| A Health Disparities Reduction Project of the American Academy of Physician Assistants, the Physician Assistant Foundation, and Physician Assistants for Health Equity |
| Heads Up! |
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| CURRICULUM MODULE |
(After reading this introductory text, the three recommended articles, and taking the web-based bias self-assessments from
the University of Chicago and Harvard University, students/members can take the post-test which is also included below.
This module was approved by the AAPA for CME in 2009. Please contact us for further information about how you can use
this module in your state/chapter/program.
CURRICULUM MODULE STEP 1:
Review Learning Objectives for Curriculum Module:
At the conclusion of this module (including the reading, online review of websites, and powerpoint presentation/lecture),
participants will be able to:
1. Define “Racial Health Disparities.”
2. Describe “implicit bias” and “unconscious stereotyping.”
3. Identify the correlation between implicit bias and clinical outcomes.
4. Explain “dual process stereotyping.”
5. Create an “equity report” for use in medical settings
6. Describe evidence relating to racial disparities in the treatment of pain
7. Place racial health disparities in the context of “Healthy People 2010.”
8. Discuss the findings of the “Unequal Treatment” report.
9. Understand evidence of racial disparities in cardiovascular care.
10. Identify web and other resources related to implicit bias.
CURRICULUM MODULE STEP 2:
Use Powerpoint Presentation For One Hour Lecture Presentation
Link to the presentation by clicking here:
(To open and save, click on link, open file, right click and select "edit slides", and save presentation to your computer)
The presentation is designed to accompany and follow the learning objectives, readings and web activities, and assessment
questions
CURRICULUM MODULE STEP 3:
Review Introductory Text:
In November 2007, the American Academy of Physician Assistants' (AAPA) Committee on Diversity launched "Heads Up!," an
awareness campaign aimed at reducing racial and ethnic disparities in health care. For three months, signage addressing the
issue of racial health care disparities, unconscious racial stereotyping, and implicit racial bias by clinicians was placed on
University of Washington Health Sciences Express shuttle buses. The buses are used by thousands of medical and health
care students and clinicians who travel daily between Seattle's University of Washington School of Medicine and its teaching
partner institution, Harborview Medical Center.
The campaign consisted of three bus signs, each of which addressed a different health disparities issue. The signs were
displayed on a rotating basis over the next three months. After the conclusion of the project, the AAPA Committee on Diversity
worked with AAPA to develop this CME module, with an assessment available at no charge to AAPA members on the AAPA
website. When the application for CME approval is accepted, one hour of category I CME may be received by completing this
module and then taking the online assessment. The application for CME approval is currently pending.
The project is among the first to address new evidence about the role of unconscious racial stereotyping in racial health
disparities. In 2007, Alexander Green, M.D., of the Disparities Solutions Center at Massachusetts General Hospital, released a
study that connected implicit and unconscious stereotyping with unequal treatment of patients. It is one of the first studies to
connect these two issues. Green and the Disparities Solutions Center provided consultation and input on the "Heads Up!"
campaign.
One "Heads Up!" sign featured photos of two males, one Caucasian and one African American, with the words: "Chest Pain,
Identical Symptoms, Matching Histories: Which Patient Doesn't Get the Appropriate Tests?" This refers to Green's study,
published in the Journal of General Internal Medicine, which had resident physicians direct treatment for hypothetical patients.
The residents based treatment decisions on a picture of the patient’s face, accompanied by a written description of the patient’
s chest pain. All of the hypothetical descriptions were identical, differing only in the race of the patients. Results revealed more
physicians prescribing thrombolysis for the white patients than for the black patients.
The study used an assessment tool from Project Implicit at Harvard University, measuring unconscious bias against black
patients on the part of providers. As the study clinician's unconscious biases against blacks increased, their likelihood of
giving thrombolysis treatment decreased. Green noted in an interview, "It's not a matter of you being a racist. It's really a
matter of the way your brain processes information is influenced by things you've seen, things you've experienced, the way
media has presented things." Green recommends that the best way to combat those impulses is by acknowledging them, and
suggests that medical personnel take an assessment measuring unconscious bias, which can be found at implicit.harvard.
edu.
