Health care disparities Stereotyping and unconscious biasHarry PomeranzMercy CollegeOctober 2008

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?

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 disparities in care?Health systems-level factors financing, structure of care; cultural and linguistic barriersPatient-level factors including patient preferences, refusal of treatment, poor adherence, biological differencesDisparities arising from the clinical encounter

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

Disparities in the Clinical Encounter: The Core ParadoxHow 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?

Perceptions of Disparities in Health CareWhat their race or ethnic background isHow well they speak EnglishWhether they are male or femaleWhether or not they have insurance27%15%47%29%58%43%70%72%Generally speaking, how often do you think our health care system treats people unfairly based onDoctorsThe PublicPercent Saying Very/Somewhat OftenSource: 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 Core Paradox

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

Disparities in the Clinical Encounter: The Core ParadoxStereotyping evidence suggests that physicians, like everyone else, use these cognitive shortcuts

Stereotyping: A DefinitionStereotyping 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: 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: RisksCan 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.

Stereotyping: RisksCan exert self-fulfilling effects, as patients behavior may be affected by providers overt or subtle attitudes and behaviors.

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.

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. 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)

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)

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)

The Elimination of Health Care Disparities

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.

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

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

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

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.

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.

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

Implicit Bias and Unconscious StereotypingResearch indicates: Implicit biases are pervasive.People are often unaware of their implicit biasesOrdinary people harbor negative associations in relation to various groups

Implicit Bias and Unconscious Stereotyping

Implicit biases predict behavior People differ in levels of implicit bias

Implicit Bias and Clinical Outcomes

Physicians reported no explicit preference for white versus black patients

Implicit Association Test (IAT) revealed implicit preference favoring white Americans

Implicit Bias and Clinical OutcomesIAT 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

Dual Process Stereotyping Two distinct methods of stereotyping:

Automatic stereotyping

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

Automatic Stereotypingoccurs when stereotypes are automatically activated and influence judgments/behaviors outside of consciousness

Occur regardless of their relevance to the perceivers goalsBurgess and van Ryn: Understanding the provider contribution to race/ethnicity disparities in pain treatment; Pain Med. 2006

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

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

Web and Other ResourcesHeads Up! Website:

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

Web and Other Resources Implicit Association Test: https://implicit.harvard.edu/implicit/ Project Implicit Information Page: 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/

Voiceover:

Another reason addressing disparities is challenging is related to the relatively low level of awareness or acknowledgement of the problem.When physicians and the public were asked about the existence of disparities in health care, there was considerable agreement that the health care system treats people unfairly based on whether they have insurance coverage.However, despite evidence of racial/ethnic disparities in care, less than a third (29%) of physicians and less than half (47%) of the public believe that our health care system treats people unfairly based on race/ethnicity.Though compelling evidence of health care disparities exists, it is not well known. Until there is greater awareness of health care disparities, it will be difficult to motivate providers, policymakers or the health care system to seek out solutions to eliminate them.