heads up! a project of the american academy of physician assistants and the physician assistant...

Heads Up!A Project of the American Academy of Physician Assistants and the Physician Assistant Foundation

What is “Heads Up?”What is “Heads Up?”

• 2007 AAPA Committee on Diversity Project2007 AAPA Committee on Diversity Project

• 90 days in University of Washington Shuttles90 days in University of Washington Shuttles

• 3 signs, each up on 5 buses for one month3 signs, each up on 5 buses for one month


What is Heads Up?What is Heads Up?

Initial Project Goals:Initial Project Goals:

1.1. Engage Clinicians and Clinicians in TrainingEngage Clinicians and Clinicians in Training

2.2. Spotlight Racial Health DisparitiesSpotlight Racial Health Disparities

3.3. Create focus on Implicit Bias/StereotypingCreate focus on Implicit Bias/Stereotyping


What is Heads Up?What is Heads Up?

• Transitioned now to CME moduleTransitioned now to CME module

• Creation of PA School Curriculum Module Creation of PA School Curriculum Module


Define “Racial Health Define “Racial Health Disparities”Disparities”

Even with the same access to care, racial and Even with the same access to care, racial and ethnic minorities receive poorer care than ethnic minorities receive poorer care than

white patientswhite patients

(IOM’s “Unequal Treatment,” 2003)(IOM’s “Unequal Treatment,” 2003)


IOM’s 2003 IOM’s 2003 Unequal Unequal TreatmentTreatment

Landmark review of data, indicating consistent disparities in care: Landmark review of data, indicating consistent disparities in care:

““Racial and ethnic minorities tend to receive a lower Racial and ethnic minorities tend to receive a lower quality of health care than non-minorities, even when quality of health care than non-minorities, even when

access-related factors, such as patient's insurance access-related factors, such as patient's insurance status and income, are controlled."status and income, are controlled."

Unequal Treatment, page 1Unequal Treatment, page 1


Disparities in Cardiovascular Disparities in Cardiovascular Care Care

• African Americans 28% more likely to die than white Americans African Americans 28% more likely to die than white Americans from cardiovascular disease, yet African Americans referred less from cardiovascular disease, yet African Americans referred less frequently for cardiac catheterization frequently for cardiac catheterization

• Whites being treated in emergency rooms for chest pain more Whites being treated in emergency rooms for chest pain more likely to receive cardiac catheterization than African Americans likely to receive cardiac catheterization than African Americans

• Likelihood of having hospital-based cardiac procedures Likelihood of having hospital-based cardiac procedures consistently greater for whites than for African Americans consistently greater for whites than for African Americans

http://www.aapa.org/clinissues/disparitiestables.html#table1http://www.aapa.org/clinissues/disparitiestables.html#table1


Disparities in Cardiovascular Disparities in Cardiovascular CareCare

• Likelihood of having cardiac procedure nearly three times Likelihood of having cardiac procedure nearly three times greater for whites than for African Americans greater for whites than for African Americans

• African Americans and Hispanics received less-frequent African Americans and Hispanics received less-frequent coronary artery bypass grafts than whites with similar diagnoses coronary artery bypass grafts than whites with similar diagnoses

• Fewer non-whites underwent cardiac catheterization when Fewer non-whites underwent cardiac catheterization when meeting initiation criteria meeting initiation criteria



Disparities in Cardiovascular Disparities in Cardiovascular CareCare

• In patients with acute myocardial infarction, African Americans In patients with acute myocardial infarction, African Americans less likely than whites to receive thrombolytic therapy, coronary less likely than whites to receive thrombolytic therapy, coronary arteriography and coronary artery bypass surgeryarteriography and coronary artery bypass surgery

• In patients discharged from hospital stays after definite or In patients discharged from hospital stays after definite or possible myocardial infarctions, Mexican Americans received possible myocardial infarctions, Mexican Americans received significantly fewer medications than whitessignificantly fewer medications than whites



Racial Disparities in Racial Disparities in Treatment of Pain Treatment of Pain

• racial and ethnic disparities in pain perception, racial and ethnic disparities in pain perception, assessment found in all settings assessment found in all settings

• postoperative, emergency room, across all types of postoperative, emergency room, across all types of pain (acute, cancer, chronic nonmalignant)pain (acute, cancer, chronic nonmalignant)


Racial Disparities in Racial Disparities in Treatment of PainTreatment of Pain

• Disparities persist after controlling for Disparities persist after controlling for comorbidities, insurance status, treatment, comorbidities, insurance status, treatment, patient preferences, and access to carepatient preferences, and access to care


““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 implicit People are often unaware of their implicit

biasesbiases• Ordinary people harbor negative associations Ordinary people harbor negative associations

in relation to various groupsin relation to various groups


““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 Association Test Implicit Association Test (IAT)(IAT)

