Skip to main content
×
Home
    • Aa
    • Aa

THE IMPACT OF RACISM ON CLINICIAN COGNITION, BEHAVIOR, AND CLINICAL DECISION MAKING

  • Michelle van Ryn (a1), Diana J. Burgess (a2), John F. Dovidio (a3), Sean M. Phelan (a1), Somnath Saha (a4), Jennifer Malat (a5), Joan M. Griffin (a6), Steven S. Fu (a6) and Sylvia Perry (a3)...
Abstract
Abstract

Over the past two decades, thousands of studies have demonstrated that Blacks receive lower quality medical care than Whites, independent of disease status, setting, insurance, and other clinically relevant factors. Despite this, there has been little progress towards eradicating these inequities. Almost a decade ago we proposed a conceptual model identifying mechanisms through which clinicians' behavior, cognition, and decision making might be influenced by implicit racial biases and explicit racial stereotypes, and thereby contribute to racial inequities in care. Empirical evidence has supported many of these hypothesized mechanisms, demonstrating that White medical care clinicians: (1) hold negative implicit racial biases and explicit racial stereotypes, (2) have implicit racial biases that persist independently of and in contrast to their explicit (conscious) racial attitudes, and (3) can be influenced by racial bias in their clinical decision making and behavior during encounters with Black patients. This paper applies evidence from several disciplines to further specify our original model and elaborate on the ways racism can interact with cognitive biases to affect clinicians' behavior and decisions and in turn, patient behavior and decisions. We then highlight avenues for intervention and make specific recommendations to medical care and grant-making organizations.

Copyright
Corresponding author
Michelle van Ryn, Department of Family Medicine and Community Health, University of Minnesota Medical School, Room 221, 925 Delaware Street SE, Minneapolis, MN 55414. E-mail: vanry001@umn.edu
References
Hide All
American Medical Association (AMA) (2005). Quality Health Care for Minorities: Understanding Physicians' Experiences: Physicians Are Becoming Engaged in Addressing Disparities: Preliminary Survey Brief, ⟨http://www.ama-assn.org/ama/pub/physician-resources/public-health/eliminating-health-disparities/commission-end-health-care-disparities/quality-health-care-minorities-understanding-physicians.shtml⟩ (accessed August 3, 2010).
Barr D. A. and Wanat S. F. (2005). Listening to Patients: Cultural and Linguistic Barriers to Health Care Access. Family Medicine, 37(3): 199204.
Batson C. D., Polycarpou M. P., Harmon-Jones E., Imhoff H.J., Mitchener E. C., Bednar L. L., Klein T. R., and Highberger L. (1997). Empathy and Attitudes: Can Feeling for a Member of a Stigmatized Group Improve Feelings toward the Group? Journal of Personality and Social Psychology, 72(1): 105118.
Beach M. C., Gary T. L., Price E. G., Robinson K., Gozu A., Palacio A., Smarth C., Jenckes M., Feuerstein C., Bass E. B., Powe N. R., and Cooper L. A. (2006). Improving Health Care Quality for Racial/Ethnic Minorities: A Systematic Review of the Best Evidence Regarding Provider and Organization Interventions. BMC Public Health, 6: 104.
Beach M. C., Price E. G., Gary T. L., Robinson K. A., Gozu A., Palacio A., Smarth C., Jenckes M. W., Feuerstein C., Bass E. B., Powe N. R., and Cooper L. A. (2005). Cultural Competence: A Systematic Review of Health Care Provider Educational Interventions. Medical Care, 43(4): 356373.
Betancourt J. R. and Green A. R. (2010). Commentary: Linking Cultural Competence Training to Improved Health Outcomes: Perspectives from the Field. Academic Medicine, 85(4): 583585.
Blanchard J. and Lurie N. (2004). R-E-S-P-E-C-T: Patient Reports of Disrespect in the Health Care Setting and Its Impact on Care. Journal of Family Practice, 53(9): 721730.
