Why do providers contribute to disparities and what can be done about it?

Abstract

This paper applies social cognition research to understanding and ameliorating the provider contribution to racial/ethnic disparities in health care. We discuss how fundamental cognitive mechanisms such as automatic, unconscious processes (e.g., stereotyping) can help explain provider bias. Even well-intentioned providers who are motivated to be nonprejudiced may stereotype racial/ethnic minority members, particularly under conditions of that diminish cognitive capacity. These conditions—time pressure, fatigue, and information overload—are frequently found in health care settings. We conclude with implications of the social-cognitive perspective for developing interventions to reduce provider bias.

This is a preview of subscription content, log in to check access.

References

  1. 1.

    Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: National Academies Press; 2003.

    Google Scholar 

  2. 2.

    Brewer MB, Brown RJ. Intergroup relations. In: Gilbert DT, Fiske ST, Lindzey G, eds. The Handbook of Social Psychology. 4th ed. Boston, Mass: McGraw-Hill; 1998;2:554–94.

    Google Scholar 

  3. 3.

    van Ryn M. Research on the provider contribution to race/ethnicity disparities in medical care. Med Care. 2002;40:I140–151.

    PubMed  Google Scholar 

  4. 4.

    van Ryn M, Fu SS. Paved with good intentions: do public health and human service providers contribute to racial/ethnic disparities in health? Am J Public Health. 2003;93:248–55.

    PubMed  Article  Google Scholar 

  5. 5.

    McConahay JB. Modern racism, ambivalence, and the Modern Racism Scale. In: Dovidio JF, Gaertner S, eds. Prejudice, Discrimination, and Racism. San Diego, Calif: Academic Press; 1986:91–125.

    Google Scholar 

  6. 6.

    Crosby F, Bromley S, Saxe L. Recent unobtrusive studies of black and white discrimination and prejudice: a literature review. Psychol Bull. 1980;87:546–63.

    Article  Google Scholar 

  7. 7.

    Devine PG, Monteith MJ. Automaticity and control in stereotyping. In: Chaiken S, Trope Y, eds. Dual-process Theories in Social Psychology. New York, NY: Guilford Press; 1999:339–60.

    Google Scholar 

  8. 8.

    Devine PG, Vasquez KA. The rocky road to positive intergroup relations. In: Eberhardt JL, Fiske T, eds. Confronting Racism: The Problem and the Response. Thousand Oaks, Calif: Sage Publications; 1998:234–62.

    Google Scholar 

  9. 9.

    Dovidio JF, Gaertner SL. On the nature of contemporary prejudice: the causes, consequences, and challenges of aversive racism. In: Eberhardt JL, Fiske T, eds. Confronting Racism: The Problem and the Response. Thousand Oaks, Calif: Sage Publications; 1998:3–32.

    Google Scholar 

  10. 10.

    Dovidio JF, Kawakami K, Gaertner SL. Implicit and explicit prejudice and interracial interaction. J Pers Soc Psychol. 2002;82:62–8.

    PubMed  Article  Google Scholar 

  11. 11.

    Fazio RH, Jackson JR, Dunton BC, Williams CJ. Variability in automatic activation as an unobtrusive measure of racial attitudes: a bona fide pipeline? J Pers Soc Psychol. 1995;69:1013–27.

    PubMed  Article  CAS  Google Scholar 

  12. 12.

    Smith ER, DeCoster J. Dual-process models in social and cognitive psychology: conceptual integration and links to underlying memory systems. Pers Soc Psychol Rev. 2000;4:108–31.

    Article  Google Scholar 

  13. 13.

    Eisenberg JM. Sociologic influences on decision-making by clinicians. Ann Intern Med. 1979;90:957–64.

    PubMed  CAS  Google Scholar 

  14. 14.

    Lewis G, Croft-Jeffreys C, David A. Are British psychiatrists racist? Br J Psychiatry. 1990;157:410–5.

