CONTEXT: Studies documenting racial/ethnic disparities in health care frequently implicate physicians' unconscious biases. No study to date has measured physicians' unconscious racial bias to test whether this predicts physicians' clinical decisions. OBJECTIVE:To test whether physicians show implicit race bias and whether the magnitude of such bias predicts thrombolysis recommendations for black and white patients with acute coronary syndromes. DESIGN, SETTING, AND PARTICIPANTS:An internetbased tool comprising a clinical vignette of a patient presenting to the emergency department with an acute coronary syndrome, followed by a questionnaire and three Implicit Association Tests (IATs). Study invitations were e-mailed to all internal medicine and emergency medicine residents at four academic medical centers in Atlanta and Boston; 287 completed the study, met inclusion criteria, and were randomized to either a black or white vignette patient.MAIN OUTCOME MEASURES: IAT scores (normal continuous variable) measuring physicians' implicit race preference and perceptions of cooperativeness. Physicians' attribution of symptoms to coronary artery disease for vignette patients with randomly assigned race, and their decisions about thrombolysis. Assessment of physicians' explicit racial biases by questionnaire. RESULTS:Physicians reported no explicit preference for white versus black patients or differences in perceived cooperativeness. In contrast, IATs revealed implicit preference favoring white Americans (mean IAT score=0.36, P<.001, one-sample t test) and implicit stereotypes of black Americans as less cooperative with medical procedures (mean IAT score 0.22, P<.001), and less cooperative generally (mean IAT score 0.30, P<.001). As physicians' prowhite implicit bias increased, so did their likelihood of treating white patients and not treating black patients with thrombolysis (P=.009).CONCLUSIONS: This study represents the first evidence of unconscious (implicit) race bias among physicians, its dissociation from conscious (explicit) bias, and its predictive validity. Results suggest that physicians' unconscious biases may contribute to racial/ ethnic disparities in use of medical procedures such as thrombolysis for myocardial infarction.

Demographic changes anticipated over the next decade magnify the importance of addressing racial/ethnic disparities in health and health care. A framework of organizational, structural, and clinical cultural competence interventions can facilitate the elimination of these disparities and improve care for all Americans.

Demographic changes anticipated over the next decade magnify the importance of addressing racial/ethnic disparities in health and health care. A framework of organizational, structural, and clinical cultural competence interventions can facilitate the elimination of these disparities and improve care for all Americans.

No abstract

Cultural competence has gained attention as a potential strategy to improve quality and eliminate racial/ethnic disparities in health care. In 2002 we conducted interviews with experts in cultural competence from managed care, government, and academe to identify their perspectives on the field. We present our findings here and then identify recent trends in cultural competence focusing on health care policy, practice, and education. Our analysis reveals that many health care stakeholders are developing initiatives in cultural competence. Yet the motivations for advancing cultural competence and approaches taken vary depending on mission, goals, and sphere of influence.

Understanding of the range of barriers to colorectal cancer screening can help develop multimodal interventions to increase colonoscopy rates for all patients including low-income Latinos. Interventions including systems improvements and navigator programs could address barriers by assisting patients with scheduling, insurance issues, and transportation and providing interpretation, education, emotional support, and motivational interviewing.

We propose a developmental model to illustrate how individuals might move from absolute denial of unconscious bias to the integration of strategies to mitigate its influence on their interactions with patients and offer recommendations to educators and education researchers.

The Institute of Medicine report entitled Unequal Treatment recommended that all health care professionals receive training in cross-cultural communication-also called "cultural competence"-as one potential strategy for addressing racial or ethnic disparities in health care. Although evidence shows that cultural competence training improves the attitudes, knowledge, and skills of physicians as well as patients' ratings of care, no definitive evidence has yet linked this training to improved health outcomes. Recently, there has been great interest in the field of cultural competence, including an expressed desire for a better understanding of its key principles, of effective ways of engaging clinicians in this area of instruction, and of the link between training and health outcomes. On the basis of years of experience in the field, the authors share key perspectives in all of these areas, with particular focus on a set of guidelines for measuring the impact of cultural competence training on health care outcomes. The authors maintain that cultural competence represents an important building block of clinical care, as well as a skill set that is central to professionalism and quality. Cultural competence training should be evaluated in a stepwise fashion by using the tools of health services research and the principles of quality improvement, and it should be held to the same standards as other educational interventions and activities. Just as medicine strives to meet other challenges in U.S. health care, so should it focus on developing the skills needed to care for the country's diverse population.