Branscombe N. R., Schmitt M. T., and Schiffhauer K. (2006). Racial Attitudes in Response to Thoughts of White Privilege. European Journal of Social Psychology, 37(2): 203215.
Burgess D., Van Ryn M., Dovidio J., and Saha S. (2007). Reducing Racial Bias among Health Care Providers: Lessons from Social-Cognitive Psychology. Journal of General Internal Medicine, 22(6): 882887.
Burgess D. J. (2010). Are Providers More Likely to Contribute to Healthcare Disparities under High Levels of Cognitive Load? How Features of the Healthcare Setting May Lead to Biases in Medical Decision Making. Medical Decision Making, 30(2): 246257.
Burgess D. J., Phelan S., Dovidio J., and van Ryn M. (Forthcoming). The Effect of Medical Authoritarianism on Physicians' Attitudes and Treatment Decisions for Chronic Pain. Journal of Applied Social Psychology.
Burgess D. J., Warren J., Phelan S., Dovidio J., and van Ryn M. (2010). Stereotype Threat and Health Disparities: What Medical Educators and Future Physicians Need to Know. Journal of General Internal Medicine, 25(Supplement 2): S169S177.
Clark-Hitt R., Malat J., Burgess D., and Friedemann-Sanchez G. (2010). Doctors' and Nurses' Explanations for Racial Disparities in Medical Treatment. Journal of Health Care for the Poor and Underserved, 21(1): 386400.
Commission to End Health Care Disparities (2005). Preliminary Survey Brief: Physicians Are Becoming Engaged in Addressing Disparities. Quality Health Care for Minorities: Understanding Physicians' Experiences. ⟨http://www.ama-assn.org/ama/pub/physician-resources/public-health/eliminating-health-disparities/commission-end-health-care-disparities/quality-health-care-minorities-understanding-physicians.shtml⟩ (accessed August 3, 2010).
Cooper L. A. (2008). Overcoming Healthcare Disparities: The Role of Patient-Centered Care. College of Public Health and Health Professions Celebrating 50 Years. University of Florida.
Crosby F., Clayton S., Alksnis O., and Hemker K. (1986). Cognitive Biases in the Perception of Discrimination: The Importance of Format. Sex Roles, 14(122): 637646.
Croskerry P. and Wears R. L. (2002). Safety Errors in Emergency Medicine. In Markovchick V. J. and Pons P. T. (Eds.), Emergency Medicine Secrets, 3 ed., pp. 2937. Philadelphia, PA: Hanley and Belfus.
Davis M. H., Soderlund T., Cole J., Gadol E., Kute M., Myers M., and Weihing J. (2004). Cognitions Associated with Attempts to Empathize: How Do We Imagine the Perspective of Another? Personality and Social Psychology Bulletin, 30: 16251635.
Delgado R. and Stefancic J. (2001). Critical Race Theory: An Introduction. New York: New York University Press.
Devine P. G. and Monteith M. J. (1993). The Role of Discrepancy-Associated Affect in Prejudice Reduction. In Mackie D. M. and Hamilton D. L. (Eds.), Affect, Cognition, and Steroetyping: Interactive Processes in Group Perception, pp. 317344. New York: Academic Press.
Dovidio J. F. and Gaertner L. (2004). Aversive Racism. In Zanna Mark P. (Ed.) Advances in Experimental Social Psychology, pp. 151. San Diego, CA: Academic Press.
Dovidio John F., Gaertner Samuel L., Isen Alice M., and Lowrance Robert (1995). Group Representations and Intergroup Bias: Positive Affect, Similarity, and Group Size. Personality and Social Psychology Bulletin, 21(8): 856865.
Dovidio J. F., Gaertner S. L., Stewart T. L., Esses V. M., and Ten Vergert M. (2004). From Intervention to Outcomes: Processes in the Reduction of Bias. In Stephan W. G. and Vogt P. (Eds.), Intergroup Relations Programs: Practice, Research, and Theory, pp. 243265. New York: Teachers College Press.