    Article  Google Scholar 

  15. 15.

    van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians’ perceptions of patients. Soc Sci Med. 2000;50:813–28.

    PubMed  Article  Google Scholar 

  16. 16.

    Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians’ recommendations for cardiac catheterization. N Engl J Med. 1999;340:618–26.

    PubMed  Article  CAS  Google Scholar 

  17. 17.

    Schneider AE, Davis RB, Phillips RS. Discussion of hormone replacement therapy between physicians and their patients. Am J Med Qual. 2000;15:143–7.

    PubMed  CAS  Google Scholar 

  18. 18.

    Shortt S. Venerable or vulnerable? Ageism in health care. J Health Serv Res Policy. 2001;6:1–2.

    PubMed  Article  CAS  Google Scholar 

  19. 19.

    Stern M, Arenson E. Childhood cancer stereotype: impact on adult perceptions of children. J Pediatr Psychol. 1989;14:593–605.

    PubMed  Article  CAS  Google Scholar 

  20. 20.

    Stern M, Moritzen SK, Carmel S, Olexa-Andrews M. The prematurity stereotype in Israeli health care providers. Med Educ. 2001;35:129–33.

    PubMed  Article  CAS  Google Scholar 

  21. 21.

    Stern M, Ross S, Bielass M. Medical students’ perceptions of children: modifying a childhood cancer stereotype. J Pediatr Psychol. 1991;16:27–38.

    PubMed  Article  CAS  Google Scholar 

  22. 22.

    Kelly CE. Bringing homophobia out of the closet: antigay bias within the patient-physician relationship. Pharos Alpha Omega Alpha Honor Med Soc. 1992;55:2–8.

    PubMed  CAS  Google Scholar 

  23. 23.

    Kelly JA, St Lawrence JS, Smith S Jr, Hood HV, Cook DJ. Stigmatization of AIDS patients by physicians. Am J Public Health. 1987;77:789–91.

    PubMed  CAS  Google Scholar 

  24. 24.

    Kelly JA, St Lawrence JS, Smith S, Hood HV, Cook DJ. Medical students’ attitudes toward AIDS and homosexual patients. J Med Educ. 1987;62:549–56.

    PubMed  CAS  Google Scholar 

  25. 25.

    Bertakis KD, Callahan EJ, Helms LJ, Azari R, Robbins JA, Miller J. Physician practice styles and patient outcomes: differences between family practice and general internal medicine. Med Care. 1998;36:879–91.

    PubMed  Article  CAS  Google Scholar 

  26. 26.

    Bertakis KD, Roter D, Putnam SM. The relationship of physician medical interview style to patient satisfaction. J Fam Pract. 1991;32:175–81.

    PubMed  CAS  Google Scholar 

  27. 27.

    Gerbert B. Perceived likeability and competence of simulated patients: influence on physicians’ management plans. Soc Sci Med. 1984;18:1053–9.

    PubMed  Article  CAS  Google Scholar 

  28. 28.

    Hall JA, Epstein AM, DeCiantis ML, McNeil BJ. Physicians’ liking for their patients: more evidence for the role of affect in medical care. Health Psychol. 1993;12:140–6.

    PubMed  Article  CAS  Google Scholar 

  29. 29.

    Kearney N, Miller M, Paul J, Smith K. Oncology healthcare professionals’ attitudes toward elderly people. Ann Oncol. 2000;11:599–601.

    PubMed  Article  CAS  Google Scholar 

  30. 30.

    Like R, Zyzanski SJ. Patient satisfaction with the clinical encounter: social psychological determinants. Soc Sci Med. 1987;24:351–7.

    PubMed  Article  CAS  Google Scholar 

  31. 31.

    Porter JR, Beuf AH. The effect of a racially consonant medical context on adjustment of African-American patients to physical disability. Med Anthropol. 1994;16:1–16.

    PubMed  CAS  Article  Google Scholar 

  32. 32.

    Revenson TA. Compassionate stereotyping of elderly patients by physicians: revising the social contact hypothesis. Psychol Aging. 1989;4:230–4.

