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<p>Compared to people who are White and have high socioeconomic status (SES), those who are Black and have low SES are more likely to receive suboptimal pain care. One potential contributor to these disparities is biased provider decision-making—there is compelling evidence that providers are influenced by patient race and SES when making pain treatment decisions. According to the dual process model, people are more likely to be influenced by demographic stereotypes, including implicit beliefs, when they are under high cognitive load (i.e., mental workload). One stereotype belief relevant to pain care is that Black and low SES people are more pain tolerant. Aligned with the dual process model, providers who are under high cognitive load and have strong implicit beliefs that Black and low SES people are more pain tolerant may be particularly likely to recommend fewer pain treatments to them. To test this hypothesis, I recruited physician residents and fellows (n=120) to make pain treatment decisions for 12 computer-simulated patients with back pain that varied by race (Black/White) and SES (low/high). Half of the providers were randomized to the high cognitive load group in which they were interrupted during the decision task to make conversions involving hypertension medications for another patient. Remaining providers completed the task without being interrupted. Providers’ implicit beliefs about race and SES differences in pain tolerance were measured with two separate Implicit Association Tests (IATs). Multilevel modeling indicated that providers recommended stronger medications to low than high SES patients (OR=.68, p=.03). There was also a significant interaction between patient SES and cognitive load (OR=-.56, p=.05) and a trending interaction between patient race and cognitive load (OR=1.7, p=.07). Under low cognitive load, providers recommended more pain treatments to high SES (vs. low SES) and Black (vs. White) patients, but under high cognitive load, providers recommended more pain treatments to low SES (vs. high SES) patients and equivalent treatment to Black and White patients. There were no three-way interactions between patient demographics (race or SES), cognitive load, and providers’ implicit beliefs (race-pain or SES-pain IAT scores). However, there was a trending interaction between patient race and race-pain IAT scores (OR=2.56, p=.09). Providers with stronger implicit beliefs that White people are pain sensitive and Black people are pain tolerant recommended more pain treatments to White patients and fewer pain treatments to Black patients. Lastly, there was a trending effect that providers with stronger implicit beliefs that high SES people are pain sensitive and low SES people are pain tolerant recommended stronger medications in general (OR=13.03, p=.07). Results support that provider cognitive load is clinically relevant and impacts clinical decision-making for chronic pain for racially and socioeconomically diverse patients. Future studies are needed to further understand the impact of cognitive load on providers’ pain care decisions, which may inform evidence-based interventions to improve pain care and reduce disparities.</p> <p>  </p>

As medical students undergo their clinical years, they exhibit a well-documented loss of idealism, increasingly negative attitudes towards poor and underserved patients, and less interest in working with these patients. Here we describe the pilot year of a longitudinal service-learning requirement implemented as a part of the medical student pre-clinical curriculum. We hypothesized that increased non-clinical contact would decrease the formation of negative attitudes towards underserved patients. Students completed service hours at assigned community sites each semester along with written reflections. Surveys were administered to track attitudes towards the underserved. Written reflections were analyzed qualitatively for thematic content as well as feedback on the experience. The requirement was largely acceptable to medical students, and many found value and enjoyment in the experience. The most common critique was that the required hours were insufficient to develop continuity, and that students desired more thorough briefing beforehand to increase their effectiveness. Students reported practicing clinical skills and communication skills. They identified social determinants of health and learned about their patients. They reflected on their professional identity, motivations for entering medicine, and specialty choices. Students experienced moments of connection and belonging, as well as feelings of guilt, otherness, and awareness of privilege. We continue to explore how working collaboratively and learning reciprocally with community members outside of the hospital and clinic may teach students cultural humility and help insulate students from cynicism and negative views of poor and medically underserved patients. / Urban Bioethics

