Discrimination and Bias: Annotated Bilbliography

Abad-Merino, S., et al. (2013). “The dynamics of intergroup helping: the case of subtle bias against Latinos.” Cultur Divers Ethnic Minor Psychol 19(4): 445-452.

Despite the traditional importance of Latinos in the U.S., the growing Latino population, and evidence of group-based disparities, psychological studies of discrimination against Latinos are surprisingly rare. The present research investigated the relationship between prejudice against Latinos and subtle bias, specifically the degree to which people offer autonomy-oriented relative to dependency-oriented assistance to a Latina in need. Participants read scenarios that described concrete social problems faced by particular Latinas, African Americans, or Whites and then indicated their support for forms of helping. Participants higher in prejudice against Latinos, assessed with an adaptation of the Modern Racism Scale, were less likely to offer autonomy-oriented help, and significantly more so after reading scenarios about a Latina than about an African American or a White woman. These findings extend previous work by identifying, experimentally, subtle bias against Latinas in helping and directly implicate the role of prejudice against Latinos in this process.

 

Aberg, J. A., et al. (2017). “Diversity in the US Infectious Diseases Workforce: Challenges for Women and Underrepresented Minorities.” J Infect Dis 216(suppl_5): S606-S610.

Research documents significant gender-based salary inequities among physicians and ongoing inadequacies in recruitment and promotion of physicians from underrepresented minority groups. Given the complexity of the social forces that promote these disparities, their elimination will likely require quantitative and qualitative research to understand the pathways that lead to them and to develop effective solutions. Interventions to combat implicit bias will be required, and structural interventions that hold medical school leadership accountable are needed to achieve and maintain salary equity and racial and gender diversity at all levels.

 

Akitsuki, Y. and J. Decety (2009). “Social context and perceived agency affects empathy for pain: an event-related fMRI investigation.” Neuroimage 47(2): 722-734.

Studying of the impact of social context on the perception of pain in others is important for understanding the role of intentionality in interpersonal sensitivity, empathy, and implicit moral reasoning. Here we used an event-related fMRI with pain and social context (i.e., the number of individuals in the stimuli) as the two factors to investigate how different social contexts and resulting perceived agency modulate the neural response to the perception of pain in others. Twenty-six healthy participants were scanned while presented with short dynamic visual stimuli depicting painful situations accidentally caused by or intentionally caused by another individual. The main effect of perception of pain was associated with signal increase in the aMCC, insula, somatosensory cortex, SMA and PAG. Importantly, perceiving the presence of another individual led to specific hemodynamic increase in regions involved in representing social interaction and emotion regulation including the temporoparietal junction, medial prefrontal cortex, inferior frontal gyrus, and orbitofrontal cortex. Furthermore, the functional connectivity pattern between the left amygdala and other brain areas was modulated by the perceived agency. Our study demonstrates that the social context in which pain occurs modulate the brain response to other’s pain. This modulation may reflect successful adaptation to potential danger present in a social interaction. Our results contribute to a better understanding of the neural mechanisms underpinning implicit moral reasoning that concern actions that can harm other people.

 

Amodio, D. M. (2010). “Coordinated roles of motivation and perception in the regulation of intergroup responses: frontal cortical asymmetry effects on the P2 event-related potential and behavior.” J Cogn Neurosci 22(11): 2609-2617.

Self-regulation is believed to involve changes in motivation and perception that function to promote goal-driven behavior. However, little is known about the way these processes interact during the on-line engagement of self-regulation. The present study examined the coordination of motivation, perception, and action control in White American participants as they regulated responses on a racial stereotyping task. Electroencephalographic indices of approach motivation (left frontal cortical asymmetry) and perceptual attention to Black versus White faces (the P2 event-related potential) were assessed during task performance. Action control was modeled from task behavior using the process-dissociation procedure. A pattern of moderated mediation emerged, such that stronger left frontal activity predicted larger P2 responses to race, which in turn predicted better action control, especially for participants holding positive racial attitudes. Results supported the hypothesis that motivation tunes perception to facilitate goal-directed action. Implications for theoretical models of intergroup response regulation, the P2 component, and the relation between motivation and perception are discussed.

 

Amodio, D. M. (2014). “The neuroscience of prejudice and stereotyping.” Nat Rev Neurosci 15(10): 670-682.

Despite global increases in diversity, social prejudices continue to fuel intergroup conflict, disparities and discrimination. Moreover, as norms have become more egalitarian, prejudices seem to have ‘gone underground’, operating covertly and often unconsciously, such that they are difficult to detect and control. Neuroscientists have recently begun to probe the neural basis of prejudice and stereotyping in an effort to identify the processes through which these biases form, influence behaviour and are regulated. This research aims to elucidate basic mechanisms of the social brain while advancing our understanding of intergroup bias in social behaviour.

 

Amodio, D. M. and P. G. Devine (2006). “Stereotyping and evaluation in implicit race bias: evidence for independent constructs and unique effects on behavior.” J Pers Soc Psychol 91(4): 652-661.

Implicit stereotyping and prejudice often appear as a single process in behavior, yet functional neuroanatomy suggests that they arise from fundamentally distinct substrates associated with semantic versus affective memory systems. On the basis of this research, the authors propose that implicit stereotyping reflects cognitive processes and should predict instrumental behaviors such as judgments and impression formation, whereas implicit evaluation reflects affective processes and should predict consummatory behaviors, such as interpersonal preferences and social distance. Study 1 showed the independence of participants’ levels of implicit stereotyping and evaluation. Studies 2 and 3 showed the unique effects of implicit stereotyping and evaluation on self-reported and behavioral responses to African Americans using double-dissociation designs. Implications for construct validity, theory development, and research design are discussed.

 

Amodio, D. M., et al. (2008). “Individual differences in the regulation of intergroup bias: the role of conflict monitoring and neural signals for control.” J Pers Soc Psychol 94(1): 60-74.

Low-prejudice people vary considerably in their ability to regulate intergroup responses. The authors hypothesized that this variability arises from a neural mechanism for monitoring conflict between automatic race-biased tendencies and egalitarian intentions. In Study 1, they found that low-prejudice participants whose nonprejudiced responses are motivated by internal (but not external) factors exhibited better control on a stereotype-inhibition task than did participants motivated by a combination of internal and external factors. This difference was associated with greater conflict-monitoring activity, measured by event-related potentials, when responses required stereotype inhibition. Study 2 demonstrated that group differences were specific to response control in the domain of prejudice. Results indicate that conflict monitoring, a preconscious component of response control, accounts for variability in intergroup bias among low-prejudice participants.

 

Amodio, D. M. and H. K. Hamilton (2012). “Intergroup anxiety effects on implicit racial evaluation and stereotyping.” Emotion 12(6): 1273-1280.

How does intergroup anxiety affect the activation of implicit racial evaluations and stereotypes? Given the common basis of social anxiety and implicit evaluative processes in memory systems linked to classical conditioning and affect, we predicted that intergroup anxiety would amplify implicit negative racial evaluations. Implicit stereotyping, which is associated primarily with semantic memory systems, was not expected to increase as a function of intergroup anxiety. This pattern was observed among White participants preparing to interact with Black partners, but not those preparing to interact with White partners. These findings shed new light on how anxiety, often elicited in real-life intergroup interactions, can affect the operation of implicit racial biases, suggesting that intergroup anxiety has more direct implications for affective and evaluative forms of implicit bias than for implicit stereotyping. These findings also support a memory-systems model of the interplay between emotion and cognition in the context of social behavior.

 

Amodio, D. M., et al. (2003). “Individual differences in the activation and control of affective race bias as assessed by startle eyeblink response and self-report.” J Pers Soc Psychol 84(4): 738-753.

The activation and control of affective race bias were measured using startle eyeblink responses (Study 1) and self-reports (Study 2) as White American participants viewed White and Black faces. Individual differences in levels of bias were predicted using E. A. Plant and P. G. Devine’s (1998) Internal and External Motivation to Respond Without Prejudice scales (IMS/EMS). Among high-IMS participants, those low in EMS exhibited less affective race bias in their blink responses than other participants. In contrast, both groups of high-IMS participants exhibited less affective race bias in self-reported responses compared with low-IMS participants. Results demonstrate individual differences in implicit affective race bias and suggest that controlled, belief-based processes are more effectively implemented in deliberative responses (e.g., self-reports).

 

Amodio, D. M., et al. (2004). “Neural signals for the detection of unintentional race bias.” Psychol Sci 15(2): 88-93.

We examined the hypothesis that unintentional race-biased responses may occur despite the activation of neural systems that detect the need for control. Participants completed a sequential priming task that induced race-biased responses on certain trials while electroencephalography was recorded. The error-related negativity (ERN) wave, a component of the event-related potential with an anterior cingulate generator, was assessed to index neural signals detecting the need for control. Responses attributed to race bias produced larger ERNs than responses not attributed to race bias. Although race-biased responses were prevalent across participants, those with larger ERNs to race-biased responses showed higher levels of control throughout the task (e.g., greater accuracy and slowed responding following errors). The results indicate that race-biased responses may be made despite the activation of neural systems designed to detect bias and to recruit controlled processing.

 

Amodio, D. M., et al. (2006). “Alternative mechanisms for regulating racial responses according to internal vs external cues.” Soc Cogn Affect Neurosci 1(1): 26-36.

Personal (internal) and normative (external) impetuses for regulating racially biased behaviour are well-documented, yet the extent to which internally and externally driven regulatory processes arise from the same mechanism is unknown. Whereas the regulation of race bias according to internal cues has been associated with conflict-monitoring processes and activation of the dorsal anterior cingulate cortex (dACC), we proposed that responses regulated according to external cues to respond without prejudice involves mechanisms of error-perception, a process associated with rostral anterior cingulate cortex (rACC) activity. We recruited low-prejudice participants who reported high or low sensitivity to non-prejudiced norms, and participants completed a stereotype inhibition task in private or public while electroencephalography was recorded. Analysis of event-related potentials revealed that the error-related negativity component, linked to dACC activity, predicted behavioural control of bias across conditions, whereas the error-perception component, linked to rACC activity, predicted control only in public among participants sensitive to external pressures to respond without prejudice.

 

Amodio, D. M. and J. K. Swencionis (2018). “Proactive control of implicit bias: A theoretical model and implications for behavior change.” J Pers Soc Psychol 115(2): 255-275.

Four experiments examined the effect of proactive control on expressions of implicit racial bias. Whereas reactive control is engaged in response to a biasing influence (e.g., a stereotype, temptation, or distraction), proactive control is engaged in advance of such biases, functioning to strengthen task focus and, by consequence, limiting the affordance for a bias to be expressed in behavior. Using manipulations of response interference to modulate proactive control, proactive control was found to eliminate expressions of weapons bias, prejudice, and stereotyping on commonly used implicit assessments. Process dissociation analysis indicated that this pattern reflected changes in controlled processing but not automatic associations, as theorized, and assessments of neural activity, using event-related potentials, revealed that proactive control reduces early attention to task-irrelevant racial cues while increasing focus on task-relevant responses. Together, these results provide initial evidence for proactive control in social cognition and demonstrate its effectiveness at reducing expressions of implicit racial bias. Based on these findings and past research, we present a model of proactive and reactive control that offers a novel and generative perspective on self-regulation and prejudice reduction. (PsycINFO Database Record

 

Arriola, K. J. (2017). “Race, Racism, and Access to Renal Transplantation among African Americans.” J Health Care Poor Underserved 28(1): 30-45.

There are clear and compelling racial disparities in access to renal transplant, which is the therapy of choice for many patients with end stage renal disease. This paper conceptualizes the role of racism (i.e., internalized, personally-mediated, and institutionalized) in creating and perpetuating these disparities at multiple levels of the social ecology by integrating two often-cited theories in the literature. Internalized racism is manifested at the intrapersonal level when, for example, African American patients devalue their self-worth, thereby not pursuing the most aggressive treatment available. Personally-mediated racism is manifested at the interpersonal level when, for example, physicians exhibit unconscious race bias that impacts their treatment decisions. One example of institutionalized racism being manifested at the institutional, community, and public policy levels is the longstanding existence of racial residential segregation and empirically established links between neighborhood racial composition and dialysis facility-level transplantation rates. This paper concludes with clinical, research, and policy recommendations.

 

Avenanti, A., et al. (2010). “Racial bias reduces empathic sensorimotor resonance with other-race pain.” Curr Biol 20(11): 1018-1022.

Although social psychology studies suggest that racism often manifests itself as a lack of empathy, i.e., the ability to share and comprehend others’ feelings and intentions, evidence for differential empathic reactivity to the pain of same- or different-race individuals is meager. Using transcranial magnetic stimulation, we explored sensorimotor empathic brain responses in black and white individuals who exhibited implicit but not explicit ingroup preference and race-specific autonomic reactivity. We found that observing the pain of ingroup models inhibited the onlookers’ corticospinal system as if they were feeling the pain. Both black and white individuals exhibited empathic reactivity also when viewing the pain of stranger, very unfamiliar, violet-hand models. By contrast, no vicarious mapping of the pain of individuals culturally marked as outgroup members on the basis of their skin color was found. Importantly, group-specific lack of empathic reactivity was higher in the onlookers who exhibited stronger implicit racial bias. These results indicate that human beings react empathically to the pain of stranger individuals. However, racial bias and stereotypes may change this reactivity into a group-specific lack of sensorimotor resonance.

 

Azevedo, R. T., et al. (2013). “Their pain is not our pain: brain and autonomic correlates of empathic resonance with the pain of same and different race individuals.” Hum Brain Mapp 34(12): 3168-3181.

Recent advances in social neuroscience research have unveiled the neurophysiological correlates of race and intergroup processing. However, little is known about the neural mechanisms underlying intergroup empathy. Combining event-related fMRI with measurements of pupil dilation as an index of autonomic reactivity, we explored how race and group membership affect empathy-related responses. White and Black subjects were presented with video clips depicting white, black, and unfamiliar violet-skinned hands being either painfully penetrated by a syringe or being touched by a Q-tip. Both hemodynamic activity within areas known to be involved in the processing of first and third-person emotional experiences of pain, i.e., bilateral anterior insula, and autonomic reactivity were greater for the pain experienced by own-race compared to that of other-race and violet models. Interestingly, greater implicit racial bias predicted increased activity within the left anterior insula during the observation of own-race pain relative to other-race pain. Our findings highlight the close link between group-based segregation and empathic processing. Moreover, they demonstrate the relative influence of culturally acquired implicit attitudes and perceived similarity/familiarity with the target in shaping emotional responses to others’ physical pain.

 

Azevedo, R. T., et al. (2014). “Weighing the stigma of weight: An fMRI study of neural reactivity to the pain of obese individuals.” Neuroimage 91: 109-119.

Explicit negative attitudes and blameful beliefs (e.g. poor diet, laziness) towards obese individuals are well documented and are pervasive even among health professionals. Here we sought to determine whether obesity stigma is reflected in a fundamental feature of intersubjectivity namely the automatic neural resonance with others’ affective experiences. During fMRI, normal-weight female participants observed short clips depicting normal-weight (NW) and obese (Ob) models experiencing pain. Importantly, participants believed that half of the Ob were overweight due to a hormonal disorder (HormOb) and ignored the cause of obesity of the remaining models (Unknown obese models; UnkOb). Analyses of hemodynamic responses showed reduced activity to the pain of Ob compared to that of NW in areas associated with pain processing and early visual processing. The comparison between the two Ob conditions revealed a further decrease of activity to HormOb’s pain compared to UnkOb’s (and NW) pain in the right inferior frontal gyrus, an area associated with emotional resonance. Our study demonstrates that stigma for obese individuals can be observed at implicit levels, and that it is modulated by knowledge concerning the etiology of obesity, with the seemingly surprising result that obesity due to disease may result in greater stigmatization. Moreover, the perceived similarity with the models and the ambivalent emotion of pity may index biased brain responses to obese individuals’ pain. The study highlights a possibly important neural link between resonance with the pain of others and obesity stigma.

 

Back, A. L. and R. M. Arnold (2013). “”Isn’t there anything more you can do?”: When empathic statements work, and when they don’t.” J Palliat Med 16(11): 1429-1432.

The query, “Isn’t there anything more you can do?” represents a classic informational question with an emotional subtext. In our previous work we have emphasized the value of noticing the emotional cue implicit in this question, and responding with an empathic statement. Yet responding explicitly to patients’ emotions is not the best initial communication strategy for all patients. In this paper we discuss four different opening communication strategies–verbalize empathy, exchange information, contain chaos, respect searching–for patients who ask, “Isn’t there anything more you can do?”

 

Bailey, A. H., et al. (2018). “Is Man the Measure of All Things? A Social Cognitive Account of Androcentrism.” Pers Soc Psychol Rev: 1088868318782848.

Androcentrism refers to the propensity to center society around men and men’s needs, priorities, and values and to relegate women to the periphery. Androcentrism also positions men as the gender-neutral standard while marking women as gender-specific. Examples of androcentrism include the use of male terms (e.g., he), images, and research participants to represent everyone. Androcentrism has been shown to have serious consequences. For example, women’s health has been adversely affected by over-generalized medical research based solely on male participants. Nonetheless, relatively little is known about androcentrism’s proximate psychological causes. In the present review, we propose a social cognitive perspective arguing that both social power and categorization processes are integral to understanding androcentrism. We present and evaluate three possible pathways to androcentrism deriving from (a) men being more frequently instantiated than women, (b) masculinity being more “ideal” than femininity, and/or

 

Berlingeri, M., et al. (2016). “Guess who’s coming to dinner: Brain signatures of racially biased and politically correct behaviors.” Neuroscience 332: 231-241.

The ability to share feelings with those of someone in pain is affected by the racial difference between the target and the onlooker. A differential empathic activation for race (DEAR effect) in favor of in-group members has been documented in the brain pain matrix. However, we are also capable of unbiased responses that manifest politically correct behaviors toward people of a different race. To address the neurofunctional signatures underlying both the DEAR effect and the manifestation of politically correct behaviors, we scanned with fMRI Caucasian participants while watching African or Caucasian actors touched by either a rubber eraser or a needle. Participants were instructed to empathize with the actors during the video presentation (stimulus phase) and to explicitly judge the pain level experienced by the actors (response phase). During the stimulus phase, we found a typical DEAR effect within the pain-matrix. This effect correlated with the level of implicit racial bias as measured by the IAT. On the other hand, during the response phase a significant out-group specific DEAR effect emerged in the prefrontal cortices. This latter effect was coupled with a revealing behavioral pattern: while the magnitude of the painful experience attributed to Caucasians and Africans was the same, our participants were significantly slower when judging the pain experience of the African actors. We propose a model that logically integrates these two contrasting forces at the neurobiological and behavioral level.

 

Blair, I. V., et al. (2013). “Clinicians’ implicit ethnic/racial bias and perceptions of care among Black and Latino patients.” Ann Fam Med 11(1): 43-52.

PURPOSE: We investigated whether clinicians’ explicit and implicit ethnic/racial bias is related to black and Latino patients’ perceptions of their care in established clinical relationships. METHODS: We administered a telephone survey to 2,908 patients, stratified by ethnicity/race, and randomly selected from the patient panels of 134 clinicians who had previously completed tests of explicit and implicit ethnic/racial bias. Patients completed the Primary Care Assessment Survey, which addressed their clinicians’ interpersonal treatment, communication, trust, and contextual knowledge. We created a composite measure of patient-centered care from the 4 subscales. RESULTS: Levels of explicit bias were low among clinicians and unrelated to patients’ perceptions. Levels of implicit bias varied among clinicians, and those with greater implicit bias were rated lower in patient-centered care by their black patients as compared with a reference group of white patients (P = .04). Latino patients gave the clinicians lower ratings than did other groups (P <.0001), and this did not depend on the clinicians’ implicit bias (P = .98). CONCLUSIONS: This is among the first studies to investigate clinicians’ implicit bias and communication processes in ongoing clinical relationships. Our findings suggest that clinicians’ implicit bias may jeopardize their clinical relationships with black patients, which could have negative effects on other care processes. As such, this finding supports the Institute of Medicine’s suggestion that clinician bias may contribute to health disparities. Latinos’ overall greater concerns about their clinicians appear to be based on aspects of care other than clinician bias.

 

Blair, I. V., et al. (2014). “An investigation of associations between clinicians’ ethnic or racial bias and hypertension treatment, medication adherence and blood pressure control.” J Gen Intern Med 29(7): 987-995.

BACKGROUND: Few studies have directly investigated the association of clinicians’ implicit (unconscious) bias with health care disparities in clinical settings. OBJECTIVE: To determine if clinicians’ implicit ethnic or racial bias is associated with processes and outcomes of treatment for hypertension among black and Latino patients, relative to white patients. RESEARCH DESIGN AND PARTICIPANTS: Primary care clinicians completed Implicit Association Tests of ethnic and racial bias. Electronic medical records were queried for a stratified, random sample of the clinicians’ black, Latino and white patients to assess treatment intensification, adherence and control of hypertension. Multilevel random coefficient models assessed the associations between clinicians’ implicit biases and ethnic or racial differences in hypertension care and outcomes. MAIN MEASURES: Standard measures of treatment intensification and medication adherence were calculated from pharmacy refills. Hypertension control was assessed by the percentage of time that patients met blood pressure goals recorded during primary care visits. KEY RESULTS: One hundred and thirty-eight primary care clinicians and 4,794 patients with hypertension participated. Black patients received equivalent treatment intensification, but had lower medication adherence and worse hypertension control than white patients; Latino patients received equivalent treatment intensification and had similar hypertension control, but lower medication adherence than white patients. Differences in treatment intensification, medication adherence and hypertension control were unrelated to clinician implicit bias for black patients (P = 0.85, P = 0.06 and P = 0.31, respectively) and for Latino patients (P = 0.55, P = 0.40 and P = 0.79, respectively). An increase in clinician bias from average to strong was associated with a relative change of less than 5 % in all outcomes for black and Latino patients. CONCLUSIONS: Implicit bias did not affect clinicians’ provision of care to their minority patients, nor did it affect the patients’ outcomes. The identification of health care contexts in which bias does not impact outcomes can assist both patients and clinicians in their efforts to build trust and partnership.

 

Blair, I. V., et al. (2011). “Unconscious (implicit) bias and health disparities: where do we go from here?” Perm J 15(2): 71-78.

Disparities in health care are of great concern, with much attention focused on the potential for unconscious (implicit) bias to play a role in this problem. Some initial studies have been conducted, but the empirical research has lagged. This article provides a research roadmap that spans investigations of the presence of implicit bias in health care settings, identification of mechanisms through which implicit bias operates, and interventions that may prevent or ameliorate its effects. The goal of the roadmap is to expand and revitalize efforts to understand implicit bias and, ultimately, eliminate health disparities. Concrete suggestions are offered for individuals in different roles, including clinicians, researchers, policymakers, patients, and community members.

 

Bowen Matthew, D. (2015). “Toward a Structural Theory of Implicit Racial and Ethnic Bias in Health Care.” Health Matrix Clevel 25: 61-85.

 

Brown, C. E., et al. (2016). “Inadequate Palliative Care in Chronic Lung Disease. An Issue of Health Care Inequality.” Ann Am Thorac Soc 13(3): 311-316.

Patients with chronic lung diseases suffer higher symptom burden, lower quality of life, and greater social isolation compared with patients with other diagnoses, such as cancer. These conditions may be alleviated by palliative care, yet palliative care is used less by patients with chronic lung disease compared with patients with cancer. Underuse is due, in part, to poor implementation of primary palliative care and inadequate referral to specialty palliative care. Lack of primary and specialty palliative care in patients with chronic lung disease falls short of the minimum standard of competent health care, and represents a disparity in health care and a social injustice. We invoke the ethical principles of justice and sufficiency to highlight the importance of this issue. We identify five barriers to implementing palliative care in patients with chronic lung disease: uncertainty in prognosis; lack of provider skill to engage in discussions about palliative care; fear of using opioids among patients with chronic lung disease; fear of diminishing hope; and perceived and implicit bias against patients with smoking-related lung diseases. We propose mechanisms for improving implementation of palliative care for patients with chronic lung disease with the goal of enhancing justice in health care.

 

Buchs, S. and K. Mulitalo (2016). “Implicit Bias: An Opportunity for Physician Assistants to Mindfully Reduce Health Care Disparities.” J Physician Assist Educ 27(4): 193-195.

 

Bucknor-Ferron, P. and L. Zagaja (2016). “Five strategies to combat unconscious bias.” Nursing 46(11): 61-62.

 

Bucknor, A., et al. (2018). “Gender Inequality for Women in Plastic Surgery: A Systematic Scoping Review.” Plast Reconstr Surg 141(6): 1561-1577.

BACKGROUND: Previous research has highlighted the gender-based disparities present throughout the field of surgery. This study aims to evaluate the breadth of the issues facing women in plastic surgery, worldwide. METHODS: A systematic scoping review was undertaken from October of 2016 to January of 2017, with no restrictions on date or language. A narrative synthesis of the literature according to themed issues was developed, together with a summary of relevant numeric data. RESULTS: From the 2247 articles identified, 55 articles were included in the analysis. The majority of articles were published from the United States. Eight themes were identified, as follows: (1) workforce figures; (2) gender bias and discrimination; (3) leadership and academia; (4) mentorship and role models; (5) pregnancy, parenting, and childcare; (6) relationships, work-life balance, and professional satisfaction; (7) patient/public preference; and (8) retirement and financial planning. Despite improvement in numbers over time, women plastic surgeons continue to be underrepresented in the United States, Canada, and Europe, with prevalence ranging from 14 to 25.7 percent. Academic plastic surgeons are less frequently female than male, and women academic plastic surgeons score less favorably when outcomes of academic success are evaluated. Finally, there has been a shift away from overt discrimination toward a more ingrained, implicit bias, and most published cases of bias and discrimination are in association with pregnancy. CONCLUSIONS: The first step toward addressing the issues facing women plastic surgeons is recognition and articulation of the issues. Further research may focus on analyzing geographic variation in the issues and developing appropriate interventions.

 

Burgess, D., et al. (2007). “Reducing racial bias among health care providers: lessons from social-cognitive psychology.” J Gen Intern Med 22(6): 882-887.

The paper sets forth a set of evidence-based recommendations for interventions to combat unintentional bias among health care providers, drawing upon theory and research in social cognitive psychology. Our primary aim is to provide a framework that outlines strategies and skills, which can be taught to medical trainees and practicing physicians, to prevent unconscious racial attitudes and stereotypes from negatively influencing the course and outcomes of clinical encounters. These strategies and skills are designed to: 1) enhance internal motivation to reduce bias, while avoiding external pressure; 2) increase understanding about the psychological basis of bias; 3) enhance providers’ confidence in their ability to successfully interact with socially dissimilar patients; 4) enhance emotional regulation skills; and 5) improve the ability to build partnerships with patients. We emphasize the need for programs to provide a nonthreatening environment in which to practice new skills and the need to avoid making providers ashamed of having racial, ethnic, or cultural stereotypes. These recommendations are also intended to provide a springboard for research on interventions to reduce unintentional racial bias in health care.

 

Burgess, D. J., et al. (2017). “Mindfulness practice: A promising approach to reducing the effects of clinician implicit bias on patients.” Patient Educ Couns 100(2): 372-376.

Like the population at large, health care providers hold implicit racial and ethnic biases that may contribute to health care disparities. Little progress has been made in identifying and implementing effective strategies to address these normal but potentially harmful unconscious cognitive processes. We propose that meditation training designed to increase healthcare providers’ mindfulness skills is a promising and potentially sustainable way to address this problem. Emerging evidence suggests that mindfulness practice can reduce the provider contribution to healthcare disparities through several mechanisms including: reducing the likelihood that implicit biases will be activated in the mind, increasing providers’ awareness of and ability to control responses to implicit biases once activated, increasing self-compassion and compassion toward patients, and reducing internal sources of cognitive load (e.g., stress, burnout, and compassion fatigue). Mindfulness training may also have advantages over current approaches to addressing implicit bias because it focuses on the development of skills through practice, promotes a nonjudgmental approach, can circumvent resistance some providers feel when directly confronted with evidence of racism, and constitutes a holistic approach to promoting providers’ well-being. We close with suggestions for how a mindfulness approach can be practically implemented and identify potential challenges and research gaps to be addressed.

 

Burke, S. E., et al. (2017). “Beyond Generalized Sexual Prejudice: Need for Closure Predicts Negative Attitudes Toward Bisexual People Relative to Gay/Lesbian People.” J Exp Soc Psychol 71: 145-150.

Increasing evidence suggests that bisexual people are sometimes evaluated more negatively than heterosexual and gay/lesbian people. A common theoretical account for this discrepancy argues that bisexuality is perceived by some as introducing ambiguity into a binary model of sexuality. The present brief report tests a single key prediction of this theory, that evaluations of bisexual people have a unique relationship with Need for Closure (NFC), a dispositional preference for simple ways of structuring information. Participants (n=3406) were heterosexual medical students from a stratified random sample of 49 U.S. medical schools. As in prior research, bisexual targets were evaluated slightly more negatively than gay/lesbian targets overall. More importantly for the present investigation, higher levels of NFC predicted negative evaluations of bisexual people after accounting for negative evaluations of gay/lesbian people, and higher levels of NFC also predicted an explicit evaluative preference for gay/lesbian people over bisexual people. These results suggest that differences in evaluations of sexual minority groups partially reflect different psychological processes, and that NFC may have a special relevance for bisexual targets even beyond its general association with prejudice. The practical value of testing this theory on new physicians is also discussed.

 

Burke, S. E., et al. (2015). “Do Contact and Empathy Mitigate Bias Against Gay and Lesbian People Among Heterosexual First-Year Medical Students? A Report From the Medical Student CHANGE Study.” Acad Med 90(5): 645-651.

PURPOSE: A recent Institute of Medicine report concluded that lesbian and gay individuals face discrimination from health care providers and called for research on provider attitudes. Medical school is a critical juncture for improving future providers’ treatment of sexual minorities. This study examined both explicit bias and implicit bias against lesbian women and gay men among first-year medical students, focusing on two predictors of such bias, contact and empathy. METHOD: This study included the 4,441 heterosexual first-year medical students who participated in the baseline survey of the Medical Student Cognitive Habits and Growth Evaluation Study, which employed a stratified random sample of 49 U.S. medical schools in fall 2010. The researchers measured explicit attitudes toward gay and lesbian people using feeling thermometer self-assessments, implicit attitudes using the Implicit Association Test, amount and favorability of contact using self-report items, and empathy using subscales of the Interpersonal Reactivity Index. RESULTS: Nearly half (45.79%; 956/2,088) of respondents with complete data on both bias measures expressed at least some explicit bias, and most (81.51%; 1,702/2,088) exhibited at least some implicit bias against gay and lesbian individuals. Both amount and favorability of contact predicted positive implicit and explicit attitudes. Both cognitive and emotional empathy predicted positive explicit attitudes, but not implicit attitudes. CONCLUSIONS: The prevalence of negative attitudes presents an important challenge for medical education, highlighting the need for more research on possible causes of bias. Findings on contact and empathy point to possible curriculum-based interventions aimed at ensuring high-quality care for sexual minorities.

 

Cassidy, B. S. and A. C. Krendl (2016). “Dynamic neural mechanisms underlie race disparities in social cognition.” Neuroimage 132: 238-246.

Race disparities in behavior may emerge in several ways, some of which may be independent of implicit bias. To mitigate the pernicious effects of different race disparities for racial minorities, we must understand whether they are rooted in perceptual, affective, or cognitive processing with regard to race perception. We used fMRI to disentangle dynamic neural mechanisms predictive of two separable race disparities that can be obtained from a trustworthiness ratings task. Increased coupling between regions involved in perceptual and affective processing when viewing Black versus White faces predicted less later racial trust disparity, which was related to implicit bias. In contrast, increased functional coupling between regions involved in controlled processing predicted less later disparity in the differentiation of Black versus White faces with regard to perceived trust, which was unrelated to bias. These findings reveal that distinct neural signatures underlie separable race disparities in social cognition that may or may not be related to implicit bias.

 

Catmur, C., et al. (2016). “Avatars and arrows in the brain.” Neuroimage 132: 8-10.