    PubMed  Article  CAS  Google Scholar 

  33. 33.

    Fiske ST. Stereotyping, prejudice, and discrimination. In: Gilbert DT, Fiske ST, Lindzey G, eds. The Handbook of Social Psychology. 4th ed. Boston, Mass: McGraw-Hill; 1998;2:357–411.

    Google Scholar 

  34. 34.

    Macrae CN, Milne AB, Bodenhausen GV. Stereotypes as energysaving devices: a peek inside the cognitive toolbox. J Pers Soc Psychol. 1994;66:33–47.

    Google Scholar 

  35. 35.

    Chen M, Bargh JA. Nonconscious behavioral confirmation processes: the self-fulfilling consequences of automatic stereotype activation processes. J Exp Soc Psychol. 1997;33:541–60.

    Article  Google Scholar 

  36. 36.

    Devine PG. Stereotypes and prejudice: their automatic and controlled components. J Pers Soc Psychol. 1989;56:5–18.

    Article  Google Scholar 

  37. 37.

    Kawakami K, Dion KL, Dovidio JF. Racial prejudice and stereotype activation. Pers Soc Psychol Bull. 1998;24:407–16.

    Article  Google Scholar 

  38. 38.

    Fazio RH, Dunton BC. Categorization by race: the impact of automatic and controlled components of racial prejudice. J Exp Soc Psychol. 1997;33:451–70.

    Article  Google Scholar 

  39. 39.

    Wittenbrink B, Judd CM, Park B. Evidence for racial prejudice at the implicit level and its relationship with questionnaire measures. J Pers Soc Psychol. 1997;72:262–74.

    PubMed  Article  CAS  Google Scholar 

  40. 40.

    Wilson TD, Lindsey S, Schooler TY. A model of dual attitudes. Psychol Rev. 2000;107:101–26.

    PubMed  Article  CAS  Google Scholar 

  41. 41.

    Banaji M, Greenwald AG. Implicit stereotyping and prejudice. In: Zanna MP, Olson JM, eds. The Psychology of Prejudice: The Ontario Symposium. Hillsdale, NJ: Erlbaum; 1994:7:55–76.

    Google Scholar 

  42. 42.

    Dovidio JF, Kawakami K, Gaertner SL. Implicit and explicit prejudice and interracial interaction. J Pers Soc Psychol. 2002;82:62–8.

    PubMed  Article  Google Scholar 

  43. 43.

    Dovidio JF, Gaertner SL, Kawakami K, Hodson G. Why can’t we just get along? Interpersonal biases and interracial distrust. Cultur Divers Ethnic Minor Psychol. 2002;8:88–102.

    PubMed  Article  Google Scholar 

  44. 44.

    Depaulo BM, Friedman HS. Nonverbal communication. In: Gilbert DT, Fiske ST, Lindzey G; eds. The Handbook of Social Psychology. 4th ed. Boston, Mass: McGraw-Hill; 1998;2:3–40.

    Google Scholar 

  45. 45.

    Race, Ethnicity and Medical Care: A Survey of Public Perceptions and Experiences. The Henry J. Kaiser Family Foundation; 1999. Available at: http://www.kff.org/minorityhealth/1529-index.cfm. Accessed September 2004.

  46. 46.

    National Survey of Physicians Part I: Doctors on Disparities in Medical Care: The Henry J. Kaiser Family Foundation; 2002. Available at: http://www.kff.org/minorityhealth/20020321a-index.cfm. Accessed September 2004.

  47. 47.

    Bodenhausen GV, Macrae CN, Sherman JS. On the dialectics of discrimination: dual processes in social stereotyping. In: Chaiken S, Trope Y, eds. Dual-process Theories in Social Psychology. New York, NY: Guilford Press; 1999:271–90.

    Google Scholar 

  48. 48.

    Balsa AI, McGuire TG. Prejudice, clinical uncertainty and stereotyping as sources of health disparities. J Health Econ. 2003;22:89–116.

