non-Black Physicians Research Articles

Heartache or Bellyache? Epigastric Pain, Communication Skills, and Implicit Bias: Can We Uncover an Association in the Simulation Lab?

Purpose: Implicit bias contributes to health disparities through physician communication behaviors. 1 Research in clinical encounters suggests certain nonverbal and verbal communication is associated with racial implicit bias. 2 To date, there are no published simulations that can be used for teaching or assessment purposes in implicit bias recognition and management (IBRM). We developed a high-fidelity simulation 3 and adapted existing checklists and global rating scales to include communication behaviors known to be associated with racial implicit bias. 2 Approach: This case involved a 52-year-old man presenting to the urgent care center with nausea, vomiting, and epigastric pain. Epigastric pain was chosen as the clinical presentation given the demonstrated racial disparities in acute coronary syndrome (ACS). 4 Cognitive stressors included time constraints, clinical ambiguity (epigastric pain, a normal EKG, asymptomatic on exam), and an interruption from a standardized nurse. We have complete data for N = 15 physician volunteers (PV) over 3 pilots. We pursued an exploratory approach investigating the associations between racial implicit bias as measured on race and race-compliance implicit association tests (IAT) and communication skills of internal/family medicine PVs. We explored the associations between IATs and communication skills of internal/family medicine PV as rated by a highly trained SP and monitor. For each communication domain and subdomain, the mean score was computed comparing the scores on SPs that were Black vs White. Communication checklist items were rated on a 3-point scale, while the entrustment items were rated on a 4-point scale. A mean score was then computed for reach domain and subdomain, and linear regression was conducted with race of the SP and race of the Physician (model 1) as independent variables, followed by race IAT (model 2). Correlation analysis was also conducted to determine if significant relationship existed between the domain/subdomain scores and IAT scores. Outcomes: Mean IAT scores for PVs were in the neutral range. A total of 11 Black SPs/monitors and 9 White SPs/monitors rated physician skills. A significant negative relationship was found between “Elicits all patient’s concerns” item from information gathering with race IAT (r = −0.68, P = .01) and compliance IAT (r = −0.72, r = 0.02). A significant main effect was found on PV race and overall mean global entrustment scores (P = .01), with non-Black physicians receiving a higher score (m = 2.43, SD = 0.35) than Black physicians (m = 1.82, SD = 0.48) when race IAT was not included (model 1). When race IAT was included, no significant differences were found. No other significant differences were found in the other competencies. Significance: We developed a high-fidelity simulation and accompanying checklists and global rating scales that were able to elicit variability in communication skills scores among practicing PVs. A significant difference was found between the Black and non-Black physicians in their overall global entrustment scores when race IAT was not controlled for. When we controlled for race IAT scores (implicit bias impact), differences were no longer present suggesting the impact of implicit bias can be measured through the use of this case and global entrustment measures rather than communication competencies. This study suggests the use of high-fidelity simulations over vignettes may be better in understanding the impact of implicit bias in the patient experience. Medical educators implementing curricula in IBRM infrequently provide learners opportunities for skill development and practice, or assessment of those skills. 5 Our simulation provides a model for skill development in IBRM as it relates to ACS. In addition, given the racial disparities treatment decisions in ACS, this simulation is timely and relevant both for its assessment of communication behaviors associated with IBRM and for its clinical content. Next steps include finalizing simulations with community member input, revisions as informed by data analysis, and assessing medical decision making.

Diversifying the dermatology workforce: Physician characteristics vary by race/ethnicity

BackgroundIn the United States (US), dermatology remains one of the least diverse specialties in medicine. Increasing the diversity of the dermatology workforce is essential for reducing health disparities. ObjectiveTo describe the experiences of racially and ethnically diverse physicians in the US who successfully matched into dermatology. MethodsBoard-certified dermatologists and dermatology residents were recruited to participate in an anonymous, online survey in which self-reported demographic, socioeconomic, pre-residency, and post-residency career data were obtained. ResultsOf the 100 participants included in the study, 30% were dermatology residents and 25% belonged to a group underrepresented in medicine (UIM). Black physicians were 3.69 times more likely to select dermatology prior to medical school (odds ratio [OR], 3.69; 95% confidence interval [CI], 1.04 – 13.0) compared to non-Black physicians. UIM dermatologists and trainees were more likely to receive a need-based scholarship in medical school (OR, 4.37; 95% CI, 1.30 – 14.7), graduate from a private medical institution (OR, 6.49; 95% CI, 1.95 – 21.6), and have at least one UIM dermatology mentor during medical school (adjusted OR, 13.1; 95% CI, 2.77 – 61.5) compared to non-UIM physicians. ConclusionsA holistic review of dermatology applicants by residency programs may reduce racial/ethnic disparities in the admission process. Our data provide further evidence in support of pre-medical outreach programs, mentorship, and institutional funding to promote diversity in dermatology.

Examining the dynamic nature of nonverbal communication between Black patients with cancer and their oncologists.

