THE SCIENCE OF RESEARCH ON RACIAL/ETHNIC DISCRIMINATION AND HEALTH
The Associations of Clinicians’ Implicit Attitudes About
Race With Medical Visit Communication and Patient
Ratings of Interpersonal Care
Lisa A. Cooper, MD, MPH, Debra L. Roter, DrPH, Kathryn A. Carson, ScM, Mary Catherine Beach, MD, MPH, Janice A. Sabin, PhD, MSW,
Anthony G. Greenwald, PhD, and Thomas S. Inui, MD
Racial/ethnic disparities in healthcare are docu-
mented 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 physi-
cians,7,8 particularly in race-discordant patient---
clinician relationships.9,10 The Institute of Med-
icine’s report “Unequal Treatment,” suggests
disparities in healthcare emerge from
bias (or prejudice) against minorities; greater
clinical uncertainty when interacting with mi-
nority 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 evi-
dence that physicians have more negative
explicit attitudes toward Blacks than towards
Whites, including stereotypes about nonad-
herence,11---13 and that negative explicit attitudes
are associated with and mediate racial dispar-
ities 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 stereo-
typing patient compliance. We explored these
distinct measures of implicit bias because they
represent potentially different pathways to
medical care (Figure A, available as a supple-
ment 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.,
May 2012, Vol 102, No. 5 | American Journal of Public Health
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 associ-
ation 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. (Am J Public Health. 2012;102:979–987.
doi:10.2105/AJPH.2011.300558)
socioemotional and stylistic, but not necessarily METHODS
medically, focused). However, the pathway by
which race-based compliance stereotyping af- Secondary data came from enrollment visits
fects communication may be different from of clinicians and patients who participated in
that proposed for general racial bias because it 2 randomized clinical trials of interventions to
may relate to physicians’ professional obliga- enhance patient---provider communication and
tions to enhance patient adherence. Two im- outcomes for patients with hypertension (study
plicit association studies have documented 1) and depression (study 2).21,22 In each study,
a physician pro-White bias regarding the con- clinicians randomized to a communication
cept of the compliant patient.15,16 We reasoned skills training program (not focused on race)
that a race and compliance stereotype would received detailed individualized feedback on
have 2 communication-related consequences: their communication behaviors measured from
less positive emotional tone, reflecting frustra- a video-recorded encounter with a Black stan-
tion with a patient perceived as nonadherent; dardized patient. Information collected from
and heightened attention to providing medical participants included a self-administered clini-
information. Given evidence that Black patients cian baseline survey (study 1: January 2002---
are sensitive to pro-White bias,19,20 we hy- January 2003; study 2: June 2004---March
pothesized that both implicit measures are 2006) and patient interviews upon study en-
associated with more negative ratings of in- rollment (study 1: September 2003---August
terpersonal care in the visits of Black, but not 2005; study 2: October 2005---August 2006).
White, patients. We audiotaped patients in both studies with
Cooper et al. | Peer Reviewed | Research and Practice | 979
 THE SCIENCE OF RESEARCH ON RACIAL/ETHNIC DISCRIMINATION AND HEALTH
their clinician at enrollment, and patients
completed a postvisit questionnaire.
We collected primary data after the clinician
interventions via an Internet survey that in-
cluded 2 cognitive tests of implicit racial atti-
tudes and stereotyping derived from the Im-
plicit Association Test (IAT). The median time
between the patient’s baseline interview and
the clinician completing the online survey was
9.4 months (range = –3.2---30.2 months).
Study Variables
Independent variables were 2 measures of
implicit attitudes about race from clinicians’
survey responses. Dependent variables, collected
in the earlier 2 studies, included patient---clinician
communication measures from audiotapes of
medical visits and patient perceptions of the
clinician from postvisit surveys.
Measures of implicit attitudes about race. The
IAT is a computer-based, indirect measure of
social cognition widely used in social psychol-
ogy to measure implicit attitudes and stereo-
types about race and other sociocultural phe-
nomena.23 It measures the relative association
strength between a pair of target concepts
such as race (White vs Black) and a pair of
attribute categories such as good versus
bad.24---26 The IAT’s measure is predicated
on the assumption that concepts that the test
taker readily associates will be sorted together
more quickly than are concepts that are weakly
associated. Whereas the race attitude IAT
examines how much generic positive terms are
associated with Black versus White faces, the
race and medical compliance IAT examines
a more complex association of a race and
treatment adherence stereotype.15,16
On the basis of previous IAT research, the
general race attitude IAT used words such as
joy, wonderful, and laughter to represent the
concept of good and agony, evil, and hurt to
represent the concept of bad (Figure B, available
as a supplement to the online version of this
article at http://www.ajph.org). We constructed
the race and compliance patient IAT to measure
the association between race and the concept of
a “compliant patient.”16 The category of com-
pliant patient is represented by, for example,
willing, reliable, and helpful. Words to repre-
sent the reluctant patient category are, for
example, reluctant, apathetic, and lax (Figure C,
available as a supplement to the online version
980 | Research and Practice | Peer Reviewed | Cooper et al.
of this article at http://www.ajph.org). The IAT
score is derived from the difference in average
response time on the 2 sorting tasks.24 We
scored the IATs according to published guide-
lines26; possible scores ranged from –2 to +2,
and scores of zero indicated no greater pref-
erence for White relative to Black or no greater
association of White than Black with the com-
pliant patient concept. Higher positive scores
indicated greater preference for White or greater
association of White with compliant patient. We
gave participants the race attitude IAT and the
race and compliance IAT16 in randomly assigned
order. The IAT is a stable measure of implicit
cognition when tested over time.27
Medical visit audio recordings. We analyzed
audiotapes of primary care visits with the widely
used Roter Interaction Analysis System, a coding
system with demonstrated reliability and pre-
dictive validity.28---30 This system assigns each
thought the patient and clinician express to
mutually exclusive and exhaustive codes that can
be combined to reflect categories of exchange,
including functions of the medical interview.31
We measured visit length (in minutes), speech
speed (the number of statements per minute),
clinician verbal dominance (ratio of clinician to
patient statements), and patient centeredness
(ratio of the sum of psychosocial, rapport-build-
ing, and facilitative behaviors by clinicians and
patients representing the patient’s agenda to the
sum of biomedical questions, information giving,
and closed-ended questions representing the
clinician’s agenda).7,9 Verbal dominance is an
indicator of the level of participation of the
clinician relative to the patient in the dialogue,
with scores greater than 1 meaning the clinician
verbally dominated the dialogue. Patient cen-
teredness and verbal dominance have demon-
strated concurrent and predictive validity and
have been linked to patient satisfaction and
reported rapport with clinicians.28,30,32
Coders also rated the emotional tone of the
dialogue on a 6-point scale (1 = low or none to
6 = high) on global dimensions of patient pos-
itive affect (e.g., responsiveness) and clinician
positive affect (e.g., friendliness). We assessed
intercoder reliability (the Pearson r) on a 10%
random sample of double coded tapes; re-
liability averaged 0.90 over clinician and 0.86
over patient verbal categories. Coder agree-
ment within 1 point on affect scales was 88%
to 100%. Except affective tone, which was only
American Journal of Public Health | May 2012, Vol 102, No. 5
socioemotional, communication measures
contained socioemotional and task-focused
medical elements (Figure A, available as a sup-
plement to the online version of this article at
http://www.ajph.org).
Patient perceptions of clinicians measured by
postvisit survey. We used measures of inter-
personal care related to continuity of care and
patient adherence in other studies33---40 and
shown to differ by patient race3,5 and race