• ““Project Implicit”: network of laboratories, Project Implicit”: network of laboratories, technicians, and research scientists at Harvard technicians, and research scientists at Harvard University, the University of Washington, and the University, the University of Washington, and the University of VirginiaUniversity of Virginia

• Initially launched as a demonstration website in 1998 Initially launched as a demonstration website in 1998 at Yale University, and began to function fully as a at Yale University, and began to function fully as a research enterprise following a grant from the research enterprise following a grant from the National Institute of Mental Health in 2003National Institute of Mental Health in 2003


Implicit Association Test Implicit Association Test (IAT)(IAT)

• Series of online assessments related to Series of online assessments related to multilple groups (sexual orientation, race, multilple groups (sexual orientation, race, gender, religion)gender, religion)

• Feedback and assessment results immediateFeedback and assessment results immediate


Implicit Bias and Clinical Implicit Bias and Clinical Outcomes Outcomes

• Physicians reported no Physicians reported no explicitexplicit preference for preference for white versus black patientswhite versus black patients

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


Implicit Bias and Clinical Implicit Bias and Clinical OutcomesOutcomes

• IAT revealed implicit stereotypes of black Americans IAT revealed implicit stereotypes of black Americans as less cooperative with medical procedures and less as less cooperative with medical procedures and less cooperative generallycooperative generally

• As physicians’ pro-white implicit bias increased, so As physicians’ pro-white implicit bias increased, so did their likelihood of treating white patients and not did their likelihood of treating white patients and not treating black patients with thrombolysis treating 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 contribution to Burgess and van Ryn: Understanding the provider contribution to race/ethnicity disparities in pain treatment; Pain Med. 2006 race/ethnicity disparities in pain treatment; Pain Med. 2006


Automatic StereotypingAutomatic Stereotyping

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

• Occur regardless of their relevance to the perceivers’ Occur regardless of their relevance to the perceivers’ goalsgoals



Goal Modified Goal Modified StereotypingStereotyping

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



Function of StereotypingFunction of Stereotyping

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

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

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

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


Healthy People 2010Healthy People 2010

Goal II:

“… to eliminate health disparities among

segments of the population, including differences

that occur by gender, race or ethnicity, education

or income, disability, geographic location, or sexual

orientation.”


• Substantial disparities between population groups Substantial disparities between population groups • Few changes in disparity since the baseline when Few changes in disparity since the baseline when

measuredmeasured• Overall, no consistent pattern of Overall, no consistent pattern of changechange in disparity in disparity

for any population group (except males)for any population group (except males)

http://www.cdc.gov/nchs/ppt/duc2006/hallquist_52.ppt#769,1,Midcourse Assessment http://www.cdc.gov/nchs/ppt/duc2006/hallquist_52.ppt#769,1,Midcourse Assessment of Healthy People 2010 Goal IIof Healthy People 2010 Goal II

HP 2010 Review in 2006:HP 2010 Review in 2006:


Creating Equity Reports Creating Equity Reports

• tool that allows a clinic/site of care to examine, tool that allows a clinic/site of care to examine, measure, and address inequalities in the care measure, and address inequalities in the care provided to patients from different cultural provided to patients from different cultural backgrounds.backgrounds.

• it can help identify areas where things are going well it can help identify areas where things are going well and those where there are opportunities for and those where there are opportunities for improvementimprovement


Creating Equity ReportsCreating Equity Reports

• can also help with monitoring progress over time can also help with monitoring progress over time toward eliminating inequalitiestoward eliminating inequalities

• Promotes goal of providing the highest quality of care Promotes goal of providing the highest quality of care to all patients, regardless of their race, ethnicity, to all patients, regardless of their race, ethnicity, language, or socioeconomic status, or sexual language, or socioeconomic status, or sexual orientation orientation


Creating Equity ReportsCreating Equity ReportsSTEPS:STEPS:

• pick a process (examples: mammograms, guideline pick a process (examples: mammograms, guideline

adherence for asthma or diabetes)adherence for asthma or diabetes)• collect data ( who gets them, who doesn’t)collect data ( who gets them, who doesn’t)• compare racial and other cultural groupscompare racial and other cultural groups• assess disparities, create action plan where disparity assess disparities, create action plan where disparity

notednotedhttp://www.massgeneral.org/disparitiessolutions/resources.htmlhttp://www.massgeneral.org/disparitiessolutions/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, Sexuality)(Recommended Tests: Race, Arab-Muslim, Gender, 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/


http://backhand.uchicago.edu/Center/ShooterEffect/


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

heads up! a project of the american academy of physician assistants and the physician assistant...

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