Welcome to the Erase the Hate. We are a group of Kossacks who oppose bigotry of all forms and created this group discuss prejudice and discrimination faced by different groups and ways of ameliorating its effects and fighting back. We will post a diary here every Monday evening at 7pm. If you are interested in writing a diary (or editing) for the group, please send a Kosmail to the group.
In tonight's inaugural diary, I write about some fascinating social psychological research on racism in medicine.
Black Patients and Aversive Racism
More prolific writers than myself have documented the difficulties that low-income Americans face in our health care delivery system. And as the American government has reported annually for many years, racial/ethnic disparities in access to and quality of health care and health outcomes persist. Given that Blacks are more likely to find themselves in racially-discordant doctor/patient relationships than Whites, social psychologists have begun to explore the extent to which that racism in the examination room might play in role in these disparities. Here, I describe a field study of doctor-patient interactions which showed that explicit and implicit measures of doctor racism predicted different aspects of race-discordant interactions between black patients and their doctors. I will be begin by talking a little bit about explicit and implicit racism and the implications for interracial interactions before talking about the doctor/patient study.
As I noted in my last diary on race relations, researchers use the term Whites and Blacks in discussing and writing about race-related research. I am using the terms in this diary to be consistent with their terminology.
Explicit Racism
While it is certainly true that explicit racial attitudes have become more tolerant since the rise of the Civil Rights movement, it is more accurate to state that racial attitudes--and racism--have evolved in two ways. First, blatant expressions of hostile racial prejudice have become a social taboo. It is no longer socially acceptable to argue that racial minorities are less intelligent or capable of performing certain tasks than Whites or that racial minorities are less deserving of access to resources or jobs as a result of such inferiorities. Second, as such hostile racism has declined, it has been replaced with a modern form of racism, which includes a denial that racism exists and the beliefs that racial minorities are being "too pushy" in their quest for equality and that what they seek are actually special rights (McConahay, 1986).
Implicit Racism
Contrast these conscious, thoughtful, effortful explicit attitudes about race with automatic, non-conscious implicit attitudes. Research shows that people can have negative attitudes/prejudices about which they are seeming unaware and can only be measured indirectly. The most popular measure of implicit racial attitudes is the Implicit Association Test (see also Project Implicit for a demonstration).
Some caution about implicit attitudes: What we are measuring is an association between stimuli, between good and bad. And what this measure tells us is the degree to which we show automatic preferences for Whites over Blacks (or vice-versa). It won't tell us if a person thinks that Blacks are lazy or Whites are inherently more intelligent. That said, measures of implicit attitudes are generally stable over time and people who take the test cannot be trained to avoid their natural responses. In addition, as I explain below, scores on implicit measures of racism can significantly predict behavior in interracial interactions.
Explicit and Implicit Racism in Interracial Interactions
Explicit and implicit racism can lead to different behaviors during interracial interactions. People are generally aware of their explicit racial attitudes can control their behavior to avoid overt displays of racism. However, people might not necessarily have control over the subtle, spontaneous behaviors (body language, posture, facial expressions) that are associated with measures of implicit racial bias.
For example, Dovidio, Kawakami, & Gaertner (2002) have shown that during interracial interactions, explicit measures of racism predicted the friendliness of their verbal--but not their non-verbal--behavior toward their Black partners, with lower explicit racism corresponding with more friendly behaviors. At the same time, their implicit racism scores predicted the friendliness of their nonverbal--but not their verbal--behavior toward their Black partners, again with lower implicit racism corresponding with more friendly behaviors. And interestingly, the White partners' implicit racism scores--but not their explicit racism scores--predicted perceptions of their friendliness by the Black partner. In other words, no matter how friendly the White partner thought he was being, it was his nonverbal behavior, predicted by implicit bias, that was shaping the Black partner's feelings.
