Empathic Communication and Implicit Bias in the Context of Cancer Among a Medical Student Sample.

Oncology clinicians often miss opportunities to communicate empathy to patients. The current study examined the relationship between implicit bias (based on cancer type and ethnicity) and medical students' empathic communication in encounters with standardized patients who presented as Hispanic (lung or colorectal) individuals diagnosed with cancer. Participants (101 medical students) completed the Implicit Association Test (IAT) to measure implicit bias based on cancer type (lung v. colorectal) and ethnicity (Hispanic v. non-Hispanic White). Empathic opportunities and responses (assessed by the Empathic Communication Coding System; ECCS) were evaluated in a mock consultation (Objective Structured Clinical Examination; OSCE) focused on smoking cessation in the context of cancer. Among the 241 empathic opportunities identified across the 101 encounters (M = 2.4), 158 (65.6%) received high empathy responses from the medical students. High empathy responses were most frequently used during challenge (73.2%) and emotion (77.3%) opportunities compared to progress (45.9%) opportunities. Higher levels of implicit bias against Hispanics predicted lower odds of an empathic response from the medical student (OR = 3.24, p = .04, 95% CI = 0.09-0.95). Further work is needed to understand the relationship between implicit bias and empathic communication and inform the development of interventions.

Investigating the Relationship between Resident Physician Implicit Bias and Language Use during a Clinical Encounter with Hispanic Patients.

Prior research suggests that the implicit biases of physicians are negatively associated with quality of medical care and patient satisfaction among minority patients. However, relatively little is known about how physicians express these subtle forms of bias in patient interactions. This study examined the implicit and explicit anti-Hispanic biases of 53 resident physicians and the relationship between anti-Hispanic bias and language use during outpatient medical appointments with 291 Hispanic patients. Physician implicit bias was positively associated with use of interrogatives and work-related words and negatively associated with the use of prepositions and relativity-related words (e.g., words related to time and the future). These findings contribute to the growing body of evidence suggesting that, in addition to nonverbal and paraverbal behaviors, providers may communicate implicit bias to patients through the words they use during a clinical visit.

Development of a Multicomponent Intervention to Decrease Racial Bias Among Healthcare Staff.

BACKGROUND: Real or perceived discrimination contributes to lower quality of care for Black compared to white patients. Some forms of discrimination come from non-physician and non-nursing (non-MD/RN) staff members (e.g., receptionists). METHODS: Utilizing the Burgess Model as a framework for racial bias intervention development, we developed an online intervention with five, 30-min modules: (1) history and effects of discrimination and racial disparities in healthcare, (2) implicit bias and how it may influence interactions with patients, (3) strategies to handle stress at work, (4) strategies to improve communication and interactions with patients, and (5) personal biases. Modules were designed to increase understanding of bias, enhance internal motivation to overcome bias, enhance emotional regulation skills, and increase empathy in patient interactions. Participants were non-MD/RN staff in nine primary care clinics. Effectiveness of the intervention was assessed using Implicit Association Test and Symbolic Racism Scale, to measure implicit and explicit racial bias, respectively, before and after the intervention. Acceptability was assessed through quantitative and qualitative feedback. RESULTS: Fifty-eight non-MD/RN staff enrolled. Out of these, 24 completed pre- and post-intervention assessments and were included. Among participants who reported characteristics, most were Black, with less than college education and average age of 43.2 years. The baseline implicit bias d-score was 0.22, indicating slight pro-white bias. After the intervention, the implicit bias score decreased to -0.06 (p=0.01), a neutral score indicating no pro-white or Black bias. Participant rating of the intervention, scored from 1 (strongly disagree) to 5 (strongly agree), for questions including whether "it was made clear how to apply the presented content in practice" and "this module was worth the time spent" was ≥4.1 for all modules. CONCLUSIONS: There was a decrease in implicit pro-white bias after, compared with before, the intervention. Intervention materials were highly rated.

