Emergency medical services (EMS) personnel provide medical care for many lowincome and underserved individuals, including people experiencing homelessness (PEH). However, whereas EMS providers report positive explicit attitudes toward PEH, when seeking care, PEH report being the target of discrimination, which may reflect automatic or implicit prejudice that EMS providers hold toward them. To examine if EMS providers hold implicit prejudice toward PEH, 42 certified emergency medical technician (EMT) workers from Southern Arizona completed an Implicit Associations Test (IAT). The results showed a moderate and significant level of implicit prejudice against PEH, with male EMTs reporting significantly higher levels than female EMTs. The results indicate that developing new education and training in implicit bias for EMS providers may improve care for PEH.

Reseach indicates that healthcare providers' interpersonal biases toward marginalized patients are linked to poorer clinical judgments, strained interactions, and worse health outcomes. These biases often lead patients to disengage from care, including avoiding future visits to the same providers or clinics, and possibly seek fewer effective alternatives for treating disease. In this paper, we use the clinical and translational science (CTS) framework to review the translational work we have done on implicit bias in health care in three domains: Documenting the implicit nature of the biases that different health care providers hold toward various marginalized patient groups, examining the associations between provider bias and interactions with marginalized patients and their outcomes, and developing and testing the effectiveness of workshops that teach providers about bias and bias reduction strategies they can use when they interact with marginalized patients.

OBJECTIVE:The present study examined links among physician implicit bias and physician word use and patient satisfaction during outpatient medical visits. METHOD:To test these relationships, we measured implicit anti-Hispanic bias of 53 internal and family medicine residents and audio recorded outpatient visits between these residents and 291 of their Hispanic-identifying patients between 2015 and 2017. After each visit, both patients and resident physicians completed surveys measuring their perceptions of the interactions (residents) or their satisfaction with their care (patients). Linguistic Inquiry and Word Count was used to quantify resident word use from each audio recording. RESULTS:A quadratic relationship between physician implicit bias and patient satisfaction suggested that increased levels of implicit anti-Hispanic bias were related to lower levels of patient satisfaction, but only at high levels of physician bias. Exploratory analyses revealed that several language variables interacted with physician implicit bias to predict patient satisfaction suggesting that implicit bias may also be communicated by more moderately biased physicians in some contexts. CONCLUSIONS:These results add to a growing literature establishing links between physician implicit bias and patient care and suggest that future work should explore how context impacts the communication of physician bias to patients.

According to cognitive-dissonance theory, performing counterattitudinal behavior produces a state of dissonance that people are motivated to resolve, usually by changing their attitude to be in line with their behavior. One of the most popular experimental paradigms used to produce such attitude change is the induced-compliance paradigm. Despite its popularity, the replication crisis in social psychology and other fields, as well as methodological limitations associated with the paradigm, raise concerns about the robustness of classic studies in this literature. We therefore conducted a multilab constructive replication of the induced-compliance paradigm based on Croyle and Cooper (Experiment 1). In a total of 39 labs from 19 countries and 14 languages, participants (N = 4,898) were assigned to one of three conditions: writing a counterattitudinal essay under high choice, writing a counterattitudinal essay under low choice, or writing a neutral essay under high choice. The primary analyses failed to support the core hypothesis: No significant difference in attitude was observed after writing a counterattitudinal essay under high choice compared with low choice. However, we did observe a significant difference in attitude after writing a counterattitudinal essay compared with writing a neutral essay. Secondary analyses revealed the pattern of results to be robust to data exclusions, lab variability, and attitude assessment. Additional exploratory analyses were conducted to test predictions from cognitive-dissonance theory. Overall, the results call into question whether the induced-compliance paradigm provides robust evidence for cognitive dissonance.

Health literacy is the ability to understand, process, and obtain health information and make suitable decisions about health care [3]. Traditionally, text has been the main medium for delivering health information. However, virtual assistants are gaining popularity in this digital era; and people increasingly rely on audio and smart speakers for health information. We aim to identify audio/text features that contribute to the difficulty of the information delivered over audio. We are creating a health-related audio corpus. We selected text snippets and calculated seven text features. Then, we converted the text snippets to audio snippets. In a pilot study with Amazon Mechanical Turk (AMT) workers, we measured the perceived and actual difficulty of the audio using the response of multiple choice and free recall questions. We collected demographic information as well as bias about doctors’ gender, task preference, and health information preference. Thirteen workers completed thirty audio snippets and related questions. We found a strong correlation between text features lexical chain, and the dependent variables, and multiple choice response, percentage of matching word, percentage of similar word, cosine similarity, and time taken (in seconds). In addition, doctors were generally perceived to be more competent than warm. How warm workers perceive male doctors correlated significantly with perceived difficulty.

