Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report
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Abstract
BACKGROUND
Physician implicit (unconscious, automatic) bias has been shown to contribute to racial disparities in medical care. The impact of medical education on implicit racial bias is unknown.
OBJECTIVE
To examine the association between change in student implicit racial bias towards African Americans and student reports on their experiences with 1) formal curricula related to disparities in health and health care, cultural competence, and/or minority health; 2) informal curricula including racial climate and role model behavior; and 3) the amount and favorability of interracial contact during school.
DESIGN
Prospective observational study involving Web-based questionnaires administered during first (2010) and last (2014) semesters of medical school.
PARTICIPANTS
A total of 3547 students from a stratified random sample of 49 U.S. medical schools.
MAIN OUTCOME(S) AND MEASURE(S)
Change in implicit racial attitudes as assessed by the Black-White Implicit Association Test administered during the first semester and again during the last semester of medical school.
KEY RESULTS
In multivariable modeling, having completed the Black-White Implicit Association Test during medical school remained a statistically significant predictor of decreased implicit racial bias (−5.34, p ≤ 0.001: mixed effects regression with random intercept across schools). Students' self-assessed skills regarding providing care to African American patients had a borderline association with decreased implicit racial bias (−2.18, p = 0.056). Having heard negative comments from attending physicians or residents about African American patients (3.17, p = 0.026) and having had unfavorable vs. very favorable contact with African American physicians (18.79, p = 0.003) were statistically significant predictors of increased implicit racial bias.
CONCLUSIONS
Medical school experiences in all three domains were independently associated with change in student implicit racial attitudes. These findings are notable given that even small differences in implicit racial attitudes have been shown to affect behavior and that implicit attitudes are developed over a long period of repeated exposure and are difficult to change.
KEY WORDS
disparities medical education implicit racial bias physician–patient relations attitude of health personnelINTRODUCTION
Over the past two decades, hundreds of studies have documented widespread racial inequalities in medical care.1,2 Disparities in health and health care relative to white populations have been most extensively and consistently documented for African Americans, but also occur for other racial and ethnic groups in the U.S. While the causes of unequal care for African Americans are complex, provider behavior and decision-making is one documented contributor.1, 2, 3, 4, 5, 6, 7 Explanations for the provision of unequal care by physicians draw heavily from research on implicit racial bias.7, 8, 9 This term refers to automatic and unconscious negative attitudes towards African Americans as compared to whites. Implicit racial bias influences behavior in unintentional but powerful and systematic ways,10 profoundly influencing clinical decision-making.11,12 In addition, implicit racial bias predicts nonverbal behavior such as eye contact and posture,13, 14, 15, 16, 17 and has been shown to influence the quality of physicians’ interpersonal communication with African American patients and, in turn, patients’ trust and perceptions of their physicians.4,18,19
Over a decade ago, the Institute of Medicine called for investigation into the way socialization into the “culture of medicine” promotes or inhibits physician expressions of racial bias.20 In response to this, and to the continued evidence of physician bias, many medical schools have developed curricula aimed at eliminating physician contribution to inequality in care, although little is known about their effectiveness in reducing implicit racial bias. Additionally, the effect of the informal or “hidden” curricula (informal climate and role model behavior) on racial attitudes of medical student is unknown.21, 22, 23, 24, 25 Thus, medical educators have limited information to inform best strategies to address implicit racial bias during training in medical school.
- 1)
Formal curricula refers to what is explicitly taught in planned educational experiences and includes both information and skill-building.26 Student experiences in this domain include participation in planned educational activities targeting quality of care for African American (and other minority) patients, cultural competence, and/or interpersonal quality of care generally.
- 2)
Informal curricula, sometimes described as the “hidden” curricula, is a term used to describe the sources of lessons absorbed outside of formal curricula.27 Informal curricula conveys information on how to interact with patients, how to perceive and respond to individuals from different social groups, and general rules for acceptable behavior. The definition of informal curriculum corresponds to definitions of informal organizational culture, a powerful determinant of behaviors and attitudes of organizational members.34,35 Educational research and theory has indicated that informal curricula is largely delivered through the behavior of faculty (role models) and organizational cultural and climate.33
- 3)
The amount and favorability of interracial contact has been shown in a large body of evidence to influence interracial attitudes and behavior.15,36, 37, 38, 39, 40, 41 Experiences in this domain include interactions with African American clerical staff, allied health staff, medical students, and physicians.