Although communication quality is associated with patient outcomes, racial disparities in communication exist, disproportionately burdening Black patients. However, most communication research focuses on verbal behaviors in predominantly White patient populations.We used a newly developed and theory-guided network analysis that examines the dynamic interplay and behavioral convergence and divergence between Black patients with cancer and their oncologists during cancer treatment discussions. We applied a nonverbal behavioral coding system to thin slices of video recordings of Black patients and their oncologists discussing treatment. We then estimated 3 networks: 1) a temporal network to determine whether a nonverbal behavior predicts another nonverbal behavior at the next time point in an interaction, and how much each nonverbal behavior influences other nonverbal behaviors and is influenced by other nonverbal behaviors; 2) a contemporaneous network to determine whether a nonverbal behavior co-occurs with other nonverbal behaviors at the same time point in an interaction; and 3) a between-dyads network to examine the covariation between nonverbal behaviors across all dyads. Black patients (n = 74) and their non-Black physicians (n = 15) showed a mix of convergence and divergence in their nonverbal behaviors at the same points in time, from one time point to the next, and across dyads. Across analyses, convergence was most likely to occur when physicians matched their behaviors to their patients; especially with smiling, gaze, leaning, and laughter behaviors. Our findings reveal patterns of modifiable behaviors that can potentially inform interventions to reduce disparities in clinical communication and, in turn, treatment and mortality disparities.

Nonconscious nonverbal synchrony and patient and physician affect and rapport in cancer treatment discussions with black and white patients.

12116 Background: Clinical communication is poorer with Black patients than with White patients, but most studies are limited to verbal communication. Nonverbal synchrony, the subtle, nonconscious coordination of movement between individuals, has been shown to reflect relationship quality. We investigated nonverbal synchrony’s association with patient and physician affect and rapport in cancer treatment discussions, and if those associations differed by patient race. Methods: We used motion detection software to measure overall synchrony and synchrony based on who is leading in the interaction (similar to leading in dancing) in video recordings of 68 Black patients and 163 White patients discussing treatment with their non-Black physicians. Additionally, naïve observers rated the interaction for six constructs: patient and physician positive and negative affect and patient-physician positive and negative rapport. We examined associations between nonverbal synchrony and the six constructs. Results: In interactions with Black patients, overall synchrony was positively associated with patients’ positive affect and positive patient-physician rapport and negatively associated with patients’ negative affect and negative patient-physician rapport. When the physician was leading, synchrony was positively associated with patients’ positive affect and positive patient-physician rapport and negatively associated with patients’ negative affect and negative patient-physician rapport. When the patient was leading, synchrony was positively associated with patients’ and physicians’ positive affect and positive patient-physician rapport, and negatively associated with patients’ negative affect and negative patient-physician rapport. In interactions with White patients, overall synchrony was positively associated with patient positive affect; when the physician was leading, synchrony was negatively associated with patient negative affect. Conclusions: This is the first study to use an innovative measure of dynamic communication in patient-physician cancer treatment discussions. Nonverbal synchrony was related to patient and physician affect and rapport in interactions with Black patients, but only patient affect in interactions with White patients, suggesting nonverbal synchrony is particularly important in interactions with Black patients. Next steps include investigating associations with patient outcomes (e.g., satisfaction). Findings could contribute to physician training.

The Value of Interracial Contact for Reducing Anti-Black Bias Among Non-Black Physicians: A Cognitive Habits and Growth Evaluation (CHANGE) Study Report

Although scholars have long studied circumstances that shape prejudice, inquiry into factors associated with long-term prejudice reduction has been more limited. Using a 6-year longitudinal study of non-Black physicians in training (N = 3,134), we examined the effect of three medical-school factors—interracial contact, medical-school environment, and diversity training—on explicit and implicit racial bias measured during medical residency. When accounting for all three factors, previous contact, and baseline bias, we found that quality of contact continued to predict lower explicit and implicit bias, although the effects were very small. Racial climate, modeling of bias, and hours of diversity training in medical school were not consistently related to less explicit or implicit bias during residency. These results highlight the benefits of interracial contact during an impactful experience such as medical school. Ultimately, professional institutions can play a role in reducing anti-Black bias by encouraging more frequent, and especially more favorable, interracial contact.

Nonverbal synchrony as a behavioural marker of patient and physician race-related attitudes and a predictor of outcomes in oncology interactions: protocol for a secondary analysis of video-recorded cancer treatment discussions

IntroductionRacial disparities in cancer treatment contribute to racial disparities in mortality rates. The quality of patient–physician communication during clinical interactions with black patients and non-black physicians (racially discordant) is poorer...

The impact of Black cancer patients' race-related beliefs and attitudes on racially-discordant oncology interactions: A field study

ObjectiveBoth 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. MethodAt 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). ResultsAs 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. ConclusionResults 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.

