摘要：Objectives. We examined the associations of clinicians’ implicit attitudes about race with visit communication and patient ratings of care. Methods. In a cross-sectional study of 40 primary care clinicians and 269 patients in urban community-based practices, we measured clinicians’ implicit general race bias and race and compliance stereotyping with 2 implicit association tests and related them to audiotape measures of visit communication and patient ratings. Results. Among Black patients, general race bias was associated with more clinician verbal dominance, lower patient positive affect, and poorer ratings of interpersonal care; race and compliance stereotyping was associated with longer visits, slower speech, less patient centeredness, and poorer ratings of interpersonal care. Among White patients, bias was associated with more verbal dominance and better ratings of interpersonal care; race and compliance stereotyping was associated with less verbal dominance, shorter visits, faster speech, more patient centeredness, higher clinician positive affect, and lower ratings of some aspects of interpersonal care. Conclusions. Clinician implicit race bias and race and compliance stereotyping are associated with markers of poor visit communication and poor ratings of care, particularly among Black patients. Racial/ethnic disparities in healthcare are documented across conditions, settings, diagnostic and treatment modalities, and dimensions of technical quality, 1 and ethnic minorities rate interpersonal quality of care from physicians more negatively than do Whites. 2–6 Minorities experience poorer communication with physicians, 7,8 particularly in race-discordant patient–clinician relationships. 9,10 The Institute of Medicine’s report “Unequal Treatment,” suggests disparities in healthcare emerge from 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. 1 (p9) Biases may reflect explicit (conscious) biases or implicit (unconscious) biases. There is evidence that physicians have more negative explicit attitudes toward Blacks than towards Whites, including stereotypes about nonadherence, 11–13 and that negative explicit attitudes are associated with and mediate racial disparities in physicians’ treatment decisions. 13,14 Physicians’ implicit racial biases have been linked to some treatment decisions in clinical vignettes. 15–17 Yet, little work has examined how clinicians’ implicit racial attitudes affect communication and patient experiences in actual medical encounters. 18 We examined 2 implicit attitudes about race among clinicians. The first relates to general racial bias; the second is specific to the medical context, assessing racial bias regarding stereotyping patient compliance. We explored these distinct measures of implicit bias because they represent potentially different pathways to medical care (Figure A, available as a supplement to the online version of this article at http://www.ajph.org ). We hypothesized that clinicians’ implicit race bias is associated with nonspecific aspects of communication (e.g., socioemotional and stylistic, but not necessarily medically, focused). However, the pathway by which race-based compliance stereotyping affects communication may be different from that proposed for general racial bias because it may relate to physicians’ professional obligations to enhance patient adherence. Two implicit association studies have documented a physician pro-White bias regarding the concept of the compliant patient. 15,16 We reasoned that a race and compliance stereotype would have 2 communication-related consequences: less positive emotional tone, reflecting frustration with a patient perceived as nonadherent; and heightened attention to providing medical information. Given evidence that Black patients are sensitive to pro-White bias, 19,20 we hypothesized that both implicit measures are associated with more negative ratings of interpersonal care in the visits of Black, but not White, patients.
