimed to elucidate the ways in which social media use among adolescent peers influences eating behaviors. Methods: A scoping review of the literature of articles published from journal inception to 2019 was performed by searching PubMed (ie, MEDLINE), Embase, CINAHL, PsycINFO, Web of Science, and other databases. The review was conducted in three steps: (1) identification of the research question and clarification of criteria using the population, intervention, comparison, and outcome (PICO) framework; (2) selection of articles from the literature using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines; and (3) charting and summarizing information from selected articles. PubMed’s Medical Subject Headings (MeSH) and Embase’s Emtree subject headings were reviewed along with specific keywords to construct a comprehensive search strategy. Subject headings and keywords were based on adolescent age groups, social media platforms, and eating behaviors. After screening 1387 peer-reviewed articles, 37 articles were assessed for eligibility. Participant age, gender, study location, social media channels utilized, user volume, and content themes related to findings were extracted from the articles. Results: Six articles met the final inclusion criteria. A final sample size of 1225 adolescents (aged 10 to 19 years) from the United States, the United Kingdom, Sweden, Norway, Denmark, Portugal, Brazil, and Australia were included in controlled and qualitative studies. Instagram and Facebook were among the most popular social media platforms that influenced healthful eating behaviors (ie, fruit and vegetable intake) as well as unhealthful eating behaviors related to fast food advertising. Online forums served as accessible channels for eating disorder relapse prevention among youth. Social media influence converged around four central themes: (1) visual appeal, (2) content dissemination, (3) socialized digital connections, and (4) adolescent marketer influencers. Conclusions: Adolescent peer influence in social media environments spans the spectrum of healthy eating (ie, pathological) to eating disorders (ie, nonpathological). Strategic network-driven approaches should be considered for engaging adolescents in the promotion of positive dietary behaviors.

Adolescent academic worries amid COVID-19 and perspectives on pandemic-related changes in teacher and peer relations.

Abstract: Despite recognition of the potential impact of the COVID-19 pandemic on secondary schooling experiences, little empirical evidence has captured adolescents' perspectives on the extent of academic and social disruption resulting from the pandemic. The present study examined adolescents' academic worries amid the COVID-19 pandemic and their perspectives on pandemic-related changes in teacher and peer relations. Participants were 452 adolescents (55% female) between the ages of 11 and 17, who completed online surveys asking them about their worries about their schoolwork and educational futures, perceived support from teachers, and perceptions of electronic (cyber) bullying during the pandemic. Results indicated that COVID-related academic worries pertaining to motivation to focus on and complete schoolwork were most frequent. High school students and female students reported heightened academic worries compared to middle school students and male students. In addition, the majority of adolescents indicated decreased support from teachers during the COVID-19 pandemic, including more than two-thirds (69%) who reported reduced communication with teachers. Adolescents perceived relative consistency in electronic (cyber) bullying throughout the pandemic, and a third of students indicated that cyberbullying has become more of a problem and increased in frequency during this time period. Perceived changes in cyberbullying were consistent across grade level and gender. Findings emphasize the psychosocial implications of the COVID-19 pandemic on adolescents' secondary schooling experiences and underscore the importance of bolstering social resources to minimize the short- and long-term impact of the pandemic on students' academic functioning. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A Systematic Review of the Literature on Aspects Affecting Positive Classroom Climate in Multicultural Early Childhood Education

Abstract: The risk for many young children from minority backgrounds of being excluded from a quality education might be reduced through the creation of a positive classroom climate. A systematic review was conducted to gain a better understanding of the pedagogical and structural aspects that foster a positive classroom climate in multicultural early childhood education settings. Following a systematic review procedure, 14 articles were selected and included in the analysis. The findings indicate that eight aspects contribute to a positive climate in these settings: on the one hand, pedagogical practices, including increased instructional time, teacher-student supportive interactions, peer interactions and friendship, child engagement, teacher training on emotionally supportive environments and teacher-family trust-based relationships, and on the other hand, structural aspects, including small peer groups and materials shared among children. This evidence may be used to foster a classroom climate that enhances learning processes and social development in multicultural preschool groups. However, more research is needed to better understand the particular role that cultural diversity plays in the classroom climate.

The effects of social norms among peer groups on risk behavior: A multilevel approach to differentiate perceived and collective norms

Abstract: Social norms have been found to be an important factor in individuals’ health and risk behaviors. Past research has typically addressed which social norms individuals perceive in their social envir...

Benefits of Peer Support for Intensive Care Unit Survivors: Sharing Experiences, Care Debriefing, and Altruism.