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Essay 1: Individuals with higher socioeconomic status (SES) also tend to enjoy better health. Evidence from the economics literature suggests that a potential mechanism behind this “social health gradient” is that human capabilities, that form SES, also facilitate health-promoting behaviors. This essay empirically investigates the significance of socioeconomic differences in health behaviors, using dental care consumption as an operationalization of health investments. I focus on adults at an age where lifetime trajectories for SES can be taken as given and use lifetime income to capture SES. I estimate the impact of lifetime income on dental care consumption and find robust evidence that the social gradient in dental care consumption steepens dramatically over the life-cycle. Considering that dental care consumption only reflects a small part of individuals' health investments the results suggest that lifetime effects of SES on health behaviors could be substantial in other dimensions. Essay 2: This essay studies the effect of competition on prices on a health care market where prices are market determined, namely the Swedish market for dental care. The empirical strategy exploits that the effect of competition differs across services, depending on the characteristics of the service. Price competition is theoretically more intense for services such as examinations and diagnostics (first-stage services), compared to more complicated and unusual treatments (follow-on services). By exploiting this difference, I identify a relative effect of competition on prices. The results suggest small but statistically significant negative short-term effects on prices for first-stage services relative to follow-on services. The results provide evidence that price-setting among dental care clinics responds to changes in the market environment and substantial effects of competition on prices over time cannot be ruled out. Essay 3: The Swedish dental care insurance subsidizes dental care costs above a threshold and becomes more generous as dental care consumption increases. On average, higher-income individuals consume more dental care and have better oral health than low-income individuals. Therefore, the redistributional effects of the Swedish dental care insurance are ambiguous a priori. I find that the dental care insurance adds to the progressive redistribution taking place through other parts of the Swedish social insurance (SI) for individuals aged 35-59 years whereas it reduces the progressivity in the SI for those aged 60-89 years. While the result for the oldest individuals is problematic from an equity point of view, the insurance seems to strengthen the progressitivy of the Swedish social insurance for the vast majority of patients.

Despite a substantially greater risk factor profile, Hispanics in the United States (US) consistently demonstrate better health outcomes compared to their non-Hispanic White counterparts, an epidemiologic phenomenon termed the Hispanic Mortality Paradox. Emerging hypotheses suggest cultural values regarding relational interconnectedness and social support may help to explain these surprising health outcomes. The present study sought to inform these hypotheses via two aims: the first was to examine racial/ethnic differences in perceived social support, and the second was to examine the relationship between acculturation and perceived social support among Hispanic college students. Non-Hispanic White, non-Hispanic Black, and Hispanic college students (N = 330) completed an online survey for course credit. Contrary to expectations, no racial/ethnic differences in perceived social support were observed, nor was an association between acculturation and perceived social support evident among the sampled Hispanic students. The limited sample size, homogeneity in social support levels across groups, and the restricted range of age and acculturation may have obscured relationships that may exist outside the college environment. Future work should consider a more heterogeneous sampling strategy to better assess these associations.

Substantial evidence demonstrates that marriage is associated with better health outcomes and lower mortality risk. Some evidence suggests that there are gender and race/ethnicity differences between the marriage-health benefits association. However, previous studies on marriage and health have mainly focused on non-Hispanic White-Black differences. Limited information is available regarding the roles of Hispanics. The present study examined marital status, gender, and the differences between non-Hispanic Whites, non-Hispanic Blacks, and Hispanics, in health outcomes. A retrospective cohort analysis of 24,119 Hispanic, NH White, and NH Black adults admitted to a large hospital was conducted. A total of 16,661 patients identified as either married or single was included in the final analyses. Consistent with the broader literature, marriage was associated with beneficial hospital utilization outcomes. With respect to differences in these benefits, results suggest that married patients, Hispanic patients, and women, were less likely to experience in-hospital mortality. Similar effects were observed in aggregated length of stay with married Hispanic women hospitalized nearly 2 days less than their single counterparts (6.83 days and 8.66 days, respectively). These findings support existing literature that marriage is associated with health benefits, add to the emerging research of a Hispanic survival advantage, and broaden the understanding of marriage and health in terms of differences by racial/ethnicity.

Although Talcott Parsons’s sick role theory, as described in 1951 in The Social System, has been severely criticized for its inapplicability to chronic illnesses, a portion of the theory is still a relevant and necessary factor in terms of understanding and treating chronic illness today. Using data from the 2012 National Health Interview Survey, this study looks at the individual effects of sex, age, race, cohabitation, education and region of residence on the likelihood of chronically ill patients considering themselves limited in their amount or kind of work as an indicator of sick role adaptation. Results show statistically significant relationships between work limitation and sex, age, cohabitation, education and region of residence, when controlling for the duration of the respondents’ condition. Further evaluation of these results is provided.