Are Providers More Likely to Contribute to Healthcare Disparities Under High Levels of Cognitive Load? How Features of the Healthcare Setting May Lead to Biases in Medical Decision Making
Restricted accessOtherFirst published online March, 2010
Are Providers More Likely to Contribute to Healthcare Disparities Under High Levels of Cognitive Load? How Features of the Healthcare Setting May Lead to Biases in Medical Decision Making
Systematic reviews of healthcare disparities suggest that clinicians’ diagnostic and therapeutic decision making varies by clinically irrelevant characteristics, such as patient race, and that this variation may contribute to healthcare disparities. However, there is little understanding of the particular features of the healthcare setting under which clinicians are most likely to be inappropriately influenced by these characteristics. This study delineates several hypotheses to stimulate future research in this area. It is posited that healthcare settings in which providers experience high levels of cognitive load will increase the likelihood of racial disparities via 2 pathways. First, providers who experience higher levels of cognitive load are hypothesized to make poorer medical decisions and provide poorer care for all patients, due to lower levels of controlled processing (H1). Second, under greater levels of cognitive load, it is hypothesized that healthcare providers’ medical decisions and interpersonal behaviors will be more likely to be influenced by racial stereotypes, leading to poorer processes and outcomes of care for racial minority patients (H2). It is further hypothesized that certain characteristics of healthcare settings will result in higher levels of cognitive load experienced by providers (H3). Finally, it is hypothesized that minority patients will be disproportionately likely to be treated in healthcare settings in which providers experience greater levels of cognitive load (H4a), which will result in racial disparities due to lower levels of controlled processing by providers (H4b) and the influence of racial stereotypes (H4c).The study concludes with implications for research and practice that flow from this framework.
Smith ER, DeCoster J.Dual-process models in social and cognitive psychology: Conceptual integration and links to underlying memory systems. Pers Soc Psychol Rev . 2000;4:108-31.
2.
Deutsch R., Strack F.Duality models in social psychology: from dual processes to interacting systems . Psychol Rev. 2006;17: 166-72.
3.
Lieberman MDSocial cognitive neuroscience: a review of core processes. Annu Rev Psychol. 2007;58:259-89.
4.
Anttila V., Juha L.Surrogate in-vehicle information systems and driver behavior in an urban environment: a field study on the effects of visual and cognitive load . Transportation Research Part F: Traffic Psychology and Behaviour. 2005;8:121-33.
5.
Horrey WJ, Simons DJExamining cognitive interference and adaptive safety behaviours in tactical vehicle control. Ergonomics. 2007 ;50:1340-50.
6.
Elstein AS, Schwartz A.Clinical problem solving and diagnostic decision making: selective review of the cognitive literature. BMJ. 2002 ;324:729-32.
7.
Croskerry P.Achieving quality in clinical decision making: cognitive strategies and detection of bias. Acad Emerg Med . 2002; 9:1184-204.
8.
Mamede S., Schmidt HG, Rikers R.Diagnostic errors and reflective practice in medicine. J Eval Clin Pract. 2007;13:138-45.
9.
Garrett C.The effect of nurse staffing patterns on medical errors and nurse burnout . Aorn J. 2008;87:1191-204.
10.
West CP, Huschka MM, Novotny PJ, et al. Association of perceived medical errors with resident distress and empathy: a prospective longitudinal study. JAMA. 2006;296:1071-8.
11.
LeBlanc VR, MacDonald RD, McArthur B., King K., Lepine T.Paramedic performance in calculating drug dosages following stressful scenarios in a human patient simulator. Prehosp Emerg Care . 2005;9:439-44.
12.
Weissman JS , Rothschild JM, Bendavid E., et al. Hospital workload and adverse events . Med Care. 2007;45:448-55.
13.
Landrigan CP , Rothschild JM, Cronin JW, et al. Effect of reducing interns’ work hours on serious medical errors in intensive care units . N Engl J Med. 2004;351:1838-48.
14.
Tamblyn R., Berkson L., Dauphinee WD, et al. Unnecessary prescribing of NSAIDs and the management of NSAID-related gastropathy in medical practice. Ann Intern Med. 1997;127: 429-38.
15.
Levinson W. , Roter DL, Mullooly JP, Dull VT, Frankel RMPhysician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277:553-9.