Dovidio J. F., Gaertner S. L., and Validzic A. (1998). Intergroup Bias: Status, Differentiation, and a Common in-Group Identity. Journal of Personality and Social Psychology, 75(1): 109120.
Dovidio J. F., Gaertner S. L., Validzic A., Matoka K., Johnson B., and Frazier S. (1997a). Extending the Benefits of Recategorization: Evaluations, Self-Disclosure, and Helping. Journal of Experimental Social Psychology, 33(4): 401420.
Dovidio J., Kawakami K., and Beach K. (2001). Implicit and Explicit Attitudes: Examination of the Relationship Between Measures of Intergroup Bias. In Brown R. and Gaertner S. L. (Eds.), Blackwell Handbook of Social Psychology: Vol. 4. Intergroup Relations, pp. 175197. Oxford, England: Blackwell.
Dovidio J., Kawakami K., Johnson C., Johnson B., and Howard A. (1997b). The Nature of Prejudice: Automatic and Controlled Processes. Journal of Experimental Social Psychology, 33: 510540.
Dovidio J. F., Penner L. A., Albrecht T. L., Norton W. E., Gaertner S. L., and Shelton J. N. (2008). Disparities and Distrust: The Implications of Psychological Processes for Understanding Racial Disparities in Health and Health Care. Social Science and Medicine, 67(3): 478486.
Eberly T., Davidoff A., and Miller C. (2010). Managing the Gap: Evaluating the Impact of Medicaid Managed Care on Preventive Care Receipt by Child and Adolescent Minority Populations. Journal of Health Care for the Poor and Underserved, 21(1): 92111.
Epstein A. J., Gray B. H., and Schlesinger M. (2010). Racial and Ethnic Differences in the Use of High-Volume Hospitals and Surgeons. Archives of Surgery, 145(2): 179186.
Fincher C., Williams J. E., Maclean V., Allison J. J., Kiefe C. I., and Canto J. (2004). Racial Disparities in Coronary Heart Disease: A Sociological View of the Medical Literature on Physician Bias. Ethnicity and Disease, 14(3): 360371.
Ford C. L. and Airhihenbuwa C. O. (2010). Critical Race Theory, Race Equity, and Public Health: Toward Antiracism Praxis. American Journal of Public Health, 100 (Supplement 1): S30S35.
Gaertner S. L. and Dovidio J. F. (2000). Reducing Intergroup Bias: The Common Ingroup Identity Model. Philadelphia, PA: Psychology Press.
Galinsky A. D. and Moskowitz G. B. (2000). Perspective-Taking: Decreasing Stereotype Expression, Stereotype Accessibility, and In-Group Favoritism. Journal of Personality and Social Psychology, 78(4): 708724.
Gates H. and Steele C. (2009). A Conversation with Claude M. Steele: Stereotype Threat and Black Achievement. Du Bois Review: Social Science Research on Race, 6(2): 251271.
Goff P. A., Steele C. M., and Davies P. G. (2008). The Space Between Us: Stereotype Threat and Distance in Interracial Contexts. Journal of Personality and Social Psychology, 94(1): 91107.
Gomez A., Dovidio J. F., Huici C., Gaertner S. L., and Cuadrado I. (2008). The Other Side of We: When Outgroup Members Express Common Identity. Personality and Social Psychology Bulletin, 34(12): 16131626.
Green A. R., Carney D. R., Pallin D. J., Ngo L. H., Raymond K. L., Iezzoni L. I., and Banaji M. R., (2007a). Implicit Bias among Physicians and Its Prediction of Thrombolysis Decisions for Black and White Patients. Journal of General Internal Medicine, 22(9): 12311238.
Green L. A., Wyszewianski L., Lowery J. C., Kowalski C. P., and Krein S. L. (2007b). An Observational Study of the Effectiveness of Practice Guideline Implementation Strategies Examined According to Physicians' Cognitive Styles. Implementation Science, 2(1): 41.
