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@epi.umn.edu
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.
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?
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?
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 .
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.
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.
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)
Primary Hypotheses:
Providers treatment recommendations
are influenced by perceptions of
patients’ social and behavioral
characteristics, which in turn are
affected by patient demographic
characteristics.
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)
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 sociodemographic characteristics can affect provider
participatory style, level of psychosocial talk, closeended question asking, warmth, information giving,
and communication effectiveness.
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.
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).
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?
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.
“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.
“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.
“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.
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.
“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
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).

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.
“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.
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 stereotypeinconsistent behavior.
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.
Will cultural competency and
anti-racism training address
this problem?
Maybe not: We are often
unconscious (no intention or
awareness) of the way
activated stereotypes affect
our interpretation of
another's behavior.
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.

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.
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.
An Ongoing Major Debate in
Social Cognition Literature:
How much control can we
exert over automatic
processes? Can we
suppress unwanted
stereotypes?
Conclusions

There is an ample body of evidence
supporting the hypothesis that patient sociodemographic 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.




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
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.
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