Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report

Journal of General Internal Medicine, Jul 2015

BACKGROUND Physician implicit (unconscious, automatic) bias has been shown to contribute to racial disparities in medical care. The impact of medical education on implicit racial bias is unknown. OBJECTIVE To examine the association between change in student implicit racial bias towards African Americans and student reports on their experiences with 1) formal curricula related to disparities in health and health care, cultural competence, and/or minority health; 2) informal curricula including racial climate and role model behavior; and 3) the amount and favorability of interracial contact during school. DESIGN Prospective observational study involving Web-based questionnaires administered during first (2010) and last (2014) semesters of medical school. PARTICIPANTS A total of 3547 students from a stratified random sample of 49 U.S. medical schools. MAIN OUTCOME(S) AND MEASURE(S) Change in implicit racial attitudes as assessed by the Black-White Implicit Association Test administered during the first semester and again during the last semester of medical school. KEY RESULTS In multivariable modeling, having completed the Black-White Implicit Association Test during medical school remained a statistically significant predictor of decreased implicit racial bias (−5.34, p ≤ 0.001: mixed effects regression with random intercept across schools). Students' self-assessed skills regarding providing care to African American patients had a borderline association with decreased implicit racial bias (−2.18, p = 0.056). Having heard negative comments from attending physicians or residents about African American patients (3.17, p = 0.026) and having had unfavorable vs. very favorable contact with African American physicians (18.79, p = 0.003) were statistically significant predictors of increased implicit racial bias. CONCLUSIONS Medical school experiences in all three domains were independently associated with change in student implicit racial attitudes. These findings are notable given that even small differences in implicit racial attitudes have been shown to affect behavior and that implicit attitudes are developed over a long period of repeated exposure and are difficult to change.

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Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report

Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report Michelle van Ryn 2 Rachel Hardeman 2 Sean M. Phelan 2 Diana J. Burgess 0 1 John F. Dovidio 4 Jeph Herrin 4 Sara E. Burke M.Phil 4 David B. Nelson 0 2 Sylvia Perry 3 Mark Yeazel 1 Julia M. Przedworski 1 0 Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Medical Center , Minneapolis, MN , USA 1 University of Minnesota , Minneapolis, MN , USA 2 Mayo Clinic College of Medicine , Rochester, MN , USA 3 University of Vermont , Burlington, VT , USA 4 Yale University , New Haven, CT , USA disparities; medical education; implicit racial bias; physician-patient relations; attitude of health personnel; J Gen Intern Med DOI; 10; 1007/s11606-015-3447-7 © The Author(s) 2015; This article is published with open access at Springerlink; com - BACKGROUND: Physician implicit (unconscious, automatic) bias has been shown to contribute to racial disparities in medical care. The impact of medical education on implicit racial bias is unknown. OBJECTIVE: To examine the association between change in student implicit racial bias towards African Americans and student reports on their experiences with 1) formal curricula related to disparities in health and health care, cultural competence, and/or minority health; 2) informal curricula including racial climate and role model behavior; and 3) the amount and favorability of interracial contact during school. DESIGN: Prospective observational study involving Webbased questionnaires administered during first (2010) and last (2014) semesters of medical school. PARTICIPANTS: A total of 3547 students from a stratified random sample of 49 U.S. medical schools. MAIN OUTCOME(S) AND MEASURE(S): Change in implicit racial attitudes as assessed by the Black-White Implicit Association Test administered during the first semester and again during the last semester of medical school. KEY RESULTS: In multivariable modeling, having completed the Black-White Implicit Association Test during medical school remained a statistically significant predictor of decreased implicit racial bias (−5.34, p≤0.001: mixed effects regression with random intercept across schools). Students' self-assessed skills regarding providing care to African American patients had a borderline association with decreased implicit racial bias (−2.18, p=0.056). Having heard negative comments from attending physicians or residents about African American patients (3.17, p=0.026) and having had unfavorable vs. very favorable contact with African American physicians (18.79, p=0.003) were statistically significant predictors of increased implicit racial bias. CONCLUSIONS: Medical school experiences in all three domains were independently associated with change in student implicit racial attitudes. These findings are notable given that even small differences in implicit racial attitudes have been shown to affect behavior and that implicit attitudes are developed over a long period of repeated exposure and are difficult to change. INTRODUCTION Over the past two decades, hundreds of studies have documented widespread racial inequalities in medical care.1,2 Disparities in health and health care relative to white populations have been most extensively and consistently documented for African Americans, but also occur for other racial and ethnic groups in the U.S. While the causes of unequal care for African Americans are complex, provider behavior and decision-making is one documented contributor.1–7 Explanations for the provision of unequal care by physicians draw heavily from research on implicit racial bias.7–9 This term refers to automatic and unconscious negative attitudes towards African Americans as compared to whites. Implicit racial bias influences behavior in unintentional but powerful and systematic ways,10 profoundly influencing clinical decision-making.11,12 In addition, implicit racial bias predicts nonverbal behavior such as eye contact and posture,13–17 and has been shown to influence the quality of physicians’ interpersonal communication with African American patients and, in turn, patients’ trust and perceptions of their physicians.4,18,19 Over a decade ago, the Institute of Medicine called for investigation into the way socialization into the Bculture of medicine^ promotes or inhibits physician expressions of racial bias.20 In response to this, and to the continued evidence of physician bias, many medical schools have developed curricula aimed at eliminating physician contribution to inequality in care, although little is known about their effectiveness in reducing implicit racial bias. Additionally, the effect of the informal or Bhidden^ curricula (informal climate and role model behavior) on racial attitudes of medical student is unknown.21–25 Thus, medical educators have limited information to inform best strategies to address implicit racial bias during traini (...truncated)


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Michelle van Ryn PhD, MPH, Rachel Hardeman PhD, Sean M. Phelan PhD, Diana J. Burgess PhD, John F. Dovidio PhD, Jeph Herrin PhD, Sara E. Burke M.Phil, David B. Nelson PhD, Sylvia Perry PhD, Mark Yeazel MD, Julia M. Przedworski. Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report, Journal of General Internal Medicine, 2015, pp. 1748-1756, Volume 30, Issue 12, DOI: 10.1007/s11606-015-3447-7