16.
Young G., Zavelina L., Hooper V.Assessment of workload using NASA Task Load Index in perianesthesia nursing . J Perianesth Nurs. 2008;23:102-10.
17.
Hashimoto M. , Kuwahara N., Naya F., Noma H., Kogure K., Osuga M.The proposal of measurement of RNs at acute care setting cognitive process when they make cognitive error. Stud Health Technol Inform. 2006;122:455-7.
18.
Paas F., Tuovinen JE, Tabbers H., Van Gerven PWM.Cognitive load measurement as a means to advance cognitive load theory . Educational Psychologist. 2003;38:63-71.
19.
Smedley BD, Stith AY , Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare . Washington, DC: National Academy Press; 2002.
20.
Burgess DJ, Fu SS, van Ryn M.Why do providers contribute to disparities and what can be done about it? J Gen Intern Med. 2004;19:1154-9.
21.
Burgess DJ, van Ryn M., Malat J., Matoka M.Understanding the provider contribution to race/ethnicity disparities in pain treatment: insights from social cognitive research on stereotyping . Pain Med. 2006;7:119-34.
22.
van Ryn M.Research on the provider contribution to race/ethnicity disparities in medical care. Med Care. 2002;40(1 Suppl): 1140-51.
23.
van Ryn M., Fu SSPaved with good intentions: do public health and human service providers contribute to racial/ethnic disparities in health? Am J Public Health . 2003;93:248-55.
24.
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;22:1231-8.
25.
Fiske ST, Lin M., Neuberg SLThe continuum model: Ten years later. In: Chaiken S, Trope Y, eds. Dual process theories in social psychology. New York: Guilford; 1999. p 211-54.
26.
Brewer MBA dual process model of impression formation. In: Wyer TSSRS , ed. Advances in Social Cognition.Hillsdale (NJ): Lawrence Erlbaum ; 1988. p 1-36.
27.
Fiske STStereotyping, Prejudice, and Discrimination. 4th ed. Boston: McGraw-Hill1998.
28.
Wegener DT, Dunn M., Tokusato D.The flexible correction model: Phenomenology and the use of naive theories in avoiding or removing bias. In: Moskowitz GB, ed. Cognitive Social Psychology: The Princeton Symposium on the Legacy and Future of Social Cognition. Matwah (NJ): Lawrence Erlbaum; 2001. p 277-90.
29.
Gilbert DT, Hixon J.The trouble of thinking: activation and application of stereotypic beliefs . J Pers Soc Psychol. 1991;60: 509-17.
30.
Macrae C., Hewstone M., Griffiths R.Processing load and memory for stereotype-based information. Eur J Soc Psychol. 1993;23: 77-87.
31.
Stangor C., Duan C.Effects of multiple task demands upon memory for information about social goups. J Exp Soc Psychol. 1991;27:357-78.
32.
Bodenhausen GV, Lichtenstein M.Social stereotypes and information processing strategies: The impact of task complexity. J Pers Soc Psychol . 1987;52:871-80.
33.
Kreuglanski AW, Freund T.The freezing and unfreezing of lay-inferences: Effects on impressional primacy, ethnic stereotyping, and numerical anchoring . J Exp Soc Psychol. 1983;19:448-68.
34.
Bodenhausen GVStereotypes as judgemental heuristics: evidence of circadian variations in discrimination. Psychol Sci. 1990;1:319-22.
35.
Martell RFSex bias at work: The effects of attentional and memory demands on performance ratings of men and women. J Appl Psychol. 1991;21:1939-60.
36.
Perry EL, Kulik CT, Bourhis ACModerating effects of personal and contextual factors in age discrimination . J Appl Psychol. 1996;81:628-47.
37.
Spears R., Haslam ASStereotyping and the burden of cognitive load. In: Spears R, Oakes PJ, Ellemers N, Haslam SA , eds. The Social Psychology of Stereotyping and Group Life . Malden (MA): Blackwell Publishing ; 1997. p 171-207.
38.
Dijker AJ, Koomen W.Stereotyping and attitudinal effects under time pressure. Eur J Soc Psychol. 1996;26:61-74.
39.
Sczesny.Meta-cognition about biological sex and gender-stereotyping physical appearance: consequences for the assessment of leadership competence. Pers Soc Psychol Bull. 2004;30:13-21.
