Racial Bias in Telemedicine: A Within-Subjects Study of Medical Student Attitudes and Affect

Abstract

Health disparities are a matter of grave public health significance. Racial health disparities have complex etiologies and correlates but remain when controlling for other social determinants of health and patient factors such as treatment refusal. Residual disparities reflect differences in provider treatment of White and minority patients. One factor contributing to disparate treatment of minority patients is provider implicit bias—non-conscious biases that alter behavior. However, research suggests that intervening directly on implicit bias may not be effective, indicating that novel directions are needed to understand and address health disparities. Effects of implicit bias on disparities may be clarified by articulating and examining the constructs underlying implicit bias. This dissertation examines intergroup anxiety (anxiety that manifests in interracial interactions in response to negative expectations) as a mediator of the relationship between implicit bias and provider behavior. I first conduct a narrative review to understand the literature related to implicit bias and intergroup behavior. Then, I report on a within-subjects study in which medical student participants (N = 71) interacted with Black and White standardized patients in a telemedicine context. In Aim 1, I conducted preliminary video review in hopes of developing a coding scheme to assess nonverbal behaviors indicative of anxiety. In Aim 2, I used regression analysis to examine the associations between intergroup anxiety and communication behaviors. In Aim 3, I used regression analysis and the Baron and Kenny mediation approach to assess the relationships between implicit bias and intergroup anxiety and the direct and indirect effects of implicit bias on communication behaviors. I report that one of six mediation models tested was significant; observer-rated nervousness was negatively associated with observer-rated warmth. However, as I explore in the results and discussion, low interrater reliability and concerns related to model assumptions indicate that readers should exercise caution in interpreting results. Despite methodological concerns, our preliminary findings indicate weak support for intergroup anxiety as a construct that contributes to disparate provider behaviors. While many health disparities researchers hope that further research will improve health disparities, it is the opinion of this author that most research exploring provider factors that contribute to racial health disparities lacks real-world impact and external validity, and that researchers should focus their work on connecting with communities in deep and intimate ways.