Recent research writings about the issue of stereotyping and disparities in care offer some novel suggestions for ways to
address and decrease these problems. Diana Burgess and Michelle Van Ryn of the University of Minnesota have proposed an
intervention called "priming," putting basic information about unequal treatment and implicit/unconscious bias and
stereotyping before clinicians and allied health providers. This technique presupposes that racial gaps in care are based on
unconscious stereotyping, not on conscious efforts, as echoed by Green.
Van Ryn and Burgess describe the mechanism of using unconscious stereotyping to allow clinicians to "fill in the gaps" to
facilitate making complex decisions in a short period of time. They note that unconscious stereotyping, while helping clinicians
arrive at decisions quickly, can lead to unequal treatment.
Pain care persists as an area with well-studied and documented disparities in care. Todd's work has indicated evidence of
unequal treatment of pain, focusing on disparities in pain care for trauma and emergency departments.
It is widely and inaccurately believed by many clinicians that unequal treatment based on race and ethnicity is a matter of
unequal access. While access to care is known to impact a variety of populations, data indicates that even when access is
factored out of studies, treatment of pain and other problems frequently varies simply based on the race of patients, even
when patients present to the same facilities with similar injuries.
The federal government’s Institute of Medicine released the congressionally mandated book "Unequal Treatment" in 2003.
Widely acclaimed for its comprehensive look at data related to racial disparities to care, "Unequal Treatment" made several
recommendations to health professionals. One of the foremost recommendations directs health professionals to share
information about racial disparities in care with colleagues, increasing awareness within the medical community about this
ongoing problem. The AAPA’s "Heads Up!" project was a response to this recommendation, as well as an effort to integrate
the Burgess and Van Ryn "priming" concept. This effort promotes awareness about racial disparities to PA and other
colleagues, while framing the issue by describing the shared human tendency to use implicit and unconscious stereotyping in
daily practice.
Green and the Disparities Solutions Center also recommend developing "equity reports" in practice sites. These reports are
ways to examine specific practice for disparities in care, and creating specific action plans to address these disparities. Their
guide to creating equity reports is available at http://www.massgeneral.org/disparitiessolutions/.
CURRICULUM MODULE STEP 4:
Assign These Three Articles
Burgess D, van Ryn M, Crowley-Matoka M, Malat J. Understanding the provider contribution to race/ethnicity disparities in pain
treatment: insights from dual process models of stereotyping. Pain Med. 2006 Mar-Apr;7(2):119-34.
Green A, Carney D, Pallin D, Ngo L, Raymond K, Iezzoni L, Banaji M. Implicit bias among physicians and its prediction of
thrombolysis decisions for black and white patients. J Gen Intern Med. 2007 Sep;22(9):1231-8.
Todd K, Deaton C, D'Adamo A, Goe L. Ethnicity and analgesic practice. Ann Emerg Med. 2000 Jan;35 (1):11-6.
CURRICULUM MODULE STEP 5:
Assign these Web Interactive Activities/Self-Assessment tests
Implicit Association Test: https://implicit.harvard.edu/implicit/
Project Implicit Information Page: http://projectimplicit.net/
(NOTE: This site requires a brief registration process. Recommended Tests: Race, Arab-Muslim, Gender, Sexuality.)
"The Police Officer's Dilemma" by the Stereotyping and Prejudice Research Laboratory of the University of Chicago:
http://home.uchicago.edu/~jcorrell/TPOD.html
and then click on the very bottom link
http://backhand.uchicago.edu/Center/ShooterEffect/
CURRICULUM MODULE STEP 6:
Administer Post Test:
1. Racial disparities in health care
a. are primarily related to access to care.
b. are not a problem in American medicine.
c. are shown to exist even when accounting for access to care.
d. are primarily problems in the southern states.
2. Racial and other cultural biases
a. usually disappear after PA school.
b. are rare in medical providers.
c. are often invisible and unidentified.
d. are easily put aside and do not impact patient care.
3. Implicit and unconscious racial and cultural biases
a. are impossible to measure.
b. may only be a problem for white providers.
c. are illegal and result in imprisonment.
d. may aid making complex decisions quickly.