    PubMed  Article  Google Scholar 

  49. 49.

    Judd CM, Park B. Definition and assessment of accuracy in social stereotypes. Psychol Rev. 1993;100:109–28.

    PubMed  Article  CAS  Google Scholar 

  50. 50.

    McKinlay JB, Potter DA, Feldman HA. Non-medical influences on medical decision-making. Soc Sci Med. 1996;42:769–76.

    PubMed  Article  CAS  Google Scholar 

  51. 51.

    Fiske ST. Stereotyping, prejudice, and discrimination at the seam between the centuries: evolution, culture, mind, and brain. Eur J Soc Psychol. 2000;30:299–322.

    Article  Google Scholar 

  52. 52.

    Fiske ST. What we know about bias and intergroup conflict: the problem of the century. Curr Direct Psychol Sci. 2002;11:123–8.

    Article  Google Scholar 

  53. 53.

    Linville PW, Fischer GW. Group variability and covariation: effects on intergroup judgment and behavior. In: Sedikides C, Insko CA, Schopler J, eds. Intergroup Cognition and Intergroup Behavior. Mahwah, NJ: Erlbaum, 1998:123–50.

    Google Scholar 

  54. 54.

    Ryan CS, Judd CM, Park B. Effects of racial stereotypes on judgments of individuals: the moderating role of perceived group variability. J Exp Soc Psychol. 1996;32:71–103.

    Article  Google Scholar 

  55. 55.

    Chatman CM, von Hippel W. Attributional mediation of in-group bias. J Exp Soc Psychol. 2001;37:267–72.

    Article  Google Scholar 

  56. 56.

    Hilton JL, von Hippel W. Stereotypes. Annu Rev Psychol. 1996;47:237–71.

    PubMed  Article  CAS  Google Scholar 

  57. 57.

    Maass A, Salvi D, Arcuri L, Semin G. Language use in intergroup contexts: the linguistic intergroup bias. J Pers Soc Psychol. 1989;57:981–93.

    PubMed  Article  CAS  Google Scholar 

  58. 58.

    Wigboldus DH, Semin GR, Spears R. How do we communicate stereotypes? Linguistic bases and inferential consequences. J Pers Soc Psychol. 2000;78:5–18.

    PubMed  Article  CAS  Google Scholar 

  59. 59.

    von Hippel W, Sekaquaptewa D, Vargas P. The linguistic intergroup bias as an implicit indicator of prejudice. J Exp Soc Psychol. 1997;33:490–509.

    Article  Google Scholar 

  60. 60.

    Bogart LM, Kelly JA, Catz SL, Sosman JM. Impact of medical and nonmedical factors on physician decision making for HIV/AIDS antiretroviral treatment. J Acquir Immune Defic Syndr. 2000;23:396–404.

    PubMed  CAS  Google Scholar 

  61. 61.

    Bogart LM, Catz SL, Kelly JA, Benotsch EG. Factors influencing physicians’ judgments of adherence and treatment decisions for patients with HIV disease. Med Decis Making. 2001;21:28–36.

    PubMed  CAS  Google Scholar 

  62. 62.

    Operario D, Fiske ST. Racism equals power plus prejudice: a social psychological equation for racial oppression. In: Eberhardt JL, Fiske T, eds. Confronting Racism: The Problem and the Response. Thousand Oaks, Calif: Sage Publications; 1998;33–53.

    Google Scholar 

  63. 63.

    Claire T, Fiske ST. A systemic view of behavioral confirmation: counterpoint to the individualist view. In: Sedikides C, Insko C, Schopler J, eds. Intergroup Cognition and Behavior. Hillsdale, NJ: Erlbaum; 1998:205–31.

    Google Scholar 

  64. 64.

    Snyder M, Stukas AA Jr. Interpersonal processes: the interplay of cognitive, motivational, and behavioral activities in social interaction. Annu Rev Psychol. 1999;50:273–303.