What complicates this is that implicit and explicit racism exist on separate continua. Someone can be low in both, high in both, or some mixture. This means that someone who is high in implicit racial prejudice, but low in explicit racial prejudice can sometimes send mixed signals with their behavior. The controlled verbal behaviors are communicating racial tolerance while their automatic, non-verbal behaviors are sending an entirely different message. This subtle form of bias is called aversive racism.
Aversive racists are people who consciously hold egalitarian attitudes and oppose prejudice and discrimination, but hold negative, unconscious racial attitudes. And they are generally unaware of these attitudes and the way they affect their behavior. Interesting, past research has shown the when Blacks and Whites are working together on a task, the dyads that perform the worst are those where the White participant is an aversive racist. To emphasize, they even perform worse than dyads where the White partner is high in both explicit and implicit racism. Given that African-Americans are generally more likely to visit nonBlack than Black physicians, a logical extension of this work on aversive racism is to look at what happens when a Black patient visits a nonBlack doctor.
Louis A. Penner (2010) and his colleagues (John F. Dovidio, Tessa V. West, Samuel L. Gaertner, Terrance L. Albrecht, Rhonda K. Dailey, Tsveti Markova) conducted this field study to investigate the effects of a nonBlack doctor's implicit and explicit bias on interactions with Black patients. They recruited 150 black patients at an inner-city primary care clinic. The researchers recorded their reactions to interactions with one of 15 nonBlack doctors (White, South Asian, East Asian). They also gave the doctors a measure of explicit racism (a 25-item scale with 5 point agree/disagree statements) and a measure of implicit racism, the race Implicit Associations Test. Finally, both doctors and patients gave their assessments of one another, and the interaction as a whole.
Findings
Note that the physician gender, patient gender, and the race of the doctor did not have an effect on the results, so I will not be discussing that any further.
Doctor Impressions
The doctors were asked about the extent to which he/she worked with the patients (as a team) to solve their medical problems. They were also asked about the extent to which they considered the patients opinion in coming up with a treatment plan. The research team found the explicit racism predict their responses to the former, while implicit racism predicted their responses to the latter. Doctors who were higher in explicit racism rated their "teamwork" with the patients lower than doctors who were low in explicit racism. Doctors who were higher in implicit racism were less likely to consider their patients opinion before deciding on a course of treatment than those who scored lower in implicit racism.
Patient Impressions
The patients' reactions to the doctors were predicted by an combination of implicit and explicit racism. The patients reacted most negatively (low ratings of satisfaction, teamwork, and physician friendliness/warmth) to doctors who were high in implicit bias and low in explicit bias, the profile of an aversive racist. The other three combinations (high implicit/high explicit, low implicit/high explicit, and low implicit/low explicit) all elicited more positive ratings from the patients and did not differ from one another significantly.
What does this mean?
These findings point to a need to address racial bias in the health care industry. The doctor's own self-reported ratings of working with the patient and considering the patients views related to his/her racism scores. Patients are clearly better served by doctors who work with them, and take their concerns about treatment seriously. In addition, the behavior of the aversive racists is having significant effects on the patients. They are picking up on the doctor's attitudes and it is coloring their impressions of the encounter. The researchers did not record the interactions to actually code the physician's behavior/effectiveness, so it is not clear if the degree to which racism is influencing the doctor's course of treatment.
What is also not clear from these findings is the consequences for the patient after they leave the office. Does a negative experience make the patient less likely to follow the doctor's instructions? Or to come back? Or trust the doctor with sensitive health concerns? At the very least, these findings should raise red flags because trust between doctor and patient is an important component of health care delivery. If you do not trust that the doctor takes you seriously and truly has your best interests at heart, how likely are you to turn to that physician--or others, if you've had repeated, negative experiences--for health concerns in the future?
If there is silver lining to the cloud I've presented, it is that research shows that making physicians aware of their implicit biases and how the biases can negatively effect race-discordant interactions is effective at motivating more positive behavior and efforts to self-regulate the unconscious, automatic behaviors associated with implicit bias. This is a problem with practical solutions if we can draw attention to it!