Abstract: Background: After critical illness, patients are often left with impairments in physical, social, emotional, and cognitive functioning Peer support interventions have been implemented internationally to ameliorate these issues Objective: To explore what patients believed to be the key mechanisms of effectiveness of peer support programs implemented during critical care recovery Methods: In a secondary analysis of an international qualitative data set, 66 telephone interviews with patients were undertaken across 14 sites in Australia, the United Kingdom, and the United States to understand the effect of peer support during recovery from critical illness Prevalent themes were documented with framework analysis Results: Most patients who had been involved in peer support programs reported benefit Patients described 3 primary mechanisms: (1) sharing experiences, (2) care debriefing, and (3) altruism Conclusion: Peer support is a relatively simple intervention that could be implemented to support patients during recovery from critical illness However, more research is required into how these programs can be implemented in a safe and sustainable way in clinical practice

Bullying Prevention in Adolescence: Solutions and New Challenges from the Past Decade.

Abstract: Bullying among youth at school continues to be a global challenge. Being exposed to bullying may be especially hurtful in adolescence, a vulnerable period during which both peer group belonging and status become key concerns. In the current review, we first summarize the effectiveness of the solutions that were offered a decade ago in the form of anti-bullying programs. We proceed by highlighting some intriguing challenges concomitant to, or emerging from these solutions, focusing especially on their relevance during adolescence. These challenges are related to (1) the relatively weak, and highly variable effects of anti-bullying programs, (2) the complex associations among bullying, victimization, and social status, (3) the questions raised regarding the beneficial (or possibly iatrogenic) effects of peer defending, and (4) the healthy context paradox, that is, the phenomenon of remaining or emerging victims being worse off in contexts where the average levels of victimization decrease. We end by providing some suggestions for the next decade of research in the area of bullying prevention among adolescents.

Neurobiological Sensitivity to Social Rewards and Punishments Moderates Link Between Peer Norms and Adolescent Risk Taking.

Abstract: Although peer influence is a strong predictor of adolescents' risk-taking behaviors, not all adolescents are susceptible to their peer group. One hundred and thirty-six adolescents (Mage = 12.79 years) completed an fMRI scan, measures of perceived peer group norms, and engagement in risky behavior. Ventral striatum (VS) sensitivity when anticipating social rewards and avoiding social punishments significantly moderated the association between perceived peer norms and adolescents' own risk behaviors. Perceptions of more deviant peer norms were associated with increased risky behavior, but only for adolescents with high VS sensitivity; adolescents with low VS sensitivity were resilient to deviant peer norms, showing low risk taking regardless of peer context. Findings provide a novel contribution to the study of peer influence susceptibility.

Using Social Media for Peer-to-Peer Cancer Support: Interviews With Young Adults With Cancer.

Abstract: Background: Web-based social support can address social isolation and unmet support needs among young adults with cancer (aged 18-39 years). Given that 94% of young adults own and use smartphones, social media can offer personalized, accessible social support among peers with cancer. Objective: This study aims to examine the specific benefits, downsides, and topics of social support via social media among young adults with cancer. Methods: We conducted semistructured interviews with young adults with cancer, aged between 18 and 39 years, who were receiving treatment or had completed treatment for cancer. Results: Most participants (N=45) used general audience platforms (eg, Facebook groups), and some cancer-specific social media (eg, Caring Bridge), to discuss relevant lived experiences for medical information (managing side effects and treatment uncertainty) and navigating life with cancer (parenting and financial issues). Participants valued socializing with other young adults with cancer, making connections outside their personal networks, and being able to validate their emotional and mental health experiences without time and physical constraints. However, using social media for peer support can be an emotional burden, especially when others post disheartening or harassing content, and can heighten privacy concerns, especially when navigating cancer-related stigma. Conclusions: Social media allows young adults to connect with peers to share and feel validated about their treatment and life concerns. However, barriers exist for receiving support from social media; these could be reduced through content moderation and developing more customizable, potentially cancer-specific social media apps and platforms to enhance one’s ability to find peers and manage groups. Trial Registration:

Developing Identification with Humanity and Social Well-Being Through Social Identification with Peer Groups in Adolescence

Abstract: Developmental literature highlights that cognitive, moral, and affective development proceeds from concrete operations to more abstract ones. However, it is not known whether this fundamental developmental trajectory also characterizes the development of social identification (i.e., the feelings of belonging, affiliation, and correctness to a group, coupled with the sense of commonality with fellow ingroup members). This longitudinal study aimed (a) to unfold the association between identifications with two proximal groups (i.e., classmates and friends) and identification with humanity, and (b) to examine how these identifications with close and abstract groups affect adolescents’ social well-being (i.e., an indicator of youth adaptation in their societies and communities). Participants were 304 adolescents (61.84% female, Mage = 17.49) involved in a three-wave longitudinal study. Identification with proximal social groups (especially classmates) was positively associated with identification with humanity, and identifications with both proximal and abstract groups were related to social well-being over time. Moreover, identification with humanity and identification with friends mediated the positive longitudinal effects of identification with classmates on social well-being. The implications of these findings for adolescents’ social inclusivity and adjustment are discussed.