4. A 2007 study by Green shows that
a. kidney removal is more common for Asian patients.
b. data supports a correlation between implicit bias and clinical decision-making.
c. animal testing causes cancer in scientists.
d. people with heart disease are often vegetarians.
5. Van Ryn and Burgess describe
a. the role of stereotyping in “filling in the gaps.”
b. problems with heart transplant patients getting the wrong organs.
c. minority medical students having difficulty finding housing.
d. race-related nutritional problems.
6. One way to examine clinical practice for racial disparities is to
a. create “equity reports” that gather and look at clinical data related to race.
b. hire minority consultants to come in and watch our students.
c. try to catch our colleagues when they discriminate.
d. use medical students to sit behind one-way mirrors and observe our practice.
7. Todd and others have gathered data related to pain showing that
a. pain is the one area where there is no demonstrated racial disparity in care.
b. minorities don’t need as much pain medicine as white patients.
c. minority patients receive less pain medication for the same injuries when compared to white patients.
d. minority patients often ask for pain medication even if they don’t need it.
8. In Todd's 2000 study "Ethnicity and Analgesic Practice," findings indicated that
a. all disparities in pain care were due to lack of insurance by some patients.
b. black patients and white patients with hip fractures both received the same amount of medication.
c. Asian patients receive twice the pain medication as white patients.
d. white patients were significantly more likely than black patients to receive emergency department analgesics despite
similar pain complaints.
9. Studies show that white patients with chest pain and angina
a. get tested at the same rate as black patients with similar problems.
b. complain more than black patients about their pain.
c. get appropriate tests more commonly than black patients.
d. are in denial about their problems.
10. The Institute of Medicine’s 2002 book “Unequal Treatment”
a. has been dismissed as inaccurate by new data.
b. makes the recommendation that medical professions establish efforts to publicize racial inequity in care to their members.
c. suggests that only mentally ill doctors provide unequal treatment to patients.
d. provides proof that racial disparities in care are decreasing due to the influx of immigrants into America.
the University of Chicago and Harvard University, students/members can take the post-test which is also included below.
This module was approved by the AAPA for CME in 2009. Please contact us for further information about how you can use
this module in your state/chapter/program.
CURRICULUM MODULE STEP 1:
Review Learning Objectives for Curriculum Module:
At the conclusion of this module (including the reading, online review of websites, and powerpoint presentation/lecture),
participants will be able to:
1. Define “Racial Health Disparities.”
2. Describe “implicit bias” and “unconscious stereotyping.”
3. Identify the correlation between implicit bias and clinical outcomes.
4. Explain “dual process stereotyping.”
5. Create an “equity report” for use in medical settings
6. Describe evidence relating to racial disparities in the treatment of pain
7. Place racial health disparities in the context of “Healthy People 2010.”
8. Discuss the findings of the “Unequal Treatment” report.
9. Understand evidence of racial disparities in cardiovascular care.
10. Identify web and other resources related to implicit bias.
CURRICULUM MODULE STEP 2:
Use Powerpoint Presentation For One Hour Lecture Presentation
Link to the presentation by clicking here:
(To open and save, click on link, open file, right click and select "edit slides", and save presentation to your computer)
The presentation is designed to accompany and follow the learning objectives, readings and web activities, and assessment
questions
CURRICULUM MODULE STEP 3:
Review Introductory Text:
In November 2007, the American Academy of Physician Assistants' (AAPA) Committee on Diversity launched "Heads Up!," an
awareness campaign aimed at reducing racial and ethnic disparities in health care. For three months, signage addressing the
issue of racial health care disparities, unconscious racial stereotyping, and implicit racial bias by clinicians was placed on
University of Washington Health Sciences Express shuttle buses. The buses are used by thousands of medical and health
care students and clinicians who travel daily between Seattle's University of Washington School of Medicine and its teaching
partner institution, Harborview Medical Center.
The campaign consisted of three bus signs, each of which addressed a different health disparities issue. The signs were
displayed on a rotating basis over the next three months. After the conclusion of the project, the AAPA Committee on Diversity
worked with AAPA to develop this CME module, with an assessment available at no charge to AAPA members on the AAPA
website. When the application for CME approval is accepted, one hour of category I CME may be received by completing this
module and then taking the online assessment. The application for CME approval is currently pending.