Implicit biases in healthcare: implications and future directions for gynecologic oncology.

Health disparities have been found among patients with gynecologic cancers, with the greatest differences arising among groups based on racial, ethnic, and socioeconomic factors. Although there may be multiple social barriers that can influence health disparities, another potential influence may stem from healthcare system factors that unconsciously perpetuate bias toward patients who are racially and socioeconomically disadvantaged. More recent research suggested that providers hold these implicit biases (automatic and unconscious attitudes) for stigmatized populations with cancer, with emerging evidence for patients with gynecologic cancer. These implicit biases may guide providers' communication and medical judgments, which, in turn, may influence the patient's satisfaction with and trust in the provider. This narrative review consolidated the current research on implicit bias in healthcare, with a specific emphasis on oncology professionals, and identified future areas of research for examining and changing implicit biases in the field of gynecologic oncology.

The Relationship Between Racial Prejudice and Cardiovascular Disease Mortality Risk at the State and County Level.

BACKGROUND: Robust evidence shows that perceived discrimination among stigmatized groups is associated with negative health outcomes. However, little work has examined whether holding prejudiced attitudes toward others is associated with health risks for prejudiced individuals. PURPOSE: The study is a test of the hypothesis that holding prejudicial attitudes has negative health implications for both the holders and targets of prejudicial attitudes. METHODS: The project connected data (2003-2015) at the state and county levels on average explicit and implicit prejudice held by White, Black, and Native American respondents from Project Implicit with data on cardiovascular disease (CVD) mortality for White, Black, and Native American individuals from the CDC Wonder database. Separate analyses regressed implicit and explicit prejudice on CVD mortality risk for White, Black, and Native American individuals, respectively. RESULTS: At the state level, among White individuals, explicit prejudice toward Blacks (ß = .431, p =.037) and implicit prejudice toward Native Americans (ß = .283, p = .045) were positively associated with greater CVD mortality for Whites. At the county level, White individuals' implicit prejudice toward Blacks (ß =.081, p = .015) and Black individuals' implicit prejudice toward Whites (ß = -.066, p = .018) were associated with greater CVD mortality for Whites. Also, at the county-level, among Black individuals, higher implicit (ß = -.133, p < .001) and explicit (ß = -.176, p < .001) prejudice toward Whites predicted CVD mortality for Blacks. Moreover, explicit prejudice held by White individuals was positively associated with Blacks' county-level CVD deaths (ß = .074, p = .036). CONCLUSIONS: This evidence suggests that across racial groups, holding racial prejudice is associated with CVD mortality risk for both the prejudiced and the stigmatized groups. Future research should verify the reliability of this potential public health effect with additional work explicating moderators and mediators to inform surveillance and interventions.

Clinician Practice Patterns That Result in the Diagnosis of Coccidioidomycosis Before or During Hospitalization.

BACKGROUND: Coccidioidomycosis (CM) is common and important within endemic regions, requiring specific testing for diagnosis. Long delays in diagnosis have been ascribed to ambulatory clinicians. However, how their testing practices have impacted patient care has not been systematically unexplored. METHODS: We analyzed practice patterns for CM diagnoses over 3 years within a large Arizona healthcare system, including diagnosis location, patient characteristics, and care-seeking patterns associated with missed diagnosis. RESULTS: For 2043 CM diagnoses, 72.9% were made during hospital admission, 21.7% in ambulatory clinics, 3.2% in emergency units, and only 0.5% in urgent care units. A 40.6% subgroup of hospitalized patients required neither intensive care unit or hospital-requiring procedures, had a median length of stay of only 3 days, but still incurred both substantial costs ($27.0 million) and unnecessary antibiotic administrations. Prior to hospital diagnosis (median of 32 days), 45.1% of patients had 1 or more visits with symptoms consistent with CM. During those visits, 71.3% were not tested for CM. Diagnoses were delayed a median of 27 days. CONCLUSIONS: Lack of testing for CM in ambulatory care settings within a region endemic for CM resulted in a large number of hospital admissions, attendant costs, and unneeded antibacterial drug use, much of which would otherwise be unnecessary. Improving this practice is challenging since many clinicians did not train where CM is common, resulting in significant inertia to change. Determining the best way to retrain clinicians to diagnose CM earlier is an opportunity to explore which strategies might be the most effective.