40.
Wigboldus DH , Sherman JW, Franzese JW, van Knippenberg A.Capacity and comprehension: spontaneous stereotyping under cognitive load . Soc Cogn . 2004;22:292-309.
41.
Pendry LF, Macrae CNWhat the disinterested perceiver overlooks: Goal-directed social categorization . Pers Soc Psychol Bull. 1996;22:249-56.
42.
Cunningham WA, Johnson MK, Raye CL, Chris Gatenby J., Gore JC, Banaji MRSeparable neural components in the processing of black and white faces. Psychol Sci. 2004 ;15:806-13.
43.
Richeson JA , Baird AA, Gordon HL, et al.An fMRI investigation of the impact of interracial contact on executive function. Nat Neurosci . 2003;6:1323-8.
44.
Goel V., Dolan RJExplaining modulation of reasoning by belief. Cognition . 2003;87:B11-22.
45.
Greicius MD , Krasnow B., Reiss AL, Menon V.Functional connectivity in the resting brain: a network analysis of the default mode hypothesis. Proc Natl Acad Sci U S A. 2003;100:253-8.
46.
Richeson JA , Trawalter S.The threat of appearing prejudiced and race-based attentional biases. Psychol Sci. 2008;19:98-102.
47.
Ackerman JM , Shapiro JR, Neuberg SL, et al. They all look the same to me (unless they’re angry): from out-group homogeneity to out-group heterogeneity . Psychol Sci. 2006 ;17:836-40.
48.
Amodio DMIntergroup anxiety effects on the control of racial stereotypes: a psychoneuroendocrine analysis. J Exp Soc Psychol. 2009;45:60-7.
49.
Muroff JR, Jackson JS, Mowbray CT, Himle JAThe influence of gender, patient volume and time on clinical diagnostic decision making in psychiatric emergency services. Gen Hosp Psychiatry . 2007;29:481-8.
50.
Rosenfield S.Race differences in involuntary hospitalization: psychiatric vs. labeling perspectives. J Health Soc Behav . 1984; 25:14-23.
51.
Jaen C., Stange K., Nutting P.Competing demands of primary care: a model for the delivery of clinical preventive services. J Fam Pract. 1994;38:859-63.
52.
Redelmeier D., Tan S., Booth G.The treatment of unrelated disorders in patients with chronic medical diseases. N Engl J Med. 1998;338:1516-20.
53.
Parchman ML , Pugh JA, Romero RL, Bowers KWCompeting demands or clinical inertia: the case of elevated glycosylated hemoglobin. Ann Fam Med. 2007;5:196-201.
54.
Jaen C., McIlvain H., Pol L., Phillips RL Jr, Flocke S., Crabtree BFTailoring tobacco counseling to the competing demands in the clinical encounter . J Fam Pract. 2001;50:859-63.
55.
Nutting P., Rost K., Smith J., Werner J., Elliot C.Competing demands from physical problems: effect on initiating and completing depression care over 6 months. Arch Fam Med. 2000;9:1059-64.
56.
Nutting P., Baier M., Werner J., Cutter G., Conry C., Stewart L.Competing demands in the office visit: what influences mammography recommendations . J Am Board Fam Pract. 2001 ;14: 352-61.
57.
Lieberman HR , Tharion WJ, Shukitt-Hale B., Speckman KL, Tulley R.Effects of caffeine, sleep loss, and stress on cognitive performance and mood during U.S. Navy SEAL training. Sea-Air-Land . Psychopharmacology ( Berl). 2002;164:250-61.
58.
Sagaspe P., Charles A., Taillard J., Bioulac B., Philip P.Inhibition and working memory: effect of acute sleep deprivation on a random generation task: Can J Exp Psychol. 2003;57:265-73.
59.
Nilsson JP, Soderstrom M., Karlsson AU, et al.Less effective executive functioning after one night’s sleep deprivation. J Sleep Res. 2005;14:1-6.
60.
Banks S., Dinges DFBehavioral and physiological consequences of sleep restriction. J Clin Sleep Med. 2007;3:519-28.
61.
Philip P., Sagaspe P., Taillard J., et al. Fatigue, sleep restriction, and performance in automobile drivers: a controlled study in a natural environment. Sleep. 2003;26:277-80.