The project is among the first to address new evidence about the role of unconscious racial stereotyping in racial health
disparities. In 2007, Alexander Green, M.D., of the Disparities Solutions Center at Massachusetts General Hospital, released a
study that connected implicit and unconscious stereotyping with unequal treatment of patients. It is one of the first studies to
connect these two issues. Green and the Disparities Solutions Center provided consultation and input on the "Heads Up!"
campaign.
One "Heads Up!" sign featured photos of two males, one Caucasian and one African American, with the words: "Chest Pain,
Identical Symptoms, Matching Histories: Which Patient Doesn't Get the Appropriate Tests?" This refers to Green's study,
published in the Journal of General Internal Medicine, which had resident physicians direct treatment for hypothetical patients.
The residents based treatment decisions on a picture of the patient’s face, accompanied by a written description of the patient’
s chest pain. All of the hypothetical descriptions were identical, differing only in the race of the patients. Results revealed more
physicians prescribing thrombolysis for the white patients than for the black patients.
The study used an assessment tool from Project Implicit at Harvard University, measuring unconscious bias against black
patients on the part of providers. As the study clinician's unconscious biases against blacks increased, their likelihood of
giving thrombolysis treatment decreased. Green noted in an interview, "It's not a matter of you being a racist. It's really a
matter of the way your brain processes information is influenced by things you've seen, things you've experienced, the way
media has presented things." Green recommends that the best way to combat those impulses is by acknowledging them, and
suggests that medical personnel take an assessment measuring unconscious bias, which can be found at implicit.harvard.
edu.
Recent research writings about the issue of stereotyping and disparities in care offer some novel suggestions for ways to
address and decrease these problems. Diana Burgess and Michelle Van Ryn of the University of Minnesota have proposed an
intervention called "priming," putting basic information about unequal treatment and implicit/unconscious bias and
stereotyping before clinicians and allied health providers. This technique presupposes that racial gaps in care are based on
unconscious stereotyping, not on conscious efforts, as echoed by Green.
Van Ryn and Burgess describe the mechanism of using unconscious stereotyping to allow clinicians to "fill in the gaps" to
facilitate making complex decisions in a short period of time. They note that unconscious stereotyping, while helping clinicians
arrive at decisions quickly, can lead to unequal treatment.
Pain care persists as an area with well-studied and documented disparities in care. Todd's work has indicated evidence of
unequal treatment of pain, focusing on disparities in pain care for trauma and emergency departments.
It is widely and inaccurately believed by many clinicians that unequal treatment based on race and ethnicity is a matter of
unequal access. While access to care is known to impact a variety of populations, data indicates that even when access is
factored out of studies, treatment of pain and other problems frequently varies simply based on the race of patients, even
when patients present to the same facilities with similar injuries.
The federal government’s Institute of Medicine released the congressionally mandated book "Unequal Treatment" in 2003.
Widely acclaimed for its comprehensive look at data related to racial disparities to care, "Unequal Treatment" made several
recommendations to health professionals. One of the foremost recommendations directs health professionals to share
information about racial disparities in care with colleagues, increasing awareness within the medical community about this
ongoing problem. The AAPA’s "Heads Up!" project was a response to this recommendation, as well as an effort to integrate
the Burgess and Van Ryn "priming" concept. This effort promotes awareness about racial disparities to PA and other
colleagues, while framing the issue by describing the shared human tendency to use implicit and unconscious stereotyping in
daily practice.
Green and the Disparities Solutions Center also recommend developing "equity reports" in practice sites. These reports are
ways to examine specific practice for disparities in care, and creating specific action plans to address these disparities. Their
guide to creating equity reports is available at http://www.massgeneral.org/disparitiessolutions/.
CURRICULUM MODULE STEP 4:
Assign These Three Articles
Burgess D, van Ryn M, Crowley-Matoka M, Malat J. Understanding the provider contribution to race/ethnicity disparities in pain
treatment: insights from dual process models of stereotyping. Pain Med. 2006 Mar-Apr;7(2):119-34.
