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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In November 2007, the American Academy of Physician Assistants (AAPA) Committee on Diversity (now the AAPA Health
Disparities Work Group) launched "Heads Up!," an awareness campaign aimed at reducing racial and ethnic disparities in
health care. For three months, signage addressing the issues of racial health care disparities, unconscious racial
stereotyping, and implicit racial bias by clinicians was placed on University of Washington Health Sciences Express shuttle
busses. 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 a CME module, with an assessment available at no charge to AAPA members on the AAPA
website. One hour of Category I CME credit may be earned by reading this introduction, three additional articles and
completing a post-test with a minimum score of 70% correct.

The project was among the first to address new evidence about the role of unconscious racial stereotyping in racial health
disparities. In 2007, Alexander Green, MD, of the
Disparities Solutions Center at Massachusetts General Hospital, authored
Implicit Bias among Physicians and its Prediction of Thrombolysis Decisions for Black and White Patients a study that
connected implicit and unconscious stereotyping with unequal treatment of patients. It was 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 White and one Black, 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
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

Recent research 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 in front of 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. One well-studied area in which documented disparities in
care are found is the assessment and management of pain. Author
Knox Todd's work has provided evidence of this 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 "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 PAs 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 practices for disparities in care, and creating specific action plans to address these disparities.
Their guide to creating equity reports is available