62.
Klein K., Boals A.The relationship of life event stress and working memory capacity . Appl Cogn Psychol. 2001;15:565-79.
63.
Sandstrom A. , Rhodin I., Lundberg M., Olsson T., Nyberg L.Impaired cognitive performance in patients with chronic burnout syndrome. Biol Psychol. 2005;69:271-9.
64.
Caswell L., Vitaliano P., Croyle K., Scanland J., Zhang J., Darwula A.Negative associations of chronic stress and cognitive performance in older adult spouse caregivers. Exp Aging Res. 2003 ; 29:303-18.
65.
Brand N., Hanson E., Godaert G.Chronic stress affects blood pressure and speed of short-term memory . Percept Mot Skills. 2000;91:291-8.
66.
Morgan C., Doran A., Steffian G., Hazlett G., Southwick S.Stress-induced deficits in working memory and visuo-constructive abilities in special operations soldiers. Biol Psychiatry. 2006; 60:722-9.
67.
Dibartolo PM , Brown TA, Barlow DHEffects of anxiety on attentional allocation and task performance: an information processing analysis. Behav Res Ther. 1997;35:1101-11.
68.
Ashcraft MH , Kirk EPThe relationships among working memory, math anxiety, and performance. J Exp Psychol. 2001 ; 130:224-37.
69.
Stephan WG, Finlay K.The role of empathy in improving intergroup relations. J Soc Issues. 1999;55:729-43.
70.
Darke S.Effects of anxiety on inferential reasoning task performance. J Pers Soc Psychol. 1988;55:499-505.
71.
Oei NY, Everaerd WT, Elzinga BM, van Well S., Bermond B.Psychosocial stress impairs working memory at high loads: an association with cortisol levels and memory retrieval. Stress. 2006;9:133-41.
72.
Robinson SJ , Sunram-Lea SI, Leach J., Owen-Lynch PJThe effects of exposure to an acute naturalistic stressor on working memory, state anxiety and salivary cortisol concentrations . Stress. 2008;11:115-24.
73.
Braunstein-Bercovitz H.Does stress enhance or impair selective attention? The effects of stress and perceptual load on negative priming. Anxiety Stress Coping. 2003;16:345-57.
74.
Braunstein-Bercovitz H., Dimentman-Ashenazi I., Lubow R.Stress affects the selection of relevant from irrelevant stimuli. Emotion. 2001;1:182-92.
75.
Williams ES , Manwell LB, Konrad TR, Linzer M.The relationship of organizational culture, stress, satisfaction, and burnout with physician-reported error and suboptimal patient care: results from the MEMO study. Health Care Manage Rev. 2007;32: 203-12.
76.
Shanafelt T. , Bradley K., Wipf J., Back A.Burnout and self-reported patient care in an internal medicine residency program . Ann Intern Med. 2002;136:358-67.
77.
Firth-Cozens J., Greenhalgh J.Doctors’ perceptions of the links between stress and lowered clinical care. Soc Sci Med . 1997;44: 1017-22.
78.
Dugan J., Lauer E., Bouquot Z., Dutro BK, Smith M., Widmeyer G.Stressful nurses: the effect on patient outcomes. J Nurs Care Qual. 1996;10:46-58.
79.
Shirom A., Nirel N., Vinokur ADOverload, autonomy, and burnout as predictors of physicians’ quality of care. J Occup Health Psychol. 2006 ;11:328-42.
80.
Linzer M., Gerrity M., Douglas JA, McMurray JE, Willaims ES, Konrad TRPhysician stress: results from the physician worklife study. Stress and Health. 2002;18:37-42.
81.
Williams ES , Konrad TR, Linzer M., et al. Physician, practice, and patient characteristics related to primary care physician physical and mental health: results from the Physician Worklife Study. Health Serv Res. 2002;37:121-43.
82.
Kassebaum DG , Cutler EROn the culture of student abuse in medical school. Acad Med. 1998;73:1149-58.
83.
Nora LM, McLaughlin MA, Fosson SE, et al. Gender discrimination and sexual harassment in medical education: perspectives gained by a 14-school study. Acad Med. 2002;77(12 Pt 1):1226-34.
84.
