Disparities between the quality of care received by white Americans and racial minorities have been documented extensively across a wide range of clinical areas and service types . There is mounting evidence that physicians contribute, often unintentionally, to racial healthcare disparities through various processes, including poorer quality communication with racial minority patients and racial/ethnic biases in clinical decision-making [2–4]. As the U.S. becomes more racially and ethnically diverse, it is imperative that future physicians receive the training necessary to help reduce healthcare disparities.
Although there is now widespread endorsement from professional organizations of the need to prepare medical students to provide equitable, high quality care to racial and ethnic minority patients, there is a paucity of evidence on how to do so effectively. An important, yet overlooked, aspect of disparities-reduction training programs involves addressing how white medical students and physicians’ anxiety and uncertainty about interracial interactions can adversely affect the care of minority patients. Specifically, research has shown that whites generally find interactions with Blacks challenging both emotionally (e.g., anxiety producing)  and cognitively (e.g., resource depleting) . These effects could impair the quality of care that white physicians give to racial minority patients, potentially impairing communication and increasing the likelihood that unconscious biases will influence clinical decision-making [7, 8]. Moreover, whites’ anxiety can be perceived as evidence of prejudice by members of minority groups [9, 10].
The role of learning versus performance orientation on interracial interactions
Recent research has drawn upon the extensive literature on achievement motivation to understand how to improve whites’ motivation and ability to engage effectively in interracial interactions and reduce their concerns about being perceived as prejudiced [11–14]. Theories about learning distinguish between learning goals, in which people view challenging situations as opportunities to improve their skills and learn from their mistakes, and performance goals, in which the focus is on how one is perceived and evaluated . Whereas learning goals lead to intrinsic motivation and persistence in the face of failure, performance goals lead to worries about making mistakes, greater anxiety, avoiding situations in which one might fail and decreases in intrinsic motivation .
Studies have found that having a learning orientation toward interracial interactions is associated with attitudes and behaviors conducive to positive interracial interactions. In two studies, interracial learning orientation was associated with greater comfort and interest in interracial contact among whites . In another study, whites who were instructed to learn from an interracial interaction sat physically closer to their black partner than those who did not receive such instructions .
Additional support for the idea that learning orientation may help whites’ ability to interact with non-whites comes from several studies, examining the effects of a growth mindset about racial bias (i.e., that racial bias is changeable) versus a fixed mindset (that racial bias is not changeable). Studies have found that growth mindsets are more likely to engender learning goals, in contrast to fixed mindsets that are more likely to engender performance goals [14, 17]. In a series of eight studies by Carr et al. , majority group members who held (or were induced to hold) a growth mindset about prejudice were less interested in interracial interactions and prejudice reduction activities and were less comfortable and more anxious in interracial interactions than those who held (or were induced to hold) a fixed mindset . Similarly, in a series of four studies by Neel and Shapiro , whites who believed or were induced to believe that racial bias is malleable were more likely to engage in learning-orientated strategies for interracial interactions (e.g., perspective-taking, getting feedback) compared to performance-oriented strategies (e.g. overcompensation, avoidance) than whites who believed or were induced to believe that bias was fixed.
There are several ways that medical school environments that foster a learning orientation regarding interracial interactions might improve white students’ ability to care for racial minority patients. Medical schools that promote a learning education may lead to a greater use of learning strategies that lead to improved communication skills (e.g., seeking out feedback and opportunities to improve one’s ability to interact effectively with members of racial and ethnic minority groups, perspective-taking and empathy) and decrease the use of performance strategies (e.g., strategic color blindness) and avoidance . Interracial learning orientation should also increase the effectiveness of coursework related to the care of minority patients, as it is linked to a greater desire to engage in learning activities designed to promote racial diversity and reduce prejudice and to increased willingness to examine one’s own biases .
The current study
The objective of the current study was to examine the effect of medical school interracial learning orientation at both the school and individual level, on white students’ readiness to provide equitable care for racial minority patients, using data from a national, longitudinal study of medical students, CHANGES. Perception of medical school learning orientation may vary from individual to individual within a medical school, even while the school exerts a common influence. It is reasonable to believe that (1) interracial learning orientation may differ among medical schools and this difference could contribute to school variance in readiness of white medical students to provide equitable care to racial minority patients in their final semester. Nonetheless, (2) it is likely that individual differences in perceived learning orientation in a medical school will exert a stronger influence on students than school-level differences.
We hypothesize that, among white students, school level interracial learning orientation will be positively associated with school level readiness to treat racial minority patients, as measured by self-assessments of (1a) self-efficacy in caring for a patient who is a member of a racial or ethnic minority, (1b) skill at developing positive relationship with racial minority patients, and (1c) interest in working with patients from a racial or ethnic minority group. Second, at the individual level, we hypothesize that white students’ perceptions of their medical school environment as supporting an interracial learning orientation will be positively associated with their readiness in caring for racial minority patients. Third, we explore whether individual level differences in perceived medical school learning orientation will moderate the effect of disparities training on white students’ readiness to care for minority patients. We focus on individual-level differences in learning orientation as a potential moderator, as we anticipate a much narrower range of perceived learning orientation among medical schools as compared to the amount of variance in students’ perceived learning orientation in a particular medical school, and expect it will be individual-level differences that will primarily affect their learning trajectory.