In this Commentary article we critically assess the claims made by Schurz, Kronbichler, Weissengrubler, Surtees, Samson and Perner (2015) relating to the neural processes underlying theory of mind and visual perspective taking. They attempt to integrate research findings in these two areas of social neuroscience using a perspective taking task contrasting mentalistic agents (‘avatars’), with non-mentalistic control stimuli (‘arrows’), during functional Magnetic Resonance Imaging. We support this endeavour whole-heartedly, agreeing that the integration of findings in these areas has been neglected in research on the social brain. However, we cannot find among the behavioural or neuroimaging data presented by Schurz et al. evidence supporting their claim of ‘implicit mentalizing’-the automatic ascription of mental states to another representing what they can see. Indeed, we suggest that neuroimaging methods may be ill-suited to address the existence of implicit mentalizing, and suggest that approaches utilizing neurostimulation methods are likely to be more successful.

 

Chae, D. H., et al. (2012). “Implicit racial bias as a moderator of the association between racial discrimination and hypertension: a study of Midlife African American men.” Psychosom Med 74(9): 961-964.

OBJECTIVES: Empirical findings on racial discrimination and hypertension risk have been inconsistent. Some studies have found no association between self-reported experiences of discrimination and cardiovascular health outcomes, whereas others have found moderated or curvilinear relationships. The current cross-sectional study examined whether the association between racial discrimination and hypertension is moderated by implicit racial bias among African American midlife men. METHODS: This study examined the data on 91 African American men between 30 and 50 years of age. Primary variables were self-reported experiences of racial discrimination and unconscious racial bias as measured by the Black-White Implicit Association Test. Modified Poisson regression models were specified, examining hypertension, defined as a mean resting systolic level of at least 140 mm Hg or diastolic level of at least 90 mm Hg, or self-reported history of cardiovascular medication use with a physician diagnosis of hypertension. RESULTS: No main effects for discrimination or implicit racial bias were found, but the interaction of the two variables was significantly related to hypertension (chi(2)(1) = 4.89, p < .05). Among participants with an implicit antiblack bias, more frequent reports of discrimination were associated with a higher probability of hypertension, whereas among those with an implicit problack bias, it was associated with lower risk. CONCLUSIONS: The combination of experiencing racial discrimination and holding an antiblack bias may have particularly detrimental consequences on hypertension among African American midlife men, whereas holding an implicit problack bias may buffer the effects of racial discrimination. Efforts to address both internalized racial bias and racial discrimination may lower cardiovascular risk in this population.

 

Chapman, E. N., et al. (2013). “Physicians and implicit bias: how doctors may unwittingly perpetuate health care disparities.” J Gen Intern Med 28(11): 1504-1510.

Although the medical profession strives for equal treatment of all patients, disparities in health care are prevalent. Cultural stereotypes may not be consciously endorsed, but their mere existence influences how information about an individual is processed and leads to unintended biases in decision-making, so called “implicit bias”. All of society is susceptible to these biases, including physicians. Research suggests that implicit bias may contribute to health care disparities by shaping physician behavior and producing differences in medical treatment along the lines of race, ethnicity, gender or other characteristics. We review the origins of implicit bias, cite research documenting the existence of implicit bias among physicians, and describe studies that demonstrate implicit bias in clinical decision-making. We then present the bias-reducing strategies of consciously taking patients’ perspectives and intentionally focusing on individual patients’ information apart from their social group. We conclude that the contribution of implicit bias to health care disparities could decrease if all physicians acknowledged their susceptibility to it, and deliberately practiced perspective-taking and individuation when providing patient care. We further conclude that increasing the number of African American/Black physicians could reduce the impact of implicit bias on health care disparities because they exhibit significantly less implicit race bias.

 

Chapman, M. V., et al. (2018). “Making a difference in medical trainees’ attitudes toward Latino patients: A pilot study of an intervention to modify implicit and explicit attitudes.” Soc Sci Med 199: 202-208.

Negative attitudes and discrimination against Latinos exist in the dominant U.S. culture and in healthcare systems, contributing to ongoing health disparities. This article provides findings of a pilot test of Yo Veo Salud (I See Health), an intervention designed to positively modify attitudes toward Latinos among medical trainees. The research question was: Compared to the comparison group, did the intervention group show lower levels of implicit bias against Latinos versus Whites, and higher levels of ethnocultural empathy, healthcare empathy, and patient-centeredness? We used a sequential cohort, post-test design to evaluate Yo Veo Salud with a sample of 69 medical trainees. The intervention setting was an academic medical institution in a Southeastern U.S. state with a fast-growing Latino population. The intervention was delivered, and data were collected online, between July and December of 2014. Participants in the intervention group showed greater ethnocultural empathy, healthcare empathy, and patient-centeredness, compared to the comparison group. The implicit measure assessed four attitudinal dimensions (pleasantness, responsibility, compliance, and safety). Comparisons between our intervention and comparison groups did not find any average differences in implicit anti-Latino bias between the groups. However, in a subset analysis of White participants, White participants in the intervention group demonstrated a significantly decreased level of implicit bias in terms of pleasantness. A dose response was also founded indicating that participants involved in more parts of the intervention showed more change on all measures. Our findings, while modest in size, provide proof of concept for Yo Veo Salud as a means for increasing ethno-cultural and physician empathy, and patient-centeredness among medical residents and decreasing implicit provider bias toward Latinos.

 

Chiesa, P. A., et al. (2017). “Brain activity induced by implicit processing of others’ pain and pleasure.” Hum Brain Mapp 38(11): 5562-5576.

Studies indicate that both explicit and implicit processing of affectively charged stimuli may be reflected in specific behavioural markers and physiological signatures. Here, we investigated whether the pleasantness ratings of a neutral target were affected by the subliminal perception of a painful (a slap) or pleasant (a caress) touch delivered to others. In particular, we combined the continuous flash suppression technique with the affective misattribution procedure to explore subliminal processing of observed pain and pleasure in others. Results show that participants rated the neutral target as more or less likeable depending on whether they were subliminally primed with the pleasant or painful facial expression, respectively. The fMRI activity associated with painful and pleasant subliminal priming was mainly present in the anterior prefrontal cortex and the primary sensorimotor cortex, respectively. Thus, our study provides behavioural and neuro-physiological evidence that: (i) emotional reactivity toward positive or negative states of others can occur at an entirely subliminal level; (ii) specific neural substrates underpin reactivity to positive- and negative-valence of social emotions. Hum Brain Mapp 38:5562-5576, 2017. (c) 2017 Wiley Periodicals, Inc.

 

Clementz, L., et al. (2017). “Starting With Lucy: Focusing on Human Similarities Rather Than Differences to Address Health Care Disparities.” Acad Med 92(9): 1259-1263.

PROBLEM: Multicultural or cultural competence education to address health care disparities using the traditional categorical approach can lead to inadvertent adverse consequences. Nontraditional approaches that address these drawbacks while promoting humanistic care are needed. APPROACH: In September 2014, the Cleveland VA Medical Center’s Center of Excellence in Primary Care Education Transforming Outpatient Care (CoEPCE-TOPC) collaborated with the Cleveland Museum of Natural History (CMNH) to develop the Original Identity program, which uses a biocultural anthropologic framework to help learners recognize and address unconscious bias and starts with a discussion of humans’ shared origins. The program comprises a two-hour initial learning session at the CMNH (consisting of an educational tour in a museum exhibit, a didactic and discussion section, and patient case studies) and a one-hour wrap-up session at the Louis Stokes Cleveland VA Medical Center. OUTCOMES: The authors delivered the complete Original Identity program four times between March and November 2015, with 30 CoEPCE-TOPC learners participating. Learners’ mean ratings (n = 29; response rate: 97%) for the three initial learning session questions were consistently high (4.2-4.6) using a five-point scale. Comments to an open-ended question and during the audio-recorded wrap-up sessions also addressed the program objectives and key elements (e.g., bias, assumptions, stereotyping). NEXT STEPS: The authors are completing additional qualitative analysis on the wrap-up session transcriptions to clarify factors that make the program successful, details of learners’ experience, and any interprofessional differences in interpreting content. The authors believe this innovative addition to health care education warrants further research.

 

Contreras-Huerta, L. S., et al. (2013). “Racial bias in neural empathic responses to pain.” PLoS One 8(12): e84001.

Recent studies have shown that perceiving the pain of others activates brain regions in the observer associated with both somatosensory and affective-motivational aspects of pain, principally involving regions of the anterior cingulate and anterior insula cortex. The degree of these empathic neural responses is modulated by racial bias, such that stronger neural activation is elicited by observing pain in people of the same racial group compared with people of another racial group. The aim of the present study was to examine whether a more general social group category, other than race, could similarly modulate neural empathic responses and perhaps account for the apparent racial bias reported in previous studies. Using a minimal group paradigm, we assigned participants to one of two mixed-race teams. We use the term race to refer to the Chinese or Caucasian appearance of faces and whether the ethnic group represented was the same or different from the appearance of the participant’ own face. Using fMRI, we measured neural empathic responses as participants observed members of their own group or other group, and members of their own race or other race, receiving either painful or non-painful touch. Participants showed clear group biases, with no significant effect of race, on behavioral measures of implicit (affective priming) and explicit group identification. Neural responses to observed pain in the anterior cingulate cortex, insula cortex, and somatosensory areas showed significantly greater activation when observing pain in own-race compared with other-race individuals, with no significant effect of minimal groups. These results suggest that racial bias in neural empathic responses is not influenced by minimal forms of group categorization, despite the clear association participants showed with in-group more than out-group members. We suggest that race may be an automatic and unconscious mechanism that drives the initial neural responses to observed pain in others.

 

Conway, J. R., et al. (2017). “Submentalizing or mentalizing in a Level 1 perspective-taking task: A cloak and goggles test.” J Exp Psychol Hum Percept Perform 43(3): 454-465.

It has been proposed that humans possess an automatic system to represent mental states (‘implicit mentalizing’). The existence of an implicit mentalizing system has generated considerable debate however, centered on the ability of various experimental paradigms to demonstrate unambiguously such mentalizing. Evidence for implicit mentalizing has previously been provided by the ‘dot perspective task,’ where participants are slower to verify the number of dots they can see when an avatar can see a different number of dots. However, recent evidence challenged a mentalizing interpretation of this effect by showing it was unaltered when the avatar was replaced with an inanimate arrow stimulus. Here we present an extension of the dot perspective task using an invisibility cloaking device to render the dots invisible on certain trials. This paradigm is capable of providing unambiguous evidence of automatic mentalizing, but no such evidence was found. Two further well-powered experiments used opaque and transparent goggles to manipulate visibility but found no evidence of automatic mentalizing, nor of individual differences in empathy or perspective-taking predicting performance, contradicting previous studies using the same design. The results cast doubt on the existence of an implicit mentalizing system, suggesting that previous effects were due to domain-general processes. (PsycINFO Database Record

 

Culyer, A. J. and Y. Bombard (2012). “An equity framework for health technology assessments.” Med Decis Making 32(3): 428-441.

Despite the inclusion of equity in the design of many health care systems, pragmatic tools for considering equity systematically, alongside the efficiency categories of cost-effectiveness in health technology assessment (HTA), remain underdeveloped. This article develops a framework to help decision makers supplement the standard efficiency criteria of HTA and avoid building inequities, explicit or implicit, into their methods. The framework is intended as a first step toward creating a checklist for alerting decision makers to a wide range of equity considerations for HTA. This framework is intended be used as part of the process through which advisory bodies receive their terms of reference; scope the agenda prior to the selection of a candidate intervention and its comparators for HTA; prepare background briefing for decision makers; and help to structure the discussion and composition of professional and lay advisory groups during the assessment process. The framework is offered as only a beginning of an ongoing process of deliberation and consultation, through which the matters covered can be expected to become more comprehensive and the record of past decisions and their contexts in any jurisdiction adopting the tool can serve to guide subsequent evidence gathering and decisions. In these ways, it may be hoped that equity will be more systematically and fully considered and implemented in both the procedures and decisions of HTA.

 

Daugherty, S. L., et al. (2017). “Implicit Gender Bias and the Use of Cardiovascular Tests Among Cardiologists.” J Am Heart Assoc 6(12).

BACKGROUND: Physicians’ gender bias may contribute to gender disparities in cardiovascular testing. We used the Implicit Association Test to examine the association of implicit gender biases with decisions to use cardiovascular tests. METHODS AND RESULTS: In 2014, cardiologists completed Implicit Association Tests and a clinical vignette with patient gender randomly assigned. The Implicit Association Tests measured implicit gender bias for the characteristics of strength and risk taking. The vignette represented an intermediate likelihood of coronary artery disease regardless of patient gender: chest pain (part 1) followed by an abnormal exercise treadmill test (part 2). Cardiologists rated the likelihood of coronary artery disease and the usefulness of stress testing and angiography for the assigned patient. Of the 503 respondents (9.3% of eligible; 87% male, median age of 45 years, 58% in private practice), the majority associated strength or risk taking implicitly with male more than female patients. The estimated likelihood of coronary artery disease for both parts of the vignette was similar by patient gender. The utility of secondary stress testing after an abnormal exercise treadmill test was rated as “high” more often for female than male patients (32.8% versus 24.3%, P=0.04); this difference did not vary with implicit bias. Angiography was more consistently rated as having “high” utility for male versus female patients (part 1: 19.7% versus 9.8%; part 2: 73.7% versus 64.3%; P<0.05 for both); this difference was larger for cardiologists with higher implicit gender bias on risk taking (P=0.01). CONCLUSIONS: Cardiologists have varying degrees of implicit gender bias. This bias explained some, but not all, of the gender variability in simulated clinical decision-making for suspected coronary artery disease.

 

Deegan, M. P., et al. (2015). “Positive expectations encourage generalization from a positive intergroup interaction to outgroup attitudes.” Pers Soc Psychol Bull 41(1): 52-65.

The current research reveals that while positive expectations about an anticipated intergroup interaction encourage generalization of positive contact to outgroup attitudes, negative expectations restrict the effects of contact on outgroup attitudes. In Study 1, when Blacks and Whites interacted with positive expectations, interaction quality predicted outgroup attitudes to a greater degree than when groups interacted with negative expectations. When expectations (Studies 2 and 3) and the actual interaction quality (Study 4) were manipulated orthogonally, negative expectations about the interaction predicted negative outgroup attitudes, regardless of actual interaction quality. By contrast, participants holding positive expectations who experienced a positive interaction expressed positive outgroup attitudes, whereas when they experienced a negative interaction, they expressed outgroup attitudes as negative as those with negative expectations. Across all four studies, positive expectations encouraged developing outgroup attitudes consistent with interaction quality.

 

Dehon, E., et al. (2017). “A Systematic Review of the Impact of Physician Implicit Racial Bias on Clinical Decision Making.” Acad Emerg Med 24(8): 895-904.

OBJECTIVES: Disparities in diagnosis and treatment of racial minorities exist in the emergency department (ED). A better understanding of how physician implicit (unconscious) bias contributes to these disparities may help identify ways to eliminate such racial disparities. The objective of this systematic review was to examine and summarize the evidence on the association between physician implicit racial bias and clinical decision making. METHODS: Based on PRISMA guidelines, a structured electronic literature search of PubMed, CINAHL, Scopus, and PsycINFO databases was conducted. Eligible studies were those that: 1) included physicians, 2) included the Implicit Association Test as a measure of implicit bias, 3) included an assessment of physician clinical decision making, and 4) were published in peer-reviewed journals between 1998 and 2016. Articles were reviewed for inclusion by two independent investigators. Data extraction was performed by one investigator and checked for accuracy by a second investigator. Two investigators independently scored the quality of articles using a modified version of the Downs and Black checklist. RESULTS: Of the 1,154 unique articles identified in the initial search, nine studies (n = 1,910) met inclusion criteria. Three of the nine studies involved emergency providers including residents, attending physicians, and advanced practice providers. The majority of studies used clinical vignettes to examine clinical decision making. Studies that included emergency medicine (EM) providers had vignettes relating to treatment of acute myocardial infarction, pain, and pediatric asthma. An implicit preference favoring white people was common across providers, regardless of specialty. Two of the nine studies found evidence of a relationship between implicit bias and clinical decision making; one of these studies included EM providers. This one study found that EM and internal medicine residents who demonstrated an implicit preference for white individuals were more likely to treat white patients and not black patients with thrombolysis for myocardial infarction. Evidence from the two studies reporting a relationship between physician implicit racial bias and decision making was low in quality. CONCLUSIONS: The current literature indicates that although many physicians, regardless of specialty, demonstrate an implicit preference for white people, this bias does not appear to impact their clinical decision making. Further studies on the impact of implicit racial bias on racial disparities in ED treatment are needed.

 

Diamond, D. (2008). “Empathy and identification in Von Donnersmarck’s The Lives of Others.” J Am Psychoanal Assoc 56(3): 811-832.

Florian Henckel von Donnersmarck’s The Lives of Others, set in the German Democratic Republic in 1984, five years before the fall of the Berlin Wall, has been called the first accurate depiction of the psychological terror wielded by the Stasi, the East German secret police, who safeguarded the dictatorship of the proletariat. The film is about the psychological and political transformation of a Stasi officer, Wiesler, who undertakes the surveillance of a prominent playwright and his actress lover. The mechanisms through which Wiesler comes to empathize and identify with the subjects of his investigation, as he observes and listens in on the rich blend of passion, poetry, and politics that characterizes their lives, are explored in depth. Wiesler’s transformation is based in part on the capacity to form implicit models of the behavior and experiences of others, based on the mirror neuron system, that Gallese and his colleagues call “embodied simulation.” Underpinning the processes of empathy and identification so central to this film, embodied simulation is an unconscious and prereflexive mechanism through which the actions, emotions, and sensations we observe activate internal representations of the bodily and mental states of the other. Embodied simulation also expands our understanding of the power of the primal scene, which has long been identified as a major organizer of unconscious fantasies and conflicts throughout life, and which forms the central metaphor of the film. Embodied simulation scaffolds our aesthetic response to art, music, and literature, underlies the dynamics of spectatorship, and potentially catalyzes resistance to totalitarian mass movements.

 

Ditlmann, R. K., et al. (2017). “The implicit power motive in intergroup dialogues about the history of slavery.” J Pers Soc Psychol 112(1): 116-135.

This research demonstrates that individual differences in the implicit power motive (i.e., the concern with impact, influence, and control) moderate how African Americans communicate with White Americans in challenging intergroup dialogues. In a study with African American participants we find that the higher their implicit power motive, the more they use an affiliation strategy to communicate with a White American partner in a conversation context that evokes the history of slavery (Study 1). In a study with White American participants we find that, in the same conversation context, they are more engaged (i.e., open, attentive, and motivated) if they receive an affiliation message rather than a no-affiliation message from an African American partner (Study 2). In interracial dyads we find that African American participants’ implicit power motives moderate how much they intend to signal warmth to a White American discussion partner, how much they display immediacy behaviors and use affiliation imagery in the discussion, and with what level of engagement White American participants respond (Study 3). High but not low implicit power African Americans thus employ a communication strategy-expressing affiliation and warmth-that can be effective for engaging White Americans with uncomfortable, race-identity-relevant topics. (PsycINFO Database Record

 

Does, S., et al. (2018). “Implications of research staff demographics for psychological science.” Am Psychol 73(5): 639-650.

Long-standing research traditions in psychology have established the fundamental impact of social categories, such as race and gender, on people’s perceptions of themselves and others, as well as on general human cognition and behavior. However, there is a general tendency to ignore research staff demographics (e.g., researchers’ race and gender) in research development and research reports. Variation in research staff demographics can exert systematic and scientifically informative influences on results from psychological research. Consequently, research staff demographics need to be considered, studied, and/or reported, along with how these demographics were allowed to vary across participants or conditions (e.g., random assignment, matched with participant demographics, or included as a factor in the experimental design). In addition to providing an overview of multidisciplinary evidence of research staff demographics effects, it is discussed how research staff demographics might influence research findings through (a) ingroup versus outgroup effects, (b) stereotype and (implicit) bias effects, and (c) priming and social tuning effects. Finally, an overview of recommended considerations is included (see Appendix) to help illustrate how to systematically incorporate relevant research staff demographics in psychological science. (PsycINFO Database Record

 

Dovidio, J. F. (2009). “Psychology. Racial bias, unspoken but heard.” Science 326(5960): 1641-1642.

 

Dovidio, J. F. (2013). “Bridging intragroup processes and intergroup relations: needing the twain to meet.” Br J Soc Psychol 52(1): 1-24.

Despite their shared focus on groups, research bridging intragroup processes and intergroup relations is surprisingly rare. The goal of the present article is to highlight how understanding the reciprocal relationship between intragroup processes and intergroup relations offers valuable new insights into both topics and suggests new, productive avenues for research and theory development – particularly for understanding and improving intergroup relations. The article next briefly reviews key findings from three dominant frameworks in the field of intergroup relations: social cognition, social identity, and functional relations. It then discusses the complementary role of intergroup and intragroup dynamics, reviewing how intergroup relations can affect intragroup processes and then discussing how intragroup dynamics can shape intergroup relations. The final section considers the implications, theoretical and practical, of the proposed reciprocal relationships between intragroup and intergroup processes.

 

Dovidio, J. F., et al. (1988). “The relationship of social power to visual displays of dominance between men and women.” J Pers Soc Psychol 54(2): 233-242.

Two studies, with undergraduate subjects, investigated how sex and situation-specific power factors relate to visual behavior in mixed-sex interactions. The power variable in Study 1 was expert power, based on differential knowledge. Mixed-sex dyads were formed such that members had complementary areas of expertise. In Study 2, reward power was manipulated. Consistent with expectation states theory, both men and women high in expertise or reward power displayed high visual dominance, defined as the ratio of looking while speaking to looking while listening. Specifically, men and women high in expertise or reward power exhibited equivalent levels of looking while speaking and looking while listening. High visual dominance ratios have been associated with high social power in previous research. Both men and women low in expertise or reward power looked more while listening than while speaking, producing a relatively low visual dominance ratio. In conditions in which men and women did not possess differential expertise or reward power, visual behavior was related to sex. Men displayed visual behavior similar to their patterns in the high expertise and high reward power conditions, whereas women exhibited visual behavior similar to their patterns in the low expertise and low reward power conditions. The results demonstrate how social expectations are reflected in nonverbal power displays.

 

Dovidio, J. F. and S. T. Fiske (2012). “Under the radar: how unexamined biases in decision-making processes in clinical interactions can contribute to health care disparities.” Am J Public Health 102(5): 945-952.

Several aspects of social psychological science shed light on how unexamined racial/ethnic biases contribute to health care disparities. Biases are complex but systematic, differing by racial/ethnic group and not limited to love-hate polarities. Group images on the universal social cognitive dimensions of competence and warmth determine the content of each group’s overall stereotype, distinct emotional prejudices (pity, envy, disgust, pride), and discriminatory tendencies. These biases are often unconscious and occur despite the best intentions. Such ambivalent and automatic biases can influence medical decisions and interactions, systematically producing discrimination in health care and ultimately disparities in health. Understanding how these processes may contribute to bias in health care can help guide interventions to address racial and ethnic disparities in health.

 

Dovidio, J. F., et al. (2002). “Why can’t we just get along? Interpersonal biases and interracial distrust.” Cultur Divers Ethnic Minor Psychol 8(2): 88-102.

The authors review a series of studies that illustrate how one form of contemporary racial bias of Whites, aversive racism, can shape different perspectives of Blacks and Whites in ways that can undermine race relations. This research demonstrates that contemporary racism among Whites is subtle, often unintentional, and unconscious but that its effects are systematically damaging to race relations by fostering miscommunication and distrust. In particular, the authors examine the effects of aversive racism on outcomes for Blacks (e.g., in selection decisions), on the ways that Whites behave in interracial interactions, in the impressions that Whites and Blacks form of each other in these interactions, and on the task efficiency of interracial dyads.

 

Dovidio, J. F., et al. (2009). “Commonality and the complexity of “we”: social attitudes and social change.” Pers Soc Psychol Rev 13(1): 3-20.

The present article explores the complex role of collective identities in the development of intergroup biases and disparities, in interventions to improve orientations toward members of other groups, and in inhibiting or facilitating social action. The article revolves around the common ingroup identity model, examining general empirical support but also acknowledging potential limitations and emphasizing new insights and extensions. It proposes that the motivations of majority group members to preserve a system that advantages them and the motivations of minority group members to enhance their status have direct implications for preferred group representations and consequent intergroup relations. In particular, the effects of majority group members’ preferences for a common, one-group identity and minority group members’ preference for a dual identity (in which differences are acknowledged within the context of a superordinate identity) are considered in terms of intergroup attitudes, recognition of unfair disparities, and support for social action.

 

Dovidio, J. F., et al. (1998). “Intergroup bias: status, differentiation, and a common in-group identity.” J Pers Soc Psychol 75(1): 109-120.

The present research examined factors that moderate and mediate the reduction of intergroup bias. Two 3-person laboratory groups, which had first worked separately on a task, were informed prior to intergroup contact that (a) the groups were equal or unequal in status based on their task performance, and (b) they had been working on the same or on different task dimensions. Consistent with M. Hewstone and R. J. Brown’s (1986) mutual intergroup differentiation model, bias was eliminated when the groups’ areas of expertise were differentiated and equally valued (i.e., in the equal status-different dimensions conditions). Moreover, as expected on the basis of the common in-group identity model, more inclusive group representations mediated this effect. The findings of the present research thus offer a theoretical integration that can suggest interventions to facilitate positive intergroup contact.

 

Dovidio, J. F., et al. (1997). “Extending the Benefits of Recategorization: Evaluations, Self-Disclosure, and Helping.” J Exp Soc Psychol 33(4): 401-420.

The Common Ingroup Identity Model proposes that if members of different groups conceive of themselves more as a single group rather than as two separate groups, intergroup bias will be reduced through processes involving pro-ingroup favoritism. The present research extended work on this model by investigating the effects of recategorization on intergroup behavior, specifically helping and self-disclosure, as well as evaluations. Participants first worked as members of two three-person groups, and then the two groups interacted under conditions designed to enhance a two-group representation or recategorization with an inclusive one-group representation. As expected, the manipulation of the intergroup contact situation that created stronger impressions of one group reduced intergroup bias in evaluations, self-disclosure, and helping. Furthermore, ratings of the extent to which the six participants felt like one group mediated the reduction in bias, particularly for evaluative bias. Conditions facilitating the generalization of the benefits of recategorization to group members not present and to other groups are considered.

 

Dovidio, J. F., et al. (2002). “Implicit and explicit prejudice and interracial interaction.” J Pers Soc Psychol 82(1): 62-68.

The present research examined how implicit racial associations and explicit racial attitudes of Whites relate to behaviors and impressions in interracial interactions. Specifically, the authors examined how response latency and self-report measures predicted bias and perceptions of bias in verbal and nonverbal behavior exhibited by Whites while they interacted with a Black partner. As predicted, Whites’ self-reported racial attitudes significantly predicted bias in their verbal behavior to Black relative to White confederates. Furthermore, these explicit attitudes predicted how much friendlier Whites felt that they behaved toward White than Black partners. In contrast, the response latency measure significantly predicted Whites’ nonverbal friendliness and the extent to which the confederates and observers perceived bias in the participants’ friendliness.

 

Dovidio, J. F. and W. N. Morris (1975). “Effects of stress and commonality of fate on helping behavior.” J Pers Soc Psychol 31(1): 145-149.

An experiment was performed in order to examine the joint effects of stress and commonality of fate on helping behavior. In a 2 times 2 factorial design, subjects were randomly assigned to one of four conditions in which (a) the subject and a confederate are both awaiting an experiment involving electric shock (high stress-common fate); (b) the subject is awaiting an experiment involving electric shock while the confederate is awaiting an innocuous word association experiment (high stress-dissimilar fate); (c) the subject is awaiting the word association experiment while the confederate awaits shock (low stress-dissimilar fate); and (d) the subject and the confederate are both awaiting an innocuous word association experiment (low stress-common fate). As predicted, a significant interaction, p less than .01, was obtained, indicating that high stress, as compared to low stress, facilitates helping if the potential recipient is in the same stressful situation but inhibits helping if the potential recipient is in a dissimilar and less stressful situation.

 

Dovidio, J. F., et al. (2008). “Disparities and distrust: the implications of psychological processes for understanding racial disparities in health and health care.” Soc Sci Med 67(3): 478-486.

This paper explores the role of racial bias toward Blacks in interracial relations, and in racial disparities in health care in the United States. Our analyses of these issues focuses primarily on studies of prejudice published in the past 10 years and on health disparity research published since the report of the US Institute of Medicine (IOM) Panel on Racial and Ethnic Disparities in Health Care in 2003. Recent social psychological research reveals that racial biases occur implicitly, without intention or awareness, as well as explicitly, and these implicit biases have implications for understanding how interracial interactions frequently produce mistrust. We further illustrate how this perspective can illuminate and integrate findings from research on disparities and biases in health care, addressing the orientations of both providers and patients. We conclude by considering future directions for research and intervention.

 

Dovidio, J. F., et al. (2004). “Perspective and prejudice: antecedents and mediating mechanisms.” Pers Soc Psychol Bull 30(12): 1537-1549.

The present work investigated mechanisms by which Whites’ prejudice toward Blacks can be reduced (Study 1) and explored how creating a common ingroup identity can reduce prejudice by promoting these processes (Study 2). In Study 1, White participants who viewed a videotape depicting examples of racial discrimination and who imagined the victim’s feelings showed greater decreases in prejudice toward Blacks than did those in the objective and no instruction conditions. Among the potential mediating affective and cognitive variables examined, reductions in prejudice were mediated primarily by feelings associated with perceived injustice. In Study 2, an intervention designed to increase perceptions of a common group identity before viewing the videotape, reading that a terrorist threat was directed at all Americans versus directed just at White Americans, also reduced prejudice toward Blacks through increases in feelings of injustice.

 

Drewniak, D., et al. (2017). “Do attitudes and behavior of health care professionals exacerbate health care disparities among immigrant and ethnic minority groups? An integrative literature review.” Int J Nurs Stud 70: 89-98.

OBJECTIVES: Recent investigations of ethnicity related disparities in health care have focused on the contribution of providers’ implicit biases. A significant effect on health care outcomes is suggested, but the results are mixed. The purpose of this integrative literature review is to provide an overview and synthesize the current empirical research on the potential influence of health care professionals’ attitudes and behaviors towards ethnic minority patients on health care disparities. DESIGN: Integrative literature review. DATA SOURCES: Four internet-based literature indexes – MedLine, PsychInfo, Sociological Abstracts and Web of Science – were searched for articles published between 1982 and 2012 discussing health care professionals’ attitudes or behaviors towards ethnic minority patients. REVIEW METHODS: Thematic analysis was used to synthesize the relevant findings. RESULTS: We found 47 studies from 12 countries. Six potential barriers to health care for ethnic minorities were identified that may be related to health care professionals’ attitudes or behaviors: Biases, stereotypes and prejudices; Language and communication barriers; Cultural misunderstandings; Gate-keeping; Statistical discrimination; Specific challenges of delivering care to undocumented migrants. CONCLUSIONS: Data on health care professionals’ attitudes or behaviors are both limited and inconsistent. We thus provide reflections on methods, conceptualization, interpretation and the importance of the geographical or socio-political settings of potential studies. More empirical data is needed, especially on health care professionals’ attitudes or behaviors towards (irregular) migrant patients.

 

Dunagan, P. B., et al. (2016). “Baccalaureate Nursing Students’ Attitudes of Prejudice: A Qualitative Inquiry.” J Nurs Educ 55(6): 345-348.

BACKGROUND: Attitudes of prejudice in nursing students have the potential to impact patient care and ultimately may contribute to culturally based health disparities. The purpose of this study was to describe attitudes of prejudice reported by baccalaureate nursing students. METHOD: Baccalaureate nursing students were recruited through Web networking and e-mailing. Participants responded to a Web-based survey that contained an open-ended item requesting them to describe a time when they held an attitude of prejudice. Qualitative data were coded and analyzed for themes. RESULTS: The majority of participants (N = 50) were women (86%) and White (68%). Qualitative data analysis revealed two major themes: Prejudice Against Obese Individuals, and Prejudice Against Someone of Another Race. Many of the participants had insight that prejudice was wrong and they wanted to change. CONCLUSION: Acknowledging prejudice, as an explicit bias, is an important step toward cultural competence. Teaching strategies focused on addressing explicit and implicit bias are warranted. [J Nurs Educ. 2016;55(6):345-348.].