Applied Racial/Ethnic Healthcare Disparities Research Using Implicit Measures.

Many healthcare disparities studies use the Implicit Association Test (IAT) to assess bias. Despite ongoing controversy around the IAT, its use has enabled researchers to reliably document an association between provider implicit prejudice and provider-to-patient communication (provider communication behaviors and patient reactions to them). Success in documenting such associations is likely due to the outcomes studied, study settings, and data structure unique to racial/ethnic healthcare disparities research. In contrast, there has been little evidence supporting the role of providers' implicit bias in treatment recommendations. Researchers are encouraged to use multiple implicit measures to further investigate how, why, and under what circumstances providers' implicit bias predicts provider-to-patient communication and treatment recommendations. Such efforts will contribute to the advancement of both basic social psychology/social cognition research and applied health disparities research: a better understanding of implicit social cognition and a more comprehensive identification of the sources of widespread racial/ethnic healthcare disparities, respectively.

Implicit bias toward cervical cancer: Provider and training differences.

OBJECTIVE: Implicit prejudice and stereotyping may exist in health care providers automatically without their awareness. These biases can correlate with outcomes that are consequential for the patient. This study examined gynecologic oncology care providers' implicit prejudice and stereotyping toward cervical cancer. METHODS: Members of professional gynecologic oncology organizations were asked to complete two Implicit Association Tests to determine if they implicitly associate cervical cancer with feelings of anger (prejudice) and beliefs about culpability for the disease (stereotypes), compared to ovarian cancer. Linear models and Student t-tests examined average levels of implicit bias and moderators of the implicit bias effects. RESULTS: One-hundred seventy-six (132 female, 43 male, 1 nonresponse; X¯age = 39.18 years, SDage = 10.58 years) providers were recruited and the final sample included 151 participants (93 physicians and 58 nurses, X¯age = 38.93, SDage = 10.59). Gynecologic oncology providers showed significant levels of implicit prejudice, X¯â€¯= 0.17, SD = 0.47, 95% CI: (0.10, 0.25), toward cervical cancer patients. They also showed significant levels of implicit stereotyping of cervical cancer patients, X¯â€¯= 0.15, SD = 0.42, 95% CI: (0.08, 0.21). Whereas physicians did not demonstrate significant levels of implicit bias, nurses demonstrated greater levels of implicit prejudice and implicit stereotyping. Providers without cultural competency/implicit bias training demonstrated greater bias than those who had completed such training (p < .05). CONCLUSIONS: This study provides the first evidence that gynecologic oncology providers hold implicit biases related to cervical cancer. Interventions may be designed to target specific groups in gynecologic oncology to improve interactions with patients.

Exploring the Association of Healthcare Worker Race and Occupation with Implicit and Explicit Racial Bias.

BACKGROUND: Racial bias is associated with suboptimal healthcare treatment for minorities. Research focuses on bias among physicians rather than non-physician healthcare staff (e.g., receptionists). Patients spend considerable amounts of time with non-physician staff. Therefore, we investigate differences in implicit and explicit racial bias by healthcare staff race and occupation using the Implicit Association Test and Modern Racism Scale, respectively. METHODS: Staff (n = 107) were recruited using the Alabama based Primary Care Research Coalition. Occupation was categorized into "medical doctors/registered nurses" (MD/RN) and "non-MD/RN" (e.g., receptionists). RESULTS: Implicit bias scores were higher among whites compared with blacks (0.62, -0.04, respectively; p < 0.01). Among whites, non-MD/RNs demonstrated more pro-white implicit bias compared with MD/RNs (0.67, 0.44, respectively; p < 0.01). Whites had higher explicit bias scores than blacks (17.7, 12.3, respectively; p < 0.01). CONCLUSION: Non-MD/RNs should not be overlooked for cultural competency training, and efforts are needed to reduce racial bias among healthcare workers identified as having higher levels of bias.