METHODS
Overview
This was a prospective observational study in which medical students completed questionnaires and measures of implicit racial bias during their first and fourth years of medical school. We examined the association between medical school experiences and changes in implicit racial bias (IRBIAS) between the first and fourth years among non-African American students using mixed effects regression models.
Study Sample
Study sample flow chart
Measures
Standard survey questions were used to measure demographic characteristics. Students’ family household income during their time in high school was used to estimate family-of-origin socioeconomic status.
Distribution of Responses on Medical School Experiences (n = 3547)
| Formal Curricula | |||
| Percentage that answered ‘Yes’ | Number | ||
| Taken a seminar on minority health | 52.3 % | 1856 | |
| Participated in a cultural awareness course/workshop | 75.7 % | 2686 | |
| Completed an implicit association test (IAT) of unconscious racial bias | 24.5 % | 869 | |
| Mean (SD) | Minimum | Maximum | |
| Hours of training devoted to communication skills | 28.97 (16.56) | 0 | 50 |
| Hours of training devoted to partnership-building skills | 18.29 (15.32) | 0 | 50 |
| Hours of training devoted to racial disparities in health care | 13.85 (11.82) | 0 | 50 |
| Hours of training devoted to identifying cultural customs that might affect clinical care | 13.49 (11.57) | 0 | 50 |
| Hours of training devoted to the potential effect of unintended racial bias on the care you provide | 8.81 (10.23) | 0 | 50 |
| Hours of training devoted to seeing things from your patient’s perspective | 21.08 (15.40) | 0 | 50 |
| How prepared are you to handle a patient from a culture different from your own | 4.09 (.78) | 1 | 5 |
| Self-efficacy regarding providing care for black patients (scale) | 3.69 (.67) | 1 | 5 |
| Informal Curricula | |||
| Percentage that answered ‘Yes’ | Number | ||
| Ever heard residents or attendings make negative comments about black patients | 48.7 % | 1728 | |
| Mean (SD) | Minimum | Maximum | |
| Learning Orientation to Racial Relations Scale | 5.39 (.50) | 1 | 7 |
| Racial Climate Scale: Racial Tension Subscale | 3.17 (1.44) | 1 | 7 |
| Racial Climate Scale: Medical School Effort Subscale | 5.61 (1.17) | 1 | 7 |
| Interracial Contact | |||
| Percentage | Number | ||
| How much interaction with black medical students | |||
| 1 None | 3.0 | 107 | |
| 2 Little | 26.1 | 925 | |
| 3 Some | 39.0 | 1385 | |
| 4 Substantial | 29.9 | 1059 | |
| Favorability of interaction with black medical students | |||
| 1 Very unfavorable | .6 | 23 | |
| 2 Unfavorable | 1.8 | 65 | |
| 3 Favorable | 41.8 | 1481 | |
| 4 Very favorable | 53.0 | 1880 | |
| How much interaction with black faculty, attending physicians and residents | |||
| 1 None | 2.6 | 91 | |
| 2 Little | 32.6 | 1158 | |
| 3 Some | 43.6 | 1545 | |
| 4 Substantial | 19.2 | 682 | |
| Favorability of interaction with black faculty, attending physicians and residents | |||
| 1 Very unfavorable | .5 | 17 | |
| 2 Unfavorable | 1.4 | 49 | |
| 3 Favorable | 42.9 | 1520 | |
| 4 Very favorable | 52.4 | 1860 | |
| How much interaction with black allied health staff | |||
| 1 None | 3.7 | 133 | |
| 2 Little | 17.1 | 606 | |
| 3 Some | 35.7 | 1266 | |
| 4 Substantial | 41.4 | 1468 | |
| Favorability of interaction with black allied health staff | |||
| 1 Very unfavorable | 1.0 | 37 | |
| 2 Unfavorable | 4.9 | 174 | |
| 3 Favorable | 50.4 | 1787 | |
| 4 Very favorable | 40.3 | 1429 | |
| How much Interaction with black clerical, administrative and secretarial staff | |||
| 1 None | 2.3 | 83 | |
| 2 Little | 15.0 | 532 | |
| 3 Some | 33.2 | 1178 | |
| 4 Substantial | 47.4 | 1682 | |
| Favorability of interaction with black clerical, administrative and secretarial staff | |||
| 1 Very unfavorable | 1.5 | 54 | |
| 2 Unfavorable | 7.2 | 256 | |
| 3 Favorable | 48.4 | 1715 | |
| 4 Very favorable | 39.9 | 1415 | |
Independent Sample Validation of Racial Climate Scores
We administered the three racial climate measures (Racial Tension, Medical School Effort, and Learning Orientation To Racial Relations) to an independent sample of students (n = 1778) in their fourth year of training in the same 49 schools while the study cohort was in their third year (2013). Correspondence between the independent sample and the study sample estimates were high (Racial Tension r = 0.87, Medical School Effort = 0.84, Learning Orientation to Racial Relations r = 0.95), suggesting that scores on these measures reflect an underlying aspect of the school racial climate vs. individual or cohort characteristics.
