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Representative Bureaucracy Contagion Effects in Health Care

SPA researchers show that a higher proportion of female physicians in the ER improves heart attack outcomes for women, even without doctor/patient gender matching.

Ken Meier (left) & Austin McCrea (right)

Hospital emergency rooms (ERs) occupy a critical role in the U.S. healthcare system. The 1986 Emergency Medical Treatment and Labor Act (EMTALA) mandated universal public access to emergency departments, regardless of race, sex, citizenship, or ability to pay. However, accessibility matters less when these factors affect the quality of ER treatment you receive.

“In dealing with any health process and its outcomes, we see tons of gender, racial, and ethnic bias towards people of certain backgrounds, leading physicians to dismiss their pain symptoms and severity and really downplay their [subjective] experience,” said Austin McCrea, who earned his PhD in Public Administration and Policy from SPA in 2021, under the advisement of SPA Distinguished Scholar in Residence Kenneth Meier.

Numerous studies have shown that gender representation matters to health outcomes: female patients get better results when seen by female physicians. Women present with different heart attack symptoms, which may be dismissed by their (likely male) ER doctor: unfortunately, according to 2019 data from the Association of American Medical Colleges, only 28.3% of ER physicians are female.

In “Sit It Out or Dance: Representative Bureaucracy Contagion Effects in Health Care,” (published last month in International Public Management Journal), Meier and McCrea (now an assistant professor at Texas Tech University) argue that, in the absence of sufficient female representation, the answer may be so-called “contagion effects,” in which the presence of under-represented bureaucrats (females) can change the behavior of those from the majority group (males).

“Majority group bureaucrats hold power and tend to behave in a way that's inconsistent with a subset of the population they serve,” said McCrea. “Contagion gets us a way to understand mechanisms that can change their behavior, rather than putting the burden of reform on more minoritized bureaucratic groups.”

Using 2005-2016 data on ER visits from the Florida Agency for Healthcare Administration, the authors built on McCrea’s previous work on gender matching and representative bureaucracy, and found that male ER physicians influence better outcomes for female heart attack patients when they work alongside female physicians. Any female presence improves the odds for female patients, and, at 30% female representation, the outcomes equalize regardless of physician gender.

“We find that contagion effects do change the behavior of men,” said McCrea. “They're more likely to detect atypical heart attack symptoms in women when they work with more female physicians in the unit. They are taking more time to identify these symptoms, taking patients more seriously, etc.”

Physician matching in emergency medicine is markedly random, making the ER context a good one for studying the effects of representation. Further, its function as a social safety net gives a unique context for identifying and addressing inequities based on prejudice or, more commonly, a lack of knowledge.

“When you're dealing with atypical symptoms, it's really a learning problem,” said Meier. “No doctor wants to see a patient die. That creates a context where we can focus on the learning process itself. One of the advantages of diversifying an organization or a bureaucracy is you bring in different experiences, new information, and new knowledge. As that knowledge spreads, it improves the entire organization.”

Meanwhile, they also found that male physicians from more prestigious medical schools (measured by rankings) tended to be more susceptible to these learning or contagion influences, possibly due to exposure to a wider breadth of topics.

“We are facing what is essentially a chronic shortage of medical providers,” said Meier. “There's a clear underinvestment in quality education and in specializing. I think it really asks medical schools what they can do to better prepare the full range of health-care practitioners.”

The Florida emergency rooms in the study sample featured just 18% female physicians. The authors argue that the healthcare system should be pressuring medical schools to recruit towards a better gender balance and avoid funneling female physicians away from emergency medicine and into other specialties.

“Any effort to steer away [from gender representation] is really detrimental for overall health-care practice,” said Meier. “Not only does it cost lives, it costs them money. This affects their hospital and insurance ratings. There are many incentives to pay attention to information like this and make adjustments.”

The frontier of social science research on contagion is moving, with new research measuring gender contagion effects on policing outcomes and global math scores. The authors hope for deeper investments in theory, and imagine that scholarship on contagion effects can be used to improve outcomes in immigration enforcement, job counseling, and drug abuse treatment.

“We need to think more broadly about the sort of things that trigger these contagion effects,” said Meier. “Gender, as we like to describe it, is, like race, a set of relevant lived experiences. You bring with you a collection of information and knowledge that often understands why certain problems exist, and you can communicate [solutions] between clientele and the organization.”

McCrea feels that the benefits of individual-level matching effects are now academically well-supported; the new goal should be gathering enough data to study these questions at the organizational level.

“The next step, not just for contagion effects, but representative bureaucracy, is to proliferate these rich, multilevel data sets that allow us to study these processes in their totality,” he said. “Most applications now are just a piecemeal look at representation, but it manifests through a lot of processes, such as direct effects, contagion, and other types of indirect effects.”

Meier cites the benefits of contagion effects for lifelong students everywhere.

“I think I want to go back to our title, ‘Sit It Out or Dance,’” he said. “Are you going to learn from somebody, or aren't you? That is the sort of thing I hope we instill through our public administration and public policy [training] programs. We hope [SPA students] don't quit learning after they've left here. You can learn from people who are very different from you, who are not trained as well as you, because they have insight.

“So we hope they dance.”