concordance with clinicians.9 Patients rated
their primary care clinician’s attitude toward
them as (1) “My doctor likes me,”33 and (2) “My
doctor has a great deal of respect for me.”34
Patients then rated how they felt about their
primary care clinician as (1) “I would recommend
this physician to a friend,” (2) “I like this doctor,”
(3) “I trust this doctor to look out for my best
interests,” and (4) “I have confidence in this
doctor’s knowledge and skills.”9,33,35 Finally,
we asked patients, if there were a choice be-
tween treatments, how often would this doctor
ask you to help make the decision?36 Five-point
Likert scales were skewed toward positive re-
sponses. We dichotomized responses as the top
category (e.g., strongly agree) versus all others.
Other variables. From clinicians we collected
age, gender, race, type of clinician (physician
vs nurse practitioner), board certification status,
location of training (United States or not), num-
ber of years in practice, and political identity
(self-report on a 6-point scale from strongly
conservative to strongly liberal). We collected
self-reported measures from clinicians designed
to parallel the targeted concepts in the IATs,
including preferences or feelings toward and
perceived cooperativeness of Whites and
Blacks.15---17 From patients, we collected age,
gender, race, educational attainment, employ-
ment status, insurance coverage, annual house-
hold income, living arrangements (alone or not),
and physical and mental health status (the
Medical Outcomes Short Form 12).41
Statistical Analyses
We used linear and logistic regression with
generalized estimating equations to assess the
strength of associations between clinician pro-
White bias or stereotyping and our dependent
variables while accounting for the nesting of
patients within clinician.42,43 We calculated
confidence intervals using robust empirical
SE estimates. We identified covariates for
 THE SCIENCE OF RESEARCH ON RACIAL/ETHNIC DISCRIMINATION AND HEALTH
multivariate analysis from their known associ-
ations with patient---physician communication
and included clinician gender; patient age,
gender, and education; and the mental com-
ponent of the Medical Outcomes Short Form
12. We evaluated the effect of clinician race on
outcomes with separate analyses stratified by
clinician race. We analyzed the data with all
patients in the models, including the IAT
measure, patient race, and the interaction of the
IAT measure and patient race as covariates.
We stratified the results by patient race only.
For communication measures, which are con-
tinuous and were analyzed with linear models
using generalized estimating equations, the
estimate for “implicit bias” is the difference in
the outcome associated with an increase in bias
score of 0.5 (considered a moderate level of
bias). For patient perceptions of clinicians,
which were dichotomous and analyzed with
logistic models using generalized estimating
equations, we estimated the predicted proba-
bilities of having each outcome for a hypothet-
ical patient whose clinician exhibited no im-
plicit bias (a score of 0.0) and a similar
hypothetical patient whose clinician exhibited
a moderate level of implicit bias (a score of 0.5).
We performed analyses using SAS version 9.2
(SAS Institute, Cary, NC).
RESULTS
Forty of the 63 clinicians (63%) with eligible
patients (self-reported race Black or White)
participated. There were no differences in de-
mographic and professional characteristics or
intervention assignments between clinician
participants and nonparticipants. Table 1
summarizes clinician characteristics and scores
on the 2 IAT measures. The mean scores
(range) for participating clinicians were 0.26
(–1.23 to 1.32) on the race attitude IAT and
0.29 (–0.60 to 1.39) on the race and compliance
IAT. The Cohen d, an effect size measure,44
indicated a moderate implicit bias (0.54) for the
race attitude IAT and a slightly stronger asso-
ciation of White race with compliance (0.70)
for the race and compliance IAT. The rela-
tionship between the 2 IAT measures was
weaker among non-Black than Black clinicians
(the Pearson q = 0.29 and 0.70, respectively).
Clinicians who considered themselves more
politically conservative had higher implicit race
May 2012, Vol 102, No. 5 | American Journal of Public Health
attitude IAT scores, and White clinicians had
higher implicit race and compliance IAT scores.
Clinician exposure to communication skills
training was not associated with lower IAT
scores. On explicit measures, clinicians per-
ceived Whites as more cooperative patients
than Blacks, but race attitudes (e.g., warmth,
preference) were neutral or favorable toward
Blacks (Table A, available as a supplement to
the online version of this article at http://www.
ajph.org).
Patient Characteristics
Of 445 potentially eligible patients, 269
(60%) had clinicians who completed the IAT
survey. Greater proportions of patients in-
cluded in the analysis were high school grad-
uates, were insured, and had an annual
household income greater than $35 000 than
did those excluded. Smaller proportions were
assigned to or had clinicians who were assigned
to patient-centered interventions. Similar pro-
portions of included and excluded patients
were audio taped at their enrollment visit. The
sample was largely middle-aged women. More
than two thirds were known to the clinician.
Blacks were younger, were less likely to be
married, were more likely to have Medicaid
insurance coverage, had poorer mental health
status, and were less likely to be in race-
concordant relationships with clinicians than
were Whites (Table 2).
General Race Bias and Interpersonal Care
More implicit bias on the race attitude IAT
was linked to 2 measures of communication
process: more clinician verbal dominance in
the visits of Blacks (9% greater) and Whites
(11% greater) and a 0.10-point lower patient
positive affect score in the visits of Blacks
(Table 3). For Black patients, higher levels of
implicit bias on the race attitude IAT were also
linked to lower predicted probabilities of per-
ceiving respect from the clinician (15% lower),
liking the clinician themselves (14% lower),
having confidence in the clinician (9% lower),
and recommending the clinician to others
(13% lower; Table 4).
For White patients, having a clinician with
higher levels of general race bias was linked to
higher likelihoods of perceiving respect from
the clinician (12% higher) and believing they
are liked by the clinician (6% higher) but
Cooper et al. | Peer Reviewed | Research and Practice | 981
a lower likelihood of perceiving the clinician as
participatory (17% lower; Table 4).
Race and Compliance Stereotyping
and Interpersonal Care
Greater implicit stereotyping on the race and
compliance IAT was linked to communication
process: for Blacks, 20% longer visits and slower
pace of the dialogue; for Whites, 21% shorter
visits with a more rapid pace of the dialogue,
25% less clinician verbal dominance, and higher
clinician positive affect. Additionally, the race
and compliance stereotype was associated with
communication content. In Black patient visits, it
was associated with less, and in White patient
visits more, patient-centered dialogue (Table 3).
Higher levels of the race and compliance IAT
were linked to lower predicted probabilities of
Blacks (12% lower) and Whites (27% lower)
perceiving the clinician as involving them in
decisions, lower likelihoods of Blacks having trust
(10% lower) and confidence (8% lower) in the
clinician, and lower likelihood of Whites recom-
mending the clinician (20% lower; Table 4).
In analyses stratified by clinicians’ race, the
associations of implicit bias or stereotyping with
most communication measures were similar re-
gardless of the race of the clinician. However,
the associations of implicit bias or stereotyping
with patient ratings were attenuated among
Black patients seeing Black clinicians.
The interaction of clinician implicit bias with
patient race was not significant for any of the
communication behaviors (although there was
suggestive evidence for patient positive affect,
P = .06). However, this interaction was statisti-
cally significant for the following patient percep-
tions: clinician respect, liking, and participatory
style, and patient liking and recommending the
clinician. The interaction of clinician implicit
compliance stereotyping with patient race was
significant for visit length, speech speed, verbal
dominance, and clinician positive affect but not
for any patient perceptions.
DISCUSSION
Clinicians, like everyone else, hold varying
attitudes toward members of racial/ethnic mi-
norities. However, clinicians differ from others
regarding their professional role and code of
conduct. We hypothesized that general implicit
racial bias would be related to socioemotional
 THE SCIENCE OF RESEARCH ON RACIAL/ETHNIC DISCRIMINATION AND HEALTH