 

Earnshaw, V. A., et al. (2013). “Stigma and racial/ethnic HIV disparities: moving toward resilience.” Am Psychol 68(4): 225-236.

Prior research suggests that stigma plays a role in racial/ethnic health disparities. However, there is limited understanding about the mechanisms by which stigma contributes to HIV-related disparities in risk, incidence and screening, treatment, and survival and what can be done to reduce the impact of stigma on these disparities. We introduce the Stigma and HIV Disparities Model to describe how societal stigma related to race and ethnicity is associated with racial/ethnic HIV disparities via its manifestations at the structural level (e.g., residential segregation) as well as the individual level among perceivers (e.g., discrimination) and targets (e.g., internalized stigma). We then review evidence of these associations. Because racial/ethnic minorities at risk of and living with HIV often possess multiple stigmas (e.g., HIV-positive, substance use), we adopt an intersectionality framework and conceptualize interdependence among co-occurring stigmas. We further propose a resilience agenda and suggest that intervening on modifiable strength-based moderators of the association between societal stigma and disparities can reduce disparities. Strengthening economic and community empowerment and trust at the structural level, creating common ingroup identities and promoting contact with people living with HIV among perceivers at the individual level, and enhancing social support and adaptive coping among targets at the individual level can improve resilience to societal stigma and ultimately reduce racial/ethnic HIV disparities.

 

Edwards, D. J., et al. (2017). “The Impact of Mindfulness and Perspective-Taking on Implicit Associations Toward the Elderly: a Relational Frame Theory Account.” Mindfulness (N Y) 8(6): 1615-1622.

Perspective-taking interventions have been shown to improve attitudes toward social outgroups. In contrast, similar interventions have produced opposite effects (i.e., enhanced negativity) in the context of attitudes toward elderly groups. The current study investigated whether a brief perspective-taking intervention enhanced with mindfulness would be associated with less negativity than perspective-taking alone. One hundred five participants were randomly assigned to 1 of 4 conditions which comprised of an active or control perspective-taking component and an active or control mindfulness component. Participants were then administered an Implicit Associated Test to assess implicit biases toward the elderly. Results supported previous findings in that the condition in which perspective-taking was active but mindfulness was inactive was associated with greater negative implicit bias toward the elderly; however, some of this negativity decreased in the active perspective-taking and active mindfulness condition. The current findings and other mixed effects that have emerged from perspective-taking interventions are discussed from a Relational Frame Theory perspective.

 

Elias, C. M., et al. (2017). “The social and behavioral influences (SBI) study: study design and rationale for studying the effects of race and activation on cancer pain management.” BMC Cancer 17(1): 575.

BACKGROUND: Racial disparities exist in the care provided to advanced cancer patients. This article describes an investigation designed to advance the science of healthcare disparities by isolating the effects of patient race and patient activation on physician behavior using novel standardized patient (SP) methodology. METHODS/DESIGN: The Social and Behavioral Influences (SBI) Study is a National Cancer Institute sponsored trial conducted in Western New York State, Northern/Central Indiana, and lower Michigan. The trial uses an incomplete randomized block design, randomizing physicians to see patients who are either black or white and who are “typical” or “activated” (e.g., ask questions, express opinions, ask for clarification, etc.). The study will enroll 91 physicians. DISCUSSION: The SBI study addresses important gaps in our knowledge about racial disparities and methods to reduce them in patients with advanced cancer by using standardized patient methodology. This study is innovative in aims, design, and methodology and will point the way to interventions that can reduce racial disparities and discrimination and draw links between implicit attitudes and physician behaviors. TRIAL REGISTRATION: https://clinicaltrials.gov/ , #NCT01501006, November 30, 2011.

 

Epstein, R. A. (2005). “Disparities and discrimination in health care coverage: a critique of the Institute of Medicine study.” Perspect Biol Med 48(1 Suppl): S26-41.

The 2003 Institute of Medicine (IOM) study on Unequal Treatment takes the strong position that many of the current disparities in health care by race are attributable to forms of conscious and unconscious discrimination by health care providers. The study, however, is flawed by imprecise definitions of discrimination that fail to distinguish between differences in treatment due to breakdown in communications and differences in the treated population that are prompted by invidious motives of health care providers. It is doubtful that hidden forms of discrimination are prevalent in a profession whose professional norms are set so strongly against it. In addition, the IOM relies too uncritically on similar studies in unrelated fields to show the ostensible forms of discrimination. These errors have adverse social consequences. A false diagnosis of discrimination where none exists will send a false signal to members of racial minorities that may induce them to avoid receiving needed medical care and instead pursue costly and ineffective remedial devices that will take away funds better spent on providing direct health care.

 

Estudillo, A. J. and M. Bindemann (2016). “Multisensory stimulation with other-race faces and the reduction of racial prejudice.” Conscious Cogn 42: 325-339.

This study investigated whether multisensory stimulation with other-race faces can reduce racial prejudice. In three experiments, the faces of Caucasian observers were stroked with a cotton bud while they watched a black face being stroked in synchrony on a computer screen. This was compared with a neutral condition, in which no tactile stimulation was administered (Experiment 1 and 2), and with a condition in which observers’ faces were stroked in asynchrony with the onscreen face (Experiment 3). In all experiments, observers experienced an enfacement illusion after synchronous stimulation, whereby they reported to embody the other-race face. However, this effect did not produce concurrent changes in implicit or explicit racial prejudice. This outcome contrasts with other procedures for the reduction of self-other differences that decrease racial prejudice, such as behavioural mimicry and intergroup contact. We speculate that enfacement is less effective for such prejudice reduction because it does not encourage perspective-taking.

 

Fabi, S. and H. Leuthold (2018). “Racial bias in empathy: Do we process dark- and fair-colored hands in pain differently? An EEG study.” Neuropsychologia 114: 143-157.

The aim of this study was to identify racial bias influences on empathic processing from early stimulus encoding, over categorization until late motor processing stages by comparing brain responses (electroencephalogram) to pictures of fair- and dark-colored hands in painful or neutral daily-life situations. Participants performed a pain judgment task and a skin color judgment task. Event-related brain potentials (ERPs) substantiated former findings of automatic empathic influences on stimulus encoding, reflected by the early posterior negativity (EPN), and late controlled influences on the stimulus categorization, as reflected by the late posterior positivity (P3b). Concerning the racial bias in empathy (RBE) effect, more positive amplitudes in the 280-340ms time window over frontocentral electrodes in the painful than the neutral condition for fair- but not dark-colored hands speak for an early influence of racial bias. This was further supported by correlations with empathic concern scores for fair- but not dark-colored stimuli. Additionally, P3b amplitude differences between fair- and dark-colored hands to painful stimuli increased with the implicit racial attitude of participants, suggesting that the categorization stage is not completely immune to racial bias. Regarding the motor processing stages, power change values in the upper beta-band (19-30Hz) revealed for painful compared to neutral stimuli larger facilitation of sensorimotor activity before the response and larger inhibition after the response, independent of skin color. In conclusion, present findings speak for an influence of the RBE on early perceptual encoding but also on the late categorization stage that depends on the participant’s implicit attitude towards racial outgroups.

 

Fallin-Bennett, K. (2015). “Implicit bias against sexual minorities in medicine: cycles of professional influence and the role of the hidden curriculum.” Acad Med 90(5): 549-552.

Despite many recent advances in rights for sexual and gender minorities in the United States, bias against lesbian, gay, bisexual, and transgender (LGBT) people still exists. In this Commentary, the author briefly reviews disparities with regard to LGBT health, in both health care and medical education, and discusses the implications of Burke and colleagues’ study of implicit and explicit biases against lesbian and gay people among heterosexual first-year medical students, published in this issue of Academic Medicine. Emphasis is placed on the ways in which physicians’ implicit bias against LGBT people can create a cycle that perpetuates a professional climate reinforcing the bias. The hidden curriculum in academic health centers is discussed as both a cause of this cycle and as a starting point for a research and intervention agenda. The findings from Burke and colleagues’ study, as well as other evidence, support raising awareness of LGBT discrimination, increasing exposure to LGBT individuals as colleagues and role models in academic health centers, and modifying medical education curricula as methods to break the cycle of implicit bias in medicine.

 

Farrell, G. and P. Salmon (1989). “Caring expressions.” Nurs Stand 3(41): 23-24.

Nurses are increasingly being urged to show empathy to their patients and to dispense reassurance as readily as medicines. In addition, whether in surgery, medicine or psychiatry, they are being expected to assess their patients’ emotional needs as routinely as they have been required to assess their physical requirements. One attractive aspect of these developments for many nurses is that they emphasise the ‘human’ quality of nursing. Good nursing becomes, in large part, a matter of simply developing a good relationship with the patient, as an equal with him or her. In turn, it is sometimes claimed, many of these skills may not need to be taught; perhaps all that needs to be done is that nurses should be helped to act normally with their patients, and say or do the things that come ‘naturally’. The importance of skills acquisition then gives way to other concepts such as ‘facilitation’, ‘self-awareness training’, ‘experiential learning’. Students may even begin to take on the [illegibal word] implicit in these developments, that they do not need to be taught special skills by experts; they may come to see this as one area of nursing in which they can be their own teachers.

 

Fiscella, K. and M. R. Sanders (2016). “Racial and Ethnic Disparities in the Quality of Health Care.” Annu Rev Public Health 37: 375-394.

The annual National Healthcare Quality and Disparities Reports document widespread and persistent racial and ethnic disparities. These disparities result from complex interactions between patient factors related to social disadvantage, clinicians, and organizational and health care system factors. Separate and unequal systems of health care between states, between health care systems, and between clinicians constrain the resources that are available to meet the needs of disadvantaged groups, contribute to unequal outcomes, and reinforce implicit bias. Recent data suggest slow progress in many areas but have documented a few notable successes in eliminating these disparities. To eliminate these disparities, continued progress will require a collective national will to ensure health care equity through expanded health insurance coverage, support for primary care, and public accountability based on progress toward defined, time-limited objectives using evidence-based, sufficiently resourced, multilevel quality improvement strategies that engage patients, clinicians, health care organizations, and communities.

 

FitzGerald, C. and S. Hurst (2017). “Implicit bias in healthcare professionals: a systematic review.” BMC Med Ethics 18(1): 19.

BACKGROUND: Implicit biases involve associations outside conscious awareness that lead to a negative evaluation of a person on the basis of irrelevant characteristics such as race or gender. This review examines the evidence that healthcare professionals display implicit biases towards patients. METHODS: PubMed, PsychINFO, PsychARTICLE and CINAHL were searched for peer-reviewed articles published between 1st March 2003 and 31st March 2013. Two reviewers assessed the eligibility of the identified papers based on precise content and quality criteria. The references of eligible papers were examined to identify further eligible studies. RESULTS: Forty two articles were identified as eligible. Seventeen used an implicit measure (Implicit Association Test in fifteen and subliminal priming in two), to test the biases of healthcare professionals. Twenty five articles employed a between-subjects design, using vignettes to examine the influence of patient characteristics on healthcare professionals’ attitudes, diagnoses, and treatment decisions. The second method was included although it does not isolate implicit attitudes because it is recognised by psychologists who specialise in implicit cognition as a way of detecting the possible presence of implicit bias. Twenty seven studies examined racial/ethnic biases; ten other biases were investigated, including gender, age and weight. Thirty five articles found evidence of implicit bias in healthcare professionals; all the studies that investigated correlations found a significant positive relationship between level of implicit bias and lower quality of care. DISCUSSION: The evidence indicates that healthcare professionals exhibit the same levels of implicit bias as the wider population. The interactions between multiple patient characteristics and between healthcare professional and patient characteristics reveal the complexity of the phenomenon of implicit bias and its influence on clinician-patient interaction. The most convincing studies from our review are those that combine the IAT and a method measuring the quality of treatment in the actual world. Correlational evidence indicates that biases are likely to influence diagnosis and treatment decisions and levels of care in some circumstances and need to be further investigated. Our review also indicates that there may sometimes be a gap between the norm of impartiality and the extent to which it is embraced by healthcare professionals for some of the tested characteristics. CONCLUSIONS: Our findings highlight the need for the healthcare profession to address the role of implicit biases in disparities in healthcare. More research in actual care settings and a greater homogeneity in methods employed to test implicit biases in healthcare is needed.

 

Fogel, G. I. (1993). “A transitional phase in our understanding of the psychoanalytic process: a new look at Ferenczi and Rank.” J Am Psychoanal Assoc 41(2): 585-602.

In The Development of Psychoanalysis, Ferenczi and Rank (1922) demonstrate an important transitional phase in the conceptualization of the psychoanalytic process. It is not the archaic language of libidinal flow that separates their work from modern psychoanalysis, but their insistence on the ideal of the analysts’s objective authority, despite the implicitly more current interpersonal and structural understandings embedded in their sound principles of character analysis. Freud’s early theory presumed the possibility that an analyst could be an objective observer of forces entirely within the patient. Today’s theories must account for newer intrapsychic, interpersonal, and intersubjective realities–the analyst’s subjective experience as well as his observing functions. In the decade preceding the monograph, implicit developmental, structural, and object-relational understandings began to emerge. A concurrent dramatic but unacknowledged change in the meaning of the terms “psychic reality” and “intrapsychic” also occurred. The controversies surrounding the monograph predicted many lines of development and dialectics for future theoretical discourse. The subjects of countertransference and empathy, almost entirely absent in the monograph, became major fields of study, and focal points for divergent schools in the new struggle to define the necessary roles of the analyst’s interaction and subjective experience.

 

Forgiarini, M., et al. (2011). “Racism and the empathy for pain on our skin.” Front Psychol 2: 108.

Empathy is a critical function regulating human social life. In particular, empathy for pain is a source of deep emotional feelings and a strong trigger of pro-social behavior. We investigated the existence of a racial bias in the emotional reaction to other people’s pain and its link with implicit racist biases. Measuring participants’ physiological arousal, we found that Caucasian observers reacted to pain suffered by African people significantly less than to pain of Caucasian people. The reduced reaction to the pain of African individuals was also correlated with the observers’ individual implicit race bias. The role of others’ race in moderating empathic reactions is a crucial clue for understanding to what extent social interactions, and possibly integration, may be influenced by deeply rooted automatic and uncontrollable responses.

 

Fredericks, M., et al. (2011). “Chiropractic physicians: toward a select conceptual understanding of bureaucratic structures and functions in the health care institution.” J Chiropr Humanit 18(1): 64-73.

OBJECTIVE: The purpose of this article is to present select concepts and theories of bureaucratic structures and functions so that chiropractic physicians and other health care professionals can use them in their respective practices. The society-culture-personality model can be applied as an organizational instrument for assisting chiropractors in the diagnosis and treatment of their patients irrespective of locality. DISCUSSION: Society-culture-personality and social meaningful interaction are examined in relationship to the structural and functional aspects of bureaucracy within the health care institution of a society. Implicit in the examination of the health care bureaucratic structures and functions of a society is the focus that chiropractic physicians and chiropractic students learn how to integrate, synthesize, and actualize values and virtues such as empathy, integrity, excellence, diversity, compassion, caring, and understanding with a deep commitment to self-reflection. CONCLUSION: It is essential that future and current chiropractic physicians be aware of the structural and functional aspects of an organization so that chiropractic and other health care professionals are able to deliver care that involves the ingredients of quality, affordability, availability, accessibility, and continuity for their patients.

 

Freund, K. M., et al. (2016). “Inequities in Academic Compensation by Gender: A Follow-up to the National Faculty Survey Cohort Study.” Acad Med 91(8): 1068-1073.

PURPOSE: Cross-sectional studies have demonstrated gender differences in salaries within academic medicine. No research has assessed longitudinal compensation patterns. This study sought to assess longitudinal patterns by gender in compensation, and to understand factors associated with these differences in a longitudinal cohort. METHOD: A 17-year longitudinal follow-up of the National Faculty Survey was conducted with a random sample of faculty from 24 U.S. medical schools. Participants employed full-time at initial and follow-up time periods completed the survey. Annual pretax compensation during academic year 2012-2013 was compared by gender. Covariates assessed included race/ethnicity; years since first academic appointment; retention in academic career; academic rank; departmental affiliation; percent effort distribution across clinical, teaching, administrative, and research duties; marital and parental status; and any leave or part-time status in the years between surveys. RESULTS: In unadjusted analyses, women earned a mean of $20,520 less than men (P = .03); women made 90 cents for every dollar earned by their male counterparts. This difference was reduced to $16,982 (P = .04) after adjusting for covariates. The mean difference of $15,159 was no longer significant (P = .06) when adjusting covariates and for those who had ever taken a leave or worked part-time. CONCLUSIONS: The continued gender gap in compensation cannot be accounted for by metrics used to calculate salary. Institutional actions to address these disparities include both initial appointment and annual salary equity reviews, training of senior faculty and administrators to understand implicit bias, and training of women faculty in negotiating skills.

 

Furlanetto, T., et al. (2016). “Altercentric interference in level 1 visual perspective taking reflects the ascription of mental states, not submentalizing.” J Exp Psychol Hum Percept Perform 42(2): 158-163.

A growing body of work suggests that in some circumstances, humans may be capable of ascribing mental states to others in a way that is fast, cognitively efficient, and implicit (implicit mentalizing hypothesis). However, the interpretation of this work has recently been challenged by suggesting that the observed effects may reflect “submentalizing” effects of attention and memory, with no ascription of mental states (submentalizing hypothesis). The present study employed a strong test between these hypotheses by examining whether apparently automatic processing of another’s visual perspective is influenced by experience-dependent beliefs about whether that person can see. Altercentric interference was observed when participants judged their own perspective on stimuli involving an avatar wearing goggles that participants believed to be transparent but not when they believed the goggles to be opaque. These results are consistent with participants ascribing mental states to the avatar and not with the submentalizing hypothesis that altercentric interference arises merely because avatars cue shifts in spatial attention. (PsycINFO Database Record

 

Gabard, D. L., et al. (2013). “Analysis of empathy in Doctor of Physical Therapy students: a multi-site study.” J Allied Health 42(1): 10-16.

BACKGROUND: Empathy is a human emotion that is important in the effective provision of health care and amenable to change through explicit and implicit experiences in an individual’s life. This study measured levels of empathy in students pursuing doctoral degrees in physical therapy and compared the influence of professional education at different institutions on these levels. METHODS: Our cross-sectional, two-cohort, multisite study used a modified version of the Jefferson Scale of Physician Empathy, Student Version, to investigate empathy levels at enrollment, mid-curriculum, and end-of-curriculum. Statistical tests of differences were performed between institutions, within institutions for each cohort across the three time points, and within institutions between cohorts. Data were analyzed using descriptive statistics, ANOVA, and the least squared difference test. Alpha was set at 0.05 for main test of difference and 0.04 for all post-hoc tests. RESULTS: For both cohorts, empathy levels differed significantly between institutions at program entry (Cohort 1, p=0.0150; Cohort 2, p=0.0273); within institutions the two cohorts were similar at the beginning of the first semester. In Cohort 1, no significant changes occurred within any institution; students at the two institutions with higher entering scores maintained their higher scores at the end of the last didactic semester. Students in Cohort 2 showed significant differences in empathy levels at the end of the last didactic semester within and between institutions (p=0.0251; p<0.0001). CONCLUSIONS: Empathy levels may differ at enrollment for PT students at different institutions even with similar recruitment approaches and no significant differences in student demographics between institutions. Despite uniform accreditation requirements for curriculum content, significant differences between institutions did exist in the last didactic semester in Cohort 2 but not Cohort 1. The direction and magnitude of such changes were not explained by institutional characteristics. This study challenges assumptions that measurements of empathy in students at one institution can be generalized to students at other institutions and that one cohort in the same institution can predict another cohort.

 

Gaertner, S. L. and J. F. Dovidio (2008). “Addressing contemporary racism: the common ingroup identity model.” Nebr Symp Motiv 53: 111-133.

 

Gaertner, S. L., et al. (1999). “Reducing intergroup bias: elements of intergroup cooperation.” J Pers Soc Psychol 76(3): 388-402.

The authors examined the potentially separable contributions of 2 elements of intergroup cooperation, interaction and common fate, and the processes through which they can operate. The manipulation of interaction reduced bias in evaluative ratings, which supports the idea that these components are separable, whereas the manipulation of common fate when the groups were interacting was associated with lower bias in nonverbal facial reactions in response to contributions by in-group and out-group members. Whereas interaction activated several processes that can lead to reduced bias, including decategorization, consistent with the common in-group identity model (S. L. Gaertner, J. F. Dovidio, P. A. Anastasio, B. A. Bachman, & M. C. Rust, 1993) as well as M. Hewstone and R. J. Brown’s (1986) group differentiation model, the primary set of mediators involved participants’ representations of the memberships as 2 subgroups within a superordinate entity.

 

Galinsky, A. D. and G. B. Moskowitz (2000). “Perspective-taking: decreasing stereotype expression, stereotype accessibility, and in-group favoritism.” J Pers Soc Psychol 78(4): 708-724.

Using 3 experiments, the authors explored the role of perspective-taking in debiasing social thought. In the 1st 2 experiments, perspective-taking was contrasted with stereotype suppression as a possible strategy for achieving stereotype control. In Experiment 1, perspective-taking decreased stereotypic biases on both a conscious and a nonconscious task. In Experiment 2, perspective-taking led to both decreased stereotyping and increased overlap between representations of the self and representations of the elderly, suggesting activation and application of the self-concept in judgments of the elderly. In Experiment 3, perspective-taking reduced evidence of in-group bias in the minimal group paradigm by increasing evaluations of the out-group. The role of self-other overlap in producing prosocial outcomes and the separation of the conscious, explicit effects from the nonconscious, implicit effects of perspective-taking are discussed.

 

Galli, G., et al. (2015). “Don’t look at my wheelchair! The plasticity of longlasting prejudice.” Med Educ 49(12): 1239-1247.

CONTEXT: Scientific research has consistently shown that prejudicial behaviour may contribute to discrimination and disparities in social groups. However, little is known about whether and how implicit assumptions and direct contact modulate the interaction and quality of professional interventions in education and health contexts. OBJECTIVES: This study was designed to examine implicit and explicit attitudes towards wheelchair users. METHODS: We investigated implicit and explicit attitudes towards wheelchair users in three different groups: patients with traumatic spinal cord injury (SCI); health professionals with intense contact with wheelchair users, and healthy participants without personal contact with wheelchair users. To assess the short-term plasticity of prejudices, we used a valid intervention that aims to change implicit attitudes through brief direct contact with a patient who uses a wheelchair in an ecologically valid real-life interaction. RESULTS: We found that: (i) wheelchair users with SCI held positive explicit but negative implicit attitudes towards their novel in-group; (ii) the amount of experience with wheelchair users affected implicit attitudes among health professionals, and (iii) interacting with a patient with SCI who contradicts prejudices modulated implicit negative bias towards wheelchair users in healthy participants. CONCLUSIONS: The use of a wheelchair immediately and profoundly affects how a person is perceived. However, our findings highlight the dynamic nature of perceptions of social identity, which are not only sensitive to personal beliefs, but also highly permeable to intergroup interactions. Having direct contact with people with disabilities might foster positive attitudes in multidisciplinary health care teams. Such interventions could be integrated into medical education programmes to successfully prevent or reduce hidden biases in a new generation of health professionals and to increase the general acceptance of disability in patients.

 

Glasford, D. E., et al. (2009). “I continue to feel so good about us: in-group identification and the use of social identity–enhancing strategies to reduce intragroup dissonance.” Pers Soc Psychol Bull 35(4): 415-427.

The present research examined the relation between in-group identification and the use of social identity- enhancing strategies for dealing with the discomfort associated with inconsistency between personal beliefs and in-group behavior (intragroup dissonance). Consistent with the hypothesis that social identity-enhancing strategies would be more effective at reducing intragroup dissonance for those highly identified with the in-group, Experiment 1 demonstrated that level of group identification moderated the effectiveness of group affirmation for reducing psychological discomfort associated with intragroup dissonance, but not the effectiveness of self-affirmation. In Experiment 2, which manipulated level of group identification, participants in a high-identification condition, relative to those in a low-identification condition, were more likely to choose to reduce intragroup dissonance with a strategy that enhanced social identity (i.e., out-group derogation) over a strategy less effective at social identity enhancement (i.e., activism to change the behavior of the group). Implications for intergroup relations are discussed.

 

Gluszek, A. and J. F. Dovidio (2010). “The way they speak: a social psychological perspective on the stigma of nonnative accents in communication.” Pers Soc Psychol Rev 14(2): 214-237.

The present review seeks to bridge research on accents, stigma, and communication by examining the empirical literature on nonnative accents, considering the perspectives of both speakers and listeners. The authors suggest that an accent, or one’s manner of pronunciation, differs from other types of stigma. They consider the role of communicative processes in the manner in which accents influence people and identify social and contextual factors related to accents that affect the speaker, the listener, and the interaction between them. The authors propose a framework of stigma of accents and possible future avenues of research to examine the social psychological and communicative effects of accents. They also discuss implications for stigma of other types of accents (e.g., other native, regional, and ethnic). Understanding how stigma of accents and communication affect each other provides a new theoretical approach to studying this type of stigma and can eventually lead to interventions.

 

Gollust, S. E., et al. (2010). “Images of illness: how causal claims and racial associations influence public preferences toward diabetes research spending.” J Health Polit Policy Law 35(6): 921-959.

Despite the salience of health disparities in media and policy discourse, little previous research has investigated if imagery associating an illness with a certain racial group influences public perceptions. This study evaluated the influence of the media’s presentation of the causes of type 2 diabetes and its implicit racial associations on attitudes toward people with diabetes and preferences toward research spending. Survey participants who viewed an article on genetic causation or social determinants of diabetes were more likely to support increased government spending on research than those viewing an article with no causal language, while participants viewing an article on behavioral choices were more likely to attribute negative stereotypes to people with diabetes. Participants who viewed a photo of a black woman accompanying the article were less likely to endorse negative stereotypes than those viewing a photo of a white woman, but those who viewed a photo of a glucose-testing device expressed the lowest negative stereotypes. The effect of social determinants language was significantly different for blacks and whites, lowering stereotypes only among blacks. Emphasizing the behavioral causes of diabetes, as is common in media coverage, may perpetuate negative stereotypes. While drawing attention to the social determinants that shape these behaviors could mitigate stereotypes, this strategy is unlikely to influence the public uniformly.

 

Gomez, A., et al. (2013). “Responses to endorsement of commonality by ingroup and outgroup members: the roles of group representation and threat.” Pers Soc Psychol Bull 39(4): 419-431.

Two experiments integrated research on the roles of common identity and social norms in intergroup orientations. Experiment 1 demonstrated that learning that ingroup members categorized the ingroup (Spaniards) and outgroup (Eastern European immigrants) within a common identity (European) produced more positive intergroup orientations toward immigrants. By contrast, learning that outgroup members held the same position elicited less positive orientations compared with a condition in which the information came from a neutral source. The effects were mediated by one-group representations. Experiment 2 also found that endorsement of a common identity generated more positive intergroup orientations when it was expressed by ingroup than outgroup members and revealed how this effect may be sequentially mediated by personal one-group representations and symbolic threat.

 

Gomez, A., et al. (2008). “The other side of we: when outgroup members express common identity.” Pers Soc Psychol Bull 34(12): 1613-1626.

Previous research on the common ingroup identity model has focused on how one’s representations of members of the ingroup and outgroup influence intergroup attitudes. Two studies reported here investigated how learning how others, ingroup or outgroup members, conceive of the groups within a superordinate category affects intergroup bias and willingness to engage in intergroup contact. Across both studies, high school students who learned that other ingroup members categorized students at both schools within the common identity of “students” showed less intergroup bias in evaluations and greater willingness for contact. However, consistent with the hypothesized effects of identity threat, when participants read that outgroup members saw the groups within the superordinate category, they exhibited a relatively negative orientation, except when ingroup members also endorsed a superordinate identity (Study 1). This result occurred even when the relative status of the groups was manipulated (Study 2).

 

Gonzalez, C. M., et al. (2018). “Patient perspectives on racial and ethnic implicit bias in clinical encounters: Implications for curriculum development.” Patient Educ Couns 101(9): 1669-1675.

OBJECTIVE: Patients describe feelings of bias and prejudice in clinical encounters; however, their perspectives on restoring the encounter once bias is perceived are not known. Implicit bias has emerged as a target for curricular interventions. In order to inform the design of novel patient-centered curricular interventions, this study explores patients’ perceptions of bias, and suggestions for restoring relationships if bias is perceived. METHODS: The authors conducted bilingual focus groups with purposive sampling of self-identified Black and Latino community members in the US. Data were analyzed using grounded theory. RESULTS: Ten focus groups (in English (6) and Spanish (4)) with N=74 participants occurred. Data analysis revealed multiple influences patients’ perception of bias in their physician encounters. The theory emerging from the analysis suggests if bias is perceived, the outcome of the encounter can still be positive. A positive or negative outcome depends on whether the physician acknowledges this perceived bias or not, and his or her subsequent actions. CONCLUSIONS: Participant lived experience and physician behaviors influence perceptions of bias, however clinical relationships can be restored following perceived bias. PRACTICE IMPLICATIONS: Providers might benefit from skill development in the recognition and acknowledgement of perceived bias in order to restore patient-provider relationships.

 

Green, A. R., et al. (2007). “Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients.” J Gen Intern Med 22(9): 1231-1238.

CONTEXT: Studies documenting racial/ethnic disparities in health care frequently implicate physicians’ unconscious biases. No study to date has measured physicians’ unconscious racial bias to test whether this predicts physicians’ clinical decisions. OBJECTIVE: To test whether physicians show implicit race bias and whether the magnitude of such bias predicts thrombolysis recommendations for black and white patients with acute coronary syndromes. DESIGN, SETTING, AND PARTICIPANTS: An internet-based tool comprising a clinical vignette of a patient presenting to the emergency department with an acute coronary syndrome, followed by a questionnaire and three Implicit Association Tests (IATs). Study invitations were e-mailed to all internal medicine and emergency medicine residents at four academic medical centers in Atlanta and Boston; 287 completed the study, met inclusion criteria, and were randomized to either a black or white vignette patient. MAIN OUTCOME MEASURES: IAT scores (normal continuous variable) measuring physicians’ implicit race preference and perceptions of cooperativeness. Physicians’ attribution of symptoms to coronary artery disease for vignette patients with randomly assigned race, and their decisions about thrombolysis. Assessment of physicians’ explicit racial biases by questionnaire. RESULTS: Physicians reported no explicit preference for white versus black patients or differences in perceived cooperativeness. In contrast, IATs revealed implicit preference favoring white Americans (mean IAT score = 0.36, P < .001, one-sample t test) and implicit stereotypes of black Americans as less cooperative with medical procedures (mean IAT score 0.22, P < .001), and less cooperative generally (mean IAT score 0.30, P < .001). As physicians’ prowhite implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis (P = .009). CONCLUSIONS: This study represents the first evidence of unconscious (implicit) race bias among physicians, its dissociation from conscious (explicit) bias, and its predictive validity. Results suggest that physicians’ unconscious biases may contribute to racial/ethnic disparities in use of medical procedures such as thrombolysis for myocardial infarction.

 

Gutierrez, B., et al. (2014). “”Fair Play”: A Videogame Designed to Address Implicit Race Bias Through Active Perspective Taking.” Games Health J 3(6): 371-378.

OBJECTIVE: Having diverse faculty in academic health centers will help diversify the healthcare workforce and reduce health disparities. Implicit race bias is one factor that contributes to the underrepresentation of Black faculty. We designed the videogame “Fair Play” in which players assume the role of a Black graduate student named Jamal Davis. As Jamal, players experience subtle race bias while completing “quests” to obtain a science degree. We hypothesized that participants randomly assigned to play the game would have greater empathy for Jamal and lower implicit race bias than participants randomized to read narrative text describing Jamal’s experience. MATERIALS AND METHODS: University of Wisconsin-Madison graduate students were recruited via e-mail and randomly assigned to play “Fair Play” or read narrative text through an online link. Upon completion, participants took an Implicit Association Test to measure implicit bias and answered survey questions assessing empathy toward Jamal and awareness of bias. RESULTS: As hypothesized, gameplayers showed the least implicit bias but only when they also showed high empathy for Jamal (P=0.013). Gameplayers did not show greater empathy than text readers, and women in the text condition reported the greatest empathy for Jamal (P=0.008). However, high empathy only predicted lower levels of implicit bias among those who actively took Jamal’s perspective through gameplay (P=0.014). CONCLUSIONS: A videogame in which players experience subtle race bias as a Black graduate student has the potential to reduce implicit bias, possibly because of a game’s ability to foster empathy through active perspective taking.