Oncology clinicians often miss opportunities to communicate empathy to patients. The current study examined the relationship between implicit bias (based on cancer type and ethnicity) and medical students' empathic communication in encounters with standardized patients who presented as Hispanic (lung or colorectal) individuals diagnosed with cancer. Participants (101 medical students) completed the Implicit Association Test (IAT) to measure implicit bias based on cancer type (lung v. colorectal) and ethnicity (Hispanic v. non-Hispanic White). Empathic opportunities and responses (assessed by the Empathic Communication Coding System; ECCS) were evaluated in a mock consultation (Objective Structured Clinical Examination; OSCE) focused on smoking cessation in the context of cancer. Among the 241 empathic opportunities identified across the 101 encounters (M = 2.4), 158 (65.6%) received high empathy responses from the medical students. High empathy responses were most frequently used during challenge (73.2%) and emotion (77.3%) opportunities compared to progress (45.9%) opportunities. Higher levels of implicit bias against Hispanics predicted lower odds of an empathic response from the medical student (OR = 3.24, p = .04, 95% CI = 0.09-0.95). Further work is needed to understand the relationship between implicit bias and empathic communication and inform the development of interventions.

Introduction: Previous literature has explored patient perceptions of discrimination by race and insurance status, but little is known about whether the payer mix of the primary care clinic (i.e., that is majority public insurance vs. majority private insurance clinics) influences patient perceptions of race-or insurance-based discrimination.Methods: Between 2015-2017, we assessed patient satisfaction and perceived race-and insurance-based discrimination using a brief, anonymous post-clinic visit survey.Results: Participants included 3,721 patients from seven primary care clinics-three public clinics and four private clinics. Results from unadjusted logistic regression models suggest higher overall reports of race-and insurance-based discrimination in public clinics compared with private clinics. In mulvariate analyses, increasing age, Black race, lower education and Medicaid insurance were associated with higher odds of reporting race-and insurance-based discrimination in both public and private settings.Conclusion: Reports of race and insurance discrimination are higher in public clinics than private clinics. Sociodemographic variables, such as age, Black race, education level, and type of insurance also influence reports of race and insurance-based discrimination in primary care.

Real or perceived discrimination contributes to lower quality of care for Black compared to white patients. Some forms of discrimination come from non-physician and non-nursing (non-MD/RN) staff members (e.g., receptionists). Utilizing the Burgess Model as a framework for racial bias intervention development, we developed an online intervention with five, 30-min modules: (1) history and effects of discrimination and racial disparities in healthcare, (2) implicit bias and how it may influence interactions with patients, (3) strategies to handle stress at work, (4) strategies to improve communication and interactions with patients, and (5) personal biases. Modules were designed to increase understanding of bias, enhance internal motivation to overcome bias, enhance emotional regulation skills, and increase empathy in patient interactions. Participants were non-MD/RN staff in nine primary care clinics. Effectiveness of the intervention was assessed using Implicit Association Test and Symbolic Racism Scale, to measure implicit and explicit racial bias, respectively, before and after the intervention. Acceptability was assessed through quantitative and qualitative feedback. Fifty-eight non-MD/RN staff enrolled. Out of these, 24 completed pre- and post-intervention assessments and were included. Among participants who reported characteristics, most were Black, with less than college education and average age of 43.2 years. The baseline implicit bias d-score was 0.22, indicating slight pro-white bias. After the intervention, the implicit bias score decreased to −0.06 (p=0.01), a neutral score indicating no pro-white or Black bias. Participant rating of the intervention, scored from 1 (strongly disagree) to 5 (strongly agree), for questions including whether “it was made clear how to apply the presented content in practice” and “this module was worth the time spent” was ≥4.1 for all modules. There was a decrease in implicit pro-white bias after, compared with before, the intervention. Intervention materials were highly rated.

Health disparities have been found among patients with gynecologic cancers, with the greatest differences arising among groups based on racial, ethnic, and socioeconomic factors. Although there may be multiple social barriers that can influence health disparities, another potential influence may stem from healthcare system factors that unconsciously perpetuate bias toward patients who are racially and socioeconomically disadvantaged. More recent research suggested that providers hold these implicit biases (automatic and unconscious attitudes) for stigmatized populations with cancer, with emerging evidence for patients with gynecologic cancer. These implicit biases may guide providers' communication and medical judgments, which, in turn, may influence the patient's satisfaction with and trust in the provider. This narrative review consolidated the current research on implicit bias in healthcare, with a specific emphasis on oncology professionals, and identified future areas of research for examining and changing implicit biases in the field of gynecologic oncology.