TABLE 1—Clinicians’ Characteristics and Implicit Association Test (IAT) Scores: The Race and
Relationship-Centered Care Study, Baltimore, MD, January 2002–August 2006

Mean 6SD, No. (%), Race Attitude IAT Race and Compliant Patient
Characteristic or Median (Range) Score,a Mean 6SD Pb IAT Score,a Mean (SD) Pb

All clinicians 40 (100) 0.26 60.49 .002 0.29 60.41 < .001
Age, y .82 .13
27–39 15 (38) 0.20 60.46 0.23 60.43
40–49 14 (36) 0.27 60.67 0.47 60.43
50–62 10 (26) 0.32 60.30 0.13 60.33
Gender .43 .12
Female 25 (62) 0.22 60.52 0.21 60.41
Male 15 (38) 0.35 60.45 0.42 60.40
Race .07 .01
White 19 (48) 0.32 60.49 0.47 60.33
Black 9 (22) –0.05 60.45 –0.01 60.39
Asian, including Indian subcontinent 12 (30) 0.41 60.45 0.20 60.43
Type of clinician .5 .93
Physician 36 (90) 0.28 60.51 0.29 60.42
Nurse practitioner 4 (10) 0.10 60.38 0.27 60.45
US medical graduate .06 .47
Yes 34 (85) 0.20 60.47 0.27 60.43
No 6 (15) 0.61 60.52 0.40 60.33
Board certified .53 .45
Yes 36 (90) 0.28 60.51 0.30 60.42
No 4 (10) 0.11 60.39 0.11 60.36
Specialty .34 .22
Internal medicine 31 (78) 0.31 60.50 0.33 60.41
Family medicine 9 (22) 0.13 60.46 0.13 60.39
Years since completing residency 13.4 67.3
Political identity .09 .37
Conservative 10 (29) 0.53 60.54 0.41 60.40
Liberal 25 (71) 0.26 60.35 0.27 60.41
Number of patients 6.5 (1–16)
Communication skills intervention assignment .19 .15
Yes 18 (45) 0.38 60.51 0.39 60.43
No 22 (55) 0.17 60.47 0.20 60.38

Note. Although 40 clinicians participated, 1 did not provide age data, 5 did not complete the political identity question, 1 did not complete the race IAT, and 1 did not complete the race and
compliant patient IAT.
a
The IAT scores do not have units. They are the standardized difference in response time to the 2 tasks (the difference in latency measures [measured in milliseconds] divided by the standard
deviation).
b
The P values for the IAT scores for all clinicians compare the mean scores to a score of zero using a 2-sided 1 sample t-test. Other P values are from t-tests or analysis of variance (if more than 2
groups) to compare mean scores across physician characteristics.

and stylistic patterns of communication—those
common to social interactions regardless of
professional setting—whereas implicit race and
compliance stereotyping would be related to
both medically focused communication and
normative patterns of interaction. We expected
more implicit bias on both measures to have
a negative influence on Black, but not White,
patients’ experiences. We were generally
correct in hypothesizing distinct communica-
tion pathways. As in previous work,15---17,45 the
correlation between the 2 IAT measures was
relatively weak for non-Black clinicians, sug-
gesting that although related, the measures
may reflect different cognitive processes re-
lated to race. Moreover, the measures were
associated with different indicators of visit
communication.
As expected, the IAT measures were con-
sistently associated with Blacks’ poor ratings of
patient care. Unexpectedly, we observed both
positive and negative associations between
implicit racial attitudes and White patient
ratings of patient care. Although 1 study has
shown an association of implicit bias with
Blacks’ negative ratings of care,19 this is the first
study, to our knowledge, to demonstrate that

982 | Research and Practice | Peer Reviewed | Cooper et al. American Journal of Public Health | May 2012, Vol 102, No. 5
 THE SCIENCE OF RESEARCH ON RACIAL/ETHNIC DISCRIMINATION AND HEALTH

TABLE 2—Patient Characteristics, Overall and by Race: The Race and Relationship-Centered Care Study,
Baltimore, MD, January 2002–August 2006

All Patients (n = 269), Black Patients (n = 213), White Patients (n = 56),

Characteristic, Frequency, % No. (%) or Mean 6SD No. (%) or Mean 6SD No. (%) or Mean 6SD Pa

