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

Health care Health care disparitiesdisparities

Stereotyping and Stereotyping and unconscious biasunconscious bias

Harry PomeranzHarry Pomeranz

Mercy CollegeMercy College

October 2008October 2008

Do you think the average African Do you think the average African American is better off, worse off, or just American is better off, worse off, or just about as well off as the average white about as well off as the average white

person in terms of access to health care?person in terms of access to health care?

0

10

20

30

40

50

60

70

Whites African Americans

Better OffAbout the SameWorse OffNo Opinion

Source: Morin, 2001

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

Black White Black-to-

White Ratio

Angioplasty (procedures per 1,000 beneficiaries per year)

2.5 5.4 0.46

Coronary Artery Bypass Graft Surgery (procedures per 1,000 beneficiaries per year)

1.9 4.8 0.40

Mammography (procedures per 100 women per year)

17.1 26.0 0.66

Hip Fracture Repair (procedures per 100 women per year)

2.9 7.0 0.42

Amputation of All or Part of Limb (procedures per 1,000 beneficiaries per year)

6.7 1.9 3.64

Bilateral Orchiectomy (procedures per 1,000 beneficiaries per year)

2.0 0.8 2.45

Source: Gornick et al., 1996

What are potential sources of What are potential sources of disparities in care?disparities in care?

Health systems-level factors – Health systems-level factors – financing, structure of care; cultural financing, structure of care; cultural and linguistic barriersand linguistic barriers

Patient-level factors – including Patient-level factors – including patient preferences, refusal of patient preferences, refusal of treatment, poor adherence, treatment, poor adherence, biological differencesbiological differences

Disparities arising from the clinical Disparities arising from the clinical encounterencounter

Potential Sources of Racial and Ethnic Potential Sources of Racial and Ethnic Healthcare Disparities – Healthcare Disparities –

Healthcare Systems-level FactorsHealthcare Systems-level Factors

Lack of stable relationships with Lack of stable relationships with primary care providers –-- primary care providers –-- minority patients, even when minority patients, even when insured at the same level as insured at the same level as whites, are more likely to receive whites, are more likely to receive care in emergency rooms and care in emergency rooms and have less access to private have less access to private physiciansphysicians

Disparities in the Clinical Encounter: The Disparities in the Clinical Encounter: The Core ParadoxCore Paradox

How could well-meaning and highly How could well-meaning and highly educated health professionals, educated health professionals, working in their usual circumstances working in their usual circumstances with diverse populations of patients, with diverse populations of patients, create a pattern of care that appears create a pattern of care that appears to be discriminatory?to be discriminatory?

Perceptions of Disparities in Perceptions of Disparities in Health CareHealth 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…

Doctors The 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

Disparities in the Clinical Encounter: The Disparities in the Clinical Encounter: The Core ParadoxCore Paradox

Uncertainty – a plausible Uncertainty – a plausible hypothesis, particularly when hypothesis, particularly when providers treat patients that are providers treat patients that are dissimilar in cultural or linguistic dissimilar in cultural or linguistic backgroundbackground

Disparities in the Clinical Encounter: The Disparities in the Clinical Encounter: The Core ParadoxCore Paradox

Stereotyping – evidence suggests Stereotyping – evidence suggests that physicians, like everyone else, that physicians, like everyone else, use these ‘cognitive shortcuts’use these ‘cognitive shortcuts’

Stereotyping: A DefinitionStereotyping: A Definition

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

Stereotyping: A DefinitionStereotyping: A Definition

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

Stereotyping: RisksStereotyping: Risks

Can exert powerful effects on Can exert powerful effects on thinking and actions at an implicit, thinking and actions at an implicit, unconscious level, even among unconscious level, even among well-meaning, well-educated well-meaning, well-educated persons who are not overtly biased.persons who are not overtly biased.

Can influence how information is Can influence how information is processed and recalled.processed and recalled.

Stereotyping: RisksStereotyping: Risks

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

Stereotyping: When Is It in Action?Stereotyping: When Is It in Action?

Situations characterized by time Situations characterized by time pressure, resource constraints, and pressure, resource constraints, and high cognitive demand promote high cognitive demand promote stereotyping due to the need for stereotyping due to the need for cognitive ‘shortcuts’ and lack of full cognitive ‘shortcuts’ and lack of full information.information.

