What can we learn from social cognition research? Advancing inquiry into the causes of race/ethnicity disparities in tre

1. What can we learn from social cognition research? Advancing inquiry into the causes of race/ethnicity disparities in treatment received Michelle van Ryn, M.P.H., Ph.D. Associate Professor, Division of Epidemiology, University of Minnesota, Suite 300 1300 S. 2nd Street Minneapolis, MN 55454-1015 Director, Colorectal Cancer Quality Enhancement Initiative and Associate Director, Center for Chronic Disease Outcomes Research, Minneapolis VAMC vanRyn@epi.umn.edu

2. Background and Problem • There is a massive body of evidence documenting race/ethnicity disparities in medical care, independent of clinical appropriateness, payer, and treatment site. • There is empirical evidence for a provider contribution to race/ethnicity inequities in access to kidney transplant and cardiac procedures, quality of in-hospital care, psychiatric care, and pain control. • Research on the contribution of provider behavior to disparities in care is in its infancy.

3. Theory and Research Driven Inquiry: • What factors may be influencing the clinical decision-making process so as to result in systematically different treatment by patient race/ethnicity? • What areas of inquiry can be drawn on to inform inquiry in this understudied area? • What existing bodies of research and theory will provide insight into understanding of the effect of patient demographic characteristics on clinical decision-making?

4. Social Cognition Theory and Research Provides Insight and a Framework For Inquiry. • Social cognition research and theory focuses on questions like... • How do we make sense of other people? • How do we develop our perceptions of others? • What factors influence the way we form beliefs about others? • How do we develop beliefs about reasons for their behavior (attributions)? • How do we make use of our “social knowledge” of others? • How do our beliefs about others influence our behavior?

5. There is considerable empirical evidence that: • Demographic (age, race/ethnicity, sex) and other characteristics (sickness, pre-maturity, diagnosis) can influence physician affect towards, opinions, beliefs and behaviors towards patients. • There is evidence that demographic characteristics influences the substantive content of encounters, including discussion of end-of-life care, advice to quit smoking, discussion of diet,exercise, mammography, prenatal preventive care advice regarding smoking cessation, alcohol use, and breastfeeding. • Provider behavior influences patient satisfaction, adherence, utilization, and outcomes .

6. Although understudied, there is some evidence that stereotyping (social cognition) is one mechanism through which provider treatment recommendations are influenced by patient race/ethnicity • Bogart and colleagues found that physicians were more likely to provide highly active antiretroviral therapy (HAART) to HIV/AIDS patients when they perceived them as likely to be adherent. • They then examined patient characteristics associated with physician predictions of adherence by randomly assigning physicians to review patient vignettes that varied only on patient gender, disease severity, ethnicity, and risk group. African American patients were more likely to be rated as non-adherent independent of other factors.

7. Although understudied, there is some evidence that stereotyping (social cognition) is one mechanism through which provider treatment recommendations are influenced by patient race/ethnicity • van Ryn and colleagues found that physician ratings of patients' likelihood of having adequate social support and/or participating in cardiac rehabilitation as found to predict physicians' recommendations for revascularization, independent of clinical appropriateness for revascularization and other demographic characteristics. • In turn, this same group of physicians were more likely to rate African American patients as lacking in social support and unlikely to participate in cardiac rehabilitation than white patients.

9. Physician Beliefs About Patient (Beliefs about clinical factors, social and behavioral factors, resources. Includes conscious and unconsciously activated beliefs) Primary Hypotheses: Physician Clinical Decision-making (Diagnosis,Treatment Recommendation) Patient Race/ethnicity Providers treatment recommendations are influenced by perceptions of patients’ social and behavioral characteristics, which in turn are affected by patient demographic characteristics.

10. Physician Beliefs About Patient (Beliefs about clinical factors, social and behavioral factors, resources. Includes conscious and unconsciously activated beliefs) Provider Interpersonal Behavior (e.g., participatory style, warmth, content, information giving, question-asking) Patient Race/ethnicity • An additional hypothesized mechanism through which provider behavior may influence race/ethnicity disparities and outcomes is through variation in communication and interpersonal behaviors, which in turn may affect quality of care and outcomes. • There is considerable evidence that patient socio-demographic characteristics can affect provider participatory style, level of psychosocial talk, close-ended question asking, warmth, information giving, and communication effectiveness.

11. Stereotypes: Not just for bigots • All humans share the cognitive strategy of making the world more manageable by using categorizing and generalizing techniques to simplify the massive amounts of complex information and stimuli to which they are exposed. • This generally adaptive process simplifies cognitive processing, reduces effort, and frees up cognitive resources. • In applying this process to the social world, people develop beliefs and expectations about categories or groups of people. • When individuals are mentally assigned to a particular class or group, the characteristics assigned to that group are unconsciously and automatically applied to the individual, a process referred to as stereotype application.

12. Stereotypes are social cognitions that contain our knowledge, beliefs, expectations, and feelings about a social group including: • Causal theories about how they obtained given characteristics. • Beliefs about degree of group variability. • Expectations about the traits, behaviors and circumstances likely for a given group or category. • Stereotypes may be connected to a feeling or elicit an emotional reaction (have an affective component).

13. Stereotypes are Efficient • Stereotypes, like all concepts, are mental representations of a category, or a class, of objects we believe belong together or hang together in some way. Apple, librarian, and cruise are all kinds concepts. • The use of stereotypes, like all concepts, is a efficient cognitive trick; concepts help us extract meaning from the huge amount of information that surrounds us. • Stereotypes allow us to automatically activate and apply a great deal of information without effort. • Think about what happens when you see an apple. What do you know about it without any conscious effort or thought? Do you “test” the degree to which this knowledge is true of each apple?