Age, y 56.2 613.2 54.5 613.3 62.7 610.4 < .001

Female gender 192 (71) 156 (73) 36 (64) .19
High school graduate 210/260 (81) 165/204 (81) 45 (80) .99
Married 107/267 (40) 70/211 (33) 37 (66) < .001
Lives alone 58 (22) 52 (24) 6 (11) .03
Health care insurance
Has any health insurance 247 (92) 194 (91) 53 (95) .58
Has Medicaid 63/259 (24) 55/203 (27) 8 (14) .05
Has Medicare 87/256 (34) 67/200 (34) 20 (36) .75
Has private health insurance 163/257 (63) 125/201 (62) 38 (68) .53
Annual household income < $35 000 150/254 (59) 122/203 (60) 28/51 (55) .53
Employment status, working 111/267 (42) 95/211 (45) 16 (29) .03
Mental component score of the Medical Outcomes Short Form 12b 47.0 612.6 46.1 613.2 50.4 69.2 .006
Physical component score of the Medical Outcomes Short Form 12b 41.8 612.9 41.7 613.0 42.2 612.5 .83
Moderately well known by clinician 155/224 (69) 113/173 (65) 42/51 (82) .02
Seen by race-concordant clinician 66 (25) 42 (20) 24 (43) < .001

Note. If there are any missing data for the characteristic, the number of patients with data is specified.
a
P value from the Fisher exact test or 2-sample t-test.
b
There were 266 patients with data for the Medical Outcomes Short Form 12 (211 Blacks and 55 Whites).

both implicit bias and stereotyping are associ-
ated with directly observed medical visit com-
munication and patient perceptions of care.
The negative effect of implicit race bias for
Black patients is evident in communication
indicators (e.g., more clinician-dominated visit
dialogue and lower coder ratings of patient
positive affect during the visit) and a broad
array of negative patient ratings. The effect of
implicit stereotyping is also negative for Black
patients. It is associated with lower levels of
patient-centered dialogue and lower patient
ratings of trust and confidence in the clinician.
These findings are consistent with other studies
demonstrating that Blacks are at greater risk
than are Whites for narrowly biomedically
focused visits with restricted patient input in
the psychosocial and lifestyle realm.7,28
Patient-centered communication is associ-
ated with greater patient trust,10,46,47 which is
in turn associated with adherence and conti-
nuity of care.37,38,40 Thus, the differences in
communication behaviors and patient ratings
of care in this study may have implications
for health outcomes. The communication
markers associated with implicit race attitudes
may be a proxy for a more pervasive pattern
of communication, including nonverbal be-
haviors not detected by our coders, that
contributes to poorer patient perceptions.
Social psychology studies show that implicit
attitudes “leak” during interactions through
the inadvertent display of negative nonverbal
behaviors48 and sentiments,49 even when in-
dividuals consciously endorse racial equality
and are averse to any suggestion of racial
bias.50 In previous studies, IAT scores reflecting
more racial bias predicted less speaking time,
less smiling, fewer social comments, less speech
fluency, and more speech errors among partic-
ipants interacting with Black (than White)
experimenters.49,51 Blacks may be sensitive to
these cues and use them in drawing conclu-
sions about poor interpersonal treatment.20
Less positive affect among Black patients may
also reflect “stereotype threat,” a phenomenon
whereby cues in one’s surroundings accentuate
negative stereotypes associated with one’s
group and activate physiological and psycho-
logical processes with negative influences on
behavior.52,53
The associations of implicit stereotyping
with longer visits and slower speech might
suggest a more conscientious and thorough
handling of the concerns of Black patients.54---58
Clinicians with more implicit compliance ster-
eotyping may be trying to compensate for what
they perceive as greater mistrust from Black
patients, or they may be making well-inten-
tioned efforts to promote patient adherence
or to not appear prejudiced. Conversely, the
combination of slow speech and low patient
centeredness may convey an authoritative tone
that creates an overall negative impression on
patients. Associations of slower speech with
more biomedically focused and information-
dense visits, less patient centeredness, and
poorer interpersonal care ratings have been
reported in previous studies.59,60
In contrast to consistent negative findings for
Blacks, the effect of implicit race attitudes for
White patients is largely, although not exclu-
sively, positive. As implicit race bias increases,
White patients report being more respected
and liked, and as implicit compliance stereo-
typing increases, coders rate the communica-
tion in their visits as more patient centered, less
verbally dominant, and higher in clinician
positive affect. Some negative influences of
implicit bias are common to both Blacks and
Whites. Clinicians with general race bias are

May 2012, Vol 102, No. 5 | American Journal of Public Health Cooper et al. | Peer Reviewed | Research and Practice | 983
 THE SCIENCE OF RESEARCH ON RACIAL/ETHNIC DISCRIMINATION AND HEALTH

TABLE 3—Implicit General Race Bias and Race and Medical Compliance Stereotyping as Predictors of Patient–Clinician
Communication by Patient Race: The Race and Relationship-Centered Care Study, Baltimore, MD, January 2002–August 2006

Implicit General Race Bias, Implicit General Race Bias, Implicit Race and Medical Implicit Race and Medical
Black Patients White Patients Compliance Stereotyping, Compliance Stereotyping,
(n = 131)a (n = 48) Black Patients (n = 135)a White Patients (n = 48)
Communication Behavior Mean Estimateb (95% CI) P Mean Estimateb (95% CI) P Mean Estimateb (95% CI) P Mean Estimateb (95% CI) P