How group processes influence, maintain, and overcome health disparities.

This special issue of Group Processes and Intergroup Relations presents new theory and research on how group processes influence, maintain, and overcome health disparities. We present eight papers that document the causes and consequences of health disparities from the perspective of stigmatized and disadvantaged groups, health care providers, and during the course of interaction between patients and providers. Several papers describe interventions and other factors that have the potential to reduce differences in health and well-being. We hope the research in this collection inspires more investigators to consider how their work on group processes and intergroup relations can address, and help to eliminate, disparities in health outcomes for the disadvantaged.

Examining the Presence, Consequences, and Reduction of Implicit Bias in Health Care: A Narrative Review.

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.

How Hispanic Patients Address Ambiguous versus Unambiguous Bias in the Doctor's Office.

Two studies examined Hispanic individuals' preferences for using ten different bias reduction strategies when interacting with a doctor whose beliefs about their group were either ambiguous or clearly biased. Consistent with predictions, participants who imagined interacting with a doctor whose beliefs were ambiguous preferred strategies that facilitate positive doctor-patient interactions, whereas participants whose doctor explicitly endorsed negative stereotypes about their group preferred strategies that address stereotype content. The results also revealed that, regardless of whether the doctor's beliefs were ambiguous or clearly biased, stigma consciousness predicted participants' preferences for using strategies that address stereotype content. These findings suggest that both doctors' behavior and individual-level factors influence how minority individuals choose to behave in a healthcare setting.

Evidence of nonconscious stereotyping of Hispanic patients by nursing and medical students.

BACKGROUND: Current research on nonconscious stereotyping in healthcare is limited by an emphasis on practicing physicians' beliefs about African American patients and by heavy reliance on a measure of nonconscious processes that allows participants to exert control over their behaviors if they are motivated to appear nonbiased. OBJECTIVES: The present research examined whether nursing and medical students exhibit nonconscious activation of stereotypes about Hispanic patients using a task that subliminally primes patient ethnicity. It was hypothesized that participants would exhibit greater activation of noncompliance and health risk stereotypes after subliminal exposure to Hispanic faces compared with non-Hispanic White faces and, because ethnicity was primed outside of conscious awareness, that explicit motivations to control prejudice would not moderate stereotype activation. METHODS: Nursing and medical students completed a sequential priming task that measured the speed with which they recognized words related to noncompliance and health risk after subliminal exposure to Hispanic and non-Hispanic White faces. They then completed explicit measures of their motivation to control prejudice against Hispanics. RESULTS: Both nursing and medical students exhibited greater activation of noncompliance and health risk words after subliminal exposure to Hispanic faces, compared with non-Hispanic White faces. Explicit motivations to control prejudice did not moderate stereotype activation. DISCUSSION: These findings show that, regardless of their motivation to treat Hispanics fairly, nursing and medical students exhibit nonconscious activation of negative stereotypes when they encounter Hispanics. Implications are discussed.

Perceived discrimination in primary care: Does Payer mix matter?