 

Hagiwara, N., et al. (2016). “The effects of racial attitudes on affect and engagement in racially discordant medical interactions between non-Black physicians and Black patients.” Group Process Intergroup Relat 19(4): 509-527.

The association between physicians’ and patients’ racial attitudes and poorer patient-physician communication in racially discordant medical interactions is well-documented. However, it is unclear how physicians’ and patients’ racial attitudes independently and jointly affect their behaviors during these interactions. In a secondary analysis of video-recorded medical interactions between non-Black physicians and Black patients, we examined how physicians’ explicit and implicit racial bias and patients’ perceived past discrimination influenced their own as well as one another’s affect and level of engagement. Affect and engagement were assessed with a “thin slice” method. For physicians, the major findings were significant three-way interactions: physicians’ affect and engagement were influenced by their implicit and explicit racial bias (i.e., aversive racism), but only when they interacted with patients who reported any incidence of prior discrimination. In contrast, patients’ affect was influenced only by perceived discrimination. Theoretical and clinical implications of current findings are discussed.

 

Hagiwara, N., et al. (2013). “Racial attitudes, physician-patient talk time ratio, and adherence in racially discordant medical interactions.” Soc Sci Med 87: 123-131.

Physician racial bias and patient perceived discrimination have each been found to influence perceptions of and feelings about racially discordant medical interactions. However, to our knowledge, no studies have examined how they may simultaneously influence the dynamics of these interactions. This study examined how (a) non-Black primary care physicians’ explicit and implicit racial bias and (b) Black patients’ perceived past discrimination affected physician-patient talk time ratio (i.e., the ratio of physician to patient talk time) during medical interactions and the relationship between this ratio and patients’ subsequent adherence. We conducted a secondary analysis of self-report and video-recorded data from a prior study of clinical interactions between 112 low-income, Black patients and their 14 non-Black physicians at a primary care clinic in the Midwestern United States between June, 2006 and February, 2008. Overall, physicians talked more than patients; however, both physician bias and patient perceived past discrimination affected physician-patient talk time ratio. Non-Black physicians with higher levels of implicit, but not explicit, racial bias had larger physician-patient talk time ratios than did physicians with lower levels of implicit bias, indicating that physicians with more negative implicit racial attitudes talked more than physicians with less negative racial attitudes. Additionally, Black patients with higher levels of perceived discrimination had smaller physician-patient talk time ratios, indicating that patients with more negative racial attitudes talked more than patients with less negative racial attitudes. Finally, smaller physician-patient talk time ratios were associated with less patient subsequent adherence, indicating that patients who talked more during the racially discordant medical interactions were less likely to adhere subsequently. Theoretical and practical implications of these findings are discussed in the context of factors that affect the dynamics of racially discordant medical interactions.

 

Haider, A. H., et al. (2014). “Unconscious race and class bias: its association with decision making by trauma and acute care surgeons.” J Trauma Acute Care Surg 77(3): 409-416.

BACKGROUND: Recent studies have found that unconscious biases may influence physicians’ clinical decision making. The objective of our study was to determine, using clinical vignettes, if unconscious race and class biases exist specifically among trauma/acute care surgeons and, if so, whether those biases impact surgeons’ clinical decision making. METHODS: A prospective Web-based survey was administered to active members of the Eastern Association for the Surgery of Trauma. Participants completed nine clinical vignettes, each with three trauma/acute care surgery management questions. Race Implicit Association Test (IAT) and social class IAT assessments were completed by each participant. Multivariable, ordered logistic regression analysis was then used to determine whether implicit biases reflected on the IAT tests were associated with vignette responses. RESULTS: In total, 248 members of the Eastern Association for the Surgery of Trauma participated. Of these, 79% explicitly stated that they had no race preferences and 55% stated they had no social class preferences. However, 73.5% of the participants had IAT scores demonstrating an unconscious preference toward white persons; 90.7% demonstrated an implicit preference toward upper social class persons. Only 2 of 27 vignette-based clinical decisions were associated with patient race or social class on univariate analyses. Multivariable analyses revealed no relationship between IAT scores and vignette-based clinical assessments. CONCLUSION: Unconscious preferences for white and upper-class persons are prevalent among trauma and acute care surgeons. In this study, these biases were not statistically significantly associated with clinical decision making. Further study of the factors that may prevent implicit biases from influencing patient management is warranted. LEVEL OF EVIDENCE: Epidemiologic study, level II.

 

Haider, A. H., et al. (2015). “Unconscious race and social class bias among acute care surgical clinicians and clinical treatment decisions.” JAMA Surg 150(5): 457-464.

IMPORTANCE: Significant health inequities persist among minority and socially disadvantaged patients. Better understanding of how unconscious biases affect clinical decision making may help to illuminate clinicians’ roles in propagating disparities. OBJECTIVE: To determine whether clinicians’ unconscious race and/or social class biases correlate with patient management decisions. DESIGN, SETTING, AND PARTICIPANTS: We conducted a web-based survey among 230 physicians from surgery and related specialties at an academic, level I trauma center from December 1, 2011, through January 31, 2012. INTERVENTIONS: We administered clinical vignettes, each with 3 management questions. Eight vignettes assessed the relationship between unconscious bias and clinical decision making. We performed ordered logistic regression analysis on the Implicit Association Test (IAT) scores and used multivariable analysis to determine whether implicit bias was associated with the vignette responses. MAIN OUTCOMES AND MEASURES: Differential response times (D scores) on the IAT as a surrogate for unconscious bias. Patient management vignettes varied by patient race or social class. Resulting D scores were calculated for each management decision. RESULTS: In total, 215 clinicians were included and consisted of 74 attending surgeons, 32 fellows, 86 residents, 19 interns, and 4 physicians with an undetermined level of education. Specialties included surgery (32.1%), anesthesia (18.1%), emergency medicine (18.1%), orthopedics (7.9%), otolaryngology (7.0%), neurosurgery (7.0%), critical care (6.0%), and urology (2.8%); 1.9% did not report a departmental affiliation. Implicit race and social class biases were present in most respondents. Among all clinicians, mean IAT D scores for race and social class were 0.42 (95% CI, 0.37-0.48) and 0.71 (95% CI, 0.65-0.78), respectively. Race and class scores were similar across departments (general surgery, orthopedics, urology, etc), race, or age. Women demonstrated less bias concerning race (mean IAT D score, 0.39 [95% CI, 0.29-0.49]) and social class (mean IAT D score, 0.66 [95% CI, 0.57-0.75]) relative to men (mean IAT D scores, 0.44 [95% CI, 0.37-0.52] and 0.82 [95% CI, 0.75-0.89], respectively). In univariate analyses, we found an association between race/social class bias and 3 of 27 possible patient-care decisions. Multivariable analyses revealed no association between the IAT D scores and vignette-based clinical assessments. CONCLUSIONS AND RELEVANCE: Unconscious social class and race biases were not significantly associated with clinical decision making among acute care surgical clinicians. Further studies involving real physician-patient interactions may be warranted.

 

Haider, A. H., et al. (2015). “Unconscious Race and Class Biases among Registered Nurses: Vignette-Based Study Using Implicit Association Testing.” J Am Coll Surg 220(6): 1077-1086 e1073.

BACKGROUND: Implicit bias is an unconscious preference for a specific social group that can have adverse consequences for patient care. Acute care clinical vignettes were used to examine whether implicit race or class biases among registered nurses (RNs) impacted patient-management decisions. STUDY DESIGN: In a prospective study conducted among surgical RNs at the Johns Hopkins Hospital, participants were presented 8 multi-stage clinical vignettes in which patients’ race or social class were randomly altered. Registered nurses were administered implicit association tests (IATs) for social class and race. Ordered logistic regression was then used to examine associations among treatment differences, race, or social class, and RN’s IAT scores. Spearman’s rank coefficients comparing RN’s implicit (IAT) and explicit (stated) preferences were also investigated. RESULTS: Two hundred and forty-five RNs participated. The majority were female (n=217 [88.5%]) and white (n=203 [82.9%]). Most reported that they had no explicit race or class preferences (n=174 [71.0%] and n=108 [44.1%], respectively). However, only 36 nurses (14.7%) demonstrated no implicit race preference as measured by race IAT, and only 16 nurses (6.53%) displayed no implicit class preference on the class IAT. Implicit association tests scores did not statistically correlate with vignette-based clinical decision making. Spearman’s rank coefficients comparing implicit (IAT) and explicit preferences also demonstrated no statistically significant correlation (r=-0.06; p=0.340 and r=-0.06; p=0.342, respectively). CONCLUSIONS: The majority of RNs displayed implicit preferences toward white race and upper social class patients on IAT assessment. However, unlike published data on physicians, implicit biases among RNs did not correlate with clinical decision making.

 

Hall, W. J., et al. (2015). “Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review.” Am J Public Health 105(12): e60-76.

BACKGROUND: In the United States, people of color face disparities in access to health care, the quality of care received, and health outcomes. The attitudes and behaviors of health care providers have been identified as one of many factors that contribute to health disparities. Implicit attitudes are thoughts and feelings that often exist outside of conscious awareness, and thus are difficult to consciously acknowledge and control. These attitudes are often automatically activated and can influence human behavior without conscious volition. OBJECTIVES: We investigated the extent to which implicit racial/ethnic bias exists among health care professionals and examined the relationships between health care professionals’ implicit attitudes about racial/ethnic groups and health care outcomes. SEARCH METHODS: To identify relevant studies, we searched 10 computerized bibliographic databases and used a reference harvesting technique. SELECTION CRITERIA: We assessed eligibility using double independent screening based on a priori inclusion criteria. We included studies if they sampled existing health care providers or those in training to become health care providers, measured and reported results on implicit racial/ethnic bias, and were written in English. DATA COLLECTION AND ANALYSIS: We included a total of 15 studies for review and then subjected them to double independent data extraction. Information extracted included the citation, purpose of the study, use of theory, study design, study site and location, sampling strategy, response rate, sample size and characteristics, measurement of relevant variables, analyses performed, and results and findings. We summarized study design characteristics, and categorized and then synthesized substantive findings. MAIN RESULTS: Almost all studies used cross-sectional designs, convenience sampling, US participants, and the Implicit Association Test to assess implicit bias. Low to moderate levels of implicit racial/ethnic bias were found among health care professionals in all but 1 study. These implicit bias scores are similar to those in the general population. Levels of implicit bias against Black, Hispanic/Latino/Latina, and dark-skinned people were relatively similar across these groups. Although some associations between implicit bias and health care outcomes were nonsignificant, results also showed that implicit bias was significantly related to patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes. Implicit attitudes were more often significantly related to patient-provider interactions and health outcomes than treatment processes. CONCLUSIONS: Most health care providers appear to have implicit bias in terms of positive attitudes toward Whites and negative attitudes toward people of color. Future studies need to employ more rigorous methods to examine the relationships between implicit bias and health care outcomes. Interventions targeting implicit attitudes among health care professionals are needed because implicit bias may contribute to health disparities for people of color.

 

Hannah, S. D. and E. Carpenter-Song (2013). “Patrolling your blind spots: introspection and public catharsis in a medical school faculty development course to reduce unconscious bias in medicine.” Cult Med Psychiatry 37(2): 314-339.

Cultural competence education has been criticized for excessively focusing on the culture of patients while ignoring how the culture of medical institutions and individual providers contribute to health disparities. Many educators are now focusing on the role of bias in medical encounters and searching for strategies to reduce its negative impact on patients. These bias-reduction efforts have often been met with resistance from those who are offended by the notion that “they” are part of the problem. This article examines a faculty development course offered to medical school faculty that seeks to reduce bias in a way that avoids this problem. Informed by recent social-psychological research on bias, the course focuses on forms of bias that operate below the level of conscious awareness. With a pedagogical strategy promoting self-awareness and introspection, instructors encourage participants to discover their own unconscious biases in the hopes that they will become less biased in the future. By focusing on hidden forms of bias that everyone shares, they hope to create a “safe-space” where individuals can discuss shameful past experiences without fear of blame or criticism. Drawing on participant-observation in all course sessions and eight in-depth interviews, this article examines the experiences and reactions of instructors and participants to this type of approach. We “lift the hood” and closely examine the philosophy and strategy of course founders, the motivations of the participants, and the experience of and reaction to the specific pedagogical techniques employed. We find that their safe-space strategy was moderately successful, largely due to the voluntary structure of the course, which ensured ample interest among participants, and their carefully designed interactive exercises featuring intimate small group discussions. However, this success comes at the expense of considering the multidimensional sources of bias. The specific focus on introspection implies that prior ignorance, not active malice, is responsible for biased actions. In this way, the individual perpetrators of bias escape blame for their actions while the underlying causes of their behavior go unexplored or unaccounted for.

 

Hardeman, R. R., et al. (2015). “Mental Well-Being in First Year Medical Students: A Comparison by Race and Gender: A Report from the Medical Student CHANGE Study.” J Racial Ethn Health Disparities 2(3): 403-413.

PURPOSE: In this study, authors sought to characterize race and gender disparities in mental health in a national sample of first year medical students early in their medical school experience. METHOD: This study used cross-sectional baseline data of Medical Student CHANGES, a large national longitudinal study of a cohort of medical students surveyed in the winter of 2010. Authors ascertained respondents via the American Association of Medical Colleges questionnaire, a third-party vendor-compiled list, and referral sampling. RESULTS: A total of 4732 first year medical students completed the baseline survey; of these, 301 were African American and 2890 were White. Compared to White students and after adjusting for relevant covariates, African American students had a greater risk of being classified as having depressive (relative risk (RR)=1.59 [95 % confidence interval, 1.37-2.40]) and anxiety symptoms (RR=1.66 [1.08-2.71]). Women also had a greater risk of being classified as having depressive (RR=1.36 [1.07-1.63]) and anxiety symptoms (RR-1.95 [1.39-2.84]). CONCLUSIONS: At the start of their first year of medical school, African American and female medical students were at a higher risk for depressive symptoms and anxiety than their White and male counterparts, respectively. The findings of this study have practical implications as poor mental and overall health inhibit learning and success in medical school, and physician distress negatively affects quality of clinical care.

 

Harris, R., et al. (2016). “Development and testing of study tools and methods to examine ethnic bias and clinical decision-making among medical students in New Zealand: The Bias and Decision-Making in Medicine (BDMM) study.” BMC Med Educ 16: 173.

BACKGROUND: Health provider racial/ethnic bias and its relationship to clinical decision-making is an emerging area of research focus in understanding and addressing ethnic health inequities. Examining potential racial/ethnic bias among medical students may provide important information to inform medical education and training. This paper describes the development, pretesting and piloting of study content, tools and processes for an online study of racial/ethnic bias (comparing Maori and New Zealand European) and clinical decision-making among final year medical students in New Zealand (NZ). METHODS: The study was developed, pretested and piloted using a staged process (eight stages within five phases). Phase 1 included three stages: 1) scoping and conceptual framework development; 2) literature review and identification of potential measures and items; and, 3) development and adaptation of study content. Three main components were identified to assess different aspects of racial/ethnic bias: (1) implicit racial/ethnic bias using NZ-specific Implicit Association Tests (IATs); (2) explicit racial/ethnic bias using direct questions; and, (3) clinical decision-making, using chronic disease vignettes. Phase 2 (stage 4) comprised expert review and refinement. Formal pretesting (Phase 3) included construct testing using sorting and rating tasks (stage 5) and cognitive interviewing (stage 6). Phase 4 (stage 7) involved content revision and building of the web-based study, followed by pilot testing in Phase 5 (stage 8). RESULTS: Materials identified for potential inclusion performed well in construct testing among six participants. This assisted in the prioritisation and selection of measures that worked best in the New Zealand context and aligned with constructs of interest. Findings from the cognitive interviewing (nine participants) on the clarity, meaning, and acceptability of measures led to changes in the final wording of items and ordering of questions. Piloting (18 participants) confirmed the overall functionality of the web-based questionnaire, with a few minor revisions made to the final study. CONCLUSIONS: Robust processes are required in the development of study content to assess racial/ethnic bias in order to optimise the validity of specific measures, ensure acceptability and minimise potential problems. This paper has utility for other researchers in this area by informing potential development approaches and identifying possible measurement tools.

 

Hasler, B. S., et al. (2017). “Virtual race transformation reverses racial in-group bias.” PLoS One 12(4): e0174965.

People generally show greater preference for members of their own racial group compared to racial out-group members. This type of ‘in-group bias’ is evident in mimicry behaviors. We tend to automatically mimic the behaviors of in-group members, and this behavior is associated with interpersonal sensitivity and empathy. However, mimicry is reduced when interacting with out-group members. Although race is considered an unchangeable trait, it is possible using embodiment in immersive virtual reality to engender the illusion in people of having a body of a different race. Previous research has used this technique to show that after a short period of embodiment of White people in a Black virtual body their implicit racial bias against Black people diminishes. Here we show that this technique powerfully enhances mimicry. We carried out an experiment with 32 White (Caucasian) female participants. Half were embodied in a White virtual body and the remainder in a Black virtual body. Each interacted in two different sessions with a White and a Black virtual character, in counterbalanced order. The results show that dyads with the same virtual body skin color expressed greater mimicry than those of different color. Importantly, this effect occurred depending on the virtual body’s race, not participants’ actual racial group. When embodied in a Black virtual body, White participants treat Black as their novel in-group and Whites become their novel out-group. This reversed in-group bias effect was obtained regardless of participants’ level of implicit racial bias. We discuss the theoretical and practical implications of this surprising psychological phenomenon.

 

Hatzenbuehler, M. L., et al. (2009). “An Implicit Measure of Anti-Gay Attitudes: Prospective Associations with Emotion Regulation Strategies and Psychological Distress.” J Exp Soc Psychol 45(6): 1316-1320.

Members of stigmatized groups are at increased risk for mental health problems, and recent research has suggested that emotion dysregulation may be one mechanism explaining the stigma-distress association. However, little is known regarding characteristics that predict vulnerabilities to emotion dysregulation and subsequent distress. We examined whether anti-gay attitudes would predict poorer emotion regulation and greater psychological distress in 31 lesbian, gay, and bisexual (LGB) respondents. Respondents completed implicit and explicit attitude measures at baseline, and participated in an experience sampling study examining stigma-related stressors, emotion regulation strategies, and mood over the course of ten days. Implicit and explicit attitude measures were not correlated. LGB respondents with greater implicit anti-gay attitudes engaged in significantly more rumination and suppression and reported more psychological distress. Rumination fully mediated the prospective association between implicit prejudicial attitudes and psychological distress, and suppression was a marginally significant mediator.

 

Hatzenbuehler, M. L., et al. (2009). “How does stigma “get under the skin”?: the mediating role of emotion regulation.” Psychol Sci 20(10): 1282-1289.

Stigma is a risk factor for mental health problems, but few studies have considered how stigma leads to psychological distress. The present research examined whether specific emotion-regulation strategies account for the stigma-distress association. In an experience-sampling study, rumination and suppression occurred more on days when stigma-related stressors were reported than on days when these stressors were not reported, and rumination mediated the relationship between stigma-related stress and psychological distress. The effect of social support on distress was moderated by the concealability of the stigma: Lesbian, gay, and bisexual (LGB) respondents reported more isolation and less social support than African American respondents subsequent to experiencing stigma-related stressors, whereas African Americans reported greater social support than LGB participants. Social isolation mediated the stigma-distress association among LGB respondents. In a second experimental study, participants who ruminated following the recall of an autobiographical discrimination event exhibited prolonged distress on both implicit and explicit measures relative to participants who distracted themselves; this finding provides support for a causal role of rumination in the stigma-distress relationship.

 

He, Y., et al. (2009). “The relation between race-related implicit associations and scalp-recorded neural activity evoked by faces from different races.” Soc Neurosci 4(5): 426-442.

The neural correlates of the perception of faces from different races were investigated. White participants performed a gender identification task in which Asian, Black, and White faces were presented while event-related potentials (ERPs) were recorded. Participants also completed an implicit association task for Black (IAT-Black) and Asian (IAT-Asian) faces. ERPs evoked by Black and White faces differed, with Black faces evoking a larger positive ERP that peaked at 168 ms over the frontal scalp, and White faces evoking a larger negative ERP that peaked at 244 ms. These Black/White ERP differences significantly correlated with participants’ scores on the IAT-Black. ERPs also differentiated White from Asian faces and a significant correlation was obtained between the White-Asian ERP difference waves at approximately 500 ms and the IAT-Asian. A positive ERP at 116 ms over occipital scalp differentiated all three races, but was not correlated with either IAT. In addition, a late positive component (around 592 ms) was greater for the same race compared to either other race faces, suggesting potentially more extended or deeper processing of the same race faces. Taken together, the ERP/IAT correlations observed for both other races indicate the influence of a race-sensitive evaluative process that may include early more automatic and/or implicit processes and relatively later more controlled processes.

 

Hebl, M. R. and J. F. Dovidio (2005). “Promoting the “social” in the examination of social stigmas.” Pers Soc Psychol Rev 9(2): 156-182.

This review highlights the value of empirical investigations examining actual interactions that occur between stigmatizers and targets, and is intended to stimulate and help guide research of this type. We identify trends in the literature demonstrating that research studying ongoing interactions between stigmatizers and targets is relatively less common than in the past. Interactive studies are challenging, complex, and have variables that are sometimes more difficult to control; yet, they offer unique insights and significant contributions to understanding stigma-related phenomena that may not be offered in other (e.g., self-report) paradigms. This article presents a conceptual and empirical overview of stigma research, delineates the unique contributions that have been made by conducting interactive studies, and proposes what can be further learned by conducting more of such research.

 

Hirsh, A. T., et al. (2015). “The interaction of patient race, provider bias, and clinical ambiguity on pain management decisions.” J Pain 16(6): 558-568.

UNLABELLED: Although racial disparities in pain care are widely reported, much remains to be known about the role of provider and contextual factors. We used computer-simulated patients to examine the influence of patient race, provider racial bias, and clinical ambiguity on pain decisions. One hundred twenty-nine medical residents/fellows made assessment (pain intensity) and treatment (opioid and nonopioid analgesics) decisions for 12 virtual patients with acute pain. Race (black/white) and clinical ambiguity (high/low) were manipulated across vignettes. Participants completed the Implicit Association Test and feeling thermometers, which assess implicit and explicit racial biases, respectively. Individual- and group-level analyses indicated that race and ambiguity had an interactive effect on providers’ decisions, such that decisions varied as a function of ambiguity for white but not for black patients. Individual differences across providers were observed for the effect of race and ambiguity on decisions; however, providers’ implicit and explicit biases did not account for this variability. These data highlight the complexity of racial disparities and suggest that differences in care between white and black patients are, in part, attributable to the nature (ie, ambiguity) of the clinical scenario. The current study suggests that interventions to reduce disparities should differentially target patient, provider, and contextual factors. PERSPECTIVE: This study examined the unique and collective influence of patient race, provider racial bias, and clinical ambiguity on providers’ pain management decisions. These results could inform the development of interventions aimed at reducing disparities and improving pain care.

 

Hutcherson, C. A., et al. (2008). “Loving-kindness meditation increases social connectedness.” Emotion 8(5): 720-724.

The need for social connection is a fundamental human motive, and it is increasingly clear that feeling socially connected confers mental and physical health benefits. However, in many cultures, societal changes are leading to growing social distrust and alienation. Can feelings of social connection and positivity toward others be increased? Is it possible to self-generate these feelings? In this study, the authors used a brief loving-kindness meditation exercise to examine whether social connection could be created toward strangers in a controlled laboratory context. Compared with a closely matched control task, even just a few minutes of loving-kindness meditation increased feelings of social connection and positivity toward novel individuals on both explicit and implicit levels. These results suggest that this easily implemented technique may help to increase positive social emotions and decrease social isolation.

 

Hymel, K. P., et al. (2018). “Racial and Ethnic Disparities and Bias in the Evaluation and Reporting of Abusive Head Trauma.” J Pediatr 198: 137-143 e131.

OBJECTIVE: To characterize racial and ethnic disparities in the evaluation and reporting of suspected abusive head trauma (AHT) across the 18 participating sites of the Pediatric Brain Injury Research Network (PediBIRN). We hypothesized that such disparities would be confirmed at multiple sites and occur more frequently in patients with a lower risk for AHT. STUDY DESIGN: Aggregate and site-specific analysis of the cross-sectional PediBIRN dataset, comparing AHT evaluation and reporting frequencies in subpopulations of white/non-Hispanic and minority race/ethnicity patients with lower vs higher risk for AHT. RESULTS: In the PediBIRN study sample of 500 young, acutely head-injured patients hospitalized for intensive care, minority race/ethnicity patients (n = 229) were more frequently evaluated (P < .001; aOR, 2.2) and reported (P = .001; aOR, 1.9) for suspected AHT than white/non-Hispanic patients (n = 271). These disparities occurred almost exclusively in lower risk patients, including those ultimately categorized as non-AHT (P = .001 [aOR, 2.4] and P = .003 [aOR, 2.1]) or with an estimated AHT probability of </=25% (P <.001 [aOR, 4.1] and P <.001 [aOR, 2.8]). Similar site-specific analyses revealed that these results reflected more extreme disparities at only 2 of 18 sites, and were not explained by local confounders. CONCLUSION: Significant race/ethnicity-based disparities in AHT evaluation and reporting were observed at only 2 of 18 sites and occurred almost exclusively in lower risk patients. In the absence of local confounders, these disparities likely represent the impact of local physicians’ implicit bias.

 

Jensen, N. M. (2014). “Physicians and implicit bias.” J Gen Intern Med 29(5): 707.

 

Johnson, T. J., et al. (2016). “The Impact of Cognitive Stressors in the Emergency Department on Physician Implicit Racial Bias.” Acad Emerg Med 23(3): 297-305.

OBJECTIVES: The emergency department (ED) is characterized by stressors (e.g., fatigue, stress, time pressure, and complex decision-making) that can pose challenges to delivering high-quality, equitable care. Although it has been suggested that characteristics of the ED may exacerbate reliance on cognitive heuristics, no research has directly investigated whether stressors in the ED impact physician racial bias, a common heuristic. We seek to determine if physicians have different levels of implicit racial bias post-ED shift versus preshift and to examine associations between demographics and cognitive stressors with bias. METHODS: This repeated-measures study of resident physicians in a pediatric ED used electronic pre- and postshift assessments of implicit racial bias, demographics, and cognitive stressors. Implicit bias was measured using the Race Implicit Association Test (IAT). Linear regression models compared differences in IAT scores pre- to postshift and determined associations between participant demographics and cognitive stressors with postshift IAT and pre- to postshift difference scores. RESULTS: Participants (n = 91) displayed moderate prowhite/antiblack bias on preshift (mean +/- SD = 0.50 +/- 0.34, d = 1.48) and postshift (mean +/- SD = 0.55 +/- 0.39, d = 1.40) IAT scores. Overall, IAT scores did not differ preshift to postshift (mean increase = 0.05, 95% CI = -0.02 to 0.14, d = 0.13). Subanalyses revealed increased pre- to postshift bias among participants working when the ED was more overcrowded (mean increase = 0.09, 95% CI = 0.01 to 0.17, d = 0.24) and among those caring for >10 patients (mean increase = 0.17, 95% CI = 0.05 to 0.27, d = 0.47). Residents’ demographics (including specialty), fatigue, busyness, stressfulness, and number of shifts were not associated with postshift IAT or difference scores. In multivariable models, ED overcrowding was associated with greater postshift bias (coefficient = 0.11 per 1 unit of NEDOCS score, SE = 0.05, 95% CI = 0.00 to 0.21). CONCLUSIONS: While resident implicit bias remained stable overall preshift to postshift, cognitive stressors (overcrowding and patient load) were associated with increased implicit bias. Physicians in the ED should be aware of how cognitive stressors may exacerbate implicit racial bias.

 

Johnson, T. J., et al. (2017). “Comparison of Physician Implicit Racial Bias Toward Adults Versus Children.” Acad Pediatr 17(2): 120-126.

BACKGROUND AND OBJECTIVES: The general population and most physicians have implicit racial bias against black adults. Pediatricians also have implicit bias against black adults, albeit less than other specialties. There is no published research on the implicit racial attitudes of pediatricians or other physicians toward children. Our objectives were to compare implicit racial bias toward adults versus children among resident physicians working in a pediatric emergency department, and to assess whether bias varied by specialty (pediatrics, emergency medicine, or other), gender, race, age, and year of training. METHODS: We measured implicit racial bias of residents before a pediatric emergency department shift using the Adult and Child Race Implicit Association Tests (IATs). Generalized linear models compared Adult and Child IAT scores and determined the association of participant demographics with Adult and Child IAT scores. RESULTS: Among 91 residents, we found moderate pro-white/anti-black bias on both the Adult (mean = 0.49, standard deviation = 0.34) and Child Race IAT (mean = 0.55, standard deviation = 0.37). There was no significant difference between Adult and Child Race IAT scores (difference = 0.06, P = .15). Implicit bias was not associated with resident demographic characteristics, including specialty. CONCLUSIONS: This is the first study demonstrating that resident physicians have implicit racial bias against black children, similar to levels of bias against black adults. Bias in our study did not vary by resident demographic characteristics, including specialty, suggesting that pediatric residents are as susceptible as other physicians to implicit bias. Future studies are needed to explore how physicians’ implicit attitudes toward parents and children may impact inequities in pediatric health care.

 

Jones-Schenk, J. (2016). “Getting to the Root of Disparities: Social Cognition and the Affective Domain.” J Contin Educ Nurs 47(10): 443-445.

Bias, prejudice, cultural insensitivity, and eroding levels of empathy all affect the health and well being of patients and families and manifest or accelerate social disparities of health. For caregivers, educational offerings and activities targeting the affective domain can positively influence the development of greater empathy and improved social cognition. As difficult as it is to develop effective teaching methods for this domain, new strides in virtual reality technology and new research on implicit bias can provide the professional development educator with options in designing educational offerings that can help. J Contin Educ Nurs. 2016;47(10):443-445.

 

Jones, D. A. (2015). “Human Dignity in Healthcare: A Virtue Ethics Approach.” New Bioeth 21(1): 87-97.

The term ‘dignity’ is used in a variety of ways but always to attribute or recognize some status in the person. The present paper concerns not the status itself but the virtue of acknowledging that status. This virtue, which Thomas Aquinas calls ‘observantia’, concerns how dignity is honoured, respected, or observed. By analogy with justice (of which it is a part) observantia can be thought of both as a general virtue and as a special virtue. As a general virtue observantia refers to that respect for human dignity that is implicit in all acts of justice. As a special virtue it concerns the specific way we show esteem for people. Healthcare represents a challenge to observantia because those in need of healthcare are doubly restricted in expressing their dignity in action: in the first place by their ill health, and in the second place by the conditions required by healthcare (hence the sick are termed ‘patients’ rather than ‘agents’). To be understood properly, especially in the context of healthcare, the virtue of observantia needs both to qualify and to be qualified by the virtue of misericordia, empathy, or compassion for affliction. The unity of the virtues requires a simultaneous recognition of the common dignity and common neediness of human existence.

 

Kale, S. and C. S. Hong (2017). “Cultural sensitvty, unconscious bias and quality of health care.” J Fam Health 27(2): 28-31.

 

Kang, O. and T. Wheatley (2017). “Pupil dilation patterns spontaneously synchronize across individuals during shared attention.” J Exp Psychol Gen 146(4): 569-576.

Human social behavior relies on the coupling of minds. Here we show that patterns of pupil dilations reveal mental coupling between speakers and listeners. Speakers were videotaped and eye-tracked as they discussed positive and negative autobiographical memories. An independent group of listeners were then eye-tracked while they watched these videos. As pupillary dilations reflect the dynamics of conscious attention, we computed the morphological similarity of speaker-listener pupillary time-series data as a metric of shared attention. The emotional salience of each narrative was also assessed, dynamically, by independent raters. Collective pupillary synchrony between speakers and listeners was greatest during the emotional peaks of a narrative, and decreased as narratives became less engaging. Individual differences in speaker expressivity and listener empathy revealed greatest synchrony in high expressive-high empathic dyads. Together, these findings suggest that pupillary synchrony is an implicit corollary of shared attention that can be used to track mental coupling in real time. (PsycINFO Database Record

 

Kang, Y., et al. (2014). “The nondiscriminating heart: lovingkindness meditation training decreases implicit intergroup bias.” J Exp Psychol Gen 143(3): 1306-1313.