Frank E., Brogan D., Schiffman M.Prevalence and correlates of harassment among US women physicians . Arch Intern Med. 199823;158:352-8.
85.
Kirkcaldy BD , Trimpop R., Cooper CLWorking hours, job stress, work satisfaction, and accident rates among medical practitioners and allied personnel. Int J Stress Manag. 1997;4:79-87.
86.
Gelsema TI, van der Doef M., Maes S., Janssen M., Akerboom S., Verhoeven C.A longitudinal study of job stress in the nursing profession: causes and consequences . J Nurs Manag. 2006;14:289-99.
87.
Lindholm M.Working conditions, psychosocial resources and work stress in nurses and physicians in chief managers’ positions . J Nurs Manag. 2006;14:300-9.
88.
Goitein L., Shanafelt TD, Wipf JE, Slatore CG, Back ALThe effects of work-hour limitations on resident well-being, patient care, and education in an internal medicine residency program. Arch Intern Med. 2005;165:2601-6.
89.
Gopal R., Glasheen JJ, Miyoshi TJ, Prochazka AVBurnout and internal medicine resident work-hour restrictions. Arch Internal Med. 2005;165:2595-600.
90.
Landrigan CP , Fahrenkopf AM, Lewin D., et al. Effects of the accreditation council for graduate medical education duty hour limits on sleep, work hours, and safety. Pediatrics. 2008;122: 250-8.
91.
Patel VL, Arocha JF, Kaufman DRA primer on aspects of cognition for medical informatics. JAMA. 2001;65:193-211.
92.
Galanter CA , Patel VLMedical decision making: a selective review for child psychiatrists and psychologists. J Child Psychol Psychiatry. 2005;46:675-89.
93.
Patel VL, Kaufman DR, Arocha JFEmerging paradigms of cognition in medical decision making. J Biomed Inform. 2002;35:52-75.
94.
Workman M., Lesser MF, Kim J.An exploratory study of cognitive load in diagnosing patient conditions . Int J Qual Health Care. 2007;19:127-33.
95.
Sequist TD, Adams A., Zhang F., Ross-Degnan D., Ayanian JZEffect of quality improvement on racial disparities in diabetes care . Arch Intern Med. 2006;166:675-81.
96.
Wells K., Sherbourne C., Schoenbaum M., et al. Five-year impact of quality improvement for depression: results of a group-level randomized controlled trial. Arch Gen Psychiatry . 2004;61: 378-86.
97.
Sehgal ARImpact of quality improvement efforts on race and sex disparities in hemodialysis . JAMA. 2003;289:996-1000.
98.
Miranda J., Duan N., Sherbourne C., et al. Improving care for minorities: can quality improvement interventions improve care and outcomes for depressed minorities? Results of a randomized, controlled trial. Health Serv Res. 2003;38:613-30.
99.
Vorauer JD, Hunter AJ, Main KJ, Roy SAMeta-stereotype activation: evidence from indirect measures for specific evaluative concerns experienced by members of dominant groups in intergroup interaction . J Pers Soc Psychol. 2000;78:690-707.
100.
Plant EA, Devine PGInternal and external motivation to respond without prejudice. J Pers Soc Psychol. 1998;75:811-32.
101.
Richeson JA , Trawalter S.Why do interracial interactions impair executive function? A resource depletion account. J Pers Soc Psychol . 2005;88:934-47.
102.
Richeson JA , Shelton JNWhen prejudice does not pay: effects of interracial contact on executive function. Psychol Sci . 2003;14:287-90.
103.
Blascovich J., Mendes WB, Hunter SB, Lickel B., Kowai-Bell N.Perceiver threat in social interactions with stigmatized others. J Pers Soc Psychol. 2001 ;80:253-67.
104.
Mendes WB, Blascovich J., Lickel B., Hunter S.Challenge and threat during social interaction with white and black men. Pers Soc Psychol Bull. 2002;28:939-952.
105.
Saha S., Korthuis P., Cohn A., Sharp V., Moore R., Beach M.Physician Interracial Anxiety, Patient Trust, and Satisfaction with HIV Care. 2008. Presentation at the International Conference on Communication in Healthcare. Oslo, Norway. September 2008.
106.
