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

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_at_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.

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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.

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Primary Hypotheses
Physician Beliefs About Patient (Beliefs about
clinical factors, social and behavioral factors,
resources. Includes conscious and unconsciously
activated beliefs)
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.

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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.

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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.

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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).

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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?

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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.

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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.

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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.

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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

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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.

34
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