disproportionately enrolled in lower-cost health plans that place greater per patient limits on healthcare expenditures and available services), the types of incentives in place to contain costs (e.g., incentives to physicians to limit services), and where minorities tend to receive care (e.g., minorities are less likely to access care in a private physician’s office, even when insured at the same level as whites).

The second set of factors emerges from the clinical encounter. Three mechanisms might be operative in healthcare disparities from the provider’s side of the exchange: bias (or prejudice) against minorities; greater clinical uncertainty when interacting with minority patients; and beliefs (or stereotypes) held by the provider about the behavior or health of minorities. Patients might also react to providers’ behavior associated with these practices in a way that also contributes to disparities. Research on how patient race or ethnicity may influence physician decision-making and the quality of care for minorities is still developing, and as yet there is no direct evidence to illustrate how prejudice, stereotypes, or bias may influence care. In the absence of such research, the study committee drew upon a mix of theory and relevant research to understand how these processes might operate in the clinical encounter.

Clinical Uncertainty 

Any degree of uncertainty a physician may have relative to the condition of a patient can contribute to disparities in treatment. Doctors must depend on inferences about severity based on what they can see about the illness and on what else they observe about the patient (e.g., race). The doctor can therefore be viewed as operating with prior beliefs about the likelihood of patients’ conditions, "priors" that will be different according to age, gender, socioeconomic status, and race or ethnicity. When these priors are considered alongside information gathered in a clinical encounter, both influence medical decisions.

Doctors must balance new information gained from the patient (sometimes with varying levels of accuracy) and their prior expectations about the patient to make a diagnosis and determine a course of treatment. If the physician has difficulty accurately understanding the symptoms or is less sure of the "signal" – the set of clues and indications that physicians rely upon to make diagnostic decisions – then he or she is likely to place greater weight on "priors." The consequence is that treatment decisions and patients’ needs are potentially less well matched.

The Implicit Nature of Stereotypes 

A large body of research in psychology has explored how stereotypes evolve, persist, shape expectations, and affect interpersonal interactions. Stereotyping can be defined as the process by which people use social categories (e.g., race, sex) in acquiring, processing, and recalling information about others. The beliefs (stereotypes) and general orientations (attitudes) that people bring to their interactions help organize and simplify complex or uncertain situations and give perceivers greater confidence in their ability to understand a situation and respond in efficient and effective ways.

Although functional, social stereotypes and attitudes also tend to be systematically biased, these biases may exist in overt, explicit forms, as represented by traditional bigotry. However, because their origins arise from virtually universal social categorization processes, they may also exist, often unconsciously, among people who strongly endorse egalitarian principles and truly believe that they are not prejudiced. In the United States, because of shared socialization influences, there is considerable empirical evidence that even well-intentioned whites who are not overtly biased and who do not believe that they are prejudiced typically demonstrate unconscious implicit negative racial attitudes and stereotypes. Both implicit and explicit stereotypes significantly shape interpersonal interactions, influencing how information is recalled and guiding expectations and inferences in systematic ways. They can also produce self-fulfilling prophecies in social interaction, in that the stereotypes of the perceiver influence the interaction with others in ways that conform to stereotypical expectations.

Healthcare Provider Prejudice or Bias 

Prejudice is defined in psychology as an unjustified negative attitude based on a person’s group membership. Survey research suggests that among white Americans, prejudicial attitudes toward minorities remain more common than not, as over half to three-quarters believe that relative to whites, minorities – particularly African Americans – are less intelligent, more prone to violence, and prefer to live off of welfare. It is reasonable to assume, however, that the vast majority of healthcare providers find prejudice morally abhorrent and at odds with their professional values. But healthcare providers, like other members of society, may not recognize manifestations of prejudice in their own behavior.

While there is no direct evidence that provider biases affect the quality of care for minority patients, research suggests that healthcare providers’ diagnostic and treatment

decisions, as well as their feelings about patients, are influenced by patients’ race or ethnicity. Schulman et al. (1999), for example, found that physicians referred white male, black male, and white female hypothetical "patients" (actually videotaped actors who displayed the same symptoms of cardiac disease) for cardiac catheterization at the same rates (approximately 90% for each group), but were significantly less likely to recommend catheterization procedures for black female patients exhibiting the same symptoms. In another experimental design, Abreu (1999) found that mental health professionals subliminally "primed" with African American stereotype-laden words were more likely to evaluate the same hypothetical patient (whose race was not identified) more negatively than when primed with neutral words. Further, in a study based on actual clinical encounters, van Ryn and Burke (2000) found that doctors rated black patients as less intelligent, less educated, more likely to abuse drugs and alcohol, more likely to fail to comply with medical advice, more likely to lack social support, and less likely to participate in cardiac rehabilitation than white patients, even after patients’ income, education, and personality characteristics were taken into account. These findings suggest that while the relationship between race or ethnicity and treatment decisions is complex and may also be influenced by gender, providers’ perceptions and attitudes toward patients are influenced by patient race or ethnicity, often in subtle ways.