Verbal dominance ratio .05 .01 .14 .02

No implicit bias 1.47 (1.29, 1.66) 1.27 (1.09, 1.49) 1.48 (1.28, 1.71) 1.56 (1.26, 1.94)
Implicit bias 9% (0, 19) 11% (2, 21) 10% (–3, 24) –25% (–42, –4)
Visit length, minutes .36 .14 .02 .001
No implicit bias 14.0 (11.7, 16.7) 17.1 (14.6, 19.9) 13.3 (11.2, 15.7) 19.5 (16.0, 23.8)
Implicit bias 7% (–7, 22) 8% (–17, 3) 20% (3, 40) –21% (–31, –9)
Speech speed, statements per minute .23 .83 .02 .001
No implicit bias 25.5 (24.1, 26.9) 23.7 (21.6, 25.8) 25.8 (24.6, 27.0) 21.6 (19.4, 23.8)
Implicit bias –0.76 (–2.02, 0.50) 0.25 (–2.05, 2.55) –1.75 (–3.25, –0.25) 3.9 (1.6, 6.3)
Patient centeredness ratio .63 .37 .06 .02
No implicit bias 1.66 (0.95, 2.37) 0.70 (0.58, 0.82) 1.97 (1.00, 2.94) 0.60 (0.45, 0.74)
Implicit bias –0.10 (–0.51, 0.31) –0.05 (–0.17, 0.07) –0.93 (–1.91, 0.04) 0.15 (0.02, 0.28)
Clinician positive affect .14 .78 .35 .02
No implicit bias 3.63 (3.51, 3.75) 3.38 (3.31, 3.45) 3.60 (3.49, 3.72) 3.30 (3.20, 3.40)
Implicit bias –0.10 (–0.23, 0.03) –0.01 (–0.07, 0.05) –0.06 (–0.19, 0.07) 0.12 (0.02, 0.21)
Patient positive affect .04 .87 .53 .09
No implicit bias 3.39 (3.30, 3.49) 3.31 (3.19, 3.43) 3.36 (3.26, 3.45) 3.24 (3.10, 3.38)
Implicit bias –0.10 (–0.19, –0.00) 0.01 (–0.09, 0.10) –0.04 (–0.16, 0.08) 0.11 (–0.02, 0.24)

Note. CI = confidence interval. Adjusted for clinician gender and patient age, gender, education, and the mental component of the Medical Outcomes Short Form 12.
a
We excluded 1 observation from speech speed and 1 from patient centeredness because they were extreme outliers.
b
We estimated the means while holding all other covariates at their means. The estimate for “no pro-White bias” for verbal dominance and visit length is the geometric mean from the generalized
estimating equations (GEE) model for a bias score of zero; the estimate for “implicit bias” is the percentage change in verbal dominance and visit length associated with a 0.5-point increase in the
bias score. For all other variables, the estimate for “no implicit bias” is the mean outcome score from the GEE model for a bias score of zero; the estimate for “implicit bias” is the change in the
outcome associated with a change in bias score of 0.5 (considered a moderate level of bias).

more verbally dominant in the visits of all
patients, and both patient groups perceive
clinicians with race and compliance stereotyp-
ing as less likely to involve patients in treatment
decisions. A more conservative political orien-
tation is a correlate of implicit bias in our sample,
and previous work suggests that politically
conservative doctors work in more traditional
settings and may be less open to partnership
relationships with their patients.61---63 To explore
whether the association of implicit bias and
stereotyping with clinician verbal dominance
might be a consequence of a more traditional,
authoritarian approach to the doctor---patient
relationship, we adjusted for clinicians’ political
ideology and found it partially explained this
finding, but only among Black patients, perhaps
because we had limited statistical power in our
smaller sample of White patients.
Limitations
The study has some limitations. The sam-
pling of clinicians and patients was not ran-
dom but contingent on participation in one of
the earlier studies. Participating clinicians may
be more motivated about communication
skills and caring for minority patients than are
other physicians; they are also from an urban
area with a high representation of Blacks,
where interracial relationships may differ
from other areas. The study sample included
mostly Black patients seeing White clinicians;
we might have seen different results with
a larger sample of White patients. However,
because most ethnic minorities in the United
States receive care from White physicians,
these findings may be relevant to a large
proportion of ethnic minority primary care
patients. Knowledge that the visit was being
recorded may have biased clinician
performance. However, studies of perfor-
mance bias conclude that recordings have
little systematic effect on performance.64---67
Patients were well known by their clinicians
and may have given socially desirable re-
sponses to survey items; however, it is un-
likely this would have differed according to
the implicit attitudes of clinicians.
Although the coders achieved high reli-
ability and identified some racial differences
in patient and clinician affect linked to implicit
attitudes, both are White women and may be
less sensitive to biased clinicians’ subtle neg-
ative nonverbal vocal cues that might be
evident to a Black coder.20 Measuring the IAT
some months after the patient interview
makes it conceivable that the patient interview
influenced IAT measures, rather than the
reverse. However, this alternative inter-
pretation is rendered implausible by, in

984 | Research and Practice | Peer Reviewed | Cooper et al. American Journal of Public Health | May 2012, Vol 102, No. 5
 THE SCIENCE OF RESEARCH ON RACIAL/ETHNIC DISCRIMINATION AND HEALTH

TABLE 4—Implicit General Race Bias and Race and Medical Compliance Stereotyping as Predictors of Patient Perceptions of
Clinician, by Patient Race: The Race and Relationship-Centered Care Study, Baltimore, MD, January 2002–August 2006

Implicit General Race Bias, Implicit General Race Bias, Implicit Race and Medical Implicit Race and Medical
Black Patients White Patients Compliance Stereotyping, Compliance Stereotyping,
(n = 191)a (n = 55) Black Patients (n = 197)a White Patients (n = 55)
Predicted Probabilitiesb Predicted Probabilitiesb Predicted Probabilitiesb Predicted Probabilitiesb
Patient Perceptions (95% CI) P (95% CI) P (95% CI) P (95% CI) P

Clinician would ask patient to help decide treatment .48 .002 .02 .04
No implicit bias 31.3 (22.8, 41.2) 33.2 (17.9, 53.3) 35.2 (27.8, 43.4) 46.3 (26.5, 67.3)
Implicit bias 28.3 (22.3, 35.1) 16.6 (7.3, 33.5) 23.0 (16.8, 30.7) 19.4 (6.8, 44.1)
Clinician respects him or her .001 < .001 .15 .47
No implicit bias 50.2 (38.6, 61.7) 14.2 (7.0, 26.5) 44.1 (33.7, 55.1) 27.9 (15.5, 44.9)
Implicit bias 34.9 (27.2, 43.5) 26.5 (18.7, 36.0) 37.0 (28.7, 46.2) 21.6 (8.3, 45.5)
Clinician likes him or her .25 .003 .41 .23
No implicit bias 28.5 (20.4, 38.2) 2.4 (0.5, 9.9) 26.5 (18.8, 35.9) 15.1 (5.0, 37.8)
Implicit bias 23.8 (17.9, 31.0) 8.0 (3.0, 19.5) 23.2 (16.7, 31.3) 6.6 (1.8, 21.4)
Likes clinician < .001 .12 .75 .12
No implicit bias 46.6 (37.5, 55.9) 22.8 (11.9, 39.1) 39.8 (31.0, 49.3) 42.1 (27.1, 58.7)
Implicit bias 32.7 (26.2, 39.9) 31.4 (20.8, 44.5) 38.4 (31.7, 45.5) 31.6 (22.5, 42.5)
Trusts clinician .29 .49 .02 .17
No implicit bias 71.2 (64.3, 77.3) 81.3 (61.7, 92.2) 74.4 (67.3, 80.5) 83.1 (64.2, 93.1)
Implicit bias 67.6 (60.6, 73.8) 76.9 (68.9, 83.4) 64.0 (56.5, 70.9) 73.9 (64.2, 81.7)
Has confidence in clinician .007 .25 .05 .15
No implicit bias 80.1 (72.9, 85.8) 83.6 (69.0, 92.1) 79.3 (72.2, 85.0) 83.9 (66.4, 93.2)
Implicit bias 71.4 (64.1, 77.7) 79.0 (70.7, 85.4) 71.2 (63.8, 77.7) 74.9 (66.0, 82.0)
Would recommend clinician .001 .51 .18 .03
No implicit bias 47.3 (38.6, 56.1) 32.3 (17.4, 51.8) 42.4 (32.8, 52.7) 43.8 (24.0, 65.8)
Implicit bias 34.4 (27.1, 42.5) 29.1 (19.4, 41.2) 36.3 (29.4, 43.8) 23.7 (15.5, 34.5)