Peer Effects in R&D Investment Policy: Evidence from China

Abstract: Using a typical linear model on a sample of listed firms in China over a period of ten years (2006-2016), this study empirically attempts proving how peer effects influence corporate research and development (R&D) investment decision. The study goes further to demonstrate that peer effects play a significant and critical role in determining corporate R&D investment policies, and by extension the more important determinant than traditional firm-specific factors. After dealing with endogeneity bias and conducting further robustness checks, the above conclusions were valid in this study. It has been theorized in contemporary research that both information and market competition are the main channels through which one can best appreciate peer effects and that firms with weak information acquisition ability and in highly uncertain or competitive environment are more likely to be affected by peer groups. We also find evidence that a firm’s R&D investment status relative to its peer firms will affect its R&D investment decision. Moreover, the direction of peer effects follows the law of imitation. Thus, firms are more likely to imitate those peers who share similar characteristics. Yet, leading firms and state-owned enterprises (SOEs) are exceptionally different as their R&D decisions are sensitive to both peer-followers and non-SOEs respectively.

Sociodevelopmental Challenges Faced by Young People with Chronic Pain: A Scoping Review.

Abstract: Objective Map the current literature investigating autonomy development, identity development, and peer relationships in young people aged 10-24 years with chronic pain. Methods A scoping review method was used to systematically search four databases (APA PsycNET, PubMed, Web of Science, and Cinahl) for peer-reviewed articles. Search results were screened against inclusion and exclusion criteria to ensure they met the objective. Eligible papers were assessed for quality, their data relating to the objective were extracted, and results are synthesized. Results Searches returned 3,815 papers after the removal of duplicates, with 42 papers included in the full review. The majority of papers investigated peer relationships (86%). Fewer papers investigated autonomy (43%) and identity (21%) development. Included papers were mostly quantitative (64%), with fewer qualitative (34%) and mixed-methods papers (2%). Overall, we found bidirectional relationships between chronic pain in young people, their social development, and a range of functional outcomes. However, the mechanisms underlying these relationships remain relatively unexplored. Conclusions Review results are mapped onto the model proposed by Palermo et al. (2014). Guided by this model, clinical treatment for young people with chronic pain should consider social development. The model also sets out a future research agenda focused on exploring: (a) identity development, (b) the mechanisms underlying the relationships between social-developmental domains, pain, and outcomes, (c) a variety of participants and populations, and (d) a variety of methods, including longitudinal study designs.

Hanging Out with the Wrong Crowd? The Role of Unstructured Socializing in Adolescents’ Specialization in Delinquency and Substance Use

Abstract: Despite abundant attention to offending specialization in criminology, scholars have only recently started to explore opportunity-driven explanations for within-individual patterns of specialization. The current study examines whether unstructured socializing with specific friends can explain within-individual changes in adolescents’ degree of specialization in delinquency and substance use. Data were derived from the PROSPER Peers Project, a longitudinal study consisting of five waves of data on 11,183 adolescents (aged 10 to 17). The data include self-reports about engagement in delinquency and substance use, sociometric information, and information on the time respondents reported spending in unstructured socializing with their nominated friends. Hypotheses were tested with negative binomial and binomial logit multilevel models. The findings indicate that involvement in unstructured socializing with friends who steal, vandalize, commit violence, use alcohol, use cigarettes, or use drugs enhances adolescents’ risks for engagement in those respective behaviors. Such activity affects adolescents’ quantitative engagement as well as their level of specialization in these behaviors. The study indicates that routine activity—in particular involvement in unstructured socializing—explains within-individual changes in deviance specialization among adolescents. Thus, exposure to opportunities can explain why adolescents specialize in certain types of delinquency and substance use in one time-period, and in other types of behavior in other time-periods. This adds a proximate explanation for this phenomenon to other explanations that focus on local life circumstances and peer group affiliation.

Perceived barriers and facilitators to diet and physical activity among adults diagnosed with type 2 diabetes in Malawi.

