Patient activation reduces effects of implicit bias on doctor-patient interactions.

Disparities between Black and White Americans persist in medical treatment and health outcomes. One reason is that physicians sometimes hold implicit racial biases that favor White (over Black) patients. Thus, disrupting the effects of physicians' implicit bias is one route to promoting equitable health outcomes. In the present research, we tested a potential mechanism to short-circuit the effects of doctors' implicit bias: patient activation, i.e., having patients ask questions and advocate for themselves. Specifically, we trained Black and White standardized patients (SPs) to be "activated" or "typical" during appointments with unsuspecting oncologists and primary care physicians in which SPs claimed to have stage IV lung cancer. Supporting the idea that patient activation can promote equitable doctor-patient interactions, results showed that physicians' implicit racial bias (as measured by an implicit association test) predicted racially biased interpersonal treatment among typical SPs (but not among activated SPs) across SP ratings of interaction quality and ratings from independent coders who read the interaction transcripts. This research supports prior work showing that implicit attitudes can undermine interpersonal treatment in medical settings and provides a strategy for ensuring equitable doctor-patient interactions.

Examining the effects of physician burnout on pain management for patients with advanced lung cancer.

PURPOSE: Physician burnout is generally associated with worse clinical outcomes. The purpose of this study is to examine the effects of physician burnout on the quality of physicians' pain assessment and opioid prescribing for patients with advanced lung cancer. Moreover, we test whether these relationships are moderated by patient-level factors, such as patient race and activation level, that have a demonstrated impact on clinical encounters. METHODS: We conducted a secondary analysis of data from a multisite randomized field experiment. From 2012 to 2016, 96 primary care physicians and oncologists who treated solid tumors were recruited from hospitals and medical sites in three small metropolitan and rural areas in the USA. Physicians saw two unannounced standardized patients who presented with advanced lung cancer. Standardized patients varied across race (Black or White) and activation level (activated, typical). Visits were audio recorded and transcribed. Pain management was evaluated by the quality of pain assessment and opioid prescribing during these visits. RESULTS: Mixed-effects linear regression and generalized mixed-effects modeling showed that higher levels of burnout were associated with a greater likelihood of prescribing an opioid and prescribing stronger opioid doses for patients. These effects were not moderated by patient race or activation level. CONCLUSION: Findings from this work inform our understanding of physician-level factors that impact clinical decision-making in the context of cancer pain management. Specifically, this study identifies the role of physician burnout on the quality of prescribing for patients with advanced lung cancer.

Psychological Pathways Through Which Social Norms and Social Identity Influence Eating Behavior: Testing a Conceptual Model.

BACKGROUND: Although interventions frequently promote healthy eating, failing to consider psychosocial factors, such as social norms, may limit the effectiveness of these efforts. Perceived social norms are a well-documented determinant of eating behavior; however, there is limited understanding of the processes through which, and for whom, this relationship emerges. Using identity-based motivation as a theoretical framework, we present a conceptual model identifying one route through which descriptive social norms-beliefs about how others behave-predict eating behavior, and test whether this process varies across social identities (e.g., self-perceived weight status). METHOD: Structured telephone interviews were conducted for a national sample of non-diabetic adults who identified as non-Hispanic White, non-Hispanic Black, or Mexican American (n = 990). RESULTS: Multigroup SEM analysis comparing individuals who self-identified as overweight (versus "about the right weight" and underweight) demonstrated that perceiving descriptive social norms that people do not eat healthy foods predicted greater perceived barriers to eating healthy foods. Perceived barriers, in turn, predicted stronger beliefs that body weight is uncontrollable, and this relationship was stronger for participants who self-identified as overweight (relative to participants who did not identify as overweight). These beliefs subsequently predicted greater self-reported consumption of unhealthy foods (e.g., sweets), but did not predict consumption of fruits or vegetables. CONCLUSIONS: This study extends our understanding of a psychosocial process that predicts consumption of unhealthy foods and underscores the importance of social identities for shaping responses to perceived norms.

Real and Perceived Discordance in Physicians and U.S. Adults' Beliefs Regarding the Causes and Controllability of Type 2 Diabetes.

Discordance between physicians and patients' health beliefs can impede health communication efforts. However, little research considers physicians' perceptions of patient beliefs, despite the importance of perceptions in shaping communication. In the current work, we examine instances of actual and perceived discordance between physicians and U.S. adults' beliefs regarding the causes and controllability of type 2 diabetes. 229 family physicians completed an online survey measuring their health beliefs and perceptions of their patients' beliefs. Physicians' responses were contrasted against beliefs from a national survey sample of 1,168 U.S. adults. T-tests assessed whether (a) physicians' beliefs diverged from the national sample's beliefs (actual discordance), (b) physicians perceived that their health beliefs diverged from their patients' beliefs (perceived discordance), and (c) physicians' perceptions of patient beliefs diverged from the national sample's beliefs (accuracy of perceived discordance). Findings revealed evidence of actual discordance; compared to the national sample, physicians were more likely to attribute type 2 diabetes to genes (versus lifestyle factors) and perceived greater control over developing diabetes. Moreover, although physicians perceived discordance between their own and their patients' beliefs, data from the national sample suggested that these gaps were less substantial than physicians expected. In particular, findings showed that physicians generally overestimated discordance, expecting that people would be less likely to (1) attribute the development of diabetes to lifestyle factors (versus genes), and (2) perceive control over developing diabetes, than was actually reported. Implications of actual and perceived discordance for effective health communication and patient education are discussed.

