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Academic Medicine:
doi: 10.1097/ACM.0b013e3181eae5ec
Clinical Skills

Does Perspective-Taking Increase Patient Satisfaction in Medical Encounters?

Blatt, Benjamin MD; LeLacheur, Susan F. DrPH, PA-C; Galinsky, Adam D. PhD; Simmens, Samuel J. PhD; Greenberg, Larrie MD

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Author Information

Dr. Blatt is associate professor, Department of Medicine, and director, CLASS Clinical Skills Center, George Washington University School of Medicine and Health Sciences, Washington, DC.

Dr. Lelacheur is assistant professor, Department of Health Care Sciences, and director of the academic curriculum, Physician Assistant Program, George Washington University School of Medicine and Health Sciences, Washington, DC.

Dr. Galinsky is Morris and Alice Kaplan Professor of Ethics and Decision in Management, Kellogg School of Management, Northwestern University, Evanston, Illinois.

Dr. Simmens is associate research professor, Department of Epidemiology and Biostatistics, and interim director, Biostatistics Center Medical Center Unit, George Washington University School of Public Health and Health Services, Washington, DC.

Dr. Greenberg is clinical professor, Department of Pediatrics, and internal consultant, Faculty Development, George Washington University School of Medicine and Health Sciences, Washington, DC.

Correspondence should be addressed to Dr. Blatt, Office of Interdisciplinary Medical Education, 900 23rd Street, N.W., Room 6216, Washington, DC 20037; telephone: (202) 994-8598; fax: (202) 994-0328; e-mail: msdbcb@gwumc.edu.

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Abstract

Purpose: To assess whether perspective-taking, which researchers in other fields have shown to induce empathy, improves patient satisfaction in encounters between student–clinicians and standardized patients (SPs).

Method: In three studies, randomly assigned students (N = 608) received either a perspective-taking instruction or a neutral instruction prior to a clinical skills examination in 2006–2007. SP satisfaction was the main outcome in all three studies. Study 1 involved 245 third-year medical students from two universities. Studies 2 and 3 extended Study 1 to examine generalizability across student and SP subpopulations. Study 2 (105 physician assistant students, one university) explored the effect of perspective-taking on African American SPs' satisfaction. Study 3 (258 third-year medical students, two universities) examined the intervention's effect on students with high and low baseline perspective-taking tendencies.

Results: Intervention students outscored controls in patient satisfaction in all studies: Study 1: P = .01, standardized effect size = 0.16; Study 2: P = .001, standardized effect size = 0.31; Study 3: P = .009, standardized effect size = 0.13. In Study 2, perspective-taking improved African American SPs' satisfaction. In Study 3, intervention students with high baseline perspective-taking tendencies outscored controls (P = .0004, standardized effect size = 0.25), whereas those with low perspective-taking tendencies did not (P = .72, standardized effect size = 0.00).

Conclusions: Perspective-taking increased patient satisfaction in all three studies, across medical schools, clinical disciplines, and racially diverse students and SPs. Perspective-taking as a means for improving patient satisfaction deserves further exploration in clinical training and practice.

The relationship between effective clinician–patient communication and patient outcomes is well supported in the literature.1–3 Effective communication is especially important for patients who are subject to health disparities, such as African Americans,4 or at particular medical risk, such as older patients with multiple health problems and complex medical regimens.5,6 Empathy—one person connecting with another person's emotional state—is an important element of effective communication.7 Medical researchers have linked it to increased patient satisfaction, fewer malpractice suits, better adherence, and improved health outcomes.8,9

Given the beneficial effect of empathy on essential outcomes, it is important to discover methods that will enhance clinicians' capacity to relate empathetically to their patients. One empathy-enhancing method that research in other fields has shown to be successful is perspective-taking, a process in which one person strives to realize what another person is thinking and feeling.

Researchers—principally in the fields of social psychology and neurobiology—have studied perspective-taking extensively and have demonstrated it to be a highly effective method of enhancing empathy in a broad range of nonmedical contexts.10–13 These researchers often activate the process by asking participants to imagine another person's situation and to put themselves “in that person's shoes.” Researchers have demonstrated that perspective-taking improves communication, facilitates altruism, limits unprovoked aggression,10,13–15 produces more efficient agreements in business negotiations,16 and decreases stereotyping and prejudice.13,17,18 In addition, perspective-taking decreases stereotyping of elderly people,12 increases willingness to help a person in trouble,10 and decreases aggressive responses to verbal aggression.12,15

Ruby and Decety19 used positron emission tomography studies to elucidate how perspective-taking induces empathy