Abstract: Diet and physical activity are crucial to Type 2 diabetes mellitus (T2DM) self-management. However, socio-environmental, and cultural factors can impede lifestyle behaviours, and hence T2DM management. This study aimed to identify barriers, facilitators and support for diet and physical activity among adults with T2DM in Malawi selected from a larger clinical assessment study, conducted in urban and semi-urban public hospitals. Four focus group discussions were conducted, and audio-recorded, transcribed verbatim, coded, then organised and analysed using thematic analysis. Emergent themes included: family, friends, and health worker ties that facilitated both diet and physical activity as socio-support systems. Diabetes peer groups occurred more often in urban than semi-urban areas. Dietary barriers to self-management of T2DM included: cost and access to food; lack of knowledge on what and how much to eat; challenges of separate preparation and purchase of food; dilemmas of what to eat during functions and travel; and conflicting dietary information from different sources. Comorbidities and fear of public ridicule were key perceived barriers to participants being physically active. Therefore, socio-environmental factors should be considered by nutritionists, dietitians, and health workers when developing and providing nutrition and physical activity education to adults with T2DM in Malawi.

Finnish model of peer-group mentoring: review of research.

Abstract: This article reviews research on the Finnish model of peer-group mentoring (PGM). The theoretical foundation of the model is based on the constructivist theory of learning, the concept of autonomy in teaching profession, peer learning, and narrative identity work. The model has been disseminated nationwide in the educational sector to promote professional development of teachers and educational staff, mainly in primary and secondary education, but also in early childhood education and higher education. The thematic review is based on 46 peer-reviewed publications about PGM in Finland in 2009-2019. Research has focused on the following main themes: (1) general aspects and characteristics of the implementation of the model; and (2) mentors' and mentees' experiences. The qualitative approach has been dominant in research. The studies show that both mentors and mentees find PGM a useful tool for individual professional learning and well-being. Indirect influences have been reported about the development of work communities. The main challenges in applying the model are the lack of national agreement concerning the organization of PGM and allocation of mentors' and mentees' working time to PGM. It is concluded that PGM, as well as teachers' professional development as a whole, should be seen as an integral part of the educational ecosystem.

Accessing Vaping Products When Underage: A Qualitative Study of Young Adults in Southern California.

Abstract: INTRODUCTION California implemented multiple strategies, such as a Tobacco 21 law and compliance checks, to reduce high rates of youth e-cigarette use. However, the prevalence of use among underage youth and young adults continues rising. Little is known about how underage individuals obtain e-cigarettes. AIMS AND METHODS We conducted structured qualitative interviews with 61 young adult (18-25 years old) vapers in the Los Angeles, CA area between June 2018 and June 2019. Interviews were comprehensive and designed to elicit information on participants' thoughts, feelings, and experiences related to vaping. We queried participants on where and how they obtained vaping products, and participants discussed their experiences accessing products while under the legal age for sale. Directed content analysis was used to analyze interviews. RESULTS Four concepts emerged: (1) early experimentation of e-cigarettes with peers often occurred in a school setting, (2) continued use of e-cigarettes commonly obtained through peer sales, (3) inconsistent implementation of age restrictions at in-person retailers, and (4) at online retailers. Participants had peers purchase products on their behalf and frequented in-person and online retailers with few to no age verification processes. Few participants faced challenges when purchasing products from retailers. CONCLUSIONS The current study's findings offer insight into where and how underage individuals obtain vaping products despite restrictions to prevent them from doing so. Participant accounts of mixed ease of underage purchasing in-person and online suggest retailer education is needed, along with additional research to inform more effective policies to reduce underage access to vaping products. IMPLICATIONS Despite legal age restrictions, e-cigarettes remain accessible to underage individuals, but specific strategies that underage youth utilize to evade legal age restrictions are largely unknown. We found that participants often accessed vaping products for the first time at school. Sales between peers were common, and participants also reported frequenting in-person retailers that inconsistently enforced age restrictions. Many participants reported little to no age verification online, though some believed online age verification measures were increasingly difficult to surpass. Knowledge of strategies underage youth utilize to access e-cigarettes can inform enforcement efforts.

The Political Economy of Peer Research: Mapping the Possibilities and Precarities of Paying People for Lived Experience

Abstract: Participatory research, or the practice of involving ‘peers’ with lived experience, has become popular in social work. Peer engagement is lauded for: ‘democratising’ the research process; providing ‘capacity building’ and facilitating opportunities to co-produce knowledge. Yet, these claims are rarely evaluated by empirical investigations into the socio-material work conditions of peer researchers. Here we present findings of a study that examined the experiences of peer researchers, focusing on payment inequities and social workers’ roles in advocating for economic justice. Together with peer research assistants, we conducted a participatory constructivist grounded theory study, interviewing peers (total n = 34) who were compensated to work on studies focused on the following: racialised communities, communities of people who use drugs, consumer/psychiatric survivor/ex-patient and mad communities and trans/non-binary communities. Our findings highlight divergent compensation practices in peer research work. Whilst some peers were satisfied with their treatment on research teams and payment received, others discussed challenges associated with precarious short-term casual work and managing formal income alongside state social assistance such as disability support. We conclude that in some cases, the peer role is characterised by precarious working conditions which compound rather than challenge injustice within the research enterprise, and we discuss implications for social work.

