Eliminating health disparities: What works?—June 2009

Stereotyping is an altogether human activity, and it allows clinicians to make complex decisions in a relatively short period of time. Van Ryn and Burgess have described what is involved with something they call dual process stereotyping.¹ The first process, called automatic stereotyping, occurs when stereotypes are activated automatically, influencing clinician judgment in unconscious ways. Researchers have shown that these kinds of stereotypes are often activated subliminally, with quick associations caused by a variety of triggers. For example, quick exposure of subjects in experiments to negative images of African Americans can trigger negative stereotypes, with the risk of impact to the clinical encounter.¹

The second process, called goal modified stereotyping, occurs when the need to make sense quickly of complex circumstances may lead to more conscious use of stereotypes to fill in gaps in information.¹ In a presentation at the 2008 Physician Assistant Education Association conference, PA educator Harry Pomeranz noted that clinical stereotyping can flow from and be exacerbated by the uncertainty that occurs when there is a cultural gap between the provider and the patient.² Stereotypes create “cognitive shortcuts.” As Pomeranz notes, stereotyping can lead to sometimes surprising situations where “... well-meaning and highly educated health professionals, working in their usual circumstances with diverse populations of patients, create a pattern of care that appears to be discriminatory...” and “can exert powerful effects on thinking and actions at an implicit, unconscious level, even among well-meaning, well-educated persons who are not overtly biased.”² 

Implicit bias is the close cousin of stereotyping, and the Harvard Implicit Association Test (IAT) provides a challenging venue to learn more about individual biases. Offering numerous self-tests looking at biases related to a wide variety of characteristics—including religion, race, and sexual orientation—the IAT is a stimulating and sometimes provocative tool to use with PAs and students. Green's 2007 study looking at the role of implicit bias among residents making prescribing decisions for patients with thrombolysis used the IAT as a data-gathering tool and is one of the first studies to provide evidence of the potential clinical impact of unconscious stereotyping and bias.³

One method to combat the impact of bias is a technique called priming, proposed by Van Ryn and Burgess.¹ They describe a process during which providers receive a brief intervention that includes data and information about the impact of bias and stereotyping, with the hypothesized goal that simply increasing awareness of bias and stereotyping can decrease their effects on patient care.^1 JAAPA

Jim Anderson is lead PA-NP, Department of Orthopedics, Seattle Children's Hospital, Seattle, Washington. He is a former chair of the AAPA's Committee on Diversity and a member of the JAAPA editorial board.