14. Stereotyping can serve to meet deep human needs and motives. • The need for belonging (to ones own group vs. out-group). • The need to promote self-esteem through downward social comparison (feel superior to others). • The need to justify existing social order, distribution of resource. • The need to believe in a just world.

15. “I believe in equal rights and justice: I treat all my clients/patients the same” • Stereotype activation and application can be an automatic process • Stereotypes are often activated automatically (without intent). • Stereotypes can operate below conscious thought - individuals may not be aware of activation nor the impact on their perceptions, emotions and behavior. • Some studies found that stereotypes were activated more quickly than conscious cognition.

16. “As a doctor, I have to be a good judge of a patient's character.” • Social cognition research suggests that beliefs about, judgments, predictions and attributions for others' traits and behavior are frequently wrong • A massive body of communication, social interaction, and social cognition research has shown that it is common for people to apply... • Incorrect beliefs • Inaccurate theories • Inaccurate memories • Attributions errors (beliefs about causes or motives for others' behavior) • …to their interpretations of others and the social world.

17. “If a person doesn't fit the group stereotype it will become clear during the encounter.” • A large body of research shows that interactions tend to confirm our expectancies regardless of accuracy. • Identical behaviors is interpreted differently depending on race of performer (e.g. white “horseplay”; black “violence”). • There is ample evidence that people give different meaning to the same observed behavior depending on the race, class, or other characteristics of the person observed.

18. Provider-specific examples: • Mental health diagnoses varied among adolescents exhibiting the identical behavior based on prior labeling and race. • Medical students and Israeli providers assessment of normal toddlers children was negatively influenced by whether they were told the child had been born prematurely or not.

19. “The interpretive function of concepts lies at the heart of one of the central lessons of research in social cognition: When we observe our social world, we do not merely watch an objective reality unfold before our eyes. Rather, we, take part in shaping our own reality; the concepts we impose on events determine the meaning we extract from them.” Ziva Kunda

20. Our interpretation of others' behavior influences our behavior. • Unconsciously activated stereotypes affect our behavior. • Our behavior toward others influences their behavior in turn (self-fulfilling prophecy).

21. Self-fulfilling prophesy • Extensively studied in educational and job interviewing domains. Interviewers' interpersonal behaviors influenced by race of applicant, and in turn, interviewer behavior influences application behavior. • White students “primed” by subliminal images of African American men were more hostile in a word-guessing game with a white partner. This hostility then elicited more hostility from naïve white partner.

22. “I assess and treat each patient individually so stereotyping isn't a problem.” • Stereotypes are often applied in the presence of individuating information • If all we know about an individual is group category, we attribute characteristics of the group to the individual (serves a “base-rate” function). • Good news: Individuating information does replace stereotypical beliefs in many cases.

23. Many cognitive processes result in confirmation of expectancies (we process information in ways that support our preconceived ideas). • Individual information is understood and interpreted through the filter of generalized beliefs (stereotypes) about the person. • This phenomena is exacerbated when individuals' behavior is at all ambiguous, which is more likely in cross-cultural communication. • Stereotypes have been shown to influence predictions about others' likely future behavior even in the presence of instances of stereotype- inconsistent behavior.

24. Factors that increase the likelihood of stereotype activation characterize physicians' work. • Individuals are more likely to activate and apply stereotypes when they are: • Tired • Distracted • Pressed for time • Anxious • These conditions may deplete the cognitive resources needed for processing individuating information and/or suppressing stereotypes.

25. Will cultural competency and anti-racism training address this problem?

26. Maybe not: We are often unconscious (no intention or awareness) of the way activated stereotypes affect our interpretation of another's behavior.

27. Maybe not: Efforts at Stereotype Suppression can Backfire • When experimental participants are asked to suppress stereotypes in arriving at judgments of an individual, they can do so. • However, initial suppression of stereotypes leads to increased activation and use in other settings encountered shortly thereafter.

28. Maybe sometimes: • There are individual and stimulus differences in automatic processing of stereotypes - those very low conscious prejudice less likely to automatically activate negative concepts/affect when stimulus is neutral, but equally likely when stimulus is negative.

29. Maybe Sometimes: • Stereotype activation can be suppressed if it conflicts with other motives, such as boosting our feelings of self-worth. • If choices between alternate stereotypes and associated characteristics serves our interests, we will make that choice. • Desire to form rapid impressions increases stereotype activation and decreases attention to individuating information.

30. An Ongoing Major Debate in Social Cognition Literature: How much control can we exert over automatic processes? Can we suppress unwanted stereotypes?

31. Conclusions • There is an ample body of evidence supporting the hypothesis that patient socio-demographic characteristics can independently influence physician expectations, perceptions, affect and behavior toward patients. • Common misunderstandings about the nature of social cognition in combination with unrealistic expectations of physicians have served as a barrier to advancing research and policy in this area. • The lack of research in this area profoundly limits our ability to develop effective interventions.

32. This literature on providers’ perceptions of patients is in its infancy and varies widely in type and quality of method used. • We do not know the circumstances under which provider perceptions will or will not be influenced by patient characteristics, • Nor can we predict the specific perceptions that will be influenced or the exact implications of a set of perceptions for patient care. • NOTE: This presentation suggests a research agenda and a number of hypotheses to be tested rather than asserting proven causal relationships

33. Selected Challenges in Research on the Effect of Social Cognition on Clinical Decision-Making: • Frequently, R's must be blind to hypotheses. • Automatic or subconscious processes cannot be directly measured. • Unclear which specific beliefs/expectancies are relevant to treatment recommendations for a given illness. • Measures must occur in close temporal proximity to exposure (encounter, videotape, etc.) • Responses to videotapes inadequately capture actual encounters and processes, unknown generalizability.

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