Health care

disparities
Harry Pomeranz
Stereotyping and
Mercy College
unconscious
October 2008bias

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

What are potential sources of

disparities in care?
Health

systems-level factors
financing, structure of care; cultural
and linguistic barriers
Patient-level factors including
patient preferences, refusal of
treatment, poor adherence, biological
differences
Disparities 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 Paradox
How 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 Care
Figure 18

Generally speaking, how often do you think our health care system treats
people unfairly based on
Percent Saying Very/Somewhat Often

Doctors
72%
70%

Whether or not they have insurance

How well they speak English

The Public

43%
58%

What their race or ethnic

background is

29%

Whether they are male or female

15%
27%

47%

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)

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 Paradox
Stereotyping evidence suggests

that physicians, like everyone else,

use these cognitive shortcuts

Stereotyping: A Definition
Stereotyping 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: Risks
Can 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: Risks
Can 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 nonminority patients education,
income, and personality

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 nonminorities, even when the
patient's insurance status and
income are controlled.

The Elimination of Health

Care Disparities

The 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 Disparities
Clinicians

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 Disparities
Alternatively,

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

Outcomes

IAT 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:
1.

Automatic stereotyping

2.

Goal modified stereotyping

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

Automatic Stereotyping

occurs when stereotypes are automatically

activated and influence
judgments/behaviors outside of
consciousness

Occur regardless of their relevance to the

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

Goal Modified Stereotyping

More

conscious process, done when

specific needs of clinician arise (time
constraints, filling in gaps in
information needed to make complex
decisions
Burgess and van Ryn: Understanding the provider
contribution to
race/ethnicity disparities in pain
treatment; Pain Med. 2006

Function of Stereotyping

Providers 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 Resources

Heads 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/