Implicit racial bias (IRBIAS) against African Americans was assessed using the Black-White Implicit Association Test (IAT)48, 49, 50 during students’ first (Y1) and last (Y4) semesters of medical school. The Black-White IAT uses reaction times to assess the strength of automatic associations between race (black, white) and evaluations (e.g., good, bad), and is very difficult to counterfeit.51, 52, 53, 54, 55, 56 The IAT has consistently and significantly predicted a wide range of judgments, choices, physiological responses, and behaviors,57 and has been shown to be a better predictor of discrimination toward a racial group than attitudes measured by self-report.15,57, 58, 59, 60 More information about IAT properties and administration can be found at https://implicit.harvard.edu/implicit/iatdetails.html. IAT scores were multiplied by 100 for ease of interpretation. The dependent variable for this study, change in IRBIAS, was computed using a simple difference score (Y4 IAT score − Y1 IAT score). Higher scores represent increases in IRBIAS against African Americans.
Analyses
Descriptive statistics were used to characterize the sample and to explore the bivariate associations between sociodemographic characteristics of the cohort and change in IRBIAS. Since student responses and outcomes likely correlated within medical schools, we used methods appropriate for clustered data in all analyses. We examined the bivariate association for the items in each of the three domains (formal curricula, informal curricula, and interracial contact) using mixed effects models with a random intercept across schools to test for an association. We then examined the relationship between the overall school mean for each of the independent variables and change in IRBIAS. We used a set of sequential analyses to reduce survey items to a more parsimonious set that would be most strongly associated with change in IRBIAS. Those that were associated (p < 0.10) were retained, and variance decomposition was used to identify collinear predictors within each domain; when two or more variables had variance decomposition portions greater than 50 %, we retained the one with the greatest percentage of variation explained in the bivariate analysis.61 The retained items were used as independent variables in three separate models—one model for each domain; those that were significant predictors independent of the other variables within their domain (p < 0.10) were then carried to a final model. This approach has been used previously in health research to reduce a large number of related factors to a more parsimonious set.62,63 This final model was then expanded to include student characteristics. Baseline (Y1) IAT scores were included in all models in order to account for baseline IRBIAS assessed upon entry to medical school.
All study procedures were reviewed and approved by the institutional review boards at the Mayo Clinic, University of Minnesota, and Yale University. All analysis was performed in Stata version 13.1 (released 2014; StataCorp LP, College Station TX, USA) and SPSS version 22.0 (released 2013; IBM Corp., Armonk, NY, USA).
RESULTS
At the year 4 follow-up, the average age of respondents was 27.8 years (SD 2.49, range 23–53). Half were women (49.3 %). Family-of-origin annual income levels ranged from less than $30,000 (4.7 %) to $250,000 or more (18.8 %), with around one-third reporting a family income of $100,000–250,000 (36.1 %). Hispanic students comprised 5.6 % and Asian students 24.7 % of the sample, consistent with the race/ethnicity distribution reported by the American Association of Medical Colleges for all medical students.64 There were no statistically significant relationships between student sociodemographic factors and change in IRBIAS.