Physician Racial Bias and Word Use during Racially Discordant Medical Interactions

ABSTRACTPhysician racial bias can negatively affect Black patients’ reactions to racially discordant medical interactions, suggesting that racial bias is manifested in physicians’ communication with their Black patients. However, little is known about how physician racial bias actually influences their communication during these interactions. This study investigated how non-Black physicians’ racial bias is related to their word use during medical interactions with Black patients. One hundred and seventeen video-recorded racially discordant medical interactions from a larger study were transcribed and analyzed using Linguistic Inquiry and Word Count (LIWC) software. Physicians with higher levels of implicit racial bias used first-person plural pronouns and anxiety-related words more frequently than physicians with lower levels of implicit bias. There was also a trend for physicians with higher levels of explicit racial bias to use first-person singular pronouns more frequently than physicians with lower levels of explicit bias. These findings suggest that non-Black physicians with higher levels of implicit racial bias may tend to use more words that reflect social dominance (i.e., first-person plural pronouns) and anxiety when interacting with Black patients.

The effects of racial attitudes on affect and engagement in racially discordant medical interactions between non-Black physicians and Black patients.

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.

Racial attitudes, physician–patient talk time ratio, and adherence in racially discordant medical interactions

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.

A Social Psychological Approach to Improving the Outcomes of Racially Discordant Medical Interactions

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. 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. 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. 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 16weeks later. Physicians provided information before and immediately after interactions. Fourteen non-Black physicians and 72 low income Black patients at a Family Medicine residency training clinic. 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 16weeks later. Four and 16weeks 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. 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.

Aversive racism and medical interactions with Black patients: A field study

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.

A healthy mistrust: how worldview relates to attitudes about breast cancer screening in a cross-sectional survey of low-income women.

BackgroundPerceived racial discrimination is one factor which may discourage ethnic minorities from using healthcare. However, existing research only partially explains why some persons do accept health promotion messages and use preventive care, while others do not. This analysis explores 1) the psychosocial characteristics of those, within disadvantaged groups, who identify their previous experiences as racially discriminatory, 2) the extent to which perceived racism is associated with broader perspectives on societal racism and powerlessness, and 3) how these views relate to disadvantaged groups' expectation of mistreatment in healthcare, feelings of mistrust, and motivation to use care.MethodsUsing survey data from 576 African-American women, we explored the prevalence and predictors of beliefs and experiences related to social disengagement, racial discrimination, desired and actual racial concordance with medical providers, and fear of medical research. We then used both sociodemographic characteristics, and experiences and attitudes about disadvantage, to model respondents' scores on an index of personal motivation to receive breast cancer screening, measuring screening knowledge, rejection of fatalistic explanatory models of cancer, and belief in early detection, and in collaborative models of patient-provider responsibility.ResultsAge was associated with lower motivation to screen, as were depressive symptoms, anomie, and fear of medical research. Motivation was low among those more comfortable with African-American providers, regardless of current provider race. However, greater awareness of societal racism positively predicted motivation, as did talking to others when experiencing discrimination. Talking was most useful for women with depressive symptoms.ConclusionSupporting the Durkheimian concepts of both anomic and altruistic suicide, both disengagement (depression, anomie, vulnerability to victimization, and discomfort with non-Black physicians) as well as over-acceptance (low awareness of discrimination in society) predict poor health maintenance attitudes in disadvantaged women. Women who recognize their connection to other African-American women, and who talk about negative experiences, appear most motivated to protect their health.

Patient-physician racial concordance and the perceived quality and use of health care.

Patients from racial and ethnic minority groups use fewer health care services and are less satisfied with their care than patients from the majority white population. These disparities may be attributable in part to racial or cultural differences between patients and their physicians. To determine whether racial concordance between patients and physicians affects patients' satisfaction with and use of health care. We analyzed data from the 1994 Commonwealth Fund's Minority Health Survey, a nationwide, telephone survey of noninstitutionalized adults. For the 2201 white, black, and Hispanic respondents who reported having a regular physician, we examined the association between patient-physician racial concordance and patients' ratings of their physicians, satisfaction with health care, reported receipt of preventive care, and reported receipt of needed medical care. Black respondents with black physicians were more likely than those with nonblack physicians to rate their physicians as excellent (adjusted odds ratio [OR], 2.40; 95% confidence interval [CI], 1.55-3.72) and to report receiving preventive care (adjusted OR, 1.74; 95% CI, 1.01-2.98) and all needed medical care (adjusted OR, 2.94; 95% CI, 1.10-7.87) during the previous year. Hispanics with Hispanic physicians were more likely than those with non-Hispanic physicians to be very satisfied with their health care overall (adjusted OR, 1.74; 95% CI, 1.01-2.99). Our findings confirm the importance of racial and cultural factors in the patient-physician relationship and reaffirm the role of black and Hispanic physicians in caring for black and Hispanic patients. Improving cultural competence among physicians may enhance the quality of health care for minority populations. In the meantime, by reducing the number of underrepresented minorities entering the US physician workforce, the reversal of affirmative action policies may adversely affect the delivery of health care to black and Hispanic Americans.