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Title: 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.

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.

8
(No Transcript)
9
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.

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.

34
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