Bach PBRacial disparities and site of care. Ethn Dis. 2005; 15(2 Suppl 2):S31-3.
107.
Varkey AB, Manwell LB, Williams ES, et al. Separate and unequal: clinics where minority and nonminority patients receive primary care. Arch Intern Med. 2009;169:243-50.
108.
Bach PB, Pham HH, Schrag D., Tate RC, Hargraves JLPrimary care physicians who treat blacks and whites. N Engl J Med. 20045;351:575-84.
109.
Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med . 2002;346:1128-37.
110.
Birkmeyer JD, Stukel TA, Siewers AE, Goodney PP, Wennberg DE, Lucas FLSurgeon volume and operative mortality in the United States. N Engl J Med . 2003;349:2117-27.
111.
Liu JH, Zingmond DS, McGory ML, et al. Disparities in the utilization of high-volume hospitals for complex surgery. JAMA. 2006;296:1973-80.
112.
Jha AK, Shlipak MG, Hosmer W., Frances CD, Browner WSRacial differences in mortality among men hospitalized in the Veterans Affairs health care system. JAMA. 2001;285:297-303.
113.
Skinner J., Chandra A., Staiger D., Lee J., McClellan M.Mortality after acute myocardial infarction in hospitals that disproportionately treat black patients. Circulation. 2005;112:2634-41.
114.
Epstein AMHealth care in America-still too separate, not yet equal. N Engl J Med. 2004;351:603-5.
115.
Clarke SP, Davis BL, Nailon RERacial segregation and differential outcomes in hospital care. West J Nurs Res. 2007;29:739-57. 116. Lucas FL, Stukel TA, Morris AM, Siewers AE, Birkmeyer JDRace and surgical mortality in the United States. Ann Surg. 2006; 243:281-6.
116.
Konety SH, Vaughan Sarrazin MS, Rosenthal GEPatient and hospital differences underlying racial variation in outcomes after coronary artery bypass graft surgery. Circulation. 2005;111: 1210-6.
117.
Barnato AE , Lucas FL, Staiger D., Wennberg DE, Chandra A.Hospital-level racial disparities in acute myocardial infarction treatment and outcomes. Med Care. 2005;43:308-19.
118.
Hasnain-Wynia R., Baker DW, Nerenz D., et al. Disparities in health care are driven by where minority patients seek care: examination of the hospital quality alliance measures. Arch Intern Med . 2007;167:1233-9.
119.
Silber JH, Rosenbaum PR, Zhang X., Even-Shoshan O.Influence of patient and hospital characteristics on anesthesia time in medicare patients undergoing general and orthopedic surgery. Anesthesiology . 2007;106:356-64.
120.
Groeneveld PW, Kruse GB, Chen Z., Asch DAVariation in cardiac procedure use and racial disparity among Veterans Affairs Hospitals. Am Heart J. 2007;153:320-7.
121.
Tamayo-Sarver JH, Dawson NV, Hinze SW, et al. The effect of race/ethnicity and desirable social characteristics on physicians’ decisions to prescribe opioid analgesics. Acad Emerg Med. 2003;10:1239-48.
122.
Battaglia TA, Ash A., Prout MN, Freund KMCancer prevention trials and primary care physicians: factors associated with recommending trial enrollment. Cancer Detect Prev. 2006; 30:34-7.
123.
Baig A., Shadigian E., Heisler M.Hidden from plain sight: residents’ domestic violence screening attitudes and reported practices. J Gen Intern Med. 2006;21:949-54.
124.
Santry HP, Lauderdale DS, Cagney KA, Rathouz PJ, Alverdy JC, Chin MHPredictors of patient selection in bariatric surgery. Ann Surg. 2007;245:59-67.
125.
Aberegg SK , Terry PBMedical decision-making and healthcare disparities: the physician’s role. J Lab Clin Med. 2004;144:11-7.
126.
Mensah GA, Mokdad AH, Ford ES, Greenlund KJ, Croft JBState of disparities in cardiovascular health in the United States. Circulation . 2005 15;111:1233-41.
127.
Kressin NR , Petersen LARacial differences in the use of invasive cardiovascular procedures: review of the literature and prescription for future research. Ann Intern Med. 2001;135:352-66.
128.