Health Care Discrimination Affects Patient Activation, Communication Self-Efficacy, and Pain for Black Americans.

This study examines whether a key psychosocial factor-perceiving racial discrimination in health care-is associated with worse patient activation, communication self-efficacy, and physical health outcomes for Black veterans with chronic pain. Moreover, we explore the role of physician-patient working alliance as a moderator that may alleviate the potential consequences of perceiving racial discrimination. This work is a secondary analysis of baseline data from a clinical trial with 250 U.S. Black veterans with chronic musculoskeletal pain. Participants were recruited from primary care clinics at a Midwestern VA hospital between 2018 and 2021. Perceiving racial discrimination in health care was associated with lower patient activation, lower self-efficacy in communicating with one's physician, higher pain intensity, and lower pain management self-efficacy (ps < .049) but was unrelated to reports of pain interference or use of pain coping strategies (ps > .157). Although the relationship between perceived discrimination and patient activation was moderated by working alliance (P = .014), having a stronger working alliance improved patient activation to varying degrees across levels of perceived discrimination (rather than buffering against negative outcomes when perceiving higher levels of discrimination). Moderation was not significant on any other measures. This study deepens our understanding of the broad range of health outcomes that are (not) associated with perceiving racial discrimination in health care. Contrary to prior theorizing, this work also indicates that having a strong working alliance does not attenuate the consequences of perceiving discrimination among Black individuals living with pain. These results highlight the need for system-level interventions to address perceptions of racial mistreatment in health care. PERSPECTIVE: This work has important public health implications by identifying the broad range of outcomes associated with perceived discrimination in health care among Black Americans. Importantly, a strong physician-patient relationship did not buffer Black individuals from the consequences of perceiving discrimination. These findings inform intervention targets to mitigate racial health disparities.

Too close for comfort: leveraging identity-based relevance through targeted health information backfires for Black Americans.

Communicators frequently make adjustments to accommodate receivers' characteristics. One strategy for accommodation is to enhance the relevance of communication for receivers. The current work uses information targeting-a communication strategy where information is disseminated to audiences believed to experience heightened risk for a health condition-to test whether and why targeting health information based on marginalized racial identities backfires. Online experimental findings from Black and White adults recruited via MTurk (Study 1) and Prolific Academic (Study 2) showed that Black Americans who received targeted (vs. nontargeted) health messages about HIV or flu reported decreased attention to the message and reduced trust in the message provider. White Americans did not differentially respond to targeting. Findings also demonstrated that (a) these negative consequences emerged for Black Americans due to social identity threat, and (b) these consequences predicted downstream cognitive and behavioral responses. Study 2 showed that these consequences replicated when the targeting manipulation signaled relevance directly via marginalized racial identities. Collectively, findings demonstrate that race-based targeting may lead to overaccommodation, thus precluding the expected benefits of relevance.

Increasing policy support for reducing racial health disparities.

Perceiving racial health disparities as unjust could catalyze or halt change.

Black (patients') lives matter: Exploring the role of identity-safety cues in healthcare settings among Black Americans.

Two online experiments investigated whether hypothetical physicians' use of an identity-safety cue acknowledging systemic injustice (a Black Lives Matter pin) improves Black Americans' evaluations of the physician and feelings of identity-safety. Across studies, findings showed that when a White physician employed the identity-safety cue, Black Americans reported stronger perceptions of physician allyship and increased identity-safety (e.g. trust). As predicted, use of the identity-safety cue produced smaller or non-significant effects when employed by a Black physician. These benefits emerged regardless of physicians' perceived motivation for employing the cue (e.g. whether the physician was personally motivated to employ the cue or his medical practice encouraged use of the cue; Study 2). Furthermore, analyses revealed that exposure to the identity-safety cue promoted a greater sense of identity-safety for Black Americans due to increased perceptions that the physician is an ally for Black individuals. Implications of identity-safety cues for racially discordant medical interactions are discussed.

Examining the Context and Content of Organizational Solidarity Statements on Black Americans' Expectations of Identity Safety.

Despite the increasing use of organizational solidarity statements following instances of social injustice, little-to-no research has examined whether these statements signal inclusion for minoritized groups. The present work investigates how different types of solidarity statements affect Black Americans' sense of identity safety and assesses mechanisms underlying their responses. Across three online experiments, Black Americans recruited from Prolific Academic (N = 1,668) saw solidarity statements from a fictional organization that were either written in response to a race-related event at the societal level (e.g., George Floyd's murder; Studies 1-2) or an instance of racism occurring at the organizational level (Study 3). The statements were manipulated on three dimensions: acknowledgment of systemic racism, acknowledgment of organizational racism, and inclusion of concrete actions to address racism (Study 2). Findings showed that statements which acknowledged systemic racism or included actions to address racism were more likely to increase identity safety, whereas statements acknowledging racist organizational practices were relatively less effective at promoting identity safety. Feelings of identity safety emerged via decreased perceptions that the organization was engaging in performative allyship and/or increased perceptions of procedural fairness. Collectively, findings elucidate features of organizational solidarity statements that are more (versus less) effective for promoting identity safety among Black Americans.