Note. CI = confidence interval. Adjusted for clinician gender and patient age, gender, education, and the mental component of the Medical Outcomes Short Form 12.
a
A few patients did not respond to some of the outcomes (minimum n = 186 for Black and n = 54 for White patients).
b
We estimated the predicted probabilities while holding all other covariates in the model constant at their mean. These are the probabilities of having the outcome for a hypothetical patient whose
clinician exhibited no implicit bias (a score of 0.0) and for a similar hypothetical patient whose clinician exhibited a moderate level of implicit bias (a score of 0.5).

combination, the known stability of IAT
measures,27 their limited malleability,45,68 and
the lack of evidence for effects of order of
administration of IAT measures on relevant
behaviors.18 We have not included an analysis
of the association of clinicians’ self-reported
race attitudes with communication behaviors
or ratings of care. However, IAT measures
have greater validity than do self-report mea-
sures in predicting stereotyping behavior.18,24
Because the study included multiple compari-
sons, the possibility of statistical type I error
exists; however, this is unlikely because analy-
ses were conceptually driven and grounded
in previous literature, most of the observed
associations are in the expected directions,
and findings across related measures are
consistent.
Conclusions
Notwithstanding these limitations, this study
informs future research and interventions tar-
geting health professionals to reduce health-
care disparities. Theoretically based interven-
tion strategies—which increase clinicians’
awareness and understanding of the basis of
bias and help them develop cultural sensitivity,
patient-centered communication, and partner-
ship-building in the patient---clinician relation-
ship—will enable clinicians to reduce their
reliance on social categories when clinically
irrelevant.69 Interpersonal bias in healthcare is
only 1 of the manifestations of racial discrim-
ination in our society; however, health pro-
fessionals can serve as influential advocates for
social justice70 by encouraging open discourse
about the existence of bias in healthcare and
upholding the elimination of healthcare dispar-
ities as a local, national, and global priority. j
About the Authors
Lisa A. Cooper and Mary Catherine Beach are with the
Department of Medicine, Johns Hopkins University School
of Medicine, Baltimore, MD. Debra L. Roter is with the
Department of Health Behavior and Society at the Johns
Hopkins Bloomberg School of Public Health, Baltimore,
MD. Kathryn A. Carson is with the Department of
Epidemiology, Johns Hopkins Bloomberg School of Public
Health. Janice A. Sabin is with the Department of Medical
Education and Biomedical Informatics, Center for Clinical
and Epidemiological Research, University of Washington,
Seattle. Anthony G. Greenwald is with the Department of
Psychology, University of Washington. Thomas S. Inui is with
the Regenstrief Institute at Indiana University School of
Medicine, Indianapolis.
Correspondence should be sent to Lisa A. Cooper, MD,
MPH, Johns Hopkins University, Welch Center for Pre-
vention, Epidemiology, and Clinical Research, 2024 East
Monument Street, Suite 2-500, Baltimore, MD 21287