What is the Evidence that Physician Biases What is the Evidence that Physician Biases and Stereotypes May Influence the Clinical and Stereotypes May Influence the Clinical

Encounter?Encounter? study conducted in actual study conducted in actual clinical settings found that clinical settings found that doctors are more likely to doctors are more likely to ascribe negative racial ascribe negative racial stereotypes to their minority stereotypes to their minority patients. patients.

These stereotypes were These stereotypes were ascribed to patients even when ascribed to patients even when differences in minority and non-differences in minority and non-minority patients’ education, minority patients’ education, income, and personality income, and personality characteristics were considered.characteristics were considered.van Ryn and Burke (2000)van Ryn and Burke (2000)

What is the Evidence that Physician Biases and What is the Evidence that Physician Biases and Stereotypes may Influence the Clinical Stereotypes may Influence the Clinical

Encounter?Encounter?

medical students were more medical students were more likely to evaluate a white male likely to evaluate a white male “patient” with symptoms of “patient” with symptoms of cardiac disease as having cardiac disease as having “definite” or “probable” angina, “definite” or “probable” angina, relative to a black female relative to a black female “patient” with objectively similar “patient” with objectively similar symptoms. symptoms. Rathore et al. (2000)Rathore et al. (2000)

What is the Evidence that Physician Biases and What is the Evidence that Physician Biases and Stereotypes may Influence the Clinical Stereotypes may Influence the Clinical

Encounter?Encounter?

mental health professionals and mental health professionals and trainees were more likely to trainees were more likely to evaluate a hypothetical patient evaluate a hypothetical patient more negatively after being more negatively after being “primed” with words associated “primed” with words associated with African American with African American stereotypes.stereotypes. Abreu (1999)Abreu (1999)

The Elimination of Health The Elimination of Health Care DisparitiesCare Disparities

In 2002, the Institute of Medicine In 2002, the Institute of Medicine (IOM) published (IOM) published Unequal Treatment: Unequal Treatment: Confronting Racial and Ethnic Confronting Racial and Ethnic Disparities in Health CareDisparities in Health Care, ,

it reported that racial and ethnic it reported that racial and ethnic minorities experience a lower minorities experience a lower quality of health care than non-quality of health care than non-minorities, minorities, even when the even when the patient's insurance status and patient's insurance status and income are controlled.income are controlled.

The Elimination of Health The Elimination of Health Care DisparitiesCare Disparities

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

The Elimination of Health The Elimination of Health Care DisparitiesCare Disparities

Clinicians may order fewer tests Clinicians may order fewer tests for racial and ethnic minorities if for racial and ethnic minorities if they do not understand the they do not understand the patient's description of patient's description of symptoms. symptoms.

The Elimination of Health The Elimination of Health Care DisparitiesCare Disparities

Alternatively, clinicians may Alternatively, clinicians may order more diagnostic tests to order more diagnostic tests to compensate for not compensate for not understanding what their understanding what their patients are saying. patients are saying.

Race was noted in 16 of 18 case Race was noted in 16 of 18 case presentations by residents, but only 19 presentations by residents, but only 19 of 36 cases involving white patients. of 36 cases involving white patients.

Race was mentioned in 10 of 10 cases Race was mentioned in 10 of 10 cases when the resident described black when the resident described black patient's unflattering characteristics, patient's unflattering characteristics, but only four of nine cases where the but only four of nine cases where the resident described unflattering resident described unflattering characteristics in white patients. characteristics in white patients.

African American patients were African American patients were viewed by physicians as less viewed by physicians as less intelligent, less educated, less likely intelligent, less educated, less likely to comply with their advice and more to comply with their advice and more likely to have problems with alcohol likely to have problems with alcohol and drugs. and drugs.

Physicians also rated African Physicians also rated African American patients as less likely to be American patients as less likely to be the kind of person whom the the kind of person whom the physician could have as a friend. physician could have as a friend.