Although meditation is increasingly accepted as having personal benefits, less is known about the broader impact of meditation on social and intergroup relations. We tested the effect of lovingkindness meditation training on improving implicit attitudes toward members of 2 stigmatized social outgroups: Blacks and homeless people. Healthy non-Black, nonhomeless adults (N = 101) were randomly assigned to 1 of 3 conditions: 6-week lovingkindness practice, 6-week lovingkindness discussion (a closely matched active control), or waitlist control. Decreases in implicit bias against stigmatized outgroups (as measured by Implicit Association Test) were observed only in the lovingkindness practice condition. Reduced psychological stress mediated the effect of lovingkindness practice on implicit bias against homeless people, but it did not mediate the reduced bias against Black people. These results suggest that lovingkindness meditation can improve automatically activated, implicit attitudes toward stigmatized social groups and that this effect occurs through distinctive mechanisms for different stigmatized social groups.

 

Kawakami, K., et al. (2000). “Just say no (to stereotyping): effects of training in the negation of stereotypic associations on stereotype activation.” J Pers Soc Psychol 78(5): 871-888.

The primary aim of the present research was to examine the effect of training in negating stereotype associations on stereotype activation. Across 3 studies, participants received practice in negating stereotypes related to skinhead and racial categories. The subsequent automatic activation of stereotypes was measured using either a primed Stroop task (Studies I and 2) or a person categorization task (Study 3). The results demonstrate that when receiving no training or training in a nontarget category stereotype, participants exhibited spontaneous stereotype activation. After receiving an extensive amount of training related to a specific category, however, participants demonstrated reduced stereotype activation. The results from the training task provide further evidence for the impact of practice on participants’ proficiency in negating stereotypes.

 

Kawakami, K., et al. (2009). “Mispredicting affective and behavioral responses to racism.” Science 323(5911): 276-278.

Contemporary race relations are marked by an apparent paradox: Overt prejudice is strongly condemned, yet acts of blatant racism still frequently occur. We propose that one reason for this inconsistency is that people misunderstand how they would feel and behave after witnessing racism. The present research demonstrates that although people predicted that they would be very upset by a racist act, when people actually experienced this event they showed relatively little emotional distress. Furthermore, people overestimated the degree to which a racist comment would provoke social rejection of the racist. These findings suggest that racism may persevere in part because people who anticipate feeling upset and believe that they will take action may actually respond with indifference when faced with an act of racism.

 

Kawakami, K., et al. (2012). “In perfect harmony: synchronizing the self to activated social categories.” J Pers Soc Psychol 102(3): 562-575.

The self-concept is one of the main organizing constructs in the behavioral sciences because it influences how people interpret their environment, the choices they make, whether and how they initiate action, and the pursuit of specific goals. Because belonging to social groups and feeling interconnected is critical to human survival, the authors propose that people spontaneously change their working self-concept so that they are more similar to salient social categories. Specifically, 4 studies investigated whether activating a variety of social categories (i.e., jocks, hippies, the overweight, Blacks, and Asians) increased associations between the self and the target category. Whereas Studies 1 and 2 focused on associations between stereotypic traits and the self, Studies 3 and 4 examined self-perceptions and self-categorizations, respectively. The results provide consistent evidence that following social category priming, people synchronized the self to the activated category. Furthermore, the findings indicate that factors that influence category activation, such as social goals, and factors that induce a focus on the interconnectedness of the self, such as an interdependent vs. independent self-construal, can impact this process. The implications of changes to the working self-concept for intergroup relations are discussed.

 

Kawakami, K., et al. (2007). “(Close) distance makes the heart grow fonder:Improving implicit racial attitudes and interracial interactions through approach behaviors.” J Pers Soc Psychol 92(6): 957-971.

In 4 studies, the authors examined the effect of approaching Blacks on implicit racial attitudes and immediacy behaviors. In Studies 1-3, participants were trained to pull a joystick toward themselves or to push it away from themselves when presented with photographs of Blacks, Whites, or Asians before completing an Implicit Association Test to measure racial bias. In Study 4, the effect of this training procedure on nonverbal behavior in an interracial contact situation was investigated. Results from the studies demonstrated that approaching Blacks decreased participants’ implicit racial prejudice and increased immediacy when interacting with a Black confederate. The implications of these findings for current theories on approach, avoidance, and intergroup relations are discussed.

 

Kenny, D. T. (2004). “Constructions of chronic pain in doctor-patient relationships: bridging the communication chasm.” Patient Educ Couns 52(3): 297-305.

This study examined interactions between doctors and their chronic pain patients in the context of investigations for medically unexplained pain. Doctor-patient interactions were explored through the analysis of the accounts of the communication process in the chronic pain consultation of 20 chronic pain patients with their pain specialists and the accounts of 22 pain specialists with their chronic pain patients. An implicit dialogue between doctors and their patients was identified that appeared to undermine the quality of their interactions, challenged each other’s credibility and caused distress to both parties. The implicit dialogue of the chronic pain patient was based on the biogenic theory while the implicit dialogue of doctors was underpinned by psychogenic theory. Potentially healing interactions between doctors and their patients that do not rely on the biogenic model of the visible body or the psychogenic model of invisible pain are needed to assist the communication between chronic pain patients and their doctors. A systemic theoretical analysis of this process is offered.

 

Khosla, N. N., et al. (2018). “A comparison of clinicians’ racial biases in the United States and France.” Soc Sci Med 206: 31-37.

RATIONALE: Clinician bias contributes to racial disparities in healthcare, but its effects may be indirect and culturally specific. OBJECTIVE: The present work aims to investigate clinicians’ perceptions of Black versus White patients’ personal responsibility for their health, whether this variable predicts racial bias against Black patients, and whether this effect differs between the U.S. and France. METHOD: American (N=83) and French (N=81) clinicians were randomly assigned to report their impressions of an identical Black or White male patient based on a physician’s notes. We measured clinicians’ views of the patient’s anticipated improvement and adherence to treatment and their perceptions concerning how personally responsible the patient was for his health. RESULTS: Whereas French clinicians did not exhibit significant racial bias on the measures of interest, American clinicians rated a hypothetical White patient, compared to an identical Black patient, as significantly more likely to improve, adhere to treatment, and be personally responsible for his health. Moreover, in the U.S., personal responsibility mediated the racial difference in expected improvement, such that as the White patient was seen as more personally responsible for his health, he was also viewed as more likely to improve. CONCLUSION: The present work indicates that American clinicians displayed less optimistic expectations for the medical treatment and health of a Black male patient, relative to a White male patient, and that this racial bias was related to their view of the Black patient as being less personally responsible for his health relative to the White patient. French clinicians did not show this pattern of racial bias, suggesting the importance of considering cultural influences for understanding racial biases in healthcare and health.

 

Kunst, J. R., et al. (2018). “White Look-Alikes: Mainstream Culture Adoption Makes Immigrants “Look” Phenotypically White.” Pers Soc Psychol Bull 44(2): 265-282.

White Americans generally equate “being American” with “being White.” In six studies, we demonstrate that White Americans perceive immigrants who adopt American mainstream culture as racially White and, reciprocally, perceive White-looking immigrants as assimilating more. In Studies 1 and 2, participants visually represented immigrants who adopted U.S. culture by acculturating to mainstream American culture or by holding a common or dual identity as more phenotypically White and less stereotypic in appearance. In Studies 3 and 4, these processes explained why participants were less likely to racially profile immigrants but also regarded them as less qualified for integration support. In Study 5, participants perceived light skin to fit to high U.S. culture adoption and dark skin to low U.S. culture adoption. Finally, in Study 6, light-skinned immigrants were seen as less threatening because they were perceived as assimilating more. Immigrants’ acculturation orientation and appearance interact and shape how they are evaluated.

 

Lages, M. and A. Scheel (2016). “Logistic Mixed Models to Investigate Implicit and Explicit Belief Tracking.” Front Psychol 7: 1681.

We investigated the proposition of a two-systems Theory of Mind in adults’ belief tracking. A sample of N = 45 participants predicted the choice of one of two opponent players after observing several rounds in an animated card game. Three matches of this card game were played and initial gaze direction on target and subsequent choice predictions were recorded for each belief task and participant. We conducted logistic regressions with mixed effects on the binary data and developed Bayesian logistic mixed models to infer implicit and explicit mentalizing in true belief and false belief tasks. Although logistic regressions with mixed effects predicted the data well a Bayesian logistic mixed model with latent task- and subject-specific parameters gave a better account of the data. As expected explicit choice predictions suggested a clear understanding of true and false beliefs (TB/FB). Surprisingly, however, model parameters for initial gaze direction also indicated belief tracking. We discuss why task-specific parameters for initial gaze directions are different from choice predictions yet reflect second-order perspective taking.

 

Lawrence, E. J., et al. (2007). “Empathy and enduring depersonalization: the role of self-related processes.” Soc Neurosci 2(3-4): 292-306.

Empathy has two key components: affective and cognitive. It relies on “embodied” processes such as the generation, representation and perception of feeling states. People diagnosed with Depersonalization Disorder (DPD) report disturbances in affective experience, such as emotional numbing, alongside aberrations in “body image” such as increased self-focus and feelings of “disembodiment”. DPD therefore provides a test bed for the role of such self-related processes in empathy. We tested 16 participants diagnosed with DPD and 48 control volunteers on measures of cognitive and affective empathy. We used self-report measures (EQ; Baron-Cohen & Wheelwright, 2004), an objective measure of cognitive empathy-the “Eyes” task (Baron-Cohen, Wheelwright, Hill, Raste, & Plumb, 2001), and a novel task tapping affective empathy, utilizing speech rate as an implicit measure of physiological arousal. We also measured participants’ tendency to use mental representations that relate to the self during the affective empathy task. The DPD group showed intact performance on the cognitive empathy task. However, there was a disruption in the physiological component of affective empathy alongside a more pronounced reliance on mental representations of the self. These findings suggest affective empathy to be reliant on intact emotional experience in the observer. In addition, excessive self-focus may be detrimental to an empathic response.

 

Lebowitz, M. S. and J. F. Dovidio (2015). “Implications of emotion regulation strategies for empathic concern, social attitudes, and helping behavior.” Emotion 15(2): 187-194.

Empathic concern-a sense of caring and compassion in response to the needs of others-is a type of emotional response to the plights and misfortunes of others that predicts positive social attitudes and altruistic interpersonal behaviors. One psychological process that has been posited to facilitate empathic concern is the ability to regulate one’s own emotions. However, existing research links some emotion-regulation approaches (e.g., suppression) to social outcomes that would appear at odds with empathic concern, such as decreased interpersonal closeness. In the present research, we tested whether relying on suppression to regulate one’s emotions would lead to decreases in empathic concern-and related downstream variables, such as negative social attitudes and unwillingness to engage in altruistic behavior-when learning about another person’s misfortune. In Study 1, dispositional and instructionally induced suppression was negatively associated with empathic concern, which led to increased stigmatizing attitudes. By contrast, instructing participants to use another emotion-regulation strategy examined for comparison-reappraisal-did not decrease empathic concern, and dispositional reliance on reappraisal was actually positively associated with empathic concern. In Study 2, the findings of Study 1 regarding the effects of habitual use of reappraisal and suppression were replicated, and reliance on suppression was also found to be associated with reluctance to engage in helping behaviors. These findings are situated within the existing literature and employed to shed new light on the interpersonal consequences of intrapersonal emotion-regulation strategies.

 

Lieberman, M. D. (2012). “A geographical history of social cognitive neuroscience.” Neuroimage 61(2): 432-436.

The history of social cognitive neuroscience (SCN) began with isolated islands of research in Europe and the United States in the 1990s. In the decade between 1995 and 2004 most of the major areas of current SCN research were identified in a series of high profile first studies. This paper reviews the timeline as well as the geography of important moments in the short history of this field. Of note is the different focus seen in European contributions (theory of mind, mirror neurons, and empathy) and the more self-focused U.S. contributions (self-knowledge, emotion regulation, implicit attitudes).

 

Lightfoote, J. B., et al. (2016). “Diversity, Inclusion, and Representation: It Is Time to Act.” J Am Coll Radiol 13(12 Pt A): 1421-1425.

Although the available pool of qualified underrepresented minority and women medical school graduates has expanded in recent decades, their representation in the radiological professions has improved only marginally. Recognizing this deficit in diversity, many professional medical societies, including the ACR, have incorporated these values as core elements of their missions and instituted programs that address previously identified barriers to a more diverse workforce. These barriers include insufficient exposure of underrepresented minorities and women to radiology and radiation oncology; misperception of these specialties as non-patient care and not community service; unconscious bias; and delayed preparation of candidates to compete successfully for residency positions. Critical success factors in expanding diversity and inclusion are well identified both outside and within the radiological professions; these are reviewed in the current communication. Radiology leaders are positioned to lead the profession in expanding the diversity and improving the inclusiveness of our professional workforce in service to an increasingly diverse society and patient population.

 

Lopez, C., et al. (2015). “In the presence of others: Self-location, balance control and vestibular processing.” Neurophysiol Clin 45(4-5): 241-254.

The degree to which others in our environment influence sensorimotor processing has been a particular focus of cognitive neuroscience for the past two decades. This process of self-other resonance, or shared body representation, has only recently been extended to more global bodily processes such as self-location, self-motion perception, balance and perspective taking. In this review, we outline these previously overlooked areas of research to bridge the distinct field of social neuroscience with global self-perception, vestibular processing and postural control. Firstly, we outline research showing that the presence and movement of others can modulate two fundamental experiences of the self: self-location (the experience of where the self is located in space) and self-motion perception (the experience that oneself has moved or has been moved in space). Secondly, we outline recent research that has shown perturbations in balance control as a result of instability in others in our environment. Conversely to this, we also highlight studies in virtual reality demonstrating the potential benefits of the presence of others in our environment for those undergoing vestibular rehabilitation. Thirdly, we outline studies of first- and third-person perspective taking, which is the ability to have or take a visuo-spatial perspective within and out-with the confines of our own body. These studies demonstrate a contamination of perspective taking processes (i.e. automatic, implicit, third-person perspective taking) in the presence of others. This collection of research highlights the importance of social cues in the more global processing of the self and its accompanying sensory inputs, particularly vestibular signals. Future research will need to better determine the mechanisms of self-other resonance within these processes, including the role of individual differences in the susceptibility to the influence of another.

 

Lorie, A., et al. (2017). “Culture and nonverbal expressions of empathy in clinical settings: A systematic review.” Patient Educ Couns 100(3): 411-424.

OBJECTIVE: To conduct a systematic review of studies examining how culture mediates nonverbal expressions of empathy with the aim to improve clinician cross-cultural competency. METHODS: We searched three databases for studies of nonverbal expressions of empathy and communication in cross-cultural clinical settings, yielding 16,143 articles. We examined peer-reviewed, experimental or observational articles. Sixteen studies met inclusion criteria. RESULTS: Nonverbal expressions of empathy varied across cultural groups and impacted the quality of communication and care. Some nonverbal behaviors appeared universally desired and others, culturally specific. Findings revealed the impact of nonverbal communication on patient satisfaction, affective tone, information exchange, visit length, and expression decoding during cross-cultural clinical encounters. Racial discordance, patients’ perception of physician racism, and physician implicit bias are among factors that appear to influence information exchange in clinical encounters. CONCLUSION: Culture-based norms impact expectations for specific nonverbal expressions within patient-clinician dyads. Nonverbal communication plays a significant role in fostering trusting provider-patient relationships, and is critical to high quality care. PRACTICE IMPLICATIONS: Medical education should include training in interpretation of nonverbal behavior to optimize empathic cross-cultural communication and training efforts should accommodate norms of local patient populations. These efforts should reduce implicit biases in providers and perceived prejudice in patients.

 

Luguri, J. B., et al. (2012). “Reconstruing intolerance: abstract thinking reduces conservatives’ prejudice against nonnormative groups.” Psychol Sci 23(7): 756-763.

Myrdal (1944) described the “American dilemma” as the conflict between abstract national values (“liberty and justice for all”) and more concrete, everyday prejudices. We leveraged construal-level theory to empirically test Myrdal’s proposition that construal level (abstract vs. concrete) can influence prejudice. We measured individual differences in construal level (Study 1) and manipulated construal level (Studies 2 and 3); across these three studies, we found that adopting an abstract mind-set heightened conservatives’ tolerance for groups that are perceived as deviating from Judeo-Christian values (gay men, lesbians, Muslims, and atheists). Among participants who adopted a concrete mind-set, conservatives were less tolerant of these nonnormative groups than liberals were, but political orientation did not have a reliable effect on tolerance among participants who adopted an abstract mind-set. Attitudes toward racial out-groups and dominant groups (e.g., Whites, Christians) were unaffected by construal level. In Study 3, we found that the effect of abstract thinking on prejudice was mediated by an increase in concerns about fairness.

 

Lundmark, M. (2007). “Vocation in theology-based nursing theories.” Nurs Ethics 14(6): 767-780.

By using the concepts of intrinsicality/extrinsicality as analytic tools, the theology-based nursing theories of Ann Bradshaw and Katie Eriksson are analyzed regarding their explicit and/or implicit understanding of vocation as a motivational factor for nursing. The results show that both theories view intrinsic values as guarantees against reducing nursing practice to mechanistic applications of techniques and as being a way of reinforcing a high ethical standard. The theories explicitly (Bradshaw) or implicitly (Eriksson) advocate a vocational understanding of nursing as being essential for nursing theories. Eriksson’s theory has a potential for conceptualizing an understanding of extrinsic and intrinsic motivational factors for nursing but one weakness in the theory could be the risk of slipping over to moral judgments where intrinsic factors are valued as being superior to extrinsic. Bradshaw’s theory is more complex and explicit in understanding the concept of vocation and is theologically more plausible, although also more confessional.

 

Luo, S., et al. (2015). “Oxytocin receptor gene and racial ingroup bias in empathy-related brain activity.” Neuroimage 110: 22-31.

The human brain responds more strongly to racial ingroup than outgroup individuals’ pain. This racial ingroup bias varies across individuals and has been attributed to social experiences. What remains unknown is whether the racial ingroup bias in brain activity is associated with a genetic polymorphism. We investigated genetic associations of racial ingroup bias in the brain activity to racial ingroup and outgroup faces that received painful or non-painful stimulations by scanning A/A and G/G homozygous of the oxytocin receptor gene polymorphism (OXTR rs53576) using functional MRI. We found that G/G compared to A/A individuals showed stronger activity in the anterior cingulate and supplementary motor area (ACC/SMA) in response to racial ingroup members’ pain, whereas A/A relative to G/G individuals exhibited greater activity in the nucleus accumbens (NAcc) in response to racial outgroup members’ pain. Moreover, the racial ingroup bias in ACC/SMA activity positively predicted participants’ racial ingroup bias in implicit attitudes and NAcc activity to racial outgroup individuals’ pain negatively predicted participants’ motivations to reduce racial outgroup members’ pain. Our results suggest that the two variants of OXTR rs53576 are associated with racial ingroup bias in brain activities that are linked to implicit attitude and altruistic motivation, respectively.

 

Maina, I. W., et al. (2018). “A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test.” Soc Sci Med 199: 219-229.

Disparities in the care and outcomes of US racial/ethnic minorities are well documented. Research suggests that provider bias plays a role in these disparities. The implicit association test enables measurement of implicit bias via tests of automatic associations between concepts. Hundreds of studies have examined implicit bias in various settings, but relatively few have been conducted in healthcare. The aim of this systematic review is to synthesize the current knowledge on the role of implicit bias in healthcare disparities. A comprehensive literature search of several databases between May 2015 and September 2016 identified 37 qualifying studies. Of these, 31 found evidence of pro-White or light-skin/anti-Black, Hispanic, American Indian or dark-skin bias among a variety of HCPs across multiple levels of training and disciplines. Fourteen studies examined the association between implicit bias and healthcare outcomes using clinical vignettes or simulated patients. Eight found no statistically significant association between implicit bias and patient care while six studies found that higher implicit bias was associated with disparities in treatment recommendations, expectations of therapeutic bonds, pain management, and empathy. All seven studies that examined the impact of implicit provider bias on real-world patient-provider interaction found that providers with stronger implicit bias demonstrated poorer patient-provider communication. Two studies examined the effect of implicit bias on real-world clinical outcomes. One found an association and the other did not. Two studies tested interventions aimed at reducing bias, but only one found a post-intervention reduction in implicit bias. This review reveals a need for more research exploring implicit bias in real-world patient care, potential modifiers and confounders of the effect of implicit bias on care, and strategies aimed at reducing implicit bias and improving patient-provider communication. Future studies have the opportunity to build on this current body of research, and in doing so will enable us to achieve equity in healthcare and outcomes.

 

Maister, L., et al. (2013). “Experiencing ownership over a dark-skinned body reduces implicit racial bias.” Cognition 128(2): 170-178.

Previous studies have investigated how existing social attitudes towards other races affect the way we ‘share’ their bodily experiences, for example in empathy for pain, and sensorimotor mapping. Here, we ask whether it is possible to alter implicit racial attitudes by experimentally increasing self-other bodily overlap. Employing a bodily illusion known as the ‘Rubber Hand Illusion’, we delivered multisensory stimulation to light-skinned Caucasian participants to induce the feeling that a dark-skinned hand belonged to them. We then measured whether this could change their implicit racial biases against people with dark skin. Across two experiments, the more intense the participants’ illusion of ownership over the dark-skinned rubber hand, the more positive their implicit racial attitudes became. Importantly, it was not the pattern of multisensory stimulation per se, but rather, it was the change in the subjective experience of body ownership that altered implicit attitudes. These findings suggest that inducing an overlap between the bodies of self and other through illusory ownership is an effective way to change and reduce negative implicit attitudes towards outgroups.

 

Major, B., et al. (2013). “Intergroup relations and health disparities: a social psychological perspective.” Health Psychol 32(5): 514-524.

OBJECTIVE: This article considers how the social psychology of intergroup processes helps to explain the presence and persistence of health disparities between members of socially advantaged and disadvantaged groups. METHOD: Social psychological theory and research on intergroup relations, including prejudice, discrimination, stereotyping, stigma, prejudice concerns, social identity threat, and the dynamics of intergroup interactions, is reviewed and applied to understand group disparities in health and health care. Potential directions for future research are considered. RESULTS: Key features of group relations and dynamics, including social categorization, social hierarchy, and the structural positions of groups along dimensions of perceived warmth and competence, influence how members of high status groups perceive, feel about, and behave toward members of low status groups, how members of low status groups construe and cope with their situation, and how members of high and low status groups interact with each other. These intergroup processes, in turn, contribute to health disparities by leading to differential exposure to and experiences of chronic and acute stress, different health behaviors, and different quality of health care experienced by members of advantaged and disadvantaged groups. Within each of these pathways, social psychological theory and research identifies mediating mechanisms, moderating factors, and individual differences that can affect health. CONCLUSIONS: A social psychological perspective illuminates the intergroup, interpersonal, and intrapersonal processes by which structural circumstances which differ between groups for historical, political, and economic reasons can lead to group differences in health.

 

Martin, A. K., et al. (2017). “Causal evidence for task-specific involvement of the dorsomedial prefrontal cortex in human social cognition.” Soc Cogn Affect Neurosci 12(8): 1209-1218.

The dorsomedial prefrontal cortex (dmPFC) is a key hub of the ‘social brain’, but little is known about specific processes supported by this region. Using focal high-definition transcranial direct current stimulation (HD-tDCS) and a social cognitive battery with differing demands on self-other processing, we demonstrate specific involvement of the dmPFC in tasks placing high demands on self-other processing. Specifically, excitatory (anodal) HD-tDCS enhanced the integration of external information into the self for explicit higher-order socio-cognitive tasks across cognitive domains; i.e. visual perspective taking (VPT) and episodic memory. These effects were task specific, as no stimulation effects were found for attributing mental states from the eyes or implicit VPT. Inhibitory (cathodal) HD-tDCS had weaker effects in the opposite direction towards reduced integration of external information into the self. We thus demonstrate for the first time a specific and causal role of the dmPFC in integrating higher-order information from others/external source into that of the self across cognitive domains.

 

Mathur, V. A., et al. (2014). “Racial bias in pain perception and response: experimental examination of automatic and deliberate processes.” J Pain 15(5): 476-484.

UNLABELLED: Racial disparities in pain treatment pose a significant public health and scientific problem. Prior studies have demonstrated that clinicians and nonclinicians are less perceptive of, and suggest less treatment for, the pain of African Americans relative to European Americans. Here we investigate the effects of explicit/implicit patient race presentation, patient race, and perceiver race on pain perception and response. African American and European American participants rated pain perception, empathy, helping motivation, and treatment suggestion in response to vignettes about patients’ pain. Vignettes were accompanied by a rapid (implicit) or static (explicit) presentation of an African or European American patient’s face. Participants perceived and responded more to European American patients in the implicit prime condition, when the effect of patient race was below the level of conscious regulation. This effect was reversed when patient race was presented explicitly. Additionally, female participants perceived and responded more to the pain of all patients, relative to male participants, and in the implicit prime condition, African American participants were more perceptive and responsive than European Americans to the pain of all patients. Taken together, these results suggest that known disparities in pain treatment may be largely due to automatic (below the level of conscious regulation) rather than deliberate (subject to conscious regulation) biases. These biases were not associated with traditional implicit measures of racial attitudes, suggesting that biases in pain perception and response may be independent of general prejudice. PERSPECTIVE: Results suggest that racial biases in pain perception and treatment are at least partially due to automatic processes. When the relevance of patient race is made explicit, however, biases are attenuated and even reversed. We also find preliminary evidence that African Americans may be more sensitive to the pain of others than are European Americans.

 

Mattarozzi, K., et al. (2017). “I care, even after the first impression: Facial appearance-based evaluations in healthcare context.” Soc Sci Med 182: 68-72.

PURPOSE: Prior research has demonstrated that healthcare providers’ implicit biases may contribute to healthcare disparities. Independent research in social psychology indicates that facial appearance-based evaluations affect social behavior in a variety of domains, influencing political, legal, and economic decisions. Whether and to what extent these evaluations influence approach behavior in healthcare contexts warrants research attention. Here we investigate the impact of facial appearance-based evaluations of trustworthiness on healthcare providers’ caring inclination, and the moderating role of experience and information about the social identity of the faces. METHOD: Novice and expert nurses rated their inclination to provide care when viewing photos of trustworthy-, neutral-, and untrustworthy-looking faces. To explore whether information about the target of care influences caring inclination, some participants were told that they would view patients’ faces while others received no information about the faces. RESULTS: Both novice and expert nurses had higher caring inclination scores for trustworthy-than for untrustworthy-looking faces; however, experts had higher scores than novices for untrustworthy-looking faces. Regardless of a face’s trustworthiness level, experts had higher caring inclination scores for patients than for unidentified individuals, while novices showed no differences. CONCLUSIONS: Facial appearance-based inferences can bias caring inclination in healthcare contexts. However, expert healthcare providers are less biased by these inferences and more sensitive to information about the target of care. These findings highlight the importance of promoting novice healthcare professionals’ awareness of first impression biases.

 

Mays, V. M., et al. (2013). “Using the Science of Psychology to Target Perpetrators of Racism and Race-Based Discrimination For Intervention Efforts: Preventing Another Trayvon Martin Tragedy.” J Soc Action Couns Psychol 5(1): 11-36.

Psychological science offers a variety of methods to both understand and intervene when acts of potential racial or ethnic racism, bias or prejudice occur. The Trayvon Martin killing is a reminder of how vulnerable African American men and boys, especially young African American men, are to becoming victims of social inequities in our society. We examine several historical events of racial bias (the Los Angeles civil disturbance after the Rodney King verdict, the federal government’s launch of a “War on Drugs” and the killing of Trayvon Martin) to illustrate the ways in which behaviors of racism and race-based discrimination can be viewed from a psychological science lens in the hopes of eliminating and preventing these behaviors. If society is to help end the genocide of African American men and boys then we must broaden our focus from simply understanding instances of victimization to a larger concern with determining how policies, laws, and societal norms serve as the foundation for maintaining implicit biases that are at the root of race-based discrimination, prejudice, bias and inequity. In our call to action, we highlight the contributions that psychologists, particularly racial and ethnic minority professionals, can make to reduce the negative impact of racial and ethnic bias through their volunteer/pro bono clinical efforts.

 

McAdams, D. P., et al. (2008). “Family metaphors and moral intuitions: how conservatives and liberals narrate their lives.” J Pers Soc Psychol 95(4): 978-990.

This research examines life-narrative interviews obtained from 128 highly religious and politically active adults to test differences between political conservatives and liberals on (a) implicit family metaphors (G. Lakoff, 2002) and (b) moral intuitions (J. Haidt & C. Joseph, 2004). Content analysis of 12 key scenes in life stories showed that conservatives, as predicted, tended to depict authority figures as strict enforcers of moral rules and to identify lessons in self-discipline. By contrast, liberals were more likely to identify lessons learned regarding empathy and openness, even though (contrary to prediction) they were no more likely than conservatives to describe nurturant authority figures. Analysis of extended discourse on the development of religious faith and personal morality showed that conservatives emphasized moral intuitions regarding respect for social hierarchy, allegiance to in-groups, and the purity or sanctity of the self, whereas liberals invested more significance in moral intuitions regarding harm and fairness. The results are discussed in terms of the recent upsurge of interest among psychologists in political ideology and the value of using life-narrative methods and concepts to explore how politically active adults attempt to construct meaningful lives.

 

Meconi, F., et al. (2015). “On the neglected role of stereotypes in empathy toward other-race pain.” Soc Neurosci 10(1): 1-6.

Recent studies on empathy toward other-race individuals demonstrate a preferential neural response to own-race members’ pain. Based on the observation that existing studies, using different techniques, did not provide a convergent scenario on how implicit racial prejudice relate to empathy in cross-racial contexts, in the current commentary we claim that future efforts in this domain should distinguish between processes of racial prejudice and racial stereotypes. These concepts have been differentiated in social psychology, and two independent measures have been provided to assess them. We propose that these aspects should be taken into further consideration in future studies to fully understand the social neuroscience of empathy in cross-racial contexts.

 

Mekawi, Y., et al. (2016). “White fear, dehumanization, and low empathy: Lethal combinations for shooting biases.” Cultur Divers Ethnic Minor Psychol 22(3): 322-332.

OBJECTIVES: A growing number of studies have documented the existence racial shooting biases against Black versus White targets (Correll et al., 2002). Little is known about individual differences that may moderate these biases. The goals of this study were to examine (a) whether White participants’ fear of racial/ethnic minorities is associated with racial shooting biases, and (b) whether dehumanization and empathy moderate this effect. METHOD: Participants (N = 290) completed a dehumanization implicit association test and simulated shooting task, then reported their fear of racial minorities (i.e., White fear) and empathic ability. RESULTS: We found that (a) individuals high in White fear showed a shooting bias, such that they had a lower threshold for shooting Black relative to White and East Asian targets, (b) Dehumanization moderated the White fear and shooting bias relation, such that individuals high in White fear and high in dehumanization had a significantly more liberal shooting threshold for Black versus White targets, and (c) Empathy moderated the White fear and shooting bias relation, such that people who were high in White fear and low in empathic ability had a more liberal shooting threshold for Black versus White targets. In sum, fearing racial/ethnic minorities can have devastating shooting bias outcomes for Black individuals, but this effect is stronger when people also dehumanize Black individuals, and weaker when people have high empathy. CONCLUSIONS: These findings contribute to the literature by identifying theory driven moderators that identify both risk and protective factors in predicting racial shooting biases. (PsycINFO Database Record

 

Melwani, S., et al. (2012). “Looking down: the influence of contempt and compassion on emergent leadership categorizations.” J Appl Psychol 97(6): 1171-1185.

