Journal of General Internal Medicine

, Volume 32, Issue 11, pp 1193–1201 | Cite as

Medical School Factors Associated with Changes in Implicit and Explicit Bias Against Gay and Lesbian People among 3492 Graduating Medical Students

  • Sean M. Phelan
  • Sara E. Burke
  • Rachel R. Hardeman
  • Richard O. White
  • Julia Przedworski
  • John F. Dovidio
  • Sylvia P. Perry
  • Michael Plankey
  • Brooke A. Cunningham
  • Deborah Finstad
  • Mark W. Yeazel
  • Michelle van Ryn
Original Research

Abstract

Background

Implicit and explicit bias among providers can influence the quality of healthcare. Efforts to address sexual orientation bias in new physicians are hampered by a lack of knowledge of school factors that influence bias among students.

Objective

To determine whether medical school curriculum, role modeling, diversity climate, and contact with sexual minorities predict bias among graduating students against gay and lesbian people.

Design

Prospective cohort study.

Participants

A sample of 4732 first-year medical students was recruited from a stratified random sample of 49 US medical schools in the fall of 2010 (81% response; 55% of eligible), of which 94.5% (4473) identified as heterosexual. Seventy-eight percent of baseline respondents (3492) completed a follow-up survey in their final semester (spring 2014).

Main Measures

Medical school predictors included formal curriculum, role modeling, diversity climate, and contact with sexual minorities. Outcomes were year 4 implicit and explicit bias against gay men and lesbian women, adjusted for bias at year 1.

Key Results

In multivariate models, lower explicit bias against gay men and lesbian women was associated with more favorable contact with LGBT faculty, residents, students, and patients, and perceived skill and preparedness for providing care to LGBT patients. Greater explicit bias against lesbian women was associated with discrimination reported by sexual minority students (b = 1.43 [0.16, 2.71]; p = 0.03). Lower implicit sexual orientation bias was associated with more frequent contact with LGBT faculty, residents, students, and patients (b = −0.04 [−0.07, −0.01); p = 0.008). Greater implicit bias was associated with more faculty role modeling of discriminatory behavior (b = 0.34 [0.11, 0.57); p = 0.004).

Conclusions

Medical schools may reduce bias against sexual minority patients by reducing negative role modeling, improving the diversity climate, and improving student preparedness to care for this population.

KEY WORDS

sexual minorities sexual orientation prejudice medical education longitudinal studies 

Notes

Acknowledgements

Dr. Phelan is supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health (award no. K01 DK095924). Other support for this research was provided by the National Heart, Lung, and Blood Institute of the National Institutes of Health (award no. R01 HL085631). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funders played no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; or the preparation, review, or approval of the manuscript.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they do not have a conflict of interest.