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

““Implicit Bias” and Implicit Bias” and “Unconscious Stereotyping”“Unconscious Stereotyping”

Research indicates: Research indicates: Implicit biases are pervasive.Implicit biases are pervasive. People are often unaware of their People are often unaware of their

implicit biasesimplicit biases Ordinary people harbor negative Ordinary people harbor negative

associations in relation to various associations in relation to various groupsgroups

““Implicit Bias” and Implicit Bias” and “Unconscious Stereotyping”“Unconscious Stereotyping”

Implicit biases predict behavior Implicit biases predict behavior People differ in levels of implicit biasPeople differ in levels of implicit bias

Implicit Bias and Clinical Implicit Bias and Clinical Outcomes Outcomes

Physicians reported no Physicians reported no explicitexplicit preference for white versus black preference for white versus black patientspatients

Implicit Association Test (IAT) Implicit Association Test (IAT) revealed revealed implicitimplicit preference favoring preference favoring white Americanswhite Americans

Implicit Bias and Clinical Implicit Bias and Clinical OutcomesOutcomes

IAT revealed implicit stereotypes of black IAT revealed implicit stereotypes of black Americans as less cooperative with Americans as less cooperative with medical procedures and less cooperative medical procedures and less cooperative generallygenerally

As physicians’ pro-white implicit bias As physicians’ pro-white implicit bias increased, so did their likelihood of increased, so did their likelihood of treating white patients and not treating treating white patients and not treating black patients with thrombolysis black patients with thrombolysis

Dual Process Stereotyping Dual Process Stereotyping

Two distinct methods of stereotyping:Two distinct methods of stereotyping:

1.1. Automatic stereotypingAutomatic stereotyping

2.2. Goal modified stereotypingGoal modified stereotyping

Burgess and van Ryn: Understanding the provider Burgess and van Ryn: Understanding the provider contribution to contribution to race/ethnicity disparities in pain treatment; race/ethnicity disparities in pain treatment; Pain Med. 2006 Pain Med. 2006

Automatic StereotypingAutomatic Stereotyping

occurs when stereotypes are automatically occurs when stereotypes are automatically activated and influence activated and influence judgments/behaviors outside of judgments/behaviors outside of consciousnessconsciousness

Occur regardless of their relevance to the Occur regardless of their relevance to the perceivers’ goalsperceivers’ goals

Burgess and van Ryn: Understanding the provider Burgess and van Ryn: Understanding the provider contribution to contribution to race/ethnicity disparities in pain treatment; Pain race/ethnicity disparities in pain treatment; Pain Med. 2006 Med. 2006

Goal Modified StereotypingGoal Modified Stereotyping

More conscious process, done when More conscious process, done when specific needs of clinician arise (time specific needs of clinician arise (time constraints, filling in gaps in constraints, filling in gaps in information needed to make complex information needed to make complex decisionsdecisions

Burgess and van Ryn: Understanding the provider Burgess and van Ryn: Understanding the provider contribution to contribution to race/ethnicity disparities in pain treatment; Pain race/ethnicity disparities in pain treatment; Pain Med. 2006 Med. 2006

Function of StereotypingFunction of Stereotyping

Providers are likely to apply information Providers are likely to apply information contained in racial/ethnic stereotypes to interpret contained in racial/ethnic stereotypes to interpret symptoms and make decisionssymptoms and make decisions

Stereotypes likely to be used when stereotypic Stereotypes likely to be used when stereotypic information is perceived as clinically relevant, information is perceived as clinically relevant, and the decision is complexand the decision is complex

Burgess and van Ryn: Understanding the provider Burgess and van Ryn: Understanding the provider

contribution to contribution to race/ethnicity disparities in pain treatment; Pain race/ethnicity disparities in pain treatment; Pain Med. 2006 Med. 2006

Web and Other ResourcesWeb and Other Resources

““Heads Up!” Website:Heads Up!” Website:

http://www.stop-disparities.org/RESOURCES.htmlhttp://www.stop-disparities.org/RESOURCES.html

Web and Other Resources Web and Other Resources

Implicit Association Test:Implicit Association Test: https://implicit.harvard.edu/implicit/https://implicit.harvard.edu/implicit/

Project Implicit Information Page:Project Implicit Information Page: http://projectimplicit.net/http://projectimplicit.net/

(Recommended Tests: Race, Arab-Muslim, Gender, (Recommended Tests: Race, Arab-Muslim, Gender, Sexuality)Sexuality)

"The Police Officer's Dilemma""The Police Officer's Dilemma" http://home.uchicago.edu/~jcorrell/TPOD.htmlhttp://home.uchicago.edu/~jcorrell/TPOD.html

and then click on the very bottom linkand then click on the very bottom linkhttp://backhand.uchicago.edu/Center/ShooterEffect/http://backhand.uchicago.edu/Center/ShooterEffect/