Greenwald A. G., Poehlman T. A., Uhlmann E. L., and Banaji M. R. (2009). Understanding and Using the Implicit Association Test: III. Meta-Analysis of Predictive Validity. Journal of Personality and Social Psychology, 97(1): 1741.
Hausmann L. R., Jeong K., Bost J. E., and Ibrahim S. A. (2008). Perceived Discrimination in Health Care and Use of Preventive Health Services. Journal of General Internal Medicine, 23(10): 16791684.
Hirsh A. T., Jensen M. P., and Robinson M. E. (2010). Evaluation of Nurses' Self-Insight into Their Pain Assessment and Treatment Decisions. Journal of Pain, 11(5): 454461.
Johnson Kareem J. and Fredrickson Barbara L. (2005). “We All Look the Same to Me”: Positive Emotions Eliminate the Own-Race Bias in Face Recognition. Psychological Science, 16: 875881.
Jost J. T. and Banaji M. R. (1994). The Role of Stereotyping in System-Justification and the Production of False Consciousness. British Journal of Social Psychology, 33: 127.
The Kaiser Family Foundation (KFF) (2002). National Survey of Physicians, Part I: Doctors on Disparities in Medical Care. March, p. 2. ⟨http://www.kff.org/minorityhealth/20020321a-index.cfm⟩ (accessed July 10, 2010).
Kelley E., Moy E., Stryer D., Burstin H., and Clancy C. (2005). The National Healthcare Quality and Disparities Reports: An Overview. Medical Care, 43(3 Supplement): I3–8.
King M. L. (1966). Presentation at the Second National Convention of the Medical Committee for Human Rights, Chicago, IL, March 25.
Le Cook B., Mcguire T. G., and Zuvekas S. H. (2009). Measuring Trends in Racial/Ethnic Health Care Disparities. Medical Care Research Review, 66(1): 2348.
Lee C., Ayers S. L., and Kronenfeld J. J. (2009). The Association Between Perceived Provider Discrimination, Healthcare Utilization, and Health Status in Racial and Ethnic Minorities. Ethnicity and Disease, 19(3): 330337.
McConnell A. R. and Leibold J. M. (2001). Relations Between the Implicit Association Test, Explicit Racial Attitudes, and Discriminatory Behavior. Journal of Experimental Social Psychology, 37: 435442.
Merrill J. M., Laux L. F., Lorimor R., Thornby J. I., and Vallbona C. (1995). Authoritarianism's Role in Medicine. American Journal of Medical Science, 310(3): 8790.
Monteith M. J., Mark A. Y., and Ashburn-Nardo L. (2010). The Self-regulation of Prejudice: Toward Understanding its Lived Character. Group Processes and Intergroup Relations, 13: 183200.
Monteith M. J., Sherman J. W., and Devine P. G. (1998). Suppression as a Stereotype Control Strategy. Personal Social Psychology Review, 2(1): 6382.
Moy E., Dayton E., and Clancy C. M. (2005). Compiling the Evidence: The National Healthcare Disparities Reports. Health Affairs, 24(2): 376387.
Newhouse D. (2009). Service Score Segmentation of Diverse Populations to Improve Patient and Physician Satisfaction—A Multicase Quality Improvement Study. Permanente Journal, 13(4): 3441.
Nunez-Smith M., Pilgrim N., Wynia M., Desai M. M., Jones B. A., Bright C., Krumholz H. M., and Bradley E. H. (2009). Race/Ethnicity and Workplace Discrimination: Results of a National Survey of Physicians. Journal of General Internal Medicine, 24(11): 11981204.
Olomu A. B., Grzybowski M., Ramanath V. S., Rogers A. M., Vautaw B. M., Chen B., Roychoudhury C., Jackson E. A., and Eagle K. A. (2010). Evidence of Disparity in the Application of Quality Improvement Efforts for the Treatment of Acute Myocardial Infarction: The American College of Cardiology's Guidelines Applied in Practice Initiative in Michigan. American Heart Journal, 159(3): 377384.