By integrating the literatures on implicit leadership and the social functions of discrete emotions, we develop and test a theoretical model of emotion expression and leadership categorizations. Specifically, we examine the influence of 2 socio-comparative emotions-compassion and contempt-on assessments of leadership made both in 1st impression contexts and over time. To demonstrate both internal and external validity, Studies 1a and 1b provide laboratory and field evidence to show that expressing the discrete emotions of contempt and compassion positively relates to perceptions that an individual is a leader. Study 2 tests the mechanism explaining these associations. Specifically, we show that in a leadership emergence context, contempt and compassion both positively relate to perceptions that the expresser is a leader because each provides cues matching the implicit theory that leaders have higher intelligence. Our findings add to a growing body of literature focused on identifying the processes through which leaders emerge in groups, showing that emotions are an important input to this process. We discuss the implications of our findings and how they might guide future research efforts.

 

Merino, Y., et al. (2018). “Implicit Bias and Mental Health Professionals: Priorities and Directions for Research.” Psychiatr Serv 69(6): 723-725.

This Open Forum explores the role of implicit bias along the mental health care continuum, which may contribute to mental health disparities among vulnerable populations. Emerging research shows that implicit bias is prevalent among service providers. These negative or stigmatizing attitudes toward population groups are held at a subconscious level and are automatically activated during practitioner-client encounters. The authors provide examples of how implicit bias may impede access to care, clinical screening and diagnosis, treatment processes, and crisis response. They also discuss how implicit attitudes may manifest at the intersection between mental health and criminal justice institutions. Finally, they discuss the need for more research on the impact of implicit bias on health practices throughout the mental health system, including the development of interventions to address implicit bias among mental health professionals.

 

Moskowitz, G. B., et al. (2012). “Implicit stereotyping and medical decisions: unconscious stereotype activation in practitioners’ thoughts about African Americans.” Am J Public Health 102(5): 996-1001.

OBJECTIVES: We investigated whether stereotypes unconsciously influence the thinking and behavior of physicians, as they have been shown to do in other professional settings, such as among law enforcement personnel and teachers. METHODS: We conducted 2 studies to examine whether stereotypes are implicitly activated in physicians. Study 1 assessed what diseases and treatments doctors associate with African Americans. Study 2 presented these (and control terms) to doctors as part of a computerized task. Subliminal images of African American and White men appeared prior to each word, and reaction times to words were recorded. RESULTS: When primed with an African American face, doctors reacted more quickly for stereotypical diseases, indicating an implicit association of certain diseases with African Americans. These comprised not only diseases African Americans are genetically predisposed to, but also conditions and social behaviors with no biological association (e.g., obesity, drug abuse). CONCLUSIONS: We found implicit stereotyping among physicians; faces they never consciously saw altered performance. This suggests that diagnoses and treatment of African American patients may be biased, even in the absence of the practitioner’s intent or awareness.

 

Moss-Racusin, C. A., et al. (2012). “Science faculty’s subtle gender biases favor male students.” Proc Natl Acad Sci U S A 109(41): 16474-16479.

Despite efforts to recruit and retain more women, a stark gender disparity persists within academic science. Abundant research has demonstrated gender bias in many demographic groups, but has yet to experimentally investigate whether science faculty exhibit a bias against female students that could contribute to the gender disparity in academic science. In a randomized double-blind study (n = 127), science faculty from research-intensive universities rated the application materials of a student-who was randomly assigned either a male or female name-for a laboratory manager position. Faculty participants rated the male applicant as significantly more competent and hireable than the (identical) female applicant. These participants also selected a higher starting salary and offered more career mentoring to the male applicant. The gender of the faculty participants did not affect responses, such that female and male faculty were equally likely to exhibit bias against the female student. Mediation analyses indicated that the female student was less likely to be hired because she was viewed as less competent. We also assessed faculty participants’ preexisting subtle bias against women using a standard instrument and found that preexisting subtle bias against women played a moderating role, such that subtle bias against women was associated with less support for the female student, but was unrelated to reactions to the male student. These results suggest that interventions addressing faculty gender bias might advance the goal of increasing the participation of women in science.

 

Moss-Racusin, C. A., et al. (2018). “Reducing STEM gender bias with VIDS (video interventions for diversity in STEM).” J Exp Psychol Appl 24(2): 236-260.

Gender biases contribute to the underrepresentation of women in STEM. In response, the scientific community has called for methods to reduce bias, but few validated interventions exist. Thus, an interdisciplinary group of researchers and filmmakers partnered to create VIDS (Video Interventions for Diversity in STEM), which are short videos that expose participants to empirical findings from published gender bias research in 1 of 3 conditions. One condition illustrated findings using narratives (compelling stories), and the second condition presented the same results using expert interviews (straightforward facts). A hybrid condition included both narrative and expert interview videos. Results of two experiments revealed that relative to controls, VIDS successfully reduced gender bias and increased awareness of gender bias, positive attitudes toward women in STEM, anger, empathy, and intentions to engage in behaviors that promote gender parity in STEM. The narratives were particularly impactful for emotions, while the expert interviews most strongly impacted awareness and attitudes. The hybrid condition reflected the strengths of both the narratives and expert interviews (though effects were sometimes slightly weaker than the other conditions). VIDS produced substantial immediate effects among both men and women in the general population and STEM faculty, and effects largely persisted at follow-up. (PsycINFO Database Record

 

Moss-Racusin, C. A., et al. (2016). “A “Scientific Diversity” Intervention to Reduce Gender Bias in a Sample of Life Scientists.” CBE Life Sci Educ 15(3).

Mounting experimental evidence suggests that subtle gender biases favoring men contribute to the underrepresentation of women in science, technology, engineering, and mathematics (STEM), including many subfields of the life sciences. However, there are relatively few evaluations of diversity interventions designed to reduce gender biases within the STEM community. Because gender biases distort the meritocratic evaluation and advancement of students, interventions targeting instructors’ biases are particularly needed. We evaluated one such intervention, a workshop called “Scientific Diversity” that was consistent with an established framework guiding the development of diversity interventions designed to reduce biases and was administered to a sample of life science instructors (N = 126) at several sessions of the National Academies Summer Institute for Undergraduate Education held nationwide. Evidence emerged indicating the efficacy of the “Scientific Diversity” workshop, such that participants were more aware of gender bias, expressed less gender bias, and were more willing to engage in actions to reduce gender bias 2 weeks after participating in the intervention compared with 2 weeks before the intervention. Implications for diversity interventions aimed at reducing gender bias and broadening the participation of women in the life sciences are discussed.

 

Murrow, G. B. and R. Murrow (2016). “A valid question: Could hate speech condition bias in the brain?” J Law Biosci 3(1): 196-201.

 

Napier, J. L., et al. (2018). “Construing the Essence: The Effects of Construal Level on Genetic Attributions for Individual and Social Group Differences.” Pers Soc Psychol Bull: 146167218768799.

The present research links a nonsocial, contextual influence (construal level) to the tendency to endorse genetic attributions for individual and social group differences. Studies 1 to 3 show that people thinking in an abstract (vs. concrete) mind-set score higher on a measure of genetic attributions for individual and racial group differences. Study 4 showed that abstract (vs. concrete) construal also increased genetic attributions for novel groups. Study 5 explored the potential downstream consequences of construal on intergroup attitudes, and found that abstract (vs. concrete) construal led people to endorse genetic attributions in general and this was associated with increased anti-Black prejudice.

 

Nelson, S. (2016). “Race, Racism, and Health Disparities: What Can I Do About It?” Creat Nurs 22(3): 161-165.

Disparities based on race that target communities of color are consistently reported in the management of many diseases. Barriers to health care equity include the health care system, the patient, the community, and health care providers. This article focuses on the health care system as well as health care providers and how racism and our implicit biases affect our medical decision making. Health care providers receive little or no training on issues of race and racism. As a result, awareness of racism and its impact on health care delivery is low. I will discuss a training module that helps improve awareness around these issues. Until racial issues are honestly addressed by members of the health care team, it is unlikely that we will see significant improvements in racial health care disparities for Americans.

 

Nelson, S. C., et al. (2015). “Training providers on issues of race and racism improve health care equity.” Pediatr Blood Cancer 62(5): 915-917.

Race is an independent factor in health disparity. We developed a training module to address race, racism, and health care. A group of 19 physicians participated in our training module. Anonymous survey results before and after the training were compared using a two-sample t-test. The awareness of racism and its impact on care increased in all participants. White participants showed a decrease in self-efficacy in caring for patients of color when compared to white patients. This training was successful in deconstructing white providers’ previously held beliefs about race and racism.

 

Newheiser, A. K. and J. F. Dovidio (2015). “High outgroup entitativity can inhibit intergroup retribution.” Br J Soc Psychol 54(2): 341-358.

Understanding the psychological processes that are involved in the perpetuation and escalation of intergroup conflict remains an important goal for intergroup relations research. In the present research, we examined perceived outgroup entitativity as a potential determinant of intergroup hostility. In intergroup conflict situations, high-entitative outgroups are perceived as particularly deserving of retribution; however, high-entitative outgroups are also perceived as efficacious and capable of retaliating successfully, suggesting that people may inhibit hostility against high-entitative (vs. low-entitative) outgroups that are in a position to retaliate. We tested this prediction in two studies. In Study 1, we manipulated intergroup provocation and outgroup entitativity, and found that higher negative mood predicted greater aggression against a low-entitative provoker outgroup, but failed to predict aggression against a high-entitative provoker outgroup that was plausibly in a position to retaliate. In Study 2, we held provocation constant while manipulating outgroup entitativity and the possibility of retaliation by the outgroup, and found that people acted in a retributive manner against a high-entitative provoker outgroup only when the outgroup was not in a position to retaliate. Implications for intergroup conflict are discussed.

 

Niemann, Y. F. and J. F. Dovidio (1998). “Relationship of solo status, academic rank, and perceived distinctiveness to job satisfaction of racial/ethnic minorities.” J Appl Psychol 83(1): 55-71.

The relationships among solo status of racial/ethnic minorities in psychology departments, job satisfaction, and subjective feelings of distinctiveness were examined. Distinctiveness was defined as stigmatizing feelings associated with token status of racial/ethnic minorities in academia. It was hypothesized that minorities in positions of solo (relative to nonsolo) status within their departments, members of more stigmatized groups, and minorities occupying lower academic ranks would feel more distinctive and less satisfied with their jobs and that perceptions of distinctiveness would mediate job satisfaction. The data partially supported these hypotheses, most notably for African Americans. The implications of situational salience and the importance of recognizing differences among and between minority groups are considered.

 

Nolan, J., et al. (2014). “Barriers to cervical cancer screening and follow-up care among Black Women in Massachusetts.” J Obstet Gynecol Neonatal Nurs 43(5): 580-588.

OBJECTIVE: To explore factors that might lead to delays in appropriate cervical cancer screening and diagnosis among Black women in Massachusetts. DESIGN: Qualitative using focus groups. SETTING: Hospitals, health centers, and community-based organizations in Boston, Massachusetts. PARTICIPANTS: Sixty-four participants including Black, non-Hispanic women from the general population and cervical cancer survivors, community leaders in women’s health, and health care providers. METHODS: Six focus groups. Data were analyzed using methods based on grounded theory. RESULTS: Findings from interviews revealed that inadequate information and education of providers and patients create barriers to appropriate screening and treatment practices for Black women. Fear, cultural beliefs, and compounding factors related to poverty, gender roles, and health system barriers create delays to screening and follow-up care. Also, unconscious bias, therapeutic delays, and miscommunication are important factors affecting continuity of care. CONCLUSION: These results suggest a need for comprehensive, culturally specific cervical cancer prevention education initiatives and interventions for Black women and strategies to improve patient-provider relationships.

 

Norton, W. E., et al. (2012). “Relative efficacy of a pregnancy, sexually transmitted infection, or human immunodeficiency virus prevention-focused intervention on changing sexual risk behavior among young adults.” J Am Coll Health 60(8): 574-582.

OBJECTIVES: Despite findings suggesting that young adults are more concerned about experiencing an unplanned pregnancy or contracting a sexually transmitted infection (STI) than becoming human immunodeficiency virus (HIV) infected, no empirical work has investigated whether the specific focus of an intervention may be more or less efficacious at changing sexual behavior. PARTICIPANTS: Participants were 198 college students randomized to 1 of 4 conditions: pregnancy intervention, STI intervention, HIV intervention, or a control condition during 2008-2009. METHODS: The authors compared the efficacy of 3 theory-based, sexual risk-reduction interventions that were exactly the same except for an exclusive focus on preventing pregnancy, STI, or HIV. Condom use and risky sexual behavior were assessed at baseline and 4-week and 8-week follow-up. RESULTS: Participants exposed to the pregnancy or STI interventions reported greater condom use and less risky sexual behavior than those exposed to the HIV intervention. CONCLUSIONS: The focus of sexual risk-reduction interventions may lead to differential behavior change among young adults.

 

Oliver, M. N., et al. (2014). “Do physicians’ implicit views of African Americans affect clinical decision making?” J Am Board Fam Med 27(2): 177-188.

BACKGROUND: Total knee replacement (TKR) is a cost-effective treatment option for severe osteoarthritis (OA). While prevalence of OA is higher among blacks than whites, TKR rates are lower among blacks. Physicians’ implicit preferences might explain racial differences in TKR recommendation. The objective of this study was to evaluate whether the magnitude of implicit racial bias predicts physician recommendation of TKR for black and white patients with OA and to assess the effectiveness of a web-based instrument as an intervention to decrease the effect of implicit racial bias on physician recommendation of TKR. METHODS: In this web-based study, 543 family and internal medicine physicians were given a scenario describing either a black or white patient with severe OA refractory to medical treatment. Questionnaires evaluating the likelihood of recommending TKR, perceived medical cooperativeness, and measures of implicit racial bias were administered. The main outcome measures included TKR recommendation, implicit racial preference, and medical cooperativeness stereotypes measured with implicit association tests. RESULTS: Subjects displayed a strong implicit preference for whites over blacks (P < .0001) and associated “medically cooperative” with whites over blacks (P < .0001). Physicians reported significantly greater liking for whites over blacks (P < .0001) and reported believing whites were more medically cooperative than blacks (P < .0001). Participants reported providing similar care for white and black patients (P = .10) but agreed that subconscious biases could influence their treatment decisions (P < .0001). There was no significant difference in the rate of recommendation for TKR when the patient was black (47%) versus white (38%) (P = .439), and neither implicit nor explicit racial biases predicted differential treatment recommendations by race (all P > .06). Although participants were more likely to recommend TKR when completing the implicit association test before the decision, patient race was not significant in the association (P = .960). CONCLUSIONS: Physicians possessed explicit and implicit racial biases, but those biases did not predict treatment recommendations. Clinicians’ biases about the medical cooperativeness of blacks versus whites, however, may have influenced treatment decisions.

 

Pagani, C. and F. Robustelli (2010). “Young people, multiculturalism, and educational interventions for the development of empathy.” Int Soc Sci J 61(200-201): 247-261.

As is maintained in the Seville Statement on Violence, the role of education in shaping human relations is fundamental. In order to develop effective educational interventions aiming to foster empathic relations, some important prerequisites need to be satisfied. One of these prerequisites, which is based on a constructivist model, is constituted by the identification and analysis of the pre-existing concepts and attitudes of those to whom interventions are directed, regarding the specific issues involved in the specific educational process. More effective positive changes can be obtained this way as they are generated from within the individuals themselves. Using this perspective, a study was conducted in Italian schools on the attitudes of young people between 9-18 years of age towards multiculturalism in contemporary society. The participants (N=350, 176 girls and 174 boys) were invited to write down anonymously their thoughts about multiculturalism. Their essays were quantitatively and qualitatively analysed. The aim was to obtain a deep understanding not only of the explicit but also of the implicit meaning of the texts and consequently also of the motivations underlying the participants’ attitudes. Some of the results of this study are discussed and suggestions are made for the development of educational interventions aiming to foster young people’s empathic attitudes.

 

Pearl, R. L. and J. F. Dovidio (2015). “Experiencing weight bias in an unjust world: Impact on exercise and internalization.” Health Psychol 34(7): 741-749.

OBJECTIVE: This research explores the effects of belief in a just world on exercise and psychological well-being among individuals who have experienced weight bias. METHODS: In Study 1, 804 participants in an online study reported belief in a just world; exercise intentions, motivation, self-efficacy, and behavior; experiences with weight bias; and height/weight and self-perceived weight status. In Study 2, 237 participants with overweight and obesity were randomly assigned to read 1 of 2 passages (online) describing weight bias and discrimination as rare versus pervasive, and rated their perceptions of pervasiveness. Participants then read 1 of 3 randomly assigned vignettes that confirmed, challenged, or did not attempt to influence belief in a just world, and completed measures of exercise intentions and motivation, body dissatisfaction, weight bias internalization, and experiences with weight bias. RESULTS: Study 1 revealed that weaker belief in a just world was associated with lower ratings on all exercise variables among participants who reported experiencing weight bias. In Study 2, regression analyses revealed an interaction between ratings of perceived pervasiveness of weight discrimination and the Challenge condition for all outcome measures. The Challenge condition led to lower ratings of exercise intentions and motivation, and higher reports of body dissatisfaction and weight bias internalization, when weight bias was perceived to be more pervasive. CONCLUSION: Threats to belief in a just world may lead to negative outcomes for health behaviors and psychological well-being among individuals who have experienced weight bias and perceive it to be pervasive.

 

Pearl, R. L., et al. (2015). “Exposure to Weight-Stigmatizing Media: Effects on Exercise Intentions, Motivation, and Behavior.” J Health Commun 20(9): 1004-1013.

This study aimed to evaluate the impact of exposure to weight-stigmatizing media on exercise intentions, motivation, and behavior, as well as to examine the interaction between this exposure and past experiences with weight stigma. A community sample of 72 women were randomly assigned to view a brief weight-stigmatizing or neutral video. Participants’ choice of taking the stairs versus the elevator was observed before they completed measures of exercise intentions, motivation, and behavior; psychological well-being; and experiences with weight stigma. A follow-up survey was sent to participants 1 week later that assessed exercise behavior and intentions. Frequency of past weight stigma correlated with worse psychological well-being and more controlled (versus autonomous) exercise motivation. Significant interactions were found between past weight-stigmatizing experiences and exposure to the weight-stigmatizing video for outcomes of exercise intentions, behavior, and drive for thinness. Participants in the stigma condition with higher frequency of past experiences reported greater exercise intentions and behavior, along with higher drive for thinness. Past experiences of weight stigma interact with exposure to weight-stigmatizing media to increase exercise intentions and behavior, although this effect is accompanied by a heightened drive for thinness that may increase risk for long-term negative health consequences.

 

Pearl, R. L., et al. (2015). “Differential effects of weight bias experiences and internalization on exercise among women with overweight and obesity.” J Health Psychol 20(12): 1626-1632.

This study investigated the effects of experiences with weight stigma and weight bias internalization on exercise. An online sample of 177 women with overweight and obesity (M(age) = 35.48 years, M(BMI) = 32.81) completed questionnaires assessing exercise behavior, self-efficacy, and motivation; experiences of weight stigmatization; weight bias internalization; and weight-stigmatizing attitudes toward others. Weight stigma experiences positively correlated with exercise behavior, but weight bias internalization was negatively associated with all exercise variables. Weight bias internalization was a partial mediator between weight stigma experiences and exercise behavior. The distinct effects of experiencing versus internalizing weight bias carry implications for clinical practice and public health.

 

Pearson, A. R., et al. (2008). “The fragility of intergroup relations: divergent effects of delayed audiovisual feedback in intergroup and intragroup interaction.” Psychol Sci 19(12): 1272-1279.

Intergroup interactions between racial or ethnic majority and minority groups are often stressful for members of both groups; however, the dynamic processes that promote or alleviate tension in intergroup interaction remain poorly understood. Here we identify a behavioral mechanism-response delay-that can uniquely contribute to anxiety and promote disengagement from intergroup contact. Minimally acquainted White, Black, and Latino participants engaged in intergroup or intragroup dyadic conversation either in real time or with a subtle temporal disruption (1-s delay) in audiovisual feedback. Whereas intergroup dyads reported greater anxiety and less interest in contact after engaging in delayed conversation than after engaging in real-time conversation, intragroup dyads reported less anxiety in the delay condition than they did after interacting in real time. These findings have theoretical and practical implications for understanding intergroup communication and social dynamics and for promoting positive intergroup contact.

 

Penner, L. A., et al. (2014). “Reducing Racial Health Care Disparities: A Social Psychological Analysis.” Policy Insights Behav Brain Sci 1(1): 204-212.

Large health disparities persist between Black and White Americans. The social psychology of intergroup relations suggests some solutions to health care disparities due to racial bias. Three paths can lead from racial bias to poorer health among Black Americans. First is the already well-documented physical and psychological toll of being a target of persistent discrimination. Second, implicit bias can affect physicians’ perceptions and decisions, creating racial disparities in medical treatments, although evidence is mixed. The third path describes a less direct route: Physicians’ implicit racial bias negatively affects communication and the patient-provider relationship, resulting in racial disparities in the outcomes of medical interactions. Strong evidence shows that physician implicit bias negatively affects Black patients’ reactions to medical interactions, and there is good circumstantial evidence that these reactions affect health outcomes of the interactions. Solutions focused on the physician, the patient, and the health care delivery system; all agree that trying to ignore patients’ race or to change physicians’ implicit racial attitudes will not be effective and may actually be counterproductive. Instead, solutions can minimize the impact of racial bias on medical decisions and on patient-provider relationships.

 

Penner, L. A., et al. (2009). “The Experience of Discrimination and Black-White Health Disparities in Medical Care.” J Black Psychol 35(2).

The current study of Black patients focuses on how discrimination contributes to racial disparities in health. The authors used a longitudinal methodology to study how perceived past discrimination affects reactions to medical interactions and adherence to physician recommendations. In addition, they explored whether these reactions and/or adherence mediate the relationship between discrimination and patients’ health. The participants in this study were 156 Black patients of low socioeconomic status at a primary care clinic. Patients completed questionnaires on their current health, past adherence, and perceived past discrimination. Then, they saw a physician and rated their reactions to the visit. Four and 16 weeks later they reported on their adherence to physician recommendations and overall health. Perceived discrimination was significantly and negatively associated with patient health, reactions to the physician, and adherence. Path analyses indicated that adherence mediated the relationship between discrimination and patient health, but patient reactions to the interaction did not.

 

Penner, L. A., et al. (2016). “The Effects of Oncologist Implicit Racial Bias in Racially Discordant Oncology Interactions.” J Clin Oncol 34(24): 2874-2880.

PURPOSE: Health providers’ implicit racial bias negatively affects communication and patient reactions to many medical interactions. However, its effects on racially discordant oncology interactions are largely unknown. Thus, we examined whether oncologist implicit racial bias has similar effects in oncology interactions. We further investigated whether oncologist implicit bias negatively affects patients’ perceptions of recommended treatments (i.e., degree of confidence, expected difficulty). We predicted oncologist implicit bias would negatively affect communication, patient reactions to interactions, and, indirectly, patient perceptions of recommended treatments. METHODS: Participants were 18 non-black medical oncologists and 112 black patients. Oncologists completed an implicit racial bias measure several weeks before video-recorded treatment discussions with new patients. Observers rated oncologist communication and recorded interaction length of time and amount of time oncologists and patients spoke. Following interactions, patients answered questions about oncologists’ patient-centeredness and difficulty remembering contents of the interaction, distress, trust, and treatment perceptions. RESULTS: As predicted, oncologists higher in implicit racial bias had shorter interactions, and patients and observers rated these oncologists’ communication as less patient-centered and supportive. Higher implicit bias also was associated with more patient difficulty remembering contents of the interaction. In addition, oncologist implicit bias indirectly predicted less patient confidence in recommended treatments, and greater perceived difficulty completing them, through its impact on oncologists’ communication (as rated by both patients and observers). CONCLUSION: Oncologist implicit racial bias is negatively associated with oncologist communication, patients’ reactions to racially discordant oncology interactions, and patient perceptions of recommended treatments. These perceptions could subsequently directly affect patient-treatment decisions. Thus, implicit racial bias is a likely source of racial treatment disparities and must be addressed in oncology training and practice.

 

Penner, L. A., et al. (2016). “An Analysis of Race-related Attitudes and Beliefs in Black Cancer Patients: Implications for Health Care Disparities.” J Health Care Poor Underserved 27(3): 1503-1520.

This research concerned relationships among Black cancer patients’ health care attitudes and behaviors (e.g., adherence, decisional control preferences,) and their race-related attitudes and beliefs shaped by (a) general life experiences (i.e., perceived discrimination, racial identity) and (b) experiences interacting with health care systems (i.e., physician mistrust, suspicion about medical care). Perceived discrimination, racial identity, and medical suspicion correlated weakly with one another; mistrust and suspicion correlated only moderately. Race-related attitudes and beliefs were associated with health care attitudes and behavior, but patterns of association varied. Physician mistrust and medical suspicion each independently correlated with adherence and decisional control preferences, but discrimination only correlated with control preferences. Associations among patients’ different racial attitudes/beliefs are more complex than previously assumed. Interventions that target patient attitudes/beliefs and health care disparities might be more productive if they focus on mistrust or suspicion specific to health care providers/systems and their correlates identified in this study.

 

Penner, L. A., et al. (2005). “Prosocial behavior: multilevel perspectives.” Annu Rev Psychol 56: 365-392.

Current research on prosocial behavior covers a broad and diverse range of phenomena. We argue that this large research literature can be best organized and understood from a multilevel perspective. We identify three levels of analysis of prosocial behavior: (a) the “meso” level–the study of helper-recipient dyads in the context of a specific situation; (b) the micro level–the study of the origins of prosocial tendencies and the sources of variation in these tendencies; and (c) the macro level–the study of prosocial actions that occur within the context of groups and large organizations. We present research at each level and discuss similarities and differences across levels. Finally, we consider ways in which theory and research at these three levels of analysis might be combined in future intra- and interdisciplinary research on prosocial behavior.

 

Penner, L. A., et al. (2010). “Aversive Racism and Medical Interactions with Black Patients: A Field Study.” J Exp Soc Psychol 46(2): 436-440.

Medical interactions between Black patients and nonBlack physicians are usually less positive and productive than same-race interactions. We investigated the role that physician explicit and implicit biases play in shaping physician and patient reactions in racially discordant medical interactions. We hypothesized that whereas physicians’ explicit bias would predict their own reactions, physicians’ implicit bias, in combination with physician explicit (self-reported) bias, would predict patients’ reactions. Specifically, we predicted that patients would react most negatively when their physician fit the profile of an aversive racist (i.e., low explicit-high implicit bias). The hypothesis about the effects of explicit bias on physicians’ reactions was partially supported. The aversive racism hypothesis received support. Black patients had less positive reactions to medical interactions with physicians relatively low in explicit but relatively high in implicit bias than to interactions with physicians who were either (a) low in both explicit and implicit bias, or (b) high in both explicit and implicit bias.

 

Penner, L. A., et al. (2013). “A social psychological approach to improving the outcomes of racially discordant medical interactions.” J Gen Intern Med 28(9): 1143-1149.

BACKGROUND: Medical interactions between Black patients and non-Black physicians are less positive and productive than racially concordant ones and contribute to racial disparities in the quality of health care. OBJECTIVE: To determine whether an intervention based on the common ingroup identity model, previously used in nonmedical settings to reduce intergroup bias, would change physician and patient responses in racially discordant medical interactions and improve patient adherence. IINTERVENTION: Physicians and patients were randomly assigned to either a common identity treatment (to enhance their sense of commonality) or a control (standard health information) condition, and then engaged in a scheduled appointment. DESIGN: Intervention occurred just before the interaction. Patient demographic characteristics and relevant attitudes and/or behaviors were measured before and immediately after interactions, and 4 and 16 weeks later. Physicians provided information before and immediately after interactions. PARTICIPANTS: Fourteen non-Black physicians and 72 low income Black patients at a Family Medicine residency training clinic. MAIN MEASURES: Sense of being on the same team, patient-centeredness, and patient trust of physician, assessed immediately after the medical interactions, and patient trust and adherence, assessed 4 and 16 weeks later. KEY RESULTS: Four and 16 weeks after interactions, patient trust of their physician and physicians in general was significantly greater in the treatment condition than control condition. Sixteen weeks after interactions, adherence was also significantly greater. CONCLUSIONS: An intervention used to reduce intergroup bias successfully produced greater Black patient trust of non-Black physicians and adherence. These findings offer promising evidence for a relatively low-cost and simple intervention that may offer a means to improve medical outcomes of racially discordant medical interactions. However, the sample size of physicians and patients was small, and thus the effectiveness of the intervention should be further tested in different settings, with different populations of physicians and other health outcomes.

 

Penner, L. A., et al. (2013). “Racial Healthcare Disparities: A Social Psychological Analysis.” Eur Rev Soc Psychol 24(1): 70-122.

Around the world, members of racial/ethnic minority groups typically experience poorer health than members of racial/ethnic majority groups. The core premise of this article is that thoughts, feelings, and behaviors related to race and ethnicity play a critical role in healthcare disparities. Social psychological theories of the origins and consequences of these thoughts, feelings, and behaviors offer critical insights into the processes responsible for these disparities and suggest interventions to address them. We present a multilevel model that explains how societal, intrapersonal, and interpersonal factors can influence ethnic/racial health disparities. We focus our literature review, including our own research, and conceptual analysis at the intrapersonal (the race-related thoughts and feelings of minority patients and non-minority physicians) and interpersonal levels (intergroup processes that affect medical interactions between minority patients and non-minority physicians). At both levels of analysis, we use theories of social categorization, social identity, contemporary forms of racial bias, stereotype activation, stigma, and other social psychological processes to identify and understand potential causes and processes of health and healthcare disparities. In the final section, we identify theory-based interventions that might reduce ethnic/racial disparities in health and healthcare.

 

Penner, L. A., et al. (2017). “The impact of Black cancer patients’ race-related beliefs and attitudes on racially-discordant oncology interactions: A field study.” Soc Sci Med 191: 99-108.

OBJECTIVE: Both physician and patient race-related beliefs and attitudes are contributors to racial healthcare disparities, but only the former have received substantial research attention. Using data from a study conducted in the Midwestern US from 2012 to 2014, we investigated whether 114 Black cancer patients’ existing race-related beliefs and attitudes would predict how they and 18 non-Black physicians (medical oncologists) would respond in subsequent clinical interactions. METHOD: At least two days before interacting with an oncologist for initial discussions of treatment options, patients completed measures of perceived past discrimination, general mistrust of physicians, and suspicion of healthcare systems; interactions were video-recorded. Measures from each interaction included patients’ verbal behavior (e.g., level of verbal activity), patients’ evaluations of physicians (e.g., trustworthiness), patients’ perceptions of recommended treatments (e.g., confidence in treatment), physicians’ evaluations of patient personal attributes (e.g., intelligence) and physicians’ expectations for patient treatment success (e.g., adherence). RESULTS: As predicted, patients’ race-related beliefs and attitudes differed in their associations with patient and physician responses to the interactions. Higher levels of perceived past discrimination predicted more patient verbal activity. Higher levels of mistrust also predicted less patient positive affect and more negative evaluations of physicians. Higher levels of suspicion predicted more negative evaluations of physicians and recommended treatments. Stronger patient race-related attitudes were directly or indirectly associated with lower physician perceptions of patient attributes and treatment expectations. CONCLUSION: Results provide new evidence for the role of Black patients’ race-related beliefs and attitudes in racial healthcare disparities and suggest the need to measure multiple beliefs and attitudes to identify these effects.

 

Pereda, B. and M. Montoya (2018). “Addressing Implicit Bias to Improve Cross-cultural Care.” Clin Obstet Gynecol 61(1): 2-9.

Health disparities cluster around race, ethnicity, education, neighborhoods, and income. Systems of exclusion that correlate with social determinants compound the disproportionate burden of poor health experienced by people of color. By 2056, ~50% of the population is expected to fall into categories currently labeled “under-represented minorities” (URMs), primarily African Americans, Latinxs, and American Indians. Although URMs comprise 30% of the general population, only 9% of medical doctors [Association of American Medical Colleges (AAMC)] are URMs. We can lessen the negative effects of implicit bias and minimize inequities and unequal treatment by medical providers with training in cross-disciplinary diversity knowledge and communication skills.

 

Perry, S. P., et al. (2015). “The joint effect of bias awareness and self-reported prejudice on intergroup anxiety and intentions for intergroup contact.” Cultur Divers Ethnic Minor Psychol 21(1): 89-96.