Green A, Carney D, Pallin D, Ngo L, Raymond K, Iezzoni L, Banaji M. Implicit bias among physicians and its prediction of
thrombolysis decisions for black and white patients. J Gen Intern Med. 2007 Sep;22(9):1231-8.
Todd K, Deaton C, D'Adamo A, Goe L. Ethnicity and analgesic practice. Ann Emerg Med. 2000 Jan;35 (1):11-6.
CURRICULUM MODULE STEP 5:
Assign these Web Interactive Activities/Self-Assessment tests
Implicit Association Test: https://implicit.harvard.edu/implicit/
Project Implicit Information Page: http://projectimplicit.net/
(NOTE: This site requires a brief registration process. Recommended Tests: Race, Arab-Muslim, Gender, Sexuality.)
"The Police Officer's Dilemma" by the Stereotyping and Prejudice Research Laboratory of the University of Chicago:
http://home.uchicago.edu/~jcorrell/TPOD.html
and then click on the very bottom link
http://backhand.uchicago.edu/Center/ShooterEffect/
CURRICULUM MODULE STEP 6:
Administer Post Test:
1. Racial disparities in health care
a. are primarily related to access to care.
b. are not a problem in American medicine.
c. are shown to exist even when accounting for access to care.
d. are primarily problems in the southern states.
2. Racial and other cultural biases
a. usually disappear after PA school.
b. are rare in medical providers.
c. are often invisible and unidentified.
d. are easily put aside and do not impact patient care.
3. Implicit and unconscious racial and cultural biases
a. are impossible to measure.
b. may only be a problem for white providers.
c. are illegal and result in imprisonment.
d. may aid making complex decisions quickly.
4. A 2007 study by Green shows that
a. kidney removal is more common for Asian patients.
b. data supports a correlation between implicit bias and clinical decision-making.
c. animal testing causes cancer in scientists.
d. people with heart disease are often vegetarians.
5. Van Ryn and Burgess describe
a. the role of stereotyping in “filling in the gaps.”
b. problems with heart transplant patients getting the wrong organs.
c. minority medical students having difficulty finding housing.
d. race-related nutritional problems.
6. One way to examine clinical practice for racial disparities is to
a. create “equity reports” that gather and look at clinical data related to race.
b. hire minority consultants to come in and watch our students.
c. try to catch our colleagues when they discriminate.
d. use medical students to sit behind one-way mirrors and observe our practice.
7. Todd and others have gathered data related to pain showing that
a. pain is the one area where there is no demonstrated racial disparity in care.
b. minorities don’t need as much pain medicine as white patients.
c. minority patients receive less pain medication for the same injuries when compared to white patients.
d. minority patients often ask for pain medication even if they don’t need it.
8. In Todd's 2000 study "Ethnicity and Analgesic Practice," findings indicated that
a. all disparities in pain care were due to lack of insurance by some patients.
b. black patients and white patients with hip fractures both received the same amount of medication.
c. Asian patients receive twice the pain medication as white patients.
d. white patients were significantly more likely than black patients to receive emergency department analgesics despite
similar pain complaints.
9. Studies show that white patients with chest pain and angina
a. get tested at the same rate as black patients with similar problems.
b. complain more than black patients about their pain.
c. get appropriate tests more commonly than black patients.
d. are in denial about their problems.
10. The Institute of Medicine’s 2002 book “Unequal Treatment”
a. has been dismissed as inaccurate by new data.
b. makes the recommendation that medical professions establish efforts to publicize racial inequity in care to their members.
c. suggests that only mentally ill doctors provide unequal treatment to patients.
d. provides proof that racial disparities in care are decreasing due to the influx of immigrants into America.
| PROJECT HISTORY FREE CME USE IT IN YOUR STATE CURRICULUM MODULE POWER POINT COLLEAGUES IN OTHER ORGANIZATIONS AND ASSOCIATIONS GET STUDENTS INVOLVED RESOURCES PHYSICIAN ASSISTANTS FOR HEALTH EQUITY |
 |  |  |  |  |  |