Paluck E. L. (2009). Reducing Intergroup Prejudice and Conflict Using the Media: A Field Experiment in Rwanda. Journal of Personality and Social Psychology, 96(3): 574587.
Penner L. A., Dovidio J. F., West T. V., Gaertner S. L., Albrecht T. L., Dailey R. K., and Markova T. (2010). Aversive Racism and Medical Interactions with Black Patients: A Field Study. Journal of Experimental Social Psychology, 46(2): 436440.
Perry S. P. and Murphy M. C. (2011). Responses to Prejudice Feedback on the Race Implicit Association Test and the Role of Bias Awareness. Forthcoming.
Pettigrew T. F. and Tropp L. R. (2008). How Does Intergroup Contact Reduce Prejudice? Meta-Analytic Tests of Three Mediators. European Journal of Social Psychology, 38(6): 922934.
Phelan S. M., van Ryn M., Wall M., and Burgess D. (2009). Understanding Primary Care Physicians' Treatment of Chronic Low Back Pain: The Role of Physician and Practice Factors. Pain Medicine, 10(7): 12701279.
Plant E. A. and Butz D. A. (2006). The Causes and Consequences of an Avoidance-Focus for Interracial Interactions. Personality and Social Psychology Bulletin, 32(6): 833846.
Plant E. A. and Devine P. G. (2009). The Active Control of Prejudice: Unpacking the Intentions Guiding Control Efforts. Journal of Personal Social Psychology, 96(3): 640652.
Powell Adam A., Branscombe Nyla R., and Schmitt Michael T. (2005). Inequality as Ingroup Privilege or Outgroup Disadvantage: The Impact of Group Focus on Collective Guilt and Interracial Attitudes. Personality and Social Psychology Bulletin, 31(4): 508521.
Pratto Felicia, Sidanius Jim, Stallworth Lisa M., and Malle Bertram F. (1994). Social Dominance Orientation: A Personality Variable Predicting Social and Political Attitudes. Journal of Personality and Social Psychology, 67(4): 741763.
Pugh S. D., Dietz J., Brief A. P., and Wiley J. W. (2008). Looking Inside and Out: The Impact of Employee and Community Demographic Composition on Organizational Diversity Climate. Journal of Applied Psychology, 93(6): 14221428.
Purdie-Vaughns V., Steele C. M., Davies P. G., Ditlmann R., and Crosby J. R. (2008). Social Identity Contingencies: How Diversity Cues Signal Threat or Safety for African Americans in Mainstream Institutions. Journal of Personality and Social Psychology, 94(4): 615630.
Roter D. (2000). The Medical Visit Context of Treatment Decision-Making and the Therapeutic Relationship. Health Expectations, 3(1): 1725.
Sabin J., Nosek B. A., Greenwald A., and Rivara F. P. (2009). Physicians' Implicit and Explicit Attitudes About Race by MD Race, Ethnicity, and Gender. Journal of Health Care for the Poor and Underserved, 20(3): 896913.
Sabin J. A., Rivara F. P., and Greenwald A. G. (2008). Physician Implicit Attitudes and Stereotypes About Race and Quality of Medical Care. Medical Care, 46(7): 678685.
Saha S., Guiton G., Wimmers P. F., and Wilkerson L. (2008). Student Body Racial and Ethnic Composition and Diversity-Related Outcomes in U.S. Medical Schools. Journal of the American Medical Association, 300(10): 11351145.
Schmader T., Johns M., and Forbes C. (2008). An Integrated Process Model of Stereotype Threat Effects on Performance. Psychology Review, 115(2): 336356.
Sidanius J., Levin S., Federico C., and Pratto F. (2001). Legitimizing Ideologies: The Social Dominance Approach. In Jost J. T. and Major B. (Eds.), The Psychology of Legitimacy: Emerging Perspectives on Ideology, Justice, and Intergroup Relations, pp. 307331. New York: Cambridge University Press.