May 2012, Vol 102, No. 5 | American Journal of Public Health Cooper et al. | Peer Reviewed | Research and Practice | 985
 THE SCIENCE OF RESEARCH ON RACIAL/ETHNIC DISCRIMINATION AND HEALTH
(e-mail: lisa.cooper@jhmi.edu). Reprints can be ordered at
http://www.ajph.org by clicking the “Reprints” link.
This article was accepted October 31, 2011.
Contributors
L. A. Cooper acquired the data; provided administrative,
technical, and material support; and supervised partici-
pant recruitment, data collection, and data analysis. L. A.
Cooper, D. L. Roter, M. C. Beach, J. A. Sabin, A. G.
Greenwald, and T. S. Inui contributed to the conceptu-
alization and design of the study. L. A. Cooper, D. L.
Roter, M. C. Beach, J. A. Sabin, A. G. Greenwald, and
K. A. Carson participated in analysis and interpretation of
data. L. A. Cooper, D. L. Roter, M. C. Beach, J. A. Sabin,
and K. A. Carson drafted the article. L. A. Cooper and
T. S. Inui obtained funding. K. A. Carson performed the
statistical analysis. All authors participated in critical
revision of the article for important intellectual content.
Acknowledgments
This work was supported in part by the Fetzer Founda-
tion Relationship-Centered Care Research Network
(grant 2005), the National Heart, Lung, and Blood
Institute (grants R01HL69403 and K24HL083113), the
Agency for Healthcare Research and Quality (grant
R01HS013645), and the Implicit and Unconscious Cogni-
tion Research Fund at University of Washington. L. A.
Cooper also gratefully acknowledges the support of the
MacArthur Foundation Fellows Program.
Human Participant Protection
The Johns Hopkins institutional review board approved
all study protocols. All patients provided written in-
formed consent. All clinicians provided either oral or
written informed consent.
References
1. Smedley BD, Stith AY, Nelson AR, eds. Unequal
Treatment: Confronting Racial and Ethnic Disparities in Health
Care. Washington, DC: National Academies Press; 2003.
2. Saha S, Arbelaez JJ, Cooper LA. Patient---physician
relationships and racial disparities in the quality of health
care. Am J Public Health. 2003;93(10):1713---1719.
3. Doescher MP, Saver BG, Franks P, Fiscella K. Racial
and ethnic disparities in perceptions of physician style
and trust. Arch Fam Med. 2000;9(10):1156---1163.
4. Malat J. Social distance and patients’ rating of health-
care providers. J Health Soc Behav. 2001;42(4):360---372.
5. Boulware LE, Cooper LA, Ratner LE, LaVeist TA,
Powe NR. Race and trust in the health care system. Public
Health Rep. 2003;118(4):358---365.
6. Ngo-Metzger Q, Legedza AT, Phillips RS. Asian
Americans’ reports of their health care experiences.
Results of a national survey. J Gen Intern Med. 2004;19
(2):111---119.
7. Johnson RL, Roter D, Powe NR, Cooper LA. Patient
race/ethnicity and quality of patient---physician commu-
nication during medical visits. Am J Public Health.
2004;94(12):2084---2090.
8. Street RL Jr, Gordon H, Haidet P. Physicians’
communication and perceptions of patients: is it how they
look, how they talk, or is it just the doctor? Soc Sci Med.
2007;65(3):586---598.
9. Cooper LA, Roter D, Johnson R, Ford D, Steinwach
DM, Powe NR. Patient-centered communication, ratings
986 | Research and Practice | Peer Reviewed | Cooper et al.
of care, and concordance of patient and physician race.
Ann Intern Med. 2003;139(11):907---915.
10. Street RL Jr, O’Malley KJ, Cooper LA, Haidet P.
Understanding concordance in patient---physician rela-
tionships: personal and ethnic dimensions of shared
identity. Ann Fam Med. 2008;6(3):198---205.
11. van Ryn M, Burke J. The effect of patient race and
socio-economic status on physicians’ perceptions of pa-
tients. Soc Sci Med. 2000;50(6):813---828.
12. Lutfey KE, Ketcham JD. Patient and provider
assessments of adherence and the sources of disparities:
evidence from diabetes care. Health Serv Res. 2005;40(6
pt 1):1803---1817.
13. Bogart LM, Catz SL, Kelley JA, et al. Factors
influencing physicians’ judgments of adherence and
treatment decisions for patients with HIV disease. Med
Decis Making. 2001;21(1):28---36.
14. van Ryn M, Burgess D, Malat J, Griffin J. Physicians’
perceptions of patients’ social and behavioral character-
istics and race disparities in treatment recommendations
for men with coronary artery disease. Am J Public Health.
2006;96:351---357.
15. 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.
16. Sabin JA, Rivara FP, Greenwald AG. Physician
implicit attitudes and stereotypes about race and quality
of medical care. Med Care. 2008;46(7):678---685.
17. Sabin J, Nosek BA, Greenwald A, Rivara FP.
Physicians’ implicit and explicit attitudes about race by
MD race, ethnicity, and gender. J Health Care Poor
Underserved. 2009;20(3):896---913.
18. Greenwald AG, Poehlman TA, Uhlmann E, Banaji
MR. Understanding and using the Implicit Association
Test: III. Meta-analysis of predictive validity. J Pers Soc
Psychol. 2009;97(1):17---41.
19. Penner LA, Dovidio JF, West TV, et al. Aversive
racism and medical interactions with Black patients:
a field study. J Exp Soc Psychol. 2010;46(2):436---440.
20. Livingston RW, Drwecki BB. Why are some in-
dividuals not racially biased? Susceptibility to affective
conditioning predicts nonprejudice toward Blacks. Psy-
chol Sci. 2007;18(9):816---823.
21. Cooper LA, Roter DL, Bone LR, et al. A randomized
controlled trial of interventions to enhance patient-- physician
partnership, patient adherence and high blood pressure
control among ethnic minorities and poor persons: study
protocol NCT00123045. Implement Sci. 2009;4:7.
22. Cooper LA, Ford DE, Ghods BK, et al. A cluster
randomized trial of standard quality improvement versus
patient-centered interventions to enhance depression
care for African Americans in the primary care setting:
study protocol NCT00243425. Implement Sci. 2010;
5:18.
23. Greenwald AG, McGhee DE, Schwartz JL. Measur-
ing individual differences in implicit cognition: the Im-
plicit Association Test. J Pers Soc Psychol. 1998;74
(6):1464---1480.
24. Nosek BA, Greenwald AG, Banaji MR. Under-
standing and using the Implicit Association Test: II.
Method variables and construct validity. Pers Soc Psychol
Bull. 2005;31(2):166---180.
25. Nosek BA, Smyth FL. A multitrait-multimethod
validation of the Implicit Association Test: implicit and
American Journal of Public Health | May 2012, Vol 102, No. 5
explicit attitudes are related but distinct constructs. Exp
Psychol. 2007;54(1):14---29.
26. Greenwald AG, Nosek BA, Banaji MR. Under-
standing and using the Implicit Association Test: I. An
improved scoring algorithm. J Pers Soc Psychol. 2003;85
(2):197---216.
27. Egloff B, Schwerdtfeger A, Schmukle SC. Temporal
stability of the Implicit Association Test—anxiety. J Pers
Assess. 2005;84(1):82---88.
28. Roter DL, Stewart M, Putnam SM, Lipkin M Jr, Stiles
W, Inui TS. Communication patterns of primary care
physicians. JAMA. 1997;277(4):350---356.
29. Roter DL, Larson S. The relationship between
residents’ and attending physicians’ communication dur-
ing primary care visits: an illustrative use of the Roter
Interaction Analysis System. Health Commun. 2001;13
(1):33---48.
30. Mead N, Bower P. Measuring patient-centredness:
a comparison of three observation-based instruments.
Patient Educ Couns. 2000;39(1):71---80.
31. Lazare A, Putnam SM, Lipkin MJ. Three functions
of the medical interview. In: Lipkin M, Putnam S,
Lazare A, eds. The Medical Interview: Clinical Care,
Education, and Research. New York: Springer-Verlag;
1995:3---19.
32. Paasche-Orlow M, Roter D. The communication
patterns of internal medicine and family practice physi-
cians. J Am Board Fam Pract. 2003;16(6):485---493.
33. Hall JA, Horgan TG, Stein TS, Roter DL. Liking in
the physician---patient relationship. Patient Educ Couns.
2002;48(1):69---77.
34. Beach MC, Roter DL, Wang NY, Duggan PS, Cooper
LA. Are physicians’ attitudes of respect accurately per-
ceived by patients and associated with more positive
communication behaviors? Patient Educ Couns. 2006;62
(3):347---354.
35. Kao AC, Green DC, Davis NA, Koplan JP, Cleary PD.
Patients’ trust in their physicians: effects of choice,
continuity, and payment method. J Gen Intern Med.
1998;13(10):681---686.
36. Kaplan SH, Gandek B, Greenfield S, Rogers W,
Ware JE. Patient and visit characteristics related to
physicians’ participatory decision-making style. Results
from the Medical Outcomes Study. Med Care. 1995;33
(12):1176---1187.
37. Schneider J, Kaplan SH, Greenfield S, Li W, Wilson
IB. Better physician---patient relationships are associated
with higher reported adherence to antiretroviral therapy
in patients with HIV infection. J Gen Intern Med. 2004;
19(11):1096---1103.
38. McGinnis B, Olson KL, Magid D, et al. Factors
related to adherence to statin therapy. Ann Pharmacother.
2007;41(11):1805---1811.
39. O’Malley AS, Sheppard VB, Schwarts M,
Mandelblatt J. The role of trust in use of preventive
services among low-income African-American women.
Prev Med. 2004;38(6):777---785.
40. Safran DG, Montgomery JE, Chang H, Murphy J,
Rogers WH. Switching doctors: predictors of voluntary
disenrollment from a primary physician’s practice. J Fam
Pract. 2001;50(2):130---136.
41. Ware J Jr, Kosinski M, Keller SD. A 12-item short-
form health survey. Construction of scales and prelimi-
nary tests of reliability and validity. Med Care. 1996;34
(3):220---233.
 THE SCIENCE OF RESEARCH ON RACIAL/ETHNIC DISCRIMINATION AND HEALTH