    PubMed  Article  CAS  Google Scholar 

  65. 65.

    Cooper LA, Roter D. Patient-provider communication: the effect of race and ethnicity on process and outcomes of healthcare. In: Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare. Washington, DC: The National Academies Press; 2003:552–93.

    Google Scholar 

  66. 66.

    Ashton CM, Haidet P, Paterniti DA, et al. Racial and ethnic disparities in the use of health services: bias, preferences, or poor communication? J Gen Intern Med. 2003;18:146–52.

    PubMed  Article  Google Scholar 

  67. 67.

    Ferguson WJ, Candib LM. Culture, language, and the doctor-patient relationship. Fam Med. 2002;34:353–61.

    PubMed  Google Scholar 

  68. 68.

    Epstein AM, Taylor WC, Seage GR III. Effects of patients’ socioeconomic status and physicians’ training and practice on patient-doctor communication. Am J Med. 1985;78:101–6.

    PubMed  Article  CAS  Google Scholar 

  69. 69.

    Zuckerman M, Knee CR, Hodgins HS, Miyake K. Hypothesis confirmation: the joint effect of positive test strategy and acquiescence response set. J Pers Soc Psychol. 1995;68:52–60.

    Article  Google Scholar 

  70. 70.

    Burk JP, Sher KJ. Labeling the child of an alcoholic: negative stereotyping by mental health professionals and peers. J Stud Alcohol. 1990;51:156–63.

    Google Scholar 

  71. 71.

    Martin TW. White therapists’ differing perceptions of black and white adolescents. Adolescence. 1993;28:281–9.

    PubMed  CAS  Google Scholar 

  72. 72.

    Blascovich J, Spencer SJ, Quinn D, et al. African Americans and high blood pressure: the role of stereotype threat. Psychol Sci. 2001;12:225–9.

    PubMed  Article  CAS  Google Scholar 

  73. 73.

    Hooper EM, Comstock LM, Goodwin JM, Goodwin JS. Patient characteristics that influence physician behavior. Med Care. 1982;20:630–8.

    PubMed  Article  CAS  Google Scholar 

  74. 74.

    Saha S, Komaromy M, Koepsell TD, Bindman AB. Patient-physician racial concordance and the perceived quality and use of health care. Arch Intern Med. 1999;159:997–1004.

    PubMed  Article  CAS  Google Scholar 

  75. 75.

    Baumeister RF, Bratslavsky E, Muraven M, Tice DM. Ego depletion: is the active self a limited resource? J Pers Soc Psychol. 1998;74:1252–65.

    PubMed  Article  CAS  Google Scholar 

  76. 76.

    Bierman AS, Lurie N, Collins KS, Eisenberg JM. Addressing racial and ethnic barriers to effective health care: the need for better data. Health Aff (Millwood). 2002;21:91–102.

    Article  Google Scholar 

  77. 77.

    Galinsky AD, Moskowitz GB. Perspective-taking: decreasing stereotype expression, stereotype accessibility, and in-group favoritism. J Pers Soc Psychol. 2000;78:708–24.

    PubMed  Article  CAS  Google Scholar 

  78. 78.

    Blair IV, Ma JE, Lenton AP. Imagining stereotypes away: the moderation of implicit stereotypes through mental imagery. J Pers Soc Psychol. 2001;81:828–41.

    PubMed  Article  CAS  Google Scholar 

  79. 79.

    Wegener DT, Dunn M, Tokusato D. The flexible correction model: phenomenology and the use of native theories in avoiding or removing bias. In: Moskowitz GB, ed. Cognitive Social Psychology: The Princeton Symposium on the Legacy and Future of Social Cognition. Mahwah, NJ: Lawrence Erlbaum. 2001:277–90.

    Google Scholar 

  80. 80.

    Snyder M, Haugen JA. Why does behavioral confirmation occur? A functional perspective on the role of the perceiver. J Exp Soc Psychol. 1994;30:218–46.

    Article  Google Scholar 

  81. 81.

