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Disparities in care for blacks linked to segregation, unconscious bias

 Two studies published in January highlight the challenges blacks face in accessing equitable, quality health care.

In one study, primary care physicians found to have unconscious bias against blacks received lower marks from their African-American patients on measures of trust and communication skills. Another study found that racial segregation exacerbates disparities in lung cancer mortality.

The speed with which the test taker associates the words with black or white faces demonstrates the existence and extent of their unconscious bias. The assessment, called the implicit association test, has been used in more than 700 studies in health care, psychology, market research and political science.More than 130 Denver-area primary care doctors and other health professionals such as nurse practitioners took psychological tests that measure implicit bias toward different racial and ethnic groups. Test takers were shown a series of faces, along with positive words such as “joy” and bad words such as “nasty.”

About two-thirds of the Denver doctors showed implicit bias against blacks, with 43% landing unconscious bias scores graded as moderate or strong, said the study, published January in Annals of Family Medicine. Then, nearly 3,000 of all the physicians’ patients were surveyed and asked to rate the doctors on items such as knowledge of the patient, patience, caring, how well they explained things and how much they helped with decision-making.

All of the patients, regardless of their race or ethnicity, gave their doctors generally good scores. On a 100-point scale, whites gave their doctors an average score of 82, compared with 80 for black patients.

But black patients cared for by doctors who demonstrated unconscious bias on the psychological testing gave those doctors much worse ratings, nearly five points lower on average. For example, physicians who showed strong bias on the testing got a grade about six points lower on a survey about interpersonal treatment that measures perceived friendliness and respect. More than 80% of the physicians were white, and the rest were Hispanic or black.

Previous studies have found that lower patient satisfaction scores are correlated with poorer outcomes on a wide range of metrics, such as medication adherence and hospital readmissions. There is still no proven way to combat the unconscious biases that can undermine some doctors’ relationships with black patients, said Irene V. Blair, PhD, lead author of the Denver study.

“We’re not at that point yet where we can say, ‘Here are the five steps to be unbiased,’ ” said Blair, associate professor in the Dept. of Psychology and Neuroscience at the University of Colorado Boulder. “It’s more about how to have better patient interactions generally, thinking about how to serve the needs of individual patients, open up communication, acknowledge the perspective of the patient and develop mutual respect.”

While Hispanic patients were the least satisfied with their care overall — grading doctors 78 out of 100, on average — there was no correlation between their physicians’ unconscious bias against Latinos and lower ratings. How unconscious bias affects physician relationships with Hispanic patients needs more study, Blair said. An Oct. 4, 2012, study in the Journal of Immigrant and Minority Health found that, surprisingly, more recent Hispanic immigrants with less English proficiency handed out higher care ratings than did more assimilated Latinos, black patients or white patients.

Segregation’s lasting legacy

If the persistence of unconscious bias poses a challenge for physicians struggling to connect with their minority patients, racial segregation appears to present a larger and deadlier quandary that extends well beyond the doctor’s office.

Researchers reviewed lung cancer mortality between 2003 and 2007 and compared it with racial segregation patterns in 1,251 U.S. counties. Overall, blacks have a higher lung cancer death rate than whites do, with 59 in 100,000 blacks dying of the disease compared with 52 in 100,000 whites. That disparity grows wider the more segregated a community is, said a study in January’s JAMA Surgery, formerly Archives of Surgery.

After accounting for smoking prevalence, income levels and other factors that could affect lung cancer mortality rates, researchers found that black patients in counties designated as highly segregated had a 26% higher lung cancer death rate — 62.9 in 100,000 — than did whites, who died at a rate of 50 in 100,000. In counties with low segregation, the death rates were virtually the same.

Poverty alone does not explain the tie between segregation and lung cancer mortality, said Awori J. Hayanga, MD, MPH, the study’s lead author.

“It is the lack of access, the deprivation, but also the intangible sociocultural aspects of it,” said Dr. Hayanga, a heart and lung transplant fellow at the University of Pittsburgh. “One, you may not have the screening services. Two, if you do have screening services, do you have the specialists to see? Will the population dealing with this trust the system enough to go or is there a cultural barrier that stops them from going to that second phase of their care? It isn’t one thing — it’s a complex equation where enough things collude to make it happen.”

The tie between segregation and lung cancer deaths “raises red flags,” said Rahn K. Bailey, MD, president of the National Medical Assn., which promotes the interests of black physicians and patients.

“Unfortunately, I cannot say that it’s surprising,” said Dr. Bailey, chair of the Dept. of Psychiatry at Meharry Medical College in Nashville, Tenn. “In these segregated settings, it’s easier to channel resources in one direction and prevent them from going in another direction. Those are the types of unfortunate strategies, employed knowingly or not, that often are the culprits of disparities in health care outcomes for African-Americans.”

Dr. Hayanga and his co-authors argue for broader availability of lung cancer screening and treatment in highly segregated areas. Renewed efforts to integrate residential areas could save lives, they said.




Lung cancer death rates and segregation linked

Research shows a connection between racially segregated communities and disparities in lung cancer mortality. The more segregation there is in a county, the higher the lung cancer death rate is for black residents in that area.

Level of segregation Black death rate 
per 100,000
White death rate 
per 100,000
Low 52.4 53.0
Moderate 57.0 51.5
High 62.9 50.0

Source: “Residential Segregation and Lung Cancer Mortality in the United States,”JAMA Surgery, formerly Archives of Surgery, January (


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