Indeed, studies suggest that several characteristics of the clinical encounter increase the likelihood that stereotypes, prejudice, or uncertainty may influence the quality of care for minorities. In the process of care, health professionals must come to judgments about patients’ conditions and make decisions about treatment, often without complete and accurate information. In most cases, they must do so under severe time pressure and resource constraints. The assembly and use of these data are affected by many influences, including various "gestalts" or cognitive shortcuts. In fact, physicians are commonly trained to rely on clusters of information that functionally resemble the application of "prototypic" or stereotypic constellations. These conditions of time pressure, resource constraints, and the need to rely on gestalts map closely onto those factors identified by social psychologists as likely to produce negative outcomes due to lack of information, to stereotypes, and to biases (van Ryn, 2002).

As noted above, the responses of racial and ethnic minority patients to healthcare providers are also a potential source of disparities. Little research has been conducted as to how patients may influence the clinical encounter. It is reasonable to speculate, however, that if patients convey mistrust, refuse treatment, or comply poorly with treatment, providers may become less engaged in the treatment process, and patients are less likely to be provided with more vigorous treatments and services. But these kinds of reactions from minority patients may be understandable as a response to negative racial experiences in other contexts, or to real or perceived mistreatment by providers. Survey research, for example, indicates that minority patients perceive higher levels of racial discrimination in healthcare than nonminorities. Patients’ and providers’ behavior and attitudes may therefore influence each other reciprocally, but reflect the attitudes, expectations, and perceptions that each has developed in a context where race and ethnicity are often more salient than these participants are even aware of.

Given that stereotypes, bias, and clinical uncertainty may influence clinicians’ diagnostic and treatment decisions, education may be one of the most important tools as part of an overall strategy to eliminate healthcare disparities. Healthcare providers should be made aware of racial and ethnic disparities in healthcare, and the fact that these disparities exist, often despite providers’ best intentions. In addition, all current and future healthcare providers can benefit from cross-cultural education. Cross-cultural education programs have been developed to enhance health professionals’ awareness of how cultural and social factors influence healthcare, while providing methods to obtain, negotiate and manage this information clinically once it is obtained. Cross-cultural education can be divided into three conceptual approaches focusing on attitudes (cultural sensitivity/awareness approach), knowledge (multicultural/categorical approach), and skills (crosscultural approach), and has been taught using a variety of interactive and experiential methodologies. Research to date demonstrates that training is effective in improving provider knowledge of cultural and behavioral aspects of healthcare and building effective communication strategies.

Many other strategies must be undertaken, in conjunction with the training and educational strategies described here, to eliminate racial and ethnic disparities in healthcare. As noted in the report, these include, for example, policy and regulatory strategies that address fragmentation of health plans along socioeconomic lines, and health systems interventions to promote the use of clinical practice guidelines and promote the use of interpretation services where community need exists. In short, a comprehensive, multilevel strategy is needed to eliminate these disparities. Broad sectors – including healthcare providers, their patients, payors, health plan purchasers, and society at large–must work together to ensure all patients receive a high quality of healthcare.

An increasing number of resources are available to healthcare providers and their patients to increase awareness of racial and ethnic healthcare disparities and means to improve the quality of care for racial and ethnic minorities. The following is only a partial list of some of these resources, and is not intended as an endorsement of the products or individuals and groups that produced them:

American Board of Internal Medicine. (1998). Cultural Competence: Addressing a Multicultural Society: The ABIM Report 1997-1998. Philadelphia: American Board of Internal Medicine.

American Medical Association. (1999). Cultural Competence Compendium. Chicago, IL: American Medical Association. Product Number OP209199/ Phone # 1800-621-8335.

Betancourt JR, Like RC, and Gottlieb BR, eds. (2000). Caring for diverse populations: Breaking down barriers. Patient Care, Special Issue, May 15, 2000.

Lavizzo-Mourey R, and Mackenzie ER. (1996). Cultural Competence: Essential Measurements of Quality for Managed Care Organizations. Annals of Internal Medicine 124, pp. 91921.

National Alliance for Hispanic Health. Quality Services for Hispanics: the Cultural Competency Component, Rockville, MD: U.S. Department of Health and Human Services, 2000.

In addition to these sources, the Henry J. Kaiser Family Foundation and the Robert Wood Johnson Foundation have recently joined forces to sponsor an initiative to increase dialogue among physicians regarding healthcare disparities. To learn more about this initiative, please visit the "Why the Difference?" website at 
www.kff.org/whythedifference.

Abreu JM. (1999). Conscious and nonconscious African American stereotypes: Impact on first impression and diagnostic ratings by therapists. Journal of Consulting and Clinical Psychology, 67(3):387-93.

Gomes C, and McGuire TG. (2001). Identifying the sources of racial and ethnic disparities in health care use. Unpublished manuscript.

Schulman, K.A., Berlin, J.A., Harless, W., Kerner, J.F., Sistrunk, S., Gersh, B.J., Dube, R., Taleghani, C.K., Burke, J.E., Williams, S., Eisenberg, J., Escarce, J.J., Ayers, W. (1999). The effect of race and sex on physicians’ recommendations for cardiac catherization. New England Journal of Medicine 340:618-626.

van Ryn M, Burke J. 2000. The effect of patient race and socio-economic status on physician’s perceptions of patients. Social Science and Medicine 50:813-828.