© 2008 American Academy of Physician Assistants. All rights reserved.
(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.
Application for AAPA approval of this module is active and pending. Please contact 2007-08 COD Chair Jim Anderson for
further information at j.eddy.anderson@gmail.com)
CURRICLULUM 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.
Application for AAPA approval of this module is active and pending. Please contact 2007-08 COD Chair Jim Anderson for
further information at j.eddy.anderson@gmail.com)
CURRICLULUM 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.
Heads Up!
CURRICULUM MODULE
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| A Health Disparities Reduction Project of the American Academy of Physician Assistants and the Physician Assistant Foundation |