Bivariate Relationship Between Medical School Experiences and Change in Student Implicit Racial Bias
| Coefficient (SE) | p value | |
|---|---|---|
| Domain 1: FORMAL CURRICULA | ||
| Took a seminar (course, workshop) on minority health (ref = No) | −3.9 (1.4) | 0.006 |
| Took a seminar (course, workshop) on cultural awareness or competence (ref = No) | −3.7 (1.7) | 0.028 |
| Completed a Race Implicit Association Test as part of medical school (ref = No) | −5.7 (1.6) | 0.001 |
| Hours of training devoted to racial disparities in health care | −0.2 (0.1) | 0.002 |
| Hours of training devoted to identifying cultural customs that might affect care | −0.1 (0.1) | 0.031 |
| Hours of training devoted to seeing things from patient’s perspective (cognitive empathy) | −0.1 (0.0) | 0.053 |
| Hours of training devoted to communication skills | −0.1 (0.0) | 0.128 |
| Self-efficacy regarding providing care for black patients (scale) | −3.2 (1.1) | 0.002 |
| Domain 2: INFORMAL CURRICULA | ||
| Heard attendings or residents make negative comments about black patients (ref = No) | 3.9 (1.4) | 0.006 |
| Learning Orientation to Interracial Interactions Scale | −1.5 (0.5) | 0.006 |
| Racial Climate Scale: Racial Tension Subscale | 0.6 (0.5) | 0.196 |
| Racial Climate Scale: Medical School Effort Subscale | −0.7 (0.6) | 0.248 |
| Domain 3: INTERRACIAL CONTACT | ||
| Amount of interaction with black medical students (ref = Substantial) | 0.021 | |
| None | 11.8 (4.3) | |
| Little | 3.7 (1.9) | |
| Some | 1.4 (1.7) | |
| Favorability of interaction with black medical students (ref = Very favorable) | 0.007 | |
| Very unfavorable | 6.8 (8.7) | |
| Unfavorable | 12.3 (5.3) | |
| Favorable | 4.0 (1.4) | |
| Amount of interaction with black faculty, attending physicians and/or residents (ref = Substantial) | 0.03 | |
| None | 9.2 (4.6) | |
| Little | 5.2 (2.0) | |
| Some | 4.6 (1.9) | |
| Favorability of interaction with black faculty, attending physicians and/or residents (ref = Very favorable) | <0.001 | |
| Very unfavorable | 16.3 (10.1) | |
| Unfavorable | 21.3 (6.2) | |
| Favorable | 3.0 (1.4) | |
| Amount of interaction with black allied health staff (ref = Substantial) | 0.315 | |
| None | 4.3 (3.8) | |
| Little | 3.1 (2.0) | |
| Some | 0.2 (1.6) | |
| Favorability of interaction with black allied health staff (ref = Very favorable) | 0.002 | |
| Very unfavorable | 21.3 (6.7) | |
| Unfavorable | 6.7 (3.3) | |
| Favorable | 2.7 (1.5) | |
| Amount of interaction with black clerical and administrative staff (ref = Substantial) | 0.65 | |
| None | 1.2 (4.8) | |
| Little | 2.5 (2.1) | |
| Some | 0.1 (1.6) | |
| Favorability of interaction with black clerical and administrative staff (ref = Very Favorable) | <0.001 | |
| Very unfavorable | 13.1 (5.7) | |
| Unfavorable | 10.9 (2.8) | |
| Favorable | 2.7 (1.5) | |
Multivariable Relationship Between Medical School Experiences and Change in Student Implicit Racial Bias
| Model 1: Multivariable Relationship Between Participation in Formal Curricula and Change in Student Implicit Racial Bias* | |||
| Training | Coefficient (SE) | Statistical Significance | |
| Took a seminar (course, workshop) on minority health (ref = No) | −2.15 (1.12, −5.41) | 0.198 | |
| Took a seminar (course, workshop) on cultural awareness or competence (ref = No) | 1.74 (−2.13, 5.61) | 0.377 | |
| Completed Race Implicit Associations Test as part of medical school (ref = No) | −4.49 (−1.12, −7.86) | 0.009 | |
| Hours of training devoted to racial disparities in health care | −0.15 (−0.33, 0.04) | 0.114 | |
| Hours of training devoted to identifying cultural customs that might affect care. | 0.05 (−0.15, 0.24) | 0.633 | |
| Hours of training devoted to seeing things from patient’s perspective (cognitive empathy) | −0.05 (−0.16, 0.06) | 0.392 | |
| Self-efficacy regarding providing care for black patients (scale) | −2.38 (−4.62, −0.14) | 0.037 | |
| Model 2: Multivariable Relationship Between Medical School Informal Curricula and Change in Student Implicit Racial Bias1 | |||
| Climate | Coef. (SE) | P Value | |
| Heard attendings or residents make negative comments about black patients (ref = No) | 3.66 (0.90, 6.43) | 0.009 | |