Clinician bias has been identified as a potential contributor to persistent healthcare disparities across many medical specialties and service settings. Few studies have examined strategies to reduce clinician bias, especially in mental healthcare, despite decades of research evidencing service and outcome disparities in adult and pediatric populations. This manuscript describes an intervention development study and a pilot feasibility trial of the Virtual Implicit Bias Reduction and Neutralization Training (VIBRANT) for mental health clinicians in schools—where most youth in the U.S. access mental healthcare. Clinicians (N = 12) in the feasibility study—a non-randomized open trial—rated VIBRANT as highly usable, appropriate, acceptable, and feasible for their school-based practice. Preliminarily, clinicians appeared to demonstrate improvements in implicit bias knowledge, use of bias-management strategies, and implicit biases (as measured by the Implicit Association Test [IAT]) post-training. Moreover, putative mediators (e.g., clinicians’ VIBRANT strategies use, IAT D scores) and outcome variables (e.g., clinician-rated quality of rapport) generally demonstrated correlations in the expected directions. These pilot results suggest that brief and highly scalable online interventions such as VIBRANT are feasible and promising for addressing implicit bias among healthcare providers (e.g., mental health clinicians) and can have potential downstream impacts on minoritized youth’s care experience.

BACKGROUND:Robust evidence shows that perceived discrimination among stigmatized groups is associated with negative health outcomes. However, little work has examined whether holding prejudiced attitudes toward others is associated with health risks for prejudiced individuals.PURPOSE:The study is a test of the hypothesis that holding prejudicial attitudes has negative health implications for both the holders and targets of prejudicial attitudes.METHODS:The project connected data (2003-2015) at the state and county levels on average explicit and implicit prejudice held by White, Black, and Native American respondents from Project Implicit with data on cardiovascular disease (CVD) mortality for White, Black, and Native American individuals from the CDC Wonder database. Separate analyses regressed implicit and explicit prejudice on CVD mortality risk for White, Black, and Native American individuals, respectively.RESULTS:At the state level, among White individuals, explicit prejudice toward Blacks (β = .431, p =.037) and implicit prejudice toward Native Americans (β = .283, p = .045) were positively associated with greater CVD mortality for Whites. At the county level, White individuals' implicit prejudice toward Blacks (β =.081, p = .015) and Black individuals' implicit prejudice toward Whites (β = -.066, p = .018) were associated with greater CVD mortality for Whites. Also, at the county-level, among Black individuals, higher implicit (β = -.133, p < .001) and explicit (β = -.176, p < .001) prejudice toward Whites predicted CVD mortality for Blacks. Moreover, explicit prejudice held by White individuals was positively associated with Blacks' county-level CVD deaths (β = .074, p = .036).CONCLUSIONS:This evidence suggests that across racial groups, holding racial prejudice is associated with CVD mortality risk for both the prejudiced and the stigmatized groups. Future research should verify the reliability of this potential public health effect with additional work explicating moderators and mediators to inform surveillance and interventions.

Clinician bias is a contributor to health care inequities, but research on racial-ethnic bias among mental health professionals, especially toward minoritized youths, is limited. This column describes two studies involving mental health clinicians in schools, where most youths access mental health services. Study 1 used a mixed-methods approach to identify stereotypes about Black and Latinx youths salient to clinicians (e.g., academic failure; anger and aggression). In study 2, the authors developed four Implicit Association Tests to assess clinicians' implicit prejudice and stereotyping of Black and Latinx youths and found pro-White and anti-Black/Latinx bias at levels similar to those of other health care providers and the general population.

•Healthcare providers have shown implicit biases toward marginalized patients.•Implicit Associations Test (IAT) show gynecologic oncologists exhibit higher biases for cervical cancers•Future research is needed to evaluate and reduce the implicit biases in gynecologic oncology.

Prior research suggests that the implicit biases of physicians are negatively associated with quality of medical care and patient satisfaction among minority patients. However, relatively little is known about how physicians express these subtle forms of bias in patient interactions. This study examined the implicit and explicit anti-Hispanic biases of 53 resident physicians and the relationship between anti-Hispanic bias and language use during outpatient medical appointments with 291 Hispanic patients. Physician implicit bias was positively associated with use of interrogatives and work-related words and negatively associated with the use of prepositions and relativity-related words (e.g., words related to time and the future). These findings contribute to the growing body of evidence suggesting that, in addition to nonverbal and paraverbal behaviors, providers may communicate implicit bias to patients through the words they use during a clinical visit.