Two correlational studies investigated the joint effect of bias awareness-a new individual difference measure that assesses Whites’ awareness and concern about their propensity to be biased-and prejudice on Whites’ intergroup anxiety and intended intergroup contact. Using a community sample (Study 1), we found the predicted Bias Awareness x Prejudice interaction. Prejudice was more strongly related to interracial anxiety among those high (vs. low) in bias awareness. Study 2 investigated potential behavioral consequences in an important real world context: medical students’ intentions for working primarily with minority patients. Study 2 replicated the Bias Awareness x Prejudice interaction and further demonstrated that interracial anxiety mediated medical students’ intentions to work with minority populations.

 

Phelan, S. M., et al. (2015). “Beliefs about the causes of obesity in a national sample of 4th year medical students.” Patient Educ Couns 98(11): 1446-1449.

OBJECTIVE: Physician knowledge of the complex contributors to obesity varies. We do not know whether today’s medical students are graduating with deep understanding of the causes of obesity. Our objective was to assess beliefs about causes of obesity in a national sample of 4th year medical students. METHOD: We randomly selected 2000 4th year students from a random sample of 50 U.S. medical schools and asked them to rate the importance of several factors as causes of obesity. Of those invited, 1244 (62%) responded. We conducted latent class analysis to identify groups with similar response patterns. RESULTS: Most students demonstrated knowledge that obesity has multiple contributors. Students fell into 1 of 4 classes: (1) more likely to endorse all contributors (28%), (2) more likely to endorse physiological contributors (27%), (3) more likely to endorse behavioral or social contributors (24%), and (4) unlikely to endorse contributors outside of overeating and physical activity (22%). CONCLUSION: Though students were generally aware of multiple causes, there were 4 distinct patterns of beliefs, with implications for patient care. PRACTICE IMPLICATIONS: Targeted interventions may help to improve depth of knowledge about the causes of obesity and lead to more effective care for obese patients.

 

Phelan, S. M., et al. (2017). “Medical School Factors Associated with Changes in Implicit and Explicit Bias Against Gay and Lesbian People among 3492 Graduating Medical Students.” J Gen Intern Med 32(11): 1193-1201.

BACKGROUND: Implicit and explicit bias among providers can influence the quality of healthcare. Efforts to address sexual orientation bias in new physicians are hampered by a lack of knowledge of school factors that influence bias among students. OBJECTIVE: To determine whether medical school curriculum, role modeling, diversity climate, and contact with sexual minorities predict bias among graduating students against gay and lesbian people. DESIGN: Prospective cohort study. PARTICIPANTS: A sample of 4732 first-year medical students was recruited from a stratified random sample of 49 US medical schools in the fall of 2010 (81% response; 55% of eligible), of which 94.5% (4473) identified as heterosexual. Seventy-eight percent of baseline respondents (3492) completed a follow-up survey in their final semester (spring 2014). MAIN MEASURES: Medical school predictors included formal curriculum, role modeling, diversity climate, and contact with sexual minorities. Outcomes were year 4 implicit and explicit bias against gay men and lesbian women, adjusted for bias at year 1. KEY RESULTS: In multivariate models, lower explicit bias against gay men and lesbian women was associated with more favorable contact with LGBT faculty, residents, students, and patients, and perceived skill and preparedness for providing care to LGBT patients. Greater explicit bias against lesbian women was associated with discrimination reported by sexual minority students (b = 1.43 [0.16, 2.71]; p = 0.03). Lower implicit sexual orientation bias was associated with more frequent contact with LGBT faculty, residents, students, and patients (b = -0.04 [-0.07, -0.01); p = 0.008). Greater implicit bias was associated with more faculty role modeling of discriminatory behavior (b = 0.34 [0.11, 0.57); p = 0.004). CONCLUSIONS: Medical schools may reduce bias against sexual minority patients by reducing negative role modeling, improving the diversity climate, and improving student preparedness to care for this population.

 

Phelan, S. M., et al. (2018). “Correction to: Medical School Factors Associated with Changes in Implicit and Explicit Bias Against Gay and Lesbian People among 3492 Graduating Medical Students.” J Gen Intern Med.

Due to a tagging error, two authors were incorrectly listed in indexing systems. Brook W. Cunningham should be B.A. Cunningham and Mark W. Yeazel should be M.W. Yeazel for indexing purposes.

 

Phelan, S. M., et al. (2014). “Implicit and explicit weight bias in a national sample of 4,732 medical students: the medical student CHANGES study.” Obesity (Silver Spring) 22(4): 1201-1208.

OBJECTIVE: To examine the magnitude of explicit and implicit weight biases compared to biases against other groups; and identify student factors predicting bias in a large national sample of medical students. METHODS: A web-based survey was completed by 4,732 1st year medical students from 49 medical schools as part of a longitudinal study of medical education. The survey included a validated measure of implicit weight bias, the implicit association test, and 2 measures of explicit bias: a feeling thermometer and the anti-fat attitudes test. RESULTS: A majority of students exhibited implicit (74%) and explicit (67%) weight bias. Implicit weight bias scores were comparable to reported bias against racial minorities. Explicit attitudes were more negative toward obese people than toward racial minorities, gays, lesbians, and poor people. In multivariate regression models, implicit and explicit weight bias was predicted by lower BMI, male sex, and non-Black race. Either implicit or explicit bias was also predicted by age, SES, country of birth, and specialty choice. CONCLUSIONS: Implicit and explicit weight bias is common among 1st year medical students, and varies across student factors. Future research should assess implications of biases and test interventions to reduce their impact.

 

Phelan, S. M., et al. (2015). “The mixed impact of medical school on medical students’ implicit and explicit weight bias.” Med Educ 49(10): 983-992.

CONTEXT: Health care trainees demonstrate implicit (automatic, unconscious) and explicit (conscious) bias against people from stigmatised and marginalised social groups, which can negatively influence communication and decision making. Medical schools are well positioned to intervene and reduce bias in new physicians. OBJECTIVES: This study was designed to assess medical school factors that influence change in implicit and explicit bias against individuals from one stigmatised group: people with obesity. METHODS: This was a prospective cohort study of medical students enrolled at 49 US medical schools randomly selected from all US medical schools within the strata of public and private schools and region. Participants were 1795 medical students surveyed at the beginning of their first year and end of their fourth year. Web-based surveys included measures of weight bias, and medical school experiences and climate. Bias change was compared with changes in bias in the general public over the same period. Linear mixed models were used to assess the impact of curriculum, contact with people with obesity, and faculty role modelling on weight bias change. RESULTS: Increased implicit and explicit biases were associated with less positive contact with patients with obesity and more exposure to faculty role modelling of discriminatory behaviour or negative comments about patients with obesity. Increased implicit bias was associated with training in how to deal with difficult patients. On average, implicit weight bias decreased and explicit bias increased during medical school, over a period of time in which implicit weight bias in the general public increased and explicit bias remained stable. CONCLUSIONS: Medical schools may reduce students’ weight biases by increasing positive contact between students and patients with obesity, eliminating unprofessional role modelling by faculty members and residents, and altering curricula focused on treating difficult patients.

 

Porcelli, P. and J. H. Kleiger (2016). “The “Feeling of Movement”: Notes on the Rorschach Human Movement Response.” J Pers Assess 98(2): 124-134.

Human movement responses (M) on the Rorschach have been traditionally viewed as lying neither completely in the inkblot (external reality) nor within the subject’s mind (inner world). The authors contend that M is not reducible to the “body that I have” but to the “body that I am,” which is a higher level organization of bottom-up and top-down brain networks, integrating body implicit awareness, psychological functioning, and social cognition. Two sources of evidence suggest the close relationship among M, psychological functions, and brain mechanisms. One comes from meta-analytical evidence supporting the close association between M and higher level cognitive functioning or empathy. The second comes from some preliminary studies showing that M activates brain circuits included in the mirror neuron system (MNS). Two conclusions can be drawn: (a) M is related to the effective use of the mentalization function; and (b) future neuroscientific investigations could lead to an understanding of the neuropsychological mechanisms underlying Rorschach responses and variables.

 

Puumala, S. E., et al. (2016). “The Role of Bias by Emergency Department Providers in Care for American Indian Children.” Med Care 54(6): 562-569.

BACKGROUND: American Indian children have high rates of emergency department (ED) use and face potential discrimination in health care settings. OBJECTIVE: Our goal was to assess both implicit and explicit racial bias and examine their relationship with clinical care. RESEARCH DESIGN: We performed a cross-sectional survey of care providers at 5 hospitals in the Upper Midwest. Questions included American Indian stereotypes (explicit attitudes), clinical vignettes, and the Implicit Association Test. Two Implicit Association Tests were created to assess implicit bias toward the child or the parent/caregiver. Differences were assessed using linear and logistic regression models with a random effect for study site. RESULTS: A total of 154 care providers completed the survey. Agreement with negative American Indian stereotypes was 22%-32%. Overall, 84% of providers had an implicit preference for non-Hispanic white adults or children. Older providers (50 y and above) had lower implicit bias than those middle aged (30-49 y) (P=0.01). American Indian children were seen as increasingly challenging (P=0.04) and parents/caregivers less compliant (P=0.002) as the proportion of American Indian children seen in the ED increased. Responses to the vignettes were not related to implicit or explicit bias. CONCLUSIONS: The majority of ED care providers had an implicit preference for non-Hispanic white children or adults compared with those who were American Indian. Provider agreement with negative American Indian stereotypes differed by practice and respondents’ characteristics. These findings require additional study to determine how these implicit and explicit biases influence health care or outcomes disparities.

 

Ravenell, J. and G. Ogedegbe (2014). “Unconscious bias and real-world hypertension outcomes: advancing disparities research.” J Gen Intern Med 29(7): 973-975.

 

Roberto, C. A., et al. (2012). “Clinical correlates of the weight bias internalization scale in a sample of obese adolescents seeking bariatric surgery.” Obesity (Silver Spring) 20(3): 533-539.

The aim of this study was to evaluate psychometric properties and clinical correlates of the Weight Bias Internalization Scale (WBIS) in a sample of obese adolescents seeking bariatric surgery. Sixty five adolescents enrolled in a bariatric surgery program at a large, urban medical center completed psychiatric evaluations, self-report questionnaires including the WBIS and other measures of psychopathology and physical assessments. The WBIS had high internal consistency (Cronbach’s alpha = 0.92). As in previous research with adults, the one underlying factor structure was replicated and 10 of the original 11 items were retained. The scale had significant partial correlations with depression (r = 0.19), anxiety (r = 0.465), social, and behavioral problems (r = 0.364), quality of life (r = -0.480), and eating (r = 0.579), shape (r = 0.815), and weight concerns (r = 0.545), controlling for BMI. However, WBIS scores did not predict current or past psychiatric diagnosis or treatment or past suicidal ideation. Overall, the WBIS had excellent psychometric properties in a sample of obese treatment-seeking adolescents and correlated significantly with levels of psychopathology. These findings suggest that the WBIS could be a useful tool for healthcare providers to assess internalized weight bias among treatment-seeking obese youth. Assessment of internalized weight bias among this clinical population has the potential to identify adolescents who might benefit from information on coping with weight stigma, which in turn may augment weight loss efforts.

 

Rojas, M., et al. (2017). “An Experimental Study of Implicit Racial Bias in Recognition of Child Abuse.” Am J Health Behav 41(3): 358-367.

OBJECTIVES: We evaluated whether implicit racial bias influences pediatricians’ suspicion of child abuse. METHODS: Child abuse experts developed 9 injury vignettes. Pediatricians (N = 342) were randomly assigned one of 2 versions to rate for suspicion of abuse, with the child’s race in each vignette varying between white and black. Data were collected online and anonymously. RESULTS: There were no statistically significant differences in suspicion for an abuse-related injury based on the race of the child. We adjusted for pediatrician race/ethnicity, years since graduation, location, and gender and did not find race effects. CONCLUSIONS: We demonstrated an experimental approach to study the influence of implicit racial bias on recognition of child abuse. Though we failed to find an effect, it is too early to conclude that none exists. The relationship among human cognition, behavior, and healthcare disparities is complex. Studies are needed that incorporate diverse approaches, clinical contexts and scenarios, patient and physician characteristics, and validated measures if we are to understand how it might be used to reduce healthcare disparities.

 

Sabin, J., et al. (2009). “Physicians’ implicit and explicit attitudes about race by MD race, ethnicity, and gender.” J Health Care Poor Underserved 20(3): 896-913.

Recent reports suggest that providers’ implicit attitudes about race contribute to racial and ethnic health care disparities. However, little is known about physicians’ implicit racial attitudes. This study measured implicit and explicit attitudes about race using the Race Attitude Implicit Association Test (IAT) for a large sample of test takers (N=404,277), including a sub-sample of medical doctors (MDs) (n=2,535). Medical doctors, like the entire sample, showed an implicit preference for White Americans relative to Black Americans. We examined these effects among White, African American, Hispanic, and Asian MDs and by physician gender. Strength of implicit bias exceeded self-report among all test takers except African American MDs. African American MDs, on average, did not show an implicit preference for either Blacks or Whites, and women showed less implicit bias than men. Future research should explore whether, and under what conditions, MDs’ implicit attitudes about race affect the quality of medical care.

 

Sabin, J. A. and A. G. Greenwald (2012). “The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma.” Am J Public Health 102(5): 988-995.

OBJECTIVES: We examined the association between pediatricians’ attitudes about race and treatment recommendations by patients’ race. METHODS: We conducted an online survey of academic pediatricians (n = 86). We used 3 Implicit Association Tests to measure implicit attitudes and stereotypes about race. Dependent variables were recommendations for pain management, urinary tract infections, attention deficit hyperactivity disorder, and asthma, measured by case vignettes. We used correlational analysis to assess associations among measures and hierarchical multiple regression to measure the interactive effect of the attitude measures and patients’ race on treatment recommendations. RESULTS: Pediatricians’ implicit (unconscious) attitudes and stereotypes were associated with treatment recommendations. The association between unconscious bias and patient’s race was statistically significant for prescribing a narcotic medication for pain following surgery. As pediatricians’ implicit pro-White bias increased, prescribing narcotic medication decreased for African American patients but not for the White patients. Self-reported attitudes about race were associated with some treatment recommendations. CONCLUSIONS: Pediatricians’ implicit attitudes about race affect pain management. There is a need to better understand the influence of physicians’ unconscious beliefs about race on pain and other areas of care.

 

Sabin, J. A., et al. (2015). “Clinicians’ Implicit and Explicit Attitudes about Weight and Race and Treatment Approaches to Overweight for American Indian Children.” Child Obes 11(4): 456-465.

PURPOSE: Obesity is one of the most serious health problems among American Indian/Alaska Native (AI/AN) children. We investigated Indian Health Service (IHS) primary care providers’ implicit and explicit attitudes about weight and race and their association with treatment approaches to overweight in children. METHODS: We conducted an online survey of long-term primary care clinicians in two western regions of the IHS. We used the existing Weight Attitude Implicit Association Test (IAT) and developed a new Native American Attitude IAT to measure implicit attitudes. Explicit attitudes about weight and race were assessed through self-report. We assessed self-rated treatment approaches to childhood overweight. We used linear regression models to evaluate the association of attitudes about weight and race with treatment approaches. RESULTS: Our sample included 75 clinicians (56% response rate) who, on average, saw 74 patients per week. Fifty-five percent of clinicians reported that 30-60% of their child and adolescent patients were overweight or obese, and 25% of clinicians reported that 60-100% of their patients were overweight or obese. We found strong implicit bias favoring thin people (Cohen’s d=1.44) and weak implicit bias favoring whites (Cohen’s d=0.35). We found no association between implicit or explicit bias scores and self-reported treatment of childhood overweight. Continuing education on obesity was associated with self-rated success and competence in weight management. CONCLUSIONS: Weight and race bias exists among long-term IHS clinicians, but may not influence treatment approaches for overweight AI/AN children. Further research should assess the effect of clinicians’ attitudes on real-world weight management.

 

Sabin, J. A., et al. (2008). “Physician implicit attitudes and stereotypes about race and quality of medical care.” Med Care 46(7): 678-685.

BACKGROUND: Recent reports speculate that provider implicit attitudes about race may contribute to racial/ethnic health care disparities. OBJECTIVES: We hypothesized that implicit racial bias exists among pediatricians, implicit and explicit measures would differ and implicit measures may be related to quality of care. RESEARCH DESIGN: A single-session, Web survey of academic pediatricians in an urban university measured implicit racial attitudes and stereotypes using a measure of implicit social cognition, the Implicit Association Test (IAT). Explicit (overt) attitudes were measured by self-report. Case vignettes were used to assess quality of care. RESULTS: We found an implicit preference for European Americans relative to African Americans, which was weaker than implicit measures for others in society (mean IAT score = 0.18; P = 0.01; Cohen’s d = 0.41). Physicians held an implicit association between European Americans relative to African Americans and the concept of “compliant patient” (mean IAT score = 0.25; P = 0.001; Cohen’s d = 0.60) and for African Americans relative to European Americans and the concept of “preferred medical care” (mean IAT score =-0.21; P = 0.001; Cohen’s d = 0.64). Medical care differed by patient race in 1 of 4 case vignettes. No significant relationship was found between implicit and explicit measures, or implicit measures and treatment recommendations. CONCLUSIONS: Pediatricians held less implicit race bias compared with other MDs and others in society. Among pediatricians we found evidence of a moderate implicit “perceived patient compliance and race” stereotype. Further research is needed to explore whether physician implicit attitudes and stereotypes about race predict quality of care.

 

Saguy, T. and J. F. Dovidio (2013). “Insecure status relations shape preferences for the content of intergroup contact.” Pers Soc Psychol Bull 39(8): 1030-1042.

Recent work demonstrated that whereas high-status and low-status group members seek to address cross-group commonalities during intergroup contact, members of low-status groups show a greater desire to discuss status differences between the groups. Drawing on social identity theory, the current research investigated the combined influence of status legitimacy and status stability on these contact preferences. In Study 1, perceived stability and perceived legitimacy were measured among members of a high-status ethnic group in Israel. In Study 2, group status, status stability, and status legitimacy were experimentally manipulated in a U.S. sample. Although they generally preferred to discuss commonalities over status differences, across studies high-status group members’ willingness to discuss status differences increased when they perceived the hierarchy as illegitimate but stable. By contrast, low-status group members were particularly inclined to address status differences and least interested in discussing commonalties, when the hierarchy was illegitimate and unstable.

 

Saguy, T., et al. (2008). “Beyond contact: intergroup contact in the context of power relations.” Pers Soc Psychol Bull 34(3): 432-445.

This work investigated how group-based power affects the motivations and preferences that members of advantaged and disadvantaged groups bring to situations of contact. To measure the preferred content of interactions, desires to address particular topics in intergroup contact were assessed for both experimental groups (Study 1) and real groups (Study 2). As predicted, across both studies, the desire to talk about power was greater among members of disadvantaged than of advantaged groups. This difference was mediated by motivation for change in group-based power. Study 2 further demonstrated that more highly identified members of disadvantaged groups wanted to talk about power more. Members of advantaged groups generally preferred to talk about commonalities between the groups more than about group-based power, and this desire was greater with higher levels of identification. However, perceiving that their group’s advantage was illegitimate increased the desire of advantaged group members to address power in intergroup interactions.

 

Saguy, T., et al. (2009). “The irony of harmony: intergroup contact can produce false expectations for equality.” Psychol Sci 20(1): 114-121.

Positive intergroup contact has been a guiding framework for research on reducing intergroup tension and for interventions aimed at that goal. We propose that beyond improving attitudes toward the out-group, positive contact affects disadvantaged-group members’ perceptions of intergroup inequality in ways that can undermine their support for social change toward equality. In Study 1, participants were assigned to either high- or low-power experimental groups and then brought together to discuss either commonalities between the groups or intergroup differences. Commonality-focused contact, relative to difference-focused contact, produced heightened expectations for fair (i.e., egalitarian) out-group behavior among members of disadvantaged groups. These expectations, however, proved unrealistic when compared against the actions of members of the advantaged groups. Participants in Study 2 were Israeli Arabs (a disadvantaged minority) who reported the amount of positive contact they experienced with Jews. More positive intergroup contact was associated with increased perceptions of Jews as fair, which in turn predicted decreased support for social change. Implications for social change are considered.

 

Santry, H. P. and S. M. Wren (2012). “The role of unconscious bias in surgical safety and outcomes.” Surg Clin North Am 92(1): 137-151.

Racial, ethnic, and gender disparities in health outcomes are a major challenge for the US health care system. Although the causes of these disparities are multifactorial, unconscious bias on the part of health care providers plays a role. Unconscious bias occurs when subconscious prejudicial beliefs about stereotypical individual attributes result in an automatic and unconscious reaction and/or behavior based on those beliefs. This article reviews the evidence in support of unconscious bias and resultant disparate health outcomes. Although unconscious bias cannot be entirely eliminated, acknowledging it, encouraging empathy, and understanding patients’ sociocultural context promotes just, equitable, and compassionate care to all patients.

 

Schaa, K. L., et al. (2015). “Genetic counselors’ implicit racial attitudes and their relationship to communication.” Health Psychol 34(2): 111-119.

OBJECTIVE: Implicit racial attitudes are thought to shape interpersonal interactions and may contribute to health-care disparities. This study explored the relationship between genetic counselors’ implicit racial attitudes and their communication during simulated genetic counseling sessions. METHOD: A nationally representative sample of genetic counselors completed a web-based survey that included the Race Implicit Association Test (IAT; Greenwald, McGhee, & Schwartz, 1998; Cooper et al., 2012). A subset of these counselors (n = 67) had participated in an earlier study in which they were video recorded counseling Black, Hispanic, and non-Hispanic White SCs about their prenatal or cancer risks. The counselors’ IAT scores were related to their session communications through robust regression modeling. RESULTS: Genetic counselors showed a moderate to strong pro-White bias on the Race IAT (M = 0.41, SD = 0.35). Counselors with stronger pro-White bias were rated as displaying lower levels of positive affect (p < .05) and tended to use less emotionally responsive communication (p < .10) when counseling minority SCs. When counseling White SCs, pro-White bias was associated with lower levels of verbal dominance during sessions (p < .10). Stronger pro-White bias was also associated with more positive ratings of counselors’ nonverbal effectiveness by White SCs. CONCLUSION: Implicit racial bias is associated with negative markers of communication in minority client sessions and may contribute to racial disparities in processes of care related to genetic services.

 

Schultz, P. L. and J. Baker (2017). “Teaching Strategies to Increase Nursing Student Acceptance and Management of Unconscious Bias.” J Nurs Educ 56(11): 692-696.

BACKGROUND: Medical providers’ unconscious biases may contribute to health disparities. Awareness and self-reflection strategies commonly used to teach cultural competence in academic settings are generally ineffective in reducing unconscious bias or motivating change. METHOD: This article describes the innovative teaching strategies implemented in a graduate setting (N = 75) to increase nursing learners’ acceptance and management of unconscious bias. Strategies used guided the debriefing and feedback that incorporated implicit association testing, interactive audience polling, categorized management strategies, and perspective taking. RESULTS: Strategies resulted in positive learner feedback, including a high likelihood to learn more about unconscious bias, acceptance of unconscious bias influence on health disparities, and importance of using management strategies to address personal bias. CONCLUSION: Increasingly diverse patient populations require nurses who have the skills to understand, assess, and correct unconscious biases. To accomplish this goal, consistent exposure to unconscious bias curricula that includes focused debriefing, feedback, and management strategies is needed at all levels of nursing education. [J Nurs Educ. 2017;56(11):692-696.].

 

Schurz, M., et al. (2018). “Avatars and arrows in the brain: Which question are we asking?” Neuroimage.

There is an ongoing debate about the involvement of Theory of Mind (ToM) processes in Visual Perspective Taking (VPT). In an fMRI study (Schurz et al., 2015), we borrowed the positive features from a novel VPT task – which is widely used in behavioral research – to study previously overlooked experimental factors in neuroimaging studies. However, as Catmur et al. (2016) rightly argue in a comment on our work, our data do not speak strongly to questions discussed in the original behavioral studies, in particular the issue of implicit mentalizing. We appreciate the clarification of these interpretational limitations of our study, but would like to point out differences between questions emerging from behavioral and neuroimaging research on Visual Perspective Taking (VPT). Different from what Catmur et al. (2016) discuss, our study was not intended as a test of implicit mentalizing. In fact, the terms “automatic” and “implicit mentalizing” were never mentioned in our manuscript. Our study addressed a methodological difference between Theory of Mind and VPT research, which we identified in two previous meta-analyses on the topics (Schurz et al., 2013, 2014). With this difference in mind we show that the critical points levelled by Catmur et al. (2016) cease to apply.

 

Schwartz, A. and A. Mazouni (2017). “Medical student, nursing student, and non-health care respondents’ implicit attitudes toward doctors and patients: Development and a pilot study of a new implicit attitudes test (IAT).” PLoS One 12(8): e0183352.

INTRODUCTION: Medical educators have been concerned that medical students may decline in empathy for patients during the course of their training, based on studies measuring clinical empathy using psychometrically strong self-report measures. Clinical empathy is a complex construct, incorporating attitudes toward patients but also other components, such as professional detachment. Triangulation of extant measures with instruments based on nonreactive methods could provide a better understanding of whether and how physician attitudes toward patients may be changing during training. We sought to develop and pilot-test such a nonreactive method. METHODS: We develop variations of an implicit association test (IAT) designed to measure attitudes toward physicians and patients based on speed of reaction to images of actors and positive and negative words. In the IATs, the same actors are photographed as doctors, clinic outpatients, hospitalized inpatients, and as a “general public” control. We examine preliminary evidence for their validity by collecting pilot data from internet participants (not involved in the health professions), medical students, and nursing students. RESULTS: Internet participants (n = 314) and nursing students (n = 31) had more negative associations (IAT scores) with doctors than did medical students (n = 89); nursing students and female internet participants had more positive associations with hospitalized patients than did medical students and male internet participants. Medical students’ associations with hospitalized patients varied by year of training. DISCUSSION: This IAT may provide insight into implicit attitudes among those who enter training for the health profession and changes in those attitudes that may be inculcated during that training.

 

Sealy-Jefferson, S., et al. (2015). “Racial and Ethnic Health Disparities and the Affordable Care Act: a Status Update.” J Racial Ethn Health Disparities 2(4): 583-588.

Persistent racial and ethnic health disparities exist in the USA, despite decades of research and public health initiatives. Several factors contribute to health disparities, including (but not limited to) implicit provider bias, access to health care, social determinants, and biological factors. Disparities in health by race/ethnicity are unacceptable and correctable. The Patient Protection and Affordable Care Act is a comprehensive legislation that is focused on improving health care access, quality, and cost control. This health care reform includes specific provisions which focus on preventive care, the standardized collection of data on race, ethnicity, primary language and disability status, and health information technology. Although some provisions of the Patient Protection and Affordable Care Act have not been implemented, such as funding for the U.S. Public Health Sciences track, which would have addressed the shortage of medical professionals in the USA who are trained to use patient-centered, interdisciplinary, and care coordination approaches, this legislation is still poised to make great strides toward eliminating health disparities. The purpose of this manuscript is to highlight the unprecedented opportunities that exist for the Patient Protection and Affordable Care Act to reduce racial and ethnic disparities in health in the USA.

 

Shapiro, N., et al. (2018). “Implicit Physician Biases in Periviability Counseling.” J Pediatr 197: 109-115 e101.

OBJECTIVE: To assess whether neonatologists show implicit racial and/or socioeconomic biases and whether these are predictive of recommendations at extreme periviability. STUDY DESIGN: A nationwide survey using a clinical vignette of a woman in labor at 23(2/7) weeks of gestation asked physicians how likely they were to recommend intensive vs comfort care. Participants were randomized to 1 of 4 versions of the vignette in which racial and socioeconomic stimuli were varied, followed by 2 implicit association tests (IATs). RESULTS: IATs revealed implicit preferences favoring white (mean IAT score = 0.48, P < .001) and greater socioeconomic status (mean IAT score = 0.73, P < .001). Multivariable linear regression analysis showed that physicians with implicit bias toward greater socioeconomic status were more likely than those without bias to recommend comfort care when presented with a patient of high socioeconomic status (P = .037). No significant effect was seen for implicit racial bias. CONCLUSIONS: Building on previous demonstrations of unconscious racial and socioeconomic biases among physicians and their predictive validity, our results suggest that unconscious socioeconomic bias influences recommendations when counseling at the limits of viability. Physicians who display a negative socioeconomic bias are less likely to recommend resuscitation when counseling women of high socioeconomic status. The influence of implicit socioeconomic bias on recommendations at periviability may influence neonatal healthcare disparities and should be explored in future studies.

 

Shavers, V. L., et al. (2012). “The state of research on racial/ethnic discrimination in the receipt of health care.” Am J Public Health 102(5): 953-966.

OBJECTIVES: We conducted a review to examine current literature on the effects of interpersonal and institutional racism and discrimination occurring within health care settings on the health care received by racial/ethnic minority patients. METHODS: We searched the PsychNet, PubMed, and Scopus databases for articles on US populations published between January 1, 2008 and November 1, 2011. We used various combinations of the following search terms: discrimination, perceived discrimination, race, ethnicity, racism, institutional racism, stereotype, prejudice or bias, and health or health care. Fifty-eight articles were reviewed. RESULTS: Patient perception of discriminatory treatment and implicit provider biases were the most frequently examined topics in health care settings. Few studies examined the overall prevalence of racial/ethnic discrimination and none examined temporal trends. In general, measures used were insufficient for examining the impact of interpersonal discrimination or institutional racism within health care settings on racial/ethnic disparities in health care. CONCLUSIONS: Better instrumentation, innovative methodology, and strategies are needed for identifying and tracking racial/ethnic discrimination in health care settings.

 

Shen, F., et al. (2017). “Racial Bias in Neural Response for Pain Is Modulated by Minimal Group.” Front Hum Neurosci 11: 661.

Whether empathic racial bias could be modulated is a subject of intense interest. The present study was carried out to explore whether empathic racial bias for pain is modulated by minimal group. Chinese/Western faces with neutral expressions receiving painful (needle penetration) or non-painful (Q-tip touch) stimulation were presented. Participants were asked to rate the pain intensity felt by Chinese/Western models of ingroup/outgroup members. Their implicit racial bias were also measured. Two lines of evidence indicated that the anterior cingulate cortex (ACC) was modulated by racial bias: (1) Chinese models elicited stronger activity than Western did in the ACC, and (2) activity in the ACC was modulated by implicit racial bias. Whereas the right anterior insula (rAI) were modulated by ingroup bias, in which ingroup member elicited stronger activity than outgroup member did. Furthermore, activity in the ACC was modulated by activity of rAI (i.e., ingroup bias) in the pain condition, while activity in the rAI was modulated by activity of ACC (i.e., racial bias) in the nopain condition. Our results provide evidence that there are different neural correlates for racial bias and ingroup bias, and neural racial bias for pain can be modulated by minimal group.

 

Sheng, F., et al. (2013). “Oxytocin modulates the racial bias in neural responses to others’ suffering.” Biol Psychol 92(2): 380-386.

The intergroup relationship between a perceiver and a target person influences empathic neural responses to others’ suffering, which are increased for racial in-group members compared to out-group members. The current study investigated whether oxytocin (OT), a neuropeptide that has been linked to empathic concern and in-group favoritism, contributes to the racial bias in empathic neural responses. Event-related brain potentials were recorded in Chinese male adults during race judgments on Asian and Caucasian faces expressing pain or showing a neutral expression after intranasal self-administration of OT or placebo. A fronto-central positive activity at 128-188 ms (P2) was of larger amplitude in response to the pain expressions compared with the neutral expressions of racial in-group members but not of racial out-group members. OT treatment increased this racial in-group bias in neural responses and resulted in its correlation with a positive implicit attitude toward racial in-group members. Our findings suggest that OT interacts with the intergroup relationship to modulate empathic neural responses to others’ suffering.

 

Shin, M. S. (2002). “Redressing wounds: finding a legal framework to remedy racial disparities in medical care.” Calif Law Rev 90(6): 2049-2100.

In recent years, numerous medical studies and reports have documented startling disparities between the health status of African Americans and White Americans. The literature is replete with evidence that one of the main causes of these racial disparities is the different treatment of patients of different racial groups. This Comment addresses the possibility that implicit cognitive bias, in the form of implicit attitudes and stereotypes, significantly contributes to these racial disparities in medical treatment. Finding existing legal frameworks inadequate to address current disparities in health care, this Comment recommends avenues for the reworking of Title VI of the Civil Rights Act of 1964. Specifically, it suggests that disparate-treatment provisions that encompass claims arising from unintentional discrimination should be incorporated into Title VI, and it offers the employment law frameworks of Title VII and the Age Discrimination in Employment Act as models for such reform.

 

Siegelman, J. N., et al. (2016). “Health care disparities education using the implicit association test.” Med Educ 50(11): 1158-1159.

 

Silke, C., et al. (2017). “The predictive effect of empathy and social norms on adolescents’ implicit and explicit stigma responses.” Psychiatry Res 257: 118-125.

Research indicates that adolescents who experience mental health difficulties are frequently stigmatised by their peers. Stigmatisation is associated with a host of negative social and psychological effects, which impacts a young person’s well-being. As a result, the development of effective anti-stigma strategies is considered a major research priority. However, in order to design effective stigma reduction strategies, researchers must be informed by an understanding of the factors that influence the expression of stigma. Although evidence suggests that empathy and social norms have a considerable effect on adolescents’ social attitudes and behaviours, research has yet to examine whether these factors significantly influence adolescents’ responses toward their peers with mental health difficulties. Thus, this study aims to examine whether empathy (cognitive and affective) and peer norms (descriptive and injunctive) influence adolescents’ implicit and explicit stigmatising responses toward peers with mental health problems. A total of 570 (221 male and 348 female; 1 non-specified) adolescents, aged between 13 and 18 years (M = 15.51, SD = 1.13), participated in this research. Adolescents read vignettes describing male/female depressed and ‘typically developing’ peers. Adolescents answered questions assessing their stigmatising responses toward each target, as well as their empathic responding and normative perceptions. A sub-sample of participants (n=173) also completed an IAT assessing their implicit stigmatising responses. Results showed that descriptive norms exerted a substantial effect on adolescents’ explicit responses. Cognitive empathy, affective empathy and injunctive norms exerted more limited effects on explicit responses. No significant effects were observed for implicit stigma. Overall, empathy was found to have limited effects on adolescents’ explicit and implicit stigmatising responses, which may suggest that other contextual variables moderate the effects of dispositional empathy on responding. In conclusion, these findings suggest that tackling the perception of negative descriptive norms may be an effective strategy for reducing explicit stigmatising responses among adolescents.

 

Smith, J. S., et al. (2017). “Categorising intersectional targets: An “either/and” approach to race- and gender-emotion congruity.” Cogn Emot 31(1): 83-97.

Research on the interaction of emotional expressions with social category cues in face processing has focused on whether specific emotions are associated with single-category identities, thus overlooking the influence of intersectional identities. Instead, we examined how quickly people categorise intersectional targets by their race, gender, or emotional expression. In Experiment 1, participants categorised Black and White faces displaying angry, happy, or neutral expressions by either race or gender. Emotion influenced responses to men versus women only when gender was made salient by the task. Similarly, emotion influenced responses to Black versus White targets only when participants categorised by race. In Experiment 2, participants categorised faces by emotion so that neither category was more salient. As predicted, responses to Black women differed from those to both Black men and White women. Thus, examining race and gender separately is insufficient to understanding how emotion and social category cues are processed.

 

Stone, J. and G. B. Moskowitz (2011). “Non-conscious bias in medical decision making: what can be done to reduce it?” Med Educ 45(8): 768-776.

CONTEXT: Non-conscious stereotyping and prejudice contribute to racial and ethnic disparities in health care. Contemporary training in cultural competence is insufficient to reduce these problems because even educated, culturally sensitive, egalitarian individuals can activate and use their biases without being aware they are doing so. However, these problems can be reduced by workshops and learning modules that focus on the psychology of non-conscious bias. THE PSYCHOLOGY OF NON-CONSCIOUS BIAS: Research in social psychology shows that over time stereotypes and prejudices become invisible to those who rely on them. Automatic categorisation of an individual as a member of a social group can unconsciously trigger the thoughts (stereotypes) and feelings (prejudices) associated with that group, even if these reactions are explicitly denied and rejected. This implies that, when activated, implicit negative attitudes and stereotypes shape how medical professionals evaluate and interact with minority group patients. This creates differential diagnosis and treatment, makes minority group patients uncomfortable and discourages them from seeking or complying with treatment. PITFALLS IN CULTURAL COMPETENCE TRAINING: Cultural competence training involves teaching students to use race and ethnicity to diagnose and treat minority group patients, but to avoid stereotyping them by over-generalising cultural knowledge to individuals. However, the Culturally and Linguistically Appropriate Services (CLAS) standards do not specify how these goals should be accomplished and psychological research shows that common approaches like stereotype suppression are ineffective for reducing non-conscious bias. To effectively address bias in health care, training in cultural competence should incorporate research on the psychology of non-conscious stereotyping and prejudice. TRAINING IN IMPLICIT BIAS ENHANCES CULTURAL COMPETENCE: Workshops or other learning modules that help medical professionals learn about non-conscious processes can provide them with skills that reduce bias when they interact with minority group patients. Examples of such skills in action include automatically activating egalitarian goals, looking for common identities and counter-stereotypical information, and taking the perspective of the minority group patient.

 

Sukhera, J., et al. (2017). “The Actual Versus Idealized Self: Exploring Responses to Feedback About Implicit Bias in Health Professionals.” Acad Med.

PURPOSE: Implicit bias can adversely affect health disparities. The implicit association test (IAT) is a prompt to stimulate reflection; however, feedback about bias may trigger emotions that reduce the effectiveness of feedback interventions. Exploring how individuals process feedback about implicit bias may inform bias recognition and management curricula. The authors sought to explore how health professionals perceive the influence of the experience of taking the IAT and receiving their results. METHOD: Using constructivist grounded theory methodology, the authors conducted semistructured interviews with 21 pediatric physicians and nurses at the Schulich School of Medicine and Dentistry, Western University, Ontario, Canada, from September 2015 to November 2016 after they completed the mental illness IAT and received their result. Data were analyzed using constant comparative procedures to work toward axial coding and development of an explanatory theory. RESULTS: When provided feedback about their implicit attitudes, participants described tensions between acceptance and justification, and between how IAT results relate to idealized and actual personal and professional identity. Participants acknowledged desire for change while accepting that change is difficult. Most participants described the experience of taking the IAT and receiving their result as positive, neutral, or interesting. CONCLUSIONS: These findings contribute to emerging understandings of the relationship between emotions and feedback and may offer potential mediators to reconcile feedback that reveals discrepancies between an individual’s actual and idealized identities. These results suggest that reflection informed by tensions between actual and aspirational aspects of professional identity may hold potential for implicit bias recognition and management curricula.

 

Swann, W. B., Jr., et al. (2010). “Dying and killing for one’s group: identity fusion moderates responses to intergroup versions of the trolley problem.” Psychol Sci 21(8): 1176-1183.

Using an intergroup version of the trolley problem, we explored participants’ willingness to sacrifice their lives for their group. In Study 1, Spaniards whose personal identities were fused with their group identity endorsed saving fellow Spaniards by jumping to their deaths in front of a runaway trolley. Studies 2 and 3 showed that the self-sacrificial behaviors of fused Spaniards generalized to saving members of an extended in-group (Europeans) but not members of an out-group (Americans). In Study 4, fused participants endorsed pushing aside a fellow Spaniard who was poised to jump to his death and initiate a chain of events that would lead to the deaths of several terrorists, so that they could commit this act themselves. In all four studies, nonfused participants expressed reluctance to sacrifice themselves, and identification with the group predicted nothing. The nature of identity fusion and its relationship to related constructs are discussed.

 

Teachman, B. A., et al. (2003). “Demonstrations of implicit anti-fat bias: the impact of providing causal information and evoking empathy.” Health Psychol 22(1): 68-78.

Three studies investigated implicit biases, and their modifiability, against overweight persons. In Study 1 (N = 144), the authors demonstrated strong implicit anti-fat attitudes and stereotypes using the Implicit Association Test, despite no explicit anti-fat bias. When participants were informed that obesity is caused predominantly by overeating and lack of exercise, higher implicit bias relative to controls was produced; informing participants that obesity is mainly due to genetic factors did not result in lower bias. In Studies 2A (N = 90) and 2B (N = 63), participants read stories of discrimination against obese persons to evoke empathy. This did not lead to lower bias compared with controls but did produce diminished implicit bias among overweight participants, suggesting an in-group bias.

 

Teal, C. R., et al. (2010). “When best intentions aren’t enough: helping medical students develop strategies for managing bias about patients.” J Gen Intern Med 25 Suppl 2: S115-118.

INTRODUCTION/AIMS: Implicit bias can impact physician-patient interactions, alter treatment recommendations, and perpetuate health disparities. Medical educators need methods for raising student awareness about the impact of bias on medical care. SETTING: Seventy-two third-year medical student volunteers participated in facilitated small group discussions about bias. PROGRAM DESCRIPTION: We tested an educational intervention to promote group-based reflection among medical students about implicit bias. PROGRAM EVALUATION: We assessed how the reflective discussion influenced students’ identification of strategies for identifying and managing their potential biases regarding patients. 67% of the students (n = 48) identified alternate strategies at post-session. A chi-square analysis demonstrated that the distribution of these strategies changed significantly from pre-session to post-session (chi(2)(11) = 27.93, p < 0.01), including reductions in the use of internal feedback and humanism and corresponding increases in the use of reflection, debriefing and other strategies. DISCUSSION: Group-based reflection sessions, with a provocative trigger to foster engagement, may be effective educational tools for fostering shifts in student reflection about bias in encounters and willingness to discuss potential biases with colleagues, with implications for reducing health disparities.

 

Theodoridou, A., et al. (2013). “Men perform comparably to women in a perspective taking task after administration of intranasal oxytocin but not after placebo.” Front Hum Neurosci 7: 197.

Oxytocin (OT) is thought to play an important role in human interpersonal information processing and behavior. By inference, OT should facilitate empathic responding, i.e., the ability to feel for others and to take their perspective. In two independent double-blind, placebo-controlled between-subjects studies, we assessed the effect of intranasally administered OT on affective empathy and perspective taking, whilst also examining potential sex differences (e.g., women being more empathic than men). In study 1, we provided 96 participants (48 men) with an empathy scenario and recorded self-reports of empathic reactions to the scenario, while in study 2, a sample of 120 individuals (60 men) performed a computerized implicit perspective taking task. Whilst results from Study 1 showed no influence of OT on affective empathy, we found in Study 2 that OT exerted an effect on perspective taking ability in men. More specifically, men responded faster than women in the placebo group but they responded as slowly as women in the OT group. We conjecture that men in the OT group adopted a social perspective taking strategy, such as did women in both groups, but not men in the placebo group. On the basis of results across both studies, we suggest that self-report measures (such as used in Study 1) might be less sensitive to OT effects than more implicit measures of empathy such as that used in Study 2. If these assumptions are confirmed, one could infer that OT effects on empathic responses are more pronounced in men than women, and that any such effect is best studied using more implicit measures of empathy rather than explicit self-report measures.

 

Thomas, E. V. (2018). “”Why Even Bother; They Are Not Going to Do It?” The Structural Roots of Racism and Discrimination in Lactation Care.” Qual Health Res 28(7): 1050-1064.

Through semi-structured interviews with 36 International Board Certified Lactation Consultants (IBCLCs) who assist mothers with breastfeeding, this study takes a systematic look at breastfeeding disparities. Specifically, this study documents race-based discrimination against patients in the course of lactation care and links the implicit bias literature to breastfeeding disparities. IBCLCs report instances of race-based discrimination against patients such as unequal care provided to patients of color and overt racist remarks said in front of or behind patient’s backs. This study connects patient discrimination in lactation to institutional inequality and offers suggestions to address these inequities.

 

Troup, L. J., et al. (2016). “An Event-Related Potential Study on the Effects of Cannabis on Emotion Processing.” PLoS One 11(2): e0149764.

The effect of cannabis on emotional processing was investigated using event-related potential paradigms (ERPs). ERPs associated with emotional processing of cannabis users, and non-using controls, were recorded and compared during an implicit and explicit emotional expression recognition and empathy task. Comparisons in P3 component mean amplitudes were made between cannabis users and controls. Results showed a significant decrease in the P3 amplitude in cannabis users compared to controls. Specifically, cannabis users showed reduced P3 amplitudes for implicit compared to explicit processing over centro-parietal sites which reversed, and was enhanced, at fronto-central sites. Cannabis users also showed a decreased P3 to happy faces, with an increase to angry faces, compared to controls. These effects appear to increase with those participants that self-reported the highest levels of cannabis consumption. Those cannabis users with the greatest consumption rates showed the largest P3 deficits for explicit processing and negative emotions. These data suggest that there is a complex relationship between cannabis consumption and emotion processing that appears to be modulated by attention.

 

Turner, R. N., et al. (2007). “Reducing explicit and implicit outgroup prejudice via direct and extended contact: The mediating role of self-disclosure and intergroup anxiety.” J Pers Soc Psychol 93(3): 369-388.

In 4 studies, the authors investigated mediators of the effect of cross-group friendship. In Study 1, cross-group friendship among White elementary school children predicted more positive explicit outgroup attitude toward South Asians, mediated by self-disclosure and intergroup anxiety. In Study 2, cross-group friendship and extended contact among White and South Asian high school students positively predicted explicit outgroup attitude, mediated by self-disclosure and intergroup anxiety. Study 3 replicated these findings in a larger independent sample. In all 3 studies, exposure to the outgroup positively predicted implicit outgroup attitude. Study 4 further showed that self-disclosure improved explicit outgroup attitude via empathy, importance of contact, and intergroup trust. The authors discuss the theoretical and practical implications of these findings, which argue for the inclusion of self-disclosure as a key component of social interventions to reduce prejudice.

 

van den Brink, D., et al. (2012). “Empathy matters: ERP evidence for inter-individual differences in social language processing.” Soc Cogn Affect Neurosci 7(2): 173-183.

When an adult claims he cannot sleep without his teddy bear, people tend to react surprised. Language interpretation is, thus, influenced by social context, such as who the speaker is. The present study reveals inter-individual differences in brain reactivity to social aspects of language. Whereas women showed brain reactivity when stereotype-based inferences about a speaker conflicted with the content of the message, men did not. This sex difference in social information processing can be explained by a specific cognitive trait, one’s ability to empathize. Individuals who empathize to a greater degree revealed larger N400 effects (as well as a larger increase in gamma-band power) to socially relevant information. These results indicate that individuals with high-empathizing skills are able to rapidly integrate information about the speaker with the content of the message, as they make use of voice-based inferences about the speaker to process language in a top-down manner. Alternatively, individuals with lower empathizing skills did not use information about social stereotypes in implicit sentence comprehension, but rather took a more bottom-up approach to the processing of these social pragmatic sentences.

 

Van Ryn, M. (2016). “Avoiding Unintended Bias: Strategies for Providing More Equitable Health Care.” Minn Med 99(2): 40-43, 46.

Research shows that unintentional bias on the part of physicians can influence the way they treat patients from certain racial and ethnic groups. Most physicians are unaware that they hold such biases, which can unknowingly contribute to inequalities in health care delivery. This article explains why a person’s thoughts and behaviors may not align, and provides strategies for preventing implicit biases from interfering with patient care.

 

van Ryn, M., et al. (2011). “The Impact of Racism on Clinician Cognition, Behavior, and Clinical Decision Making.” Du Bois Rev 8(1): 199-218.

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.

 

van Ryn, M., et al. (2015). “Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report.” J Gen Intern Med 30(12): 1748-1756.

BACKGROUND: Physician implicit (unconscious, automatic) bias has been shown to contribute to racial disparities in medical care. The impact of medical education on implicit racial bias is unknown. OBJECTIVE: To examine the association between change in student implicit racial bias towards African Americans and student reports on their experiences with 1) formal curricula related to disparities in health and health care, cultural competence, and/or minority health; 2) informal curricula including racial climate and role model behavior; and 3) the amount and favorability of interracial contact during school. DESIGN: Prospective observational study involving Web-based questionnaires administered during first (2010) and last (2014) semesters of medical school. PARTICIPANTS: A total of 3547 students from a stratified random sample of 49 U.S. medical schools. MAIN OUTCOME(S) AND MEASURE(S): Change in implicit racial attitudes as assessed by the Black-White Implicit Association Test administered during the first semester and again during the last semester of medical school. KEY RESULTS: In multivariable modeling, having completed the Black-White Implicit Association Test during medical school remained a statistically significant predictor of decreased implicit racial bias (-5.34, p </= 0.001: mixed effects regression with random intercept across schools). Students’ self-assessed skills regarding providing care to African American patients had a borderline association with decreased implicit racial bias (-2.18, p = 0.056). Having heard negative comments from attending physicians or residents about African American patients (3.17, p = 0.026) and having had unfavorable vs. very favorable contact with African American physicians (18.79, p = 0.003) were statistically significant predictors of increased implicit racial bias. CONCLUSIONS: Medical school experiences in all three domains were independently associated with change in student implicit racial attitudes. These findings are notable given that even small differences in implicit racial attitudes have been shown to affect behavior and that implicit attitudes are developed over a long period of repeated exposure and are difficult to change.

 

van Ryn, M., et al. (2014). “Psychosocial predictors of attitudes toward physician empathy in clinical encounters among 4732 1st year medical students: a report from the CHANGES study.” Patient Educ Couns 96(3): 367-375.

OBJECTIVE: Medical school curricula intended to promote empathy varies widely. Even the most effective curricula leave a significant group of students untouched. Pre-existing student factors influence their response to learning experiences. We examined the individual predictors of first semester medical students’ attitudes toward the value of physician empathy in clinical encounters. METHODS: First year students (n=4732) attending a stratified random sample of 49 US medical schools completed an online questionnaire that included measures of dispositional characteristics, attitudes and beliefs, self-concept and well-being. RESULTS: Discomfort with uncertainty, close-mindedness, dispositional empathy, elitism, medical authoritarianism, egalitarianism, self-concept and well-being all independently predicted first year medical students’ attitudes toward the benefit of physician empathy in clinical encounters. CONCLUSION: Students vary on their attitude toward the value of physician empathy when they start medical school. The individual factors that predict their attitudes toward empathy may also influence their response to curricula promoting empathic care. PRACTICE IMPLICATIONS: Curricula in medical school promoting empathic care may be more universally effective if students’ preexisting attitudes are taken into account. Messages about the importance of physician empathy may need to be framed in ways that are consistent with the beliefs and prior world-views of medical students.

 

van Ryn, M. and S. Saha (2011). “Exploring unconscious bias in disparities research and medical education.” JAMA 306(9): 995-996.

 

Vial, A. C., et al. (2018). “Differential support for female supervisors among men and women.” J Appl Psychol 103(2): 215-227.

Two studies evaluated the lay belief that women feel particularly negatively about other women in the workplace and particularly in supervisory roles. The authors tested the general proposition, derived from social identity theory (Tajfel & Turner, 1979, 2004), that women, compared to men, may be more supportive of other women in positions of authority, whereas men would respond more favorably to other men than to women in positions of authority. Consistent with predictions, data from an online experiment (n = 259), in which the authors randomly assigned men and women to evaluate identical female (vs. male) supervisors in a masculine industry, and a correlational study in the workplace using a Knowledge Networks sample (n = 198) converged to demonstrate a pattern of gender in-group favoritism. Specifically, in Study 1, female participants (vs. male participants) rated the female supervisor as higher status, were more likely to believe that a female supervisor had attained her supervisory position because of high competence, and viewed the female supervisor as warmer. Study 2 results replicated this pattern. Female employees (vs. male employees) rated their female supervisors as higher status and practiced both in-role and extra-role behaviors more often when their supervisor was female. In both studies, male respondents had a tendency to rate male supervisors more favorably than female supervisors, whereas female respondents tended to rate female supervisors more favorably than male supervisors. Thus, across both studies, the authors found a pattern consistent with gender in-group favoritism and inconsistent with lay beliefs that women respond negatively to women in authority positions. (PsycINFO Database Record

 

von Hippel, W., et al. (2008). “Implicit prejudice toward injecting drug users predicts intentions to change jobs among drug and alcohol nurses.” Psychol Sci 19(1): 7-11.

The meaning and importance of implicit prejudice is a source of considerable debate. One way to advance this debate is to assess whether implicit prejudice can predict independent variance, beyond that predicted by explicit prejudice, in meaningful and unambiguous behaviors or behavioral intentions. In the current research, drug and alcohol nurses reported their level of stress working with injecting drug users, their job satisfaction, their explicit prejudice toward injecting drug users, and their intentions to leave drug and alcohol nursing. The nurses also completed the Single Category Implicit Association Test, which measured their implicit prejudice toward injecting drug users. Analyses revealed that implicit prejudice was a significant mediator, beyond explicit prejudice and job satisfaction, of the relation between job stress and intention to change jobs.

 

Wahls, W. P. (2018). “The NIH must reduce disparities in funding to maximize its return on investments from taxpayers.” Elife 7.

New data from the NIH reveal that the scientific return on its sponsored research reaches a maximum at around $400,000 of annual support per principal investigator. We discuss the implications of this ‘sweet spot’ for funding policy, and propose that the NIH should limit both the minimum and maximum amount of funding per researcher.

 

Wang, K. and J. F. Dovidio (2011). “Disability and autonomy: priming alternative identities.” Rehabil Psychol 56(2): 123-127.

OBJECTIVE: Despite the broad stigmatization that people with disabilities experience, the ways they respond as targets of prejudice have received little attention in the psychological literature. The present study examined the reactions of college students with disabilities to being primed with different aspects of their identity and how individual differences in stigma consciousness moderate this effect. DESIGN: After being primed with their identity as a person with a disability or a student, college students with disabilities (n = 116) completed measures of autonomy-related thoughts, help-seeking, and stigma consciousness. RESULTS: Students primed with their disability status activated autonomy-related thoughts less than the participants primed with their student identity. Moreover, as predicted, the priming manipulation had a stronger impact for participants higher in stigma consciousness. Across all participants, greater activation of autonomy-related thoughts was associated with a lower likelihood of seeking help. CONCLUSION: Depending on the aspect of their identity that is most salient in a given context and their level of stigma consciousness, people with disabilities can access autonomy-related thoughts to a greater or lesser extent. The theoretical and practical implications of these findings are discussed.

 

Wang, K. and J. F. Dovidio (2017). “Perceiving and Confronting Sexism: The Causal Role of Gender Identity Salience.” Psychol Women Q 41(1): 65-76.

Although many researchers have explored the relations among gender identification, discriminatory attributions, and intentions to challenge discrimination, few have examined the causal impact of gender identity salience on women’s actual responses to a sexist encounter. In the current study, we addressed this question by experimentally manipulating the salience of gender identity and assessing its impact on women’s decision to confront a sexist comment in a simulated online interaction. Female participants (N = 114) were randomly assigned to complete a short measure of either personal or collective self-esteem, which was designed to increase the salience of personal versus gender identity. They were then given the opportunity to confront a male interaction partner who expressed sexist views. Compared to those who were primed to focus on their personal identity, participants who were primed to focus on their gender identity perceived the interaction partner’s remarks as more sexist and were more likely to engage in confrontation. By highlighting the powerful role of subtle contextual cues in shaping women’s perceptions of, and responses to, sexism, our findings have important implications for the understanding of gender identity salience as an antecedent of prejudice confrontation. Online slides for instructors who want to use this article for teaching are available on PWQ’s website at http://journals.sagepub.com/page/pwq/suppl/index.

 

Weech-Maldonado, R., et al. (2018). “Hospital cultural competency as a systematic organizational intervention: Key findings from the national center for healthcare leadership diversity demonstration project.” Health Care Manage Rev 43(1): 30-41.

BACKGROUND: Cultural competency or the ongoing capacity of health care systems to provide for high-quality care to diverse patient populations (National Quality Forum, 2008) has been proposed as an organizational strategy to address disparities in quality of care, patient experience, and workforce representation. But far too many health care organizations still do not treat cultural competency as a business imperative and driver of strategy. PURPOSES: The aim of the study was to examine the impact of a systematic, multifaceted, and organizational level cultural competency initiative on hospital performance metrics at the organizational and individual levels. METHODOLOGY/APPROACH: This demonstration project employs a pre-post control group design. Two hospital systems participated in the study. Within each system, two hospitals were selected to serve as the intervention and control hospitals. Executive leadership (C-suite) and all staff at one general medical/surgical nursing unit at the intervention hospitals experienced a systematic, planned cultural competency intervention. Assessments and interventions focused on three organizational level competencies of cultural competency (diversity leadership, strategic human resource management, and patient cultural competency) and three individual level competencies (diversity attitudes, implicit bias, and racial/ethnic identity status). In addition, we evaluated the impact of the intervention on diversity climate and workforce diversity. FINDINGS: Overall performance improvement was greater in each of the two intervention hospitals than in the control hospital within the same health care system. Both intervention hospitals experienced improvements in the organizational level competencies of diversity leadership and strategic human resource management. Similarly, improvements were observed in the individual level competencies for diversity attitudes and implicit bias for Blacks among the intervention hospitals. Furthermore, intervention hospitals outperformed their respective control hospitals with respect to diversity climate. PRACTICE IMPLICATIONS: A focused and systematic approach to organizational change when coupled with interventions that encourage individual growth and development may be an effective approach to building culturally competent health care organizations.

 

White-Davis, T., et al. (2018). “Addressing Racism in Medical Education An Interactive Training Module.” Fam Med 50(5): 364-368.

BACKGROUND AND OBJECTIVES: Education of health care clinicians on racial and ethnic disparities has primarily focused on emphasizing statistics and cultural competency, with minimal attention to racism. Learning about racism and unconscious processes provides skills that reduce bias when interacting with minority patients. This paper describes the responses to a relationship-based workshop and toolkit highlighting issues that medical educators should address when teaching about racism in the context of pernicious health disparities. METHODS: A multiracial, interdisciplinary team identified essential elements of teaching about racism. A 1.5-hour faculty development workshop consisted of a didactic presentation, a 3-minute video vignette depicting racial and gender microaggression within a hospital setting, small group discussion, large group debrief, and presentation of a toolkit. RESULTS: One hundred twenty diverse participants attended the workshop at the 2016 Society of Teachers of Family Medicine Annual Spring Conference. Qualitative information from small group facilitators and large group discussions identified some participants’ emotional reactions to the video including dismay, anger, fear, and shame. A pre/postsurvey (N=72) revealed significant changes in attitude and knowledge regarding issues of racism and in participants’ personal commitment to address them. DISCUSSION: Results suggest that this workshop changed knowledge and attitudes about racism and health inequities. Findings also suggest this workshop improved confidence in teaching learners to reduce racism in patient care. The authors recommend that curricula continue to be developed and disseminated nationally to equip faculty with the skills and teaching resources to effectively incorporate the discussion of racism into the education of health professionals.

 

White-Means, S., et al. (2009). “Cultural competency, race, and skin tone bias among pharmacy, nursing, and medical students: implications for addressing health disparities.” Med Care Res Rev 66(4): 436-455.

The Institute of Medicine report, Unequal Treatment, asserts that conscious and unconscious bias of providers may affect treatments delivered and contribute to health disparities. The primary study objective is to measure, compare, and contrast objective and subjective cognitive processes among pharmacy, nursing, and medical students to discern potential implications for health disparities. Data were collected using a cultural competency questionnaire and two implicit association tests (IATs). Race and skin tone IATs measure unconscious bias. Cultural competency scores were significantly higher for non-Hispanic Blacks and Hispanics in medicine and pharmacy compared with non-Hispanic Whites. Multiracial nursing students also had significantly higher cultural competency scores than non-Hispanic Whites. The IAT results indicate that these health care preprofessionals exhibit implicit race and skin tone biases: preferences for Whites versus Blacks and light skin versus dark skin. Cultural competency curricula and disparities research will be advanced by understanding the factors contributing to cultural competence and bias.

 

White, A. A., 3rd, et al. (2018). “Self-Awareness and Cultural Identity as an Effort to Reduce Bias in Medicine.” J Racial Ethn Health Disparities 5(1): 34-49.

In response to persistently documented health disparities based on race and other demographic factors, medical schools have implemented “cultural competency” coursework. While many of these courses have focused on strategies for treating patients of different cultural backgrounds, very few have addressed the impact of the physician’s own cultural background and offered methods to overcome his or her own unconscious biases. In hopes of training physicians to contextualize the impact of their own cultural background on their ability to provide optimal patient care, the authors created a 14-session course on culture, self-reflection, and medicine. After completing the course, students reported an increased awareness of their blind spots and that providing equitable care and treatment would require lifelong reflection and attention to these biases. In this article, the authors describe the formation and implementation of a novel medical school course on self-awareness and cultural identity designed to reduce unconscious bias in medicine. Finally, we discuss our observations and lessons learned after more than 10 years of experience teaching the course.

 

White, A. A., 3rd and B. Stubblefield-Tave (2017). “Some Advice for Physicians and Other Clinicians Treating Minorities, Women, and Other Patients at Risk of Receiving Health Care Disparities.” J Racial Ethn Health Disparities 4(3): 472-479.

Studies of inequalities in health care have documented 13 groups of patients who receive disparate care. Disparities are partly due to socioeconomic factors, but nonsocioeconomic factors also play a large contributory role. This article reviews nonsocioeconomic factors, including unconscious bias, stereotyping, racism, gender bias, and limited English proficiency. The authors discuss the clinician’s role in addressing these factors and reducing their impact on the quality of health care. They indicate the significance of cultural humility on the part of caregivers as a means of amelioration. Based on a review of the clinician’s role as well as background considerations in the health care environment, the authors put forward a set of 18 recommendations in the form of a checklist. They posit that implementing these recommendations as part of the patient clinician interaction will maximize the delivery of equitable care, even in the absence of desirable in-depth cross-cultural and psychosocial literacy on the part of the clinician. Trust, mutual respect, and understanding on the part of the caregiver and patient are crucial to optimizing therapeutic outcomes. The guidelines incorporated here are tools to furthering this goal.

 

Whitford, D. K. and A. M. Emerson (2018). “Empathy Intervention to Reduce Implicit Bias in Pre-Service Teachers.” Psychol Rep: 33294118767435.

There have been long-term concerns regarding discriminatory discipline practices used with culturally and linguistically diverse students, with little research on the impact teacher-centered empathy interventions may have on this population. This randomized pretest-posttest control group design investigates the ability of a brief empathy-inducing intervention to improve the implicit bias of pre-service teachers, as measured by the Implicit Association Test. We found the empathy intervention statistically significant at decreasing the implicit bias of White female pre-service teachers toward Black individuals ( F = 7.55, eta(2) = 0.22, p = 0.01). Implications and future research are discussed, including extended intervention periods.

 

Williams, D. R. and T. D. Rucker (2000). “Understanding and addressing racial disparities in health care.” Health Care Financ Rev 21(4): 75-90.

Racial disparities in medical care should be understood within the context of racial inequities in societal institutions. Systematic discrimination is not the aberrant behavior of a few but is often supported by institutional policies and unconscious bias based on negative stereotypes. Effectively addressing disparities in the quality of care requires improved data systems, increased regulatory vigilance, and new initiatives to appropriately train medical professionals and recruit more providers from disadvantaged minority backgrounds. Identifying and implementing effective strategies to eliminate racial inequities in health status and medical care should be made a national priority.

 

Williams, R. M. (2016). “Addressing Implicit Bias: Leading by Example.” Acad Med 91(2): 163.

 

Zestcott, C. A., et al. (2016). “Examining the Presence, Consequences, and Reduction of Implicit Bias in Health Care: A Narrative Review.” Group Process Intergroup Relat 19(4): 528-542.

Recent evidence suggests that one possible cause of disparities in health outcomes for stigmatized groups is the implicit biases held by health care providers. In response, several health care organizations have called for, and developed, new training in implicit bias for their providers. This review examines current evidence on the role that provider implicit bias may play in health disparities, and whether training in implicit bias can effectively reduce the biases that providers exhibit. Directions for future research on the presence and consequences of provider implicit bias, and best practices for training to reduce such bias, will be discussed.