1. 1 Physician Racial Bias and Medical Care Janice A. Sabin, PhD, MSW Frederick Rivara, MD, MPH, Anthony Greenwald, PhD University of Washington Seattle, WA American Public Health Association Annual Meeting Washington DC, November 5, 2007

2. 2 Overview  Health care disparities  Research question  Measuring racial bias/discrimination  Theoretical perspective  Research study  Implications

3. 3 Disparities in Medical Care  Evidence that medical visits are less patient- centered for African Americans compared to whites (Johnson, Roter, Howe & Cooper, 2004, audiotaped)  Physician 23% more verbally dominant, 33% less patient-centered  Positive affect of physician lower  Black and Hispanic children are significantly less often referred to specialists than white children (Flores, et al. 2005)  Well child visits are shorter for Latino children, black and Latino families received less preventive counseling at these visits (Hambridge et al. 2007)

4. 4 Question and Speculation Why would health care providers, who generally believe in providing quality care for all patients, offer poorer or inappropriate care to racial and ethnic minority patients? Racial bias/discrimination? Trans-disciplinary collaboration

5. 5 Measuring Racial Discrimination  Patient perceptions of discrimination  Observation of discrimination event  Recognized or not  Review of records  Provider attitudes stereotypes and effect on behavior (discrimination, treatment)  Self-report of attitudes  Indirect measures of attitudes

6. 6 Understanding a Mechanism of Unequal Treatment: Theoretical Perspective  Medical Cognition:  Physicians use heuristics to cognitively sort and quickly retrieve clusters of medical information from memory  Unknowingly, clusters of implicit social attitudes, stereotypes and bias stored in unconscious memory may be retrieved with medical information  Environment:  Conditions of time pressure, fatigue, high cognitive demand may activate implicit attitudes and stereotypes and influence quality of care  Social Cognition:  Discrimination may be the result of normal cognitive processes

7. 7 Racial Bias (Dovidio, Gaertner & Kawakami, 2002; Greenwald & Banaji, 1995)  Racial bias: a favorable or unfavorable attitude toward person based upon race  A stereotype is a set of beliefs or fixed impression about members of a social group  Explicit refers to attitudes and beliefs we know we have ( deliberate/verbal behavior)  Implicit refers to attitudes and beliefs that are not readily apparent to the individual ( automatic/unconscious- non verbal behavior)

8. 8 Implicit Social Cognition  Implicit attitudes/stereotypes may form and exist without awareness and be in opposition to explicit beliefs ( Dovidio, Kawakami, & Gaertner, 2002; Greenwald & Banaji, 1995)  Implicit and explicit attitudes/stereotypes about race often differ (Hofmann, W., Gawronski, B., Gschwender, T., Le, H., & Schmitt, M., 2005)  Implicit attitudes/stereotypes about race/ethnicity are a better predictor of the behavior of discrimination than is self- report (Poehlman, A.T., Ulhman, E., Greenwald, A.G., & Banaji, M.R., 2007)

9. 9 The Implicit Association Test (IAT) Greenwald, McGhee, Schwartz, 1998  An indirect measure of implicit social cognition that assesses relative association strengths (African American/European American and good/bad)  Subjects are asked to quickly sort pairs of images as they rapidly appear on a computer screen using right and left computer key  Based on the assumption that response to images that are more easily associated will be faster than response to images that are less easily associated  IAT validity issues http://faculty.washington.edu/agg/iat_validity.htm  Resistant to social desirability  In the areas of prejudice, stereotyping and discrimination, IAT scores are a better predictor of behavior than is self-report (Poehlman et al., 2007)

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11. 11 Race Attitude IAT Task that estimates implicit positivity toward European American & African American bad awful nasty terrible horrible agony evil failure hurt Give one response to words for European American & good love happy peace joy wonderful laughter pleasure glorious Give another response to words for

12. 12 Race Attitude IAT Task that estimates implicit positivity toward African American & Bad awful nasty terrible horrible agony evil failure hurt Give one response to words for European American African American & Good love happy peace joy wonderful laughter pleasure glorious Give another response to words for