Arber S., McKinlay J., Adams A., Marceau L., Link C., O’Donnell A.Influence of patient characteristics on doctors’ questioning and lifestyle advice for coronary heart disease: a UK/US video experiment . Br J Gen Pract. 2004;54:673-8.
129.
Arber S., McKinlay J., Adams A., Marceau L., Link C., O’Donnell A.Patient characteristics and inequalities in doctors’ diagnostic and management strategies relating to CHD: a video-simulation experiment. Soc Sci Med. 2006;62:103-15.
130.
McKinlay JB , Link CL, Freund KM, Marceau LD, O’Donnell AB, Lutfey KLSources of variation in physician adherence with clinical guidelines: results from a factorial experiment. J Gen Intern Med. 2007;22:289-96.
131.
Barnhart JM , Wassertheil-Smoller S.The effect of race/ethnicity, sex, and social circumstances on coronary revascularization preferences: a vignette comparison. Cardiol Rev. 2006;14: 215-22.
132.
Schulman KA , Berlin JA, Harless W., et al. The effect of race and sex on physicians’ recommendations for cardiac catheterization . N Engl J Med . 1999;340:618-26.
133.
Kales HC, Neighbors HW, Blow FC, et al. Race, gender, and psychiatrists’ diagnosis and treatment of major depression among elderly patients. Psychiatr Serv . 2005;56:721-8.
134.
Kales HC, Neighbors HW, Valenstein M., et al. Effect of race and sex on primary care physicians’ diagnosis and treatment of late-life depression. J Am Geriatr Soc. 2005;53:777-84.
135.
McKinlay JB , Lin T., Freund K., Moskowitz M.The unexpected influence of physician attributes on clinical decisions: results of an experiment . J Health Soc Behav. 2002;43:92-106.
136.
Schenstrom A., Ronnberg S., Bodlund O.Mindfulness-based cognitive attitude training for primary care staff: a pilot study. Complement Health Pract Rev. 2006;11:144-52.
137.
Mackenzie CS, Poulin PA, Seidman-Carlson R.A brief mindfulness-based stress reduction intervention for nurses and nurse aides. Appl Nurs Res. 2006;19:105-9.
138.
Shapiro SL , Astin JA, Bishop SR, Cordova M.Mindfulness-based stress reduction for health care professionals: Results from a randomized trial. Int J Stress Manag. 2005;12:164-76.
139.
Shapiro SL , Shapiro DE, Schwartz GEStress management in medical education: a review of the literature. Acad Med. 2000; 75:748-59.
140.
Monteith MJ , Ashburn-Nardo L., Voils CI, Czopp AMPutting the brakes on prejudice: on the development and operation of cues for control. J Pers Soc Psychol. 2002;83:1029-50.
141.
Feldon DFCognitive load and classroom teaching: The double-edged sword of automaticity . Educational Psychologist. 2007; 42:123-37.
142.
Epstein RMMindful practice. JAMA. 19991;282:833-9. 144. Smith RC, Dwamena FC, Fortin AHt.Teaching personal awareness. J Gen Intern Med. 2005;20:201-7.
143.
Fackler J. , Watts C., Grome A., Miller T., Crandall B., Pronovost P.Critical care physician cognitive task analysis: an exploratory study. Crit Care. 2009;13:R33.
144.
Burgess D. , van Ryn M., Dovidio J., Saha S.Reducing racial bias among health care providers: lessons from social-cognitive psychology . J Gen Intern Med . 2007;22:882-7.
145.
Gawande A.The checklist. The New Yorker . 2007 December 10.
146.
Pronovost PJ , Berenholtz SM, Goeschel C., et al. Improving patient safety in intensive care units in Michigan . J Crit Care. 2008 ;23:207-21.
147.
Dreachslin JL , Weech-Maldonado R., Dansky KHRacial and ethnic diversity and organizational behavior: a focused research agenda for health services management. Soc Sci Med. 2004;59: 961-71.
148.
van Ryn M. , Burke J.The effect of patient race and socio-economic status on physicians’ perceptions of patients. Soc Sci Med. 2000;50:813-28.
149.
van Ryn M. , Burgess D., Malat J., Griffin J.Physicians’ perceptions of patients’ social and behavioral characteristics and race disparities in treatment recommendations for men with coronary artery disease . Am J Public Health. 2006;96:351-7.