Estimation of Peer Effects in Endogenous Social Networks: Control Function Approach

Abstract: We propose methods of estimating the linear-in-means model of peer effects in which the peer group, defined by a social network, is endogenous in the outcome equation for peer effects. Endogeneity ...

Felt Pressure to Conform to Cultural Gender Roles: Correlates and Consequences

Abstract: Many children feel obligated by their parents and peers to behave in ways that are consistent with traditional gender roles of their culture, an obligation referred to as “felt pressure to conform to gender roles” (abbreviated as felt pressure) (Egan and Perry 2001). The current research was designed to examine links between children’s felt pressure and (a) their own responses to other peers’ “gender policing” and (b) their parents’ reports of gender socialization attitudes. U.S. children (6–12-years-old; 37 girls; 40 boys) completed self-report measures assessing (a) felt pressure to conform to gender roles and (b) responses to children described as making sexist remarks to peers (12 vignettes). Parents (66 mothers; 7 fathers) completed a gender-socialization measure of attitudes toward their children’s gender-typical and atypical behaviors. As hypothesized, children who reported more felt pressure were less likely to confront—and more likely to agree with—vignette peers’ sexist comments to another child. Specifically, felt pressure from parents was negatively related to children’s confrontation of vignette peers’ sexist comments, and felt pressure from peers was positively related to children’s agreement with vignette peers’ sexist comments. Children’s felt pressure was unrelated to parents’ self-reported attitudes. Findings suggest that felt pressure experiences with parents and peers are differentially related to children’s peer interactions, suggesting a possible mechanism by which levels of sexism may be shaped in peer groups. Results may inform interventions aimed at gender-related bullying, identifying the groups (i.e., parents or peers) most influential for various bullying behaviors and bystander responses.

Work-life balance in medical students: self-care in a culture of self-sacrifice

Abstract: Work-life balance is a key contributor to doctors’ wellbeing and consequently is a central factor in their career decisions. General Medical Council guidance outlines the importance of work-life balance as part of compassionate self-care. Learning self-care should begin as an undergraduate, when academic and clinical workload can contribute to stress, anxiety and burnout. Sequential mixed methods study of medical students in Years 3–5 at the University of Birmingham, UK. Students (n = 145) defined work-life balance in free-text answers and self-assessed their current work-life balance via questionnaires. Following this, a sub-sample of students (n = 44) participated in exploratory individual mini-interviews. Work-life balance emerged as a broad and multifactorial concept. Questionnaire respondents most frequently referenced enjoyment, meeting work requirements and time management in their definitions. Interview participants highlighted additional influencing factors such as peer groups, study skills, family and professional culture. Students expect a significant shift towards work after graduating and expressed concerns about the stresses of delivering patient care. 42% (n = 60) of students felt they had received support with their work-life balance during their training, mostly from family and friends. Most students had not received support or advice on their work-life balance from University or hospital staff. Self-care and work-life balance are essential for medical students and doctors to cope with lifelong learning and deliver effective care. Medical school staff should be pro-active in supporting students to develop these skills, particularly during critical transition periods. Early interventions targeting study skills and time management may be beneficial. Further research should include students in Years 1–2 and compare different institutions.

Haste or Waste? Peer Pressure and Productivity in the Emergency Department

Abstract: Motivated by wide cross-sectional variations in intensity of care that are unrelated to quality of care, researchers and policymakers commonly claim that healthcare providers waste considerable resources, engaging in so-called “flat-of-the-curve” medicine. A key yet elusive prediction of this hypothesis is that providers ought to be able to cut back on care without sacrificing quality. This article examines the effects of a particular form of provider cutbacks—those generated by physicians working in high-pressure peer group environments. Using expansive, time-stamped discharge data from 137 hospital-based emergency departments, I document that physicians systematically alter their pace and intensity of care across frequently shuffled peer groups. Peer groups that induce a physician to work faster also induce her to order fewer tests and spend less money. Contrary to the flat-of-the-curve hypothesis, these cutbacks lead to large reductions in quality of care. This evidence, paired with the fact that slower physicians do not produce better average outcomes, suggests that cross-physician differences in resource utilization reflect substantial differences in physician productivity within a hospital.