References

  1. 1.
    Office of Disease Prevention and Health Promotion. Lesbian, Gay, Bisexual, and Transgender Health. [Webpage]. https://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health. Accessed 6/14. 2017.
  2. 2.
    2014 National Healthcare Quality and Disparities Report. Rockville, MD: Agency for Healthcare Research and Quality; 2015.Google Scholar
  3. 3.
    Committee on Lesbian G, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding. Washington, DC: Institute of Medicine.Google Scholar
  4. 4.
    Lim FA, Brown DV, Jr, Justin Kim SM. Addressing health care disparities in the lesbian, gay, bisexual, and transgender population: a review of best practices. Am J Nurs. 2014;114(6):24–34; quiz 35, 45.CrossRefPubMedGoogle Scholar
  5. 5.
    van Ryn M, Burgess D, Dovidio J, et al. The impact of racism on clinician cognition, behavior, and clinical decision making. Du Bois Review. 2011;8(1):199–218.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington D.C.: National Academies Press; 2002.Google Scholar
  7. 7.
    Morrison M, Morrison T. Sexual Orientation Bias Toward Gay Men and Lesbian Women: Modern Homonegative Attitudes and Their Association With Discriminatory Behavioral Intentions. Journal of Applied Social Psychology. 2011;41(11):2573–2599.CrossRefGoogle Scholar
  8. 8.
    Cooper L, Roter D, Carson K, et al. The associations of clinicians’ implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. Am J Public Health. 2012;102(5):979–987.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Dovidio J, Kawakami K, Johnson C, Johnson B, Howard A. On the nature of prejudice: automatic and controlled processes. J Exp Soc Psychol. 1997;33:510–540.CrossRefGoogle Scholar
  10. 10.
    Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231–1238.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Sabin JA, Greenwald AG. The influence of implicit bias on treatment recommendations for 4 common pediatric conditions: pain, urinary tract infection, attention deficit hyperactivity disorder, and asthma. Am J Public Health. 2012;102(5):988–995.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Hafferty FW. Beyond curriculum reform: confronting medicine’s hidden curriculum. Acad Med. 1998;73(4):403–407.CrossRefPubMedGoogle Scholar
  13. 13.
    Beach MC, Price EG, Gary TL, et al. Cultural competence: a systematic review of health care provider educational interventions. Med Care. 2005;43(4):356–373.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Vela MB, Kim KE, Tang H, Chin MH. Innovative health care disparities curriculum for incoming medical students. J Gen Intern Med. 2008;23(7):1028–1032.CrossRefPubMedPubMedCentralGoogle Scholar
  15. 15.
    Brown B, Heaton PC, Wall A. A service-learning elective to promote enhanced understanding of civic, cultural, and social issues and health disparities in pharmacy. Am J Pharm Educ. 2007;71(1):9.CrossRefPubMedGoogle Scholar
  16. 16.
    Moss-Racusin CA, van der Toorn J, Dovidio JF, Brescoll VL, Graham MJ, Handelsman J. Social science. Scientific diversity interventions. Science. 2014;343(6171):615–616.CrossRefPubMedGoogle Scholar
  17. 17.
    Phelan SM, Puhl RM, Burke SE, et al. The mixed impact of medical school on medical students’ implicit and explicit weight bias. Med Educ. 2015.Google Scholar
  18. 18.
    van Ryn M, Hardeman R, Phelan SM, et al. Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A Medical Student CHANGES Study Report. J Gen Intern Med. 2015;30(12):1748–1756.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Kim D-Y. Voluntary controllability of the Implicit association test (IAT). Soc Psychol Q. 2003;66(1):83–96.CrossRefGoogle Scholar
  20. 20.
    Greenwald AG, Poehlman TA, Uhlmann EL, Banaji MR. Understanding and using the Implicit Association Test: III. Meta-analysis of predictive validity. J Pers Soc Psychol. 2009;97(1):17–41.CrossRefPubMedGoogle Scholar
  21. 21.
    Alwin D. Feeling thermometers versus 7-point scales: Which are better? Sociological Methods and Research. 1997;25:318–340.CrossRefGoogle Scholar
  22. 22.
    Hafler JP, Ownby AR, Thompson BM, et al. Decoding the learning environment of medical education: a hidden curriculum perspective for faculty development. Acad Med. 2011;86(4):440–444.CrossRefPubMedGoogle Scholar
  23. 23.
    Crowne DP, Marlowe D. A new scale of social desirability independent of psychopathology. J Consult Psychol. 1960;24:349–354.CrossRefPubMedGoogle Scholar
  24. 24.
    Rezaei AR. Validity and reliability of the IAT: Measuring gender and ethnic stereotypes. Computers in Human Behavior. 2011;27(5):5p.CrossRefGoogle Scholar
  25. 25.
    Williams DR, Rucker TD. Understanding and addressing racial disparities in health care. Health Care Financ Rev. 2000;21(4):75–90.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Seifer SD. Service-learning: community-campus partnerships for health professions education. Acad Med. 1998;73(3):273–277.CrossRefPubMedGoogle Scholar
  27. 27.
    Hojat M, Vergare MJ, Maxwell K, et al. The devil is in the third year: a longitudinal study of erosion of empathy in medical school. Acad Med. 2009;84(9):1182–1191.CrossRefPubMedGoogle Scholar
  28. 28.
    Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA. 2011;306(9):971–977.CrossRefPubMedGoogle Scholar
  29. 29.
    Burke SE, Dovidio JF, Przedworski JM, et al. Do Contact and Empathy Mitigate Bias Against Gay and Lesbian People Among Heterosexual First-Year Medical Students? A Report From the Medical Student CHANGE Study. Acad Med. 2015;90(5):645–651.CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Sanchez NF, Rabatin J, Sanchez JP, Hubbard S, Kalet A. Medical students’ ability to care for lesbian, gay, bisexual, and transgendered patients. Fam Med. 2006;38(1):21–27.PubMedGoogle Scholar
  31. 31.
    Pettigrew T, Tropp L, Wagner U, Christ O. Recent advances in intergroup contact theory. International Journal of Intercultural Relations. 2011;35(3):271–280.CrossRefGoogle Scholar
  32. 32.
    Pettigrew TF, Tropp LR. How does intergroup contact reduce prejudice? Meta-analytic tests of three mediators. European Journal of Social Psychology. 2008;38(6):922–934.CrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2017

Authors and Affiliations

  • Sean M. Phelan
    • 1
  • Sara E. Burke
    • 2
  • Rachel R. Hardeman
    • 3
  • Richard O. White
    • 4
  • Julia Przedworski
    • 3
  • John F. Dovidio
    • 2
  • Sylvia P. Perry
    • 5
  • Michael Plankey
    • 6
  • Brooke A. Cunningham
    • 7
  • Deborah Finstad
    • 7
  • Mark W. Yeazel
    • 7
  • Michelle van Ryn
    • 1
  1. 1.Division of Healthcare Policy and ResearchMayo ClinicRochesterUSA
  2. 2.Department of PsychologyYale UniversityNew HavenUSA
  3. 3.Division of Health Policy and ManagementUniversity of MinnesotaMinneapolisUSA
  4. 4.Division of Community Internal MedicineMayo ClinicJacksonvilleUSA
  5. 5.Department of PsychologyNorthwestern UniversityEvanstonUSA
  6. 6.Division of Infectious Diseases, Department of MedicineGeorgetown University Medical SchoolWashingtonUSA
  7. 7.Department of Family Medicine and Community HealthUniversity of Minnesota Medical SchoolMinneapolisUSA

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