    Snyder M, Haugen JA. Why does behavioral confirmation occur? A functional perspective on the role of the target. Pers Soc Psychol Bull. 1995;21:963–74.

    Article  Google Scholar 

  82. 82.

    Adams RJ, Smith BJ, Ruffin RE. Impact of the physician’s participatory style in asthma outcomes and patient satisfaction. Ann Allergy Asthma Immunol. 2001;86:263–71.

    PubMed  CAS  Article  Google Scholar 

  83. 83.

    Bensing J. Doctor-patient communication and the quality of care. Soc Sci Med. 1991;32:1301–10.

    PubMed  Article  CAS  Google Scholar 

  84. 84.

    Charles C, Gafni A, Whelan T. How to improve communication between doctors and patients. Learning more about the decision making context is important. BMJ. 2000;320:1220–1.

    PubMed  Article  CAS  Google Scholar 

  85. 85.

    Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282:583–9.

    PubMed  Article  CAS  Google Scholar 

  86. 86.

    Curtis JR, Patrick DL, Caldwell E, Greenlee H, Collier AC. The quality of patient-doctor communication about end-of-life care: a study of patients with advanced AIDS and their primary care clinicians. AIDS. 1999;13:1123–31.

    PubMed  Article  CAS  Google Scholar 

  87. 87.

    DiMatteo MR, Hays R. The significance of patients’ perceptions of physician conduct: a study of patient satisfaction in a family practice center. J Community Health. 1980;6:18–34.

    PubMed  Article  CAS  Google Scholar 

  88. 88.

    DiMatteo MR, Sherbourne CD, Hays RD, et al. Physicians’ characteristics influence patients’ adherence to medical treatment: results from the Medical Outcomes Study. Health Psychol. 1993;12:93–102.

    PubMed  Article  CAS  Google Scholar 

  89. 89.

    Fox SA, Stein JA. The effect of physician-patient communication on mammography utilization by different ethnic groups. Med Care. 1991;29:1065–82.

    PubMed  Article  CAS  Google Scholar 

  90. 90.

    Greenfield S, Kaplan S, Ware JE Jr. Expanding patient involvement in care. Effects on patient outcomes. Ann Intern Med. 1985;102:520–8.

    PubMed  CAS  Google Scholar 

  91. 91.

    Greenfield S, Kaplan SH, Ware JE Jr, Yano EM, Frank HJ. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. 1988;3:448–57.

    PubMed  Article  CAS  Google Scholar 

  92. 92.

    Greenlund KJ, Giles WH, Keenan NL, Croft JB, Mensah GA. Physician advice, patient actions, and health-related quality of life in secondary prevention of stroke through diet and exercise. Stroke. 2002;33:565–71.

    PubMed  Article  Google Scholar 

  93. 93.

    Roter D. The enduring and evolving nature of the patient-physician relationship. Patient Educ Couns. 2000;39:5–15.

    PubMed  Article  CAS  Google Scholar 

  94. 94.

    Roter DL, Hall JA. Studies of doctor-patient interaction. Annu Rev Public Health. 1989;10:163–80.

    PubMed  Article  CAS  Google Scholar 

  95. 95.

    Roter D. The medical visit context of treatment decision-making and the therapeutic relationship. Health Expect. 2000;3:17–25.

    Article  PubMed  Google Scholar 

  96. 96.

    Stewart D. The attitudes and attributions of student nurses: do they alter according to a person’s diagnosis or sexuality and what is the effect of nurse training? J Adv Nurs. 1999;30:740–8.

    PubMed  Article  CAS  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Dr. Diana J. Burgess PhD.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Burgess, D.J., Fu, S.S. & van Ryn, M. Why do providers contribute to disparities and what can be done about it?. J GEN INTERN MED 19, 1154–1159 (2004). https://doi.org/10.1111/j.1525-1497.2004.30227.x

Download citation

Key words

  • provider behavior
  • disparities
  • race
  • ethnicity
  • social cognition