13. 13 IAT Research in Health Care  Green et al. (2007):  Physicians hold strong implicit preference for white Americans  Strong implicit association for black patients as being “less cooperative”  As pro-white implicit bias increased, physicians were more likely to treat White patients and not treat black patients  Sabin, Nosek, Rivara and Greenwald (in progress):  MDs showed strong implicit preference for European Americans (N= 2535, Cohen’s d= 0.89)  Implicit and explicit attitudes were weakly related  African American MDs showed no racial preference on Race IAT (N=206, Cohen’s d= 0.05)  Female MDs showed weaker implicit white preference than male MDs  Female African American MDs reported a strong explicit preference for African Americans (no implicit bias)

14. 14 Physician Racial Bias and Medical Care: Hypotheses (funded by the AHRQ) 1.Pediatricians will show strong implicit preference for White Americans on the Race Attitude IAT 2.Pediatricians will show a strong implicit association between European Americans and the concept of “compliant patient” 3.Implicit and explicit attitudes will differ 4.May find differences in case vignette decisions by patient race 5.Implicit bias may be related to quality of care

15. 15 Methods  University IRB approved study  Recruited pediatricians from one academic medicine department  Data collection Sept-Oct, 2005  Project Implicit® (Harvard University) web server  Single session, 20 minute on line survey  Anonymous participation  Survey on line for 34 days  Response rate 58 %

16. 16 Measures  Physician Characteristics  Explicit measure: Self-report of attitudes about race and medical care  Implicit Association Tests (IAT)  Race Attitude IAT (Greenwald, McGhee, & Schwartz, 1998)  Compliant Patient IAT (Sabin, Rivara, & Greenwald, 2005)  4 pediatric case vignettes varied by race

17. 17 Results  N=95  65% female  64% ages 26-35  59% residents/41% faculty  82% self ID as white  94% born USA  57% in past month > 60% of patients white

18. 18 Results: Explicit (N=86)

19. 19 Results: Implicit Measures

20. 20 Results: Case Vignettes Compared “best” vs. “good” recommendation  No significant difference in treatment choice by race for asthma, ADHD, pain management  For urinary tract infection case vignette: 2 weeks hospitalization vs. home care  Significantly more likely to choose best recommendation (home care) for African American patient than for white patient  May suggest “over use” of the health care system for white patients (consistent with study that examined severity of illness and pediatric hospitalization rates and found that white pediatric patients vs. black and Hispanic children are over-admitted when not severely ill, Chamberlain, Joseph, Patel &Pollack, 2007)

21. 21 Correlational Results  Significant positive relationship between the Compliant IAT and Race IAT (r=.39, P=.01)  No significant relationship between explicit and implicit measures  No significant relationship between difference in case vignette treatment recommendations by race and implicit bias measures

22. 22 Limitations  One department of physicians in one university  Limited ability to generalize  Small sample size  Case vignettes do not necessarily capture clinical practice  However, this sample may represent a “best case scenario” early career MDs, liberal community, pediatric training

23. 23 Conclusions  Explicit (self-report of feelings) did not differ toward European Americans and African Americans  Explicit attitudes about race and medical care in pediatricians’ own practice favored African Americans  Likely reflects genuine attitudes, social desirability  Implicit preference for European Americans was weak compared to other MDs and other IAT test takers  Implicit association found between the concept of “compliant patient” and European Americans (vs. African Americans)  “Implicit perceived compliance and race bias”

24. 24 Implications  The Implicit Association Test can be a useful tool to measure implicit attitudes about race and relation to quality of care  Direct evidence beginning to emerge that provider implicit racial bias exists  Do pediatricians hold less implicit racial bias than others?  Targeting specific implicit associations such as patient race and concept of “compliant patient” may be the key to understanding how racial bias affects medical care

25. 25 Acknowledgements  David Takeuchi, Lewayne Gilchrist, The Department of Pediatrics, Project Implicit®  Agency for Healthcare Research and Quality (AHRQ) 1-R36HS15676-01, Dissertation grant award (2005-2006)  NIMH T32-MH20010, Prevention Science Training grant (2002-2005)

26. 26 Resources  IAT demonstration/information http://implicit.harvard.edu  IAT validity issues http://faculty.washington.edu/agg/iat_validity.htm  Nosek, B. A., Greenwald, A. G., & Banaji, M. R. (2007) The Implicit Association Test at Age 7: A methodological and conceptual review. In J. A. Bargh (Ed.), Automatic processes in social thinking and behavior. Psychology Press

27. 27 Sample Case Vignette