To produce overall differences in care, the choice of hospitals or clinics that different groups attend and variations in treatment within those institutions could reinforce each other, or cancel each other out, or one or another factor could be more important. An example of the first possibility is one study of inadequate pain management, which found that all patients treated in settings where the patient population was primarily black or Hispanic were more likely to receive inadequate analgesia than those treated in settings where the patient population was primarily white (Cleeland et al., 1997). In addition, minority patients were more likely to be undermedicated for pain than white patients and more likely to have the severity of their pain underestimated by physicians. In contrast, in a five-state study, Kahn et al. (1994) found that blacks received poorer care in acute care hospitals than whites in the same hospitals, but because more blacks in the study were seen at higher-quality urban teaching hospitals, their overall quality of care was no worse. Finally, focusing on acute myocardial infarction, Skinner et al. (2003) found that, nationwide, blacks received care at lower-quality hospitals, where they tended to make up a larger proportion of the patients. Within groups of hospitals with different proportions of black admissions, however, white patients actually received poorer care than blacks, as reflected in 30-day mortality rates adjusted for various factors.

STEREOTYPING BY PROVIDERS

Some differences in medical care may be due to stereotypes of different groups held by health care providers. The authors of Unequal Treatment (Institute of Medicine, 2002) argue that unconscious or unthinking discrimination based on negative stereotypes, even in the absence of conscious prejudice, may contribute to systematic bias in care.

This argument is based on a chain of reasoning. Stereotypes are common in American society for various racial and ethnic groups. National data show that whites view blacks, Hispanics, and Asians more negatively than they view themselves, with perceptions of blacks being the most unfavorable and perceptions of Hispanics being substantially more negative than perceptions of Asians. For instance, 29 percent of whites agree with the statement that most blacks are unintelligent, while 6 percent of whites say the same of most whites. Similarly, many more whites say that most blacks are prone to violence (51 percent) than those who say the same about most whites (16 percent) (Davis and Smith, 1990; Williams, 2001b). Such stereotypes can be activated, and affect behavior, under conditions of time pressure, when quick judgments must be made on complex tasks, with cognitive overload and in the presence of such emotions as anger and



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