| Learning Orientation to Interracial Interactions Scale | −1.36 (−2.40, −0.32) | 0.01 | |
| Model 3: Multivariable Relationship Between Interracial Contact and Change in Student Implicit Racial Bias1 | |||
| Interracial Contact | Coefficient (SE) | Statistical Significance | Wald P |
| Amount of interaction with black medical students (ref = Substantial) | 0.180 | ||
| None | 8.75 (−0.48, 17.99) | 0.063 | |
| Little | 1.60 (−3.18, 6.37) | 0.512 | |
| Some | −0.76 (−4.65, 3.13) | 0.701 | |
| Amount of interaction with black faculty, attending physicians and/or residents (ref = Substantial) | 0.233 | ||
| None | 7.30 (−3.16, 17.75) | 0.171 | |
| Little | 3.40 (−1.70, 8.50) | 0.191 | |
| Some | 4.21 (−0.11, 8.53) | 0.056 | |
| Favorability of interaction with black faculty, attending physicians and/or residents (ref = Very Favorable) | 0.057 | ||
| Very unfavorable | 3.17 (−18.62, 24.96) | 0.776 | |
| Unfavorable | 17.76 (5.04, 30.49) | 0.006 | |
| Favorable | 1.39 (−2.61, 5.40) | 0.496 | |
| Favorability of interaction with black allied health staff (ref = Very favorable) | 0.083 | ||
| Very unfavorable | 18.10 (3.52, 32.69) | 0.015 | |
| Unfavorable | 3.84 (−3.24, 10.91) | 0.288 | |
| Favorable | 0.83 (−3.22, 4.88) | 0.687 | |
Multivariable Relationship Between Statistically Significant Factors in all Domains and Change in Medical Student Implicit Racial Bias
| Coefficient (SE) | Statistical Significance | Wald p | |
|---|---|---|---|
| Domain 1: FORMAL CURRICULA | |||
| Completed a race implicit association test as part of medical school (ref = No) | −5.34 (−2.15, −8.53) | 0.001 | |
| Adequacy of training: Self-efficacy regarding working effectively with black patients (scale) | −2.18 (−4.42, 0.06) | 0.056 | |
| Domain 2: INFORMAL CURRICULA | |||
| Heard attendings or residents make negative comments about black patients (ref = No) | 3.17 (0.39, 5.96) | 0.026 | |
| Learning Orientation to Interracial Interactions Scale | −0.67 (−1.81, 0.46) | 0.246 | |
| Domain 3: INTERRACIAL CONTACT | |||
| Favorability of interaction with black faculty, attending physicians and/or residents (ref = Very favorable) | 0.019 | ||
| Very unfavorable | 7.71 (−12.83, 28.25) | 0.462 | |
| Unfavorable | 18.79 (6.61, 30.98) | 0.003 | |
| Favorable | 1.63 (−1.30, 4.57) | 0.275 | |
DISCUSSION
In this cohort of 3764 medical students, one or more medical school experiences within each of the three domains, (formal curricula, informal curricula, and interracial contact) had small but statistically significant associations with changes in IRBIAS. These findings are important, as very small differences in implicit racial attitudes have been shown to affect behavior.65 Implicit attitudes are developed over a long period of repeated exposure, consistently reinforced by cultural factors, and are notoriously difficult to change.10,66, 67, 68, 69
Formal Curricula
Many of the training experiences within this domain had small but significant bivariate associations with change in IRBIAS. However, when adjusted for each other and baseline implicit bias (Table 3), having completed an IAT as part of medical training and self-efficacy regarding care for African American patients remained the only statistically significant predictors of a decrease in IRBIAS. These findings warrant further investigation. The impact of taking an IAT may be reflected by an increase in the relevance of and perceived need for bias reduction. Alternately, if instructors who included an IAT in their classes were systematically different from those who did not, what appears to be an association between the IAT and change in IRBIAS might be spurious, reflecting instead an association between a quality of the instructors and reduction in student IRBIAS. For example, it is possible that instructors who included an IAT had a deeper understanding or comfort with discussing IRBIAS. In either case, the finding supports the benefit of implementing curricula taught by instructors with sufficient depth of knowledge of the nature of IRBIAS to effectively and appropriately incorporate implicit self-assessment into their curriculum.