42. Zeger SL, Liang K. Longitudinal data analysis for
discrete and continuous outcomes. Biometrics. 1986;42
(1):121---130.
43. Liang K-Y, Zeger SL. Longitudinal data analysis using
generalized linear models. Biometrika. 1986;73(1):13---22.
44. Cohen J. Statistical Power Analysis for the Behavioral
Sciences. 2nd ed. Hillsdale, NJ: Erlbaum; 1988.
61. Mechanic D. Politics, Medicine, and Social Science.
New York: John Wiley & Sons; 1974.
62. Whitney SN, Brown BW Jr, Brody H, Alcser KH,
Bachman JG, Greely HT. Views of United States physi-
cians and members of the American Medical Association
House of Delegates on physician-assisted suicide. J Gen
Intern Med. 2001;16(5):290---296.

45. Nosek BA, Smyth FL, Jansen JJ, et al. Pervasiveness 63. Waitzkin H. Information-giving in medical care. J
and correlates of implicit attitudes and stereotypes. Eur Health Soc Behav. 1985;26:81---101.
Rev Soc Psychol. 2007;18(1):36---88. 64. Inui TS, Carter WB, Kukull WA, Haigh VH. Out-
come based doctor---patient interaction analysis: I. Com-
46. Zolnierek KB, Dimatteo MR. Physician communi-
parison of techniques. Med Care. 1982;20(6):535---549.
cation and patient adherence to treatment: a meta-anal-
ysis. Med Care. 2009;47(8):826---834. 65. Redman S, Dickinson JA, Cockburn J, Hennrikus D,
Sanson-Fisher RW. The assessment of reactivity in direct
47. Fiscella K, Meldrum S, Franks P, et al. Patient trust: is
observation studies of doctor---patient interactions. Psy-
it related to patient-centered behavior of primary care
chol Health. 1989;3(1):17---28.
physicians? Med Care. 2004;42(11):1049---1055.
66. Pringle M, Stewart-Evans C. Does awareness of
48. Dovidio JF, Kawakami K, Gaertner SL. Implicit and
being video recorded affect doctors’ consultation behav-
explicit prejudice and interracial interaction. J Pers Soc
ior? Br J Gen Pract. 1990;40(340):455---458.
Psychol. 2002;82(1):62---68.
67. Coleman T, Manku-Scott T. Comparison of video-
49. Richeson JA, Shelton JN. Brief report: thin slices of
recorded consultations with those in which patients’
racial bias. J Nonverbal Behav. 2005;29(1):75---86.
consent is withheld. Br J Gen Pract. 1998;48(427):971---
50. Dovidio JF, Penner LA, Albrecht TL, Norton WE, 974.
Gaertner SL, Shelton JN. Disparities and distrust: the
68. Joy-Gaba JA, Nosek BA. The surprisingly limited
implications of psychological processes for understanding
malleability of implicit racial evaluations. Soc Psychol.
racial disparities in health and health care. Soc Sci Med.
2010;41(3):137---146.
2008;67(3):478---486.
69. Burgess D, van Ryn M, Dovidio J, Saha S. Reducing
51. McConnell AR, Leibold JM. Relations among the
racial bias among health professionals: lessons from
Implicit Association Test, discriminatory behavior, and
social-cognitive psychology. J Gen Intern Med. 2007;22
explicit measures of racial attitudes. J Exp Soc Psychol.
(6):882---887.
2001;37(5):435---442.
70. Medical professionalism in the new millennium: a
52. Steele CM, Aronson J. Stereotype threat and the
physician charter. Ann Intern Med. 2002;136(3):243---
intellectual test performance of African Americans. J Pers
246.
Soc Psychol. 1995;69(5):797---811.
53. Burgess DJ, Warren J, Phelan S, Dovidio J, van Ryn
M. Stereotype threat and health disparities: what medical
educators and future physicians need to know. J Gen
Intern Med. 2010;25(suppl 2):S169---S177.
54. Wiggers JH, Sanson-Fisher R. Duration of general
practice consultations: association with patient occupa-
tional and educational status. Soc Sci Med. 1997;44
(7):925---934.
55. Gross DA, Zyzanski SJ, Borawski EA, Cebul RD,
Stange KC. Patient satisfaction with time spent with their
physician. J Fam Pract. 1998;47(2):133---137.
56. Wilson IB, Kaplan S. Physician---patient communi-
cation in HIV disease: the importance of patient, physi-
cian, and visit characteristics. J Acquir Immune Defic
Syndr. 2000;25(5):417---425.
57. Howie JG, Porter AM, Heaney DJ, Hopton JL. Long
to short consultation ratio: a proxy measure of quality
of care for general practice. Br J Gen Pract. 1991;41
(343):48---54.
58. Morrell DC, Evans ME, Morris RW, Roland MO.
The “five minute” consultation: effect of time constraint
on clinical content and patient satisfaction. Br Med J (Clin
Res Ed). 1986;292(6524):870---873.
59. Erby LH, Roter D, Larson S, Cho J. The rapid
estimate of adult literacy in genetics (REAL-G): a means
to assess literacy deficits in the context of genetics. Am
J Med Genet A. 2008;146A(2):174---181.
60. Roter DL, Larson SM, Beach MC, Cooper LA.
Interactive and evaluative correlates of dialogue sequence:
a simulation study applying the RIAS to turn taking
structures. Patient Educ Couns. 2008;71(1):26---33.

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