Siegel B. D. Bear, Andres E., and Mead H. (2009). Measuring Equity: An Index of Health Care Disparities. Quality Managed Health Care, 18(2): 8490.
Smedley B. D., Stith A. Y., and Nelson A. R. (Eds.) (2003). Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press.
Smith W. R., Betancourt J. R., Wynia M. K., Bussey-Jones J., Stone V. E., Phillips C. O., Fernandez A., Jacobs E., and Bowles J. (2007). Recommendations for Teaching About Racial and Ethnic Disparities in Health and Health Care. Annals of Internal Medicine, 147(9): 654665.
Sorkin D. H., Ngo-Metzger Q., and De Alba I. (2010). Racial/Ethnic Discrimination in Health Care: Impact on Perceived Quality of Care. Journal of General Internal Medicine, 25(5): 390396.
Spencer S. J., Steele C. M., and Quinn D. M. (1999). Stereotype Threat and Women's Math Performance. Journal of Experimental Social Psychology, 35: 428.
Steele C. M. (1992). Race and the Schooling of Black Americans. The Atlantic Monthly, 269(4): 6878.
Steele C. M. and Aronson J. (1995). Stereotype Threat and the Intellectual Test Performance of African Americans. Journal of Personality and Social Psychology, 69(5): 797811.
Stewart M., Brown J. B., Donner A., Mcwhinney I. R., Oates J., Weston W. W., and Jordan J. (2000). The Impact of Patient-Centered Care on Outcomes. Journal of Family Practice, 49(9): 796804.
Street R. L. Jr., Gordon H., and Haidet P. (2007). Physicians' Communication and Perceptions of Patients: Is It How They Look, How They Talk, or Is It Just the Doctor? Social Science and Medicine, 65(3): 586598.
Tamblyn R., Berkson L., Dauphinee W. D., Gayton D., Grad R., Huang A., Isaac L., Mcleod P., and Snell L. (1997). Unnecessary Prescribing of NSAIDs and the Management of NSAID-Related Gastropathy in Medical Practice. Annals of Internal Medicine, 127(6): 429438.
van Ryn M., Burgess D., Malat J., and Griffin J. (2006). Physicians' Perceptions of Patients' Social and Behavioral Characteristics and Race Disparities in Treatment Recommendations for Men with Coronary Artery Disease. American Journal of Public Health, 96(2): 351357.
van Ryn M. and Burke J. (2000). The Effect of Patient Race and Socio-Economic Status on Physicians' Perceptions of Patients. Social Science and Medicine, 50(6): 813828.
van Ryn M. and Fu S. S. (2003). Paved with Good Intentions: Do Public Health and Human Service Providers Contribute to Racial/Ethnic Disparities in Health? American Journal of Public Health, 93(2): 248255.
White-Means S., Zhiyong Dong, Hufstader M., and Brown L. T. (2009). Cultural Competency, Race, and Skin Tone Bias among Pharmacy, Nursing, and Medical Students: Implications for Addressing Health Disparities. Medical Care Research Review, 66(4): 436455.
Williams E. S., Manwell L. B., Konrad T. R., and Linzer M. (2007). The Relationship of Organizational Culture, Stress, Satisfaction, and Burnout with Physician-Reported Error and Suboptimal Patient Care: Results from the Memo Study. Health Care Management Review, 32(3): 203212.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Du Bois Review: Social Science Research on Race
  • ISSN: 1742-058X
  • EISSN: 1742-0598
  • URL: /core/journals/du-bois-review-social-science-research-on-race
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×

Keywords:

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 27
Total number of PDF views: 193 *
Loading metrics...

Abstract views

Total abstract views: 909 *
Loading metrics...

* Views captured on Cambridge Core between September 2016 - 19th October 2017. This data will be updated every 24 hours.