Student self-efficacy regarding providing care to African American patients remained statistically significant in the model, adjusting for other training variables and baseline IAT. It is possible that the bivariate associations between the training variables and change in implicit bias (Table 2) were mediated by the impact of the training experiences on student self-efficacy regarding care for African American patients. Nevertheless, these findings support the recommendation that medical schools evaluate their current training, and implement and evaluate improved training, intended to increase non-African American students’ self-efficacy in providing care for African American patients.
Informal Curricula
The degree to which the school had a learning orientation to interracial interactions and students’ exposure to negative role modeling in the form of negative comments from faculty and attendings were associated with a change in implicit bias in bivariate analyses (Table 2), and remained statistically significant after adjusting for each other and Y1 IRBIAS (Table 3); learning orientation was associated with a greater decrease, and exposure to negative role modelling with a greater increase, in IRBIAS. When formal training and interracial contact were entered into the model (Table 4), learning orientation dropped from the model while negative role modelling persisted in having a statistically significant detrimental effect on IRBIAS, reinforcing the assertion that medical schools have powerful informal or “hidden” curricula that can be “unearthed in the language used”.25 These findings point to the need for medical schools, in partnership with clinical training sites, to assess, monitor and, if needed, intervene to improve racial attitudes and behaviors among attending and resident physicians.
Interracial Contact
Students who reported having had highly favorable contact with African American faculty had decreased racial bias, while those who reported unfavorable contact had increased racial bias. However, only 46 students reported having unfavorable, and 17 very unfavorable, contact with African American faculty, residents and attending physicians, making these results difficult to interpret. Student reports on the amount of contact with African American faculty, residents and attending physicians were not associated with change in IRBIAS, but this may reflect very limited opportunities for contact. African Americans make up only around 3 % of medical school faculty,70 and in that group, a significant number are practicing physicians with very limited or non-existent teaching roles.71 These findings add support to long-standing recommendations to increase the number of African American physicians in faculty roles, especially those that provide opportunities for positive interactions with medical students.2,72, 73, 74, 75
This study had several limitations. First, findings may not generalize to all medical students. Second, combining faculty and resident physicians in a single category may have obscured any impact of one or the other group. Third, interpretation of the terms contained in the measures (e.g., “unintended or unconscious racial bias”) may have been affected by whether these concepts were included in their curricula. Fourth, measures of the formal curricula only assessed exposure to topics—the actual quality of the formal curricula is unknown. Fifth, self-reported data on school experiences may have been influenced by student characteristics, and students may have differed in how they interpreted response options. While this last limitation is common to all studies involving self-reporting, the independent sample validation of the racial climate measures and scores was reassuring.
The results of this study indicate that while curricula is important, a sole focus on improving curricula will be insufficient for addressing medical school contributors to graduating student implicit racial bias. The deleterious impact of negative role model behavior speaks to the importance of overall culture change in medical schools and clinical training sites. Findings that medical school experiences were associated with changes in student implicit racial bias point to the potential for medical education to reduce physician contribution to racial disparities in health care.
Notes
Acknowledgments
Authors van Ryn, Hardeman, Phelan, Dovidio, Burgess, Nelson, Perry, and Yeazel contributed to the conceptualization and design of the study and interpretation of results. Authors Herrin, Nelson, Burke, and Przedworski contributed to analysis and/or interpretation of data. Authors van Ryn and Hardeman drafted the manuscript. Authors Phelan, Burgess, Dovidio, Burke, Perry, Herrin, Yeazel, Nelson, and Przedworski contributed to critical revision of the manuscript for important intellectual content. Authors van Ryn, Dovidio, and Nelson wrote the original proposal that obtained funding for the study.
We wish to thank Deborah Finstad for data acquisition, management, and analysis. We thank Jamie Odiet for study coordination support. We thank Jennifer Ridgeway and Caroline Plank for editing and administrative assistance. We thank Louis Penner, PhD, and Susan Eggly, PhD, for helpful comments and feedback on interpretation of results.
This study was supported by the National Heart, Lung and Blood Institute, National Institutes of Health, award number R01-HL085631.
Dr. Perry was further supported by the National Heart, Lung and Blood Institute through a Research Supplement to Promote Diversity in Health-Related Research R01HL085631-S1.
Dr. Hardeman was further supported by the National Heart, Lung and Blood Institute through a Research Supplement to Promote Diversity in Health-Related Research 3R01HL085631-S2.
Ms. Przedworski was further supported by the National Cancer Institute Cancer Education and Career Development Program under award number 5R25CA163184.
Conflict of Interest
The authors declare that they do not have a conflict of interest.
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