Abstract Cognitive dissonance theory (CDT) was first introduced by Leon Festinger. Cognitive dissonance is the process by which people detect an inconsistency between cognitions, such as attitudes, beliefs, and behavior. When individuals become aware of an inconsistency between cognitions, they experience a state of psychological discomfort that motivates them to restore consistency. Factors such as the importance of the cognitions and the magnitude of the discomfort play a role in determining how people restore consistency. Festinger described three primary ways people can reduce dissonance: change a cognition; add new cognitions; or change the importance of the inconsistent cognitions. Many early studies showed that when people are unable to change their behavior, they will change their attitudes to be more in line with the inconsistent behavior. Over the years, CDT has undergone many challenges and revisions. Some revisions focus on the importance of cognitions about the self in the processes by which dissonance motivates attitude change. Others focused on the consequences of the behavior and various cognitive mechanisms that underlie the experience of dissonance. In the early 21st century, research has examined the underlying motivation for dissonance-induced attitude and behavior change, and how people prefer to reduce dissonance once it is present. And, as with the entire field of social psychology, dissonance researchers are also raising concerns about the replicability of classic dissonance effects and focusing their attention on the need to improve the methods the field uses to test predictions going forward.

Importance:Racial bias is associated with the allocation of advanced heart failure therapies, heart transplants, and ventricular assist devices. It is unknown whether gender and racial biases are associated with the allocation of advanced therapies among women.Objective:To determine whether the intersection of patient gender and race is associated with the decision-making of clinicians during the allocation of advanced heart failure therapies.Design, Setting, and Participants:In this qualitative study, 46 US clinicians attending a conference for an international heart transplant organization in April 2019 were interviewed on the allocation of advanced heart failure therapies. Participants were randomized to examine clinical vignettes that varied 1:1 by patient race (African American to white) and 20:3 by gender (women to men) to purposefully target vignettes of women patients to compare with a prior study of vignettes of men patients. Participants were interviewed about their decision-making process using the think-aloud technique and provided supplemental surveys. Interviews were analyzed using grounded theory methodology, and surveys were analyzed with Wilcoxon tests.Exposure:Randomization to clinical vignettes.Main Outcomes and Measures:Thematic differences in allocation of advanced therapies by patient race and gender.Results:Among 46 participants (24 [52%] women, 20 [43%] racial minority), participants were randomized to the vignette of a white woman (20 participants [43%]), an African American woman (20 participants [43%]), a white man (3 participants [7%]), and an African American man (3 participants [7%]). Allocation differences centered on 5 themes. First, clinicians critiqued the appearance of the women more harshly than the men as part of their overall impressions. Second, the African American man was perceived as experiencing more severe illness than individuals from other racial and gender groups. Third, there was more concern regarding appropriateness of prior care of the African American woman compared with the white woman. Fourth, there were greater concerns about adequacy of social support for the women than for the men. Children were perceived as liabilities for women, particularly the African American woman. Family dynamics and finances were perceived to be greater concerns for the African American woman than for individuals in the other vignettes; spouses were deemed inadequate support for women. Last, participants recommended ventricular assist devices over transplantation for all racial and gender groups. Surveys revealed no statistically significant differences in allocation recommendations for African American and white women patients.Conclusions and Relevance:This national study of health care professionals randomized to clinical vignettes that varied only by gender and race found evidence of gender and race bias in the decision-making process for offering advanced therapies for heart failure, particularly for African American women patients, who were judged more harshly by appearance and adequacy of social support. There was no associated between patient gender and race and final recommendations for allocation of advanced therapies. However, it is possible that bias may contribute to delayed allocation and ultimately inequity in the allocation of advanced therapies in a clinical setting.

The present research tested if having first year medical students complete active learning workshops would reduce their implicit stereotyping of Hispanics as medically noncompliant. The workshops were tested with 78-majority (White) group, 16-target minority (Hispanic, African-American and American-Indian) group, and 42-non-target minority (Asian-American and foreign born students from East Asia and Southeast Asia) group students in the 2018 and 2021 classes in the American Southwest. Prior to the workshops, students completed an implicit association test (IAT), and then participated in two workshops that covered the psychology of intergroup bias, the role of implicit bias in patient care, and activities for learning six strategies for controlling the implicit stereotyping of patients. The results showed that before the workshops, the level of implicit stereotyping of Hispanics was significant for the majority and non-target minority group students, but it was not significant for the target minority group students. After the workshops, target minority students again showed no bias, and implicit stereotyping was significantly lower for the majority group students, but not for the non-target minority students. The results suggest that the workshops may have been effective for majority group and target minority group students, but that more cultural tailoring of the materials and activities may be necessary to address implicit bias among some minority group medical students.