INTRODUCTION: Previous literature has explored patient perceptions of discrimination by race and insurance status, but little is known about whether the payer mix of the primary care clinic (i.e., that is majority public insurance vs. majority private insurance clinics) influences patient perceptions of race- or insurance-based discrimination. METHODS: Between 2015-2017, we assessed patient satisfaction and perceived race- and insurance-based discrimination using a brief, anonymous post-clinic visit survey. RESULTS: Participants included 3,721 patients from seven primary care clinics-three public clinics and four private clinics. Results from unadjusted logistic regression models suggest higher overall reports of race- and insurance-based discrimination in public clinics compared with private clinics. In mulvariate analyses, increasing age, Black race, lower education and Medicaid insurance were associated with higher odds of reporting race- and insurance-based discrimination in both public and private settings. CONCLUSION: Reports of race and insurance discrimination are higher in public clinics than private clinics. Sociodemographic variables, such as age, Black race, education level, and type of insurance also influence reports of race- and insurance-based discrimination in primary care.

Audio delivery of health information: An NLP study of information difficulty and bias in listeners.

Health literacy is the ability to understand, process, and obtain health information and make suitable decisions about health care [3]. Traditionally, text has been the main medium for delivering health information. However, virtual assistants are gaining popularity in this digital era; and people increasingly rely on audio and smart speakers for health information. We aim to identify audio/text features that contribute to the difficulty of the information delivered over audio. We are creating a health-related audio corpus. We selected text snippets and calculated seven text features. Then, we converted the text snippets to audio snippets. In a pilot study with Amazon Mechanical Turk (AMT) workers, we measured the perceived and actual difficulty of the audio using the response of multiple choice and free recall questions. We collected demographic information as well as bias about doctors' gender, task preference, and health information preference. Thirteen workers completed thirty audio snippets and related questions. We found a strong correlation between text features lexical chain, and the dependent variables, and multiple choice response, percentage of matching word, percentage of similar word, cosine similarity, and time taken (in seconds). In addition, doctors were generally perceived to be more competent than warm. How warm workers perceive male doctors correlated significantly with perceived difficulty.

Implicit stereotyping and medical decisions: unconscious stereotype activation in practitioners' thoughts about African Americans.

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.

School Mental Health Professionals' Knowledge of Stereotypes and Implicit Bias Toward Black and Latinx Youths.

Clinician bias is a contributor to health care inequities, but research on racial-ethnic bias among mental health professionals, especially toward minoritized youths, is limited. This column describes two studies involving mental health clinicians in schools, where most youths access mental health services. Study 1 used a mixed-methods approach to identify stereotypes about Black and Latinx youths salient to clinicians (e.g., academic failure; anger and aggression). In study 2, the authors developed four Implicit Association Tests to assess clinicians' implicit prejudice and stereotyping of Black and Latinx youths and found pro-White and anti-Black/Latinx bias at levels similar to those of other health care providers and the general population.

A Brief Online Implicit Bias Intervention for School Mental Health Clinicians.

Clinician bias has been identified as a potential contributor to persistent healthcare disparities across many medical specialties and service settings. Few studies have examined strategies to reduce clinician bias, especially in mental healthcare, despite decades of research evidencing service and outcome disparities in adult and pediatric populations. This manuscript describes an intervention development study and a pilot feasibility trial of the Virtual Implicit Bias Reduction and Neutralization Training (VIBRANT) for mental health clinicians in schools-where most youth in the U.S. access mental healthcare. Clinicians (N = 12) in the feasibility study-a non-randomized open trial-rated VIBRANT as highly usable, appropriate, acceptable, and feasible for their school-based practice. Preliminarily, clinicians appeared to demonstrate improvements in implicit bias knowledge, use of bias-management strategies, and implicit biases (as measured by the Implicit Association Test [IAT]) post-training. Moreover, putative mediators (e.g., clinicians' VIBRANT strategies use, IAT D scores) and outcome variables (e.g., clinician-rated quality of rapport) generally demonstrated correlations in the expected directions. These pilot results suggest that brief and highly scalable online interventions such as VIBRANT are feasible and promising for addressing implicit bias among healthcare providers (e.g., mental health clinicians) and can have potential downstream impacts on minoritized youth's care experience.

Non-conscious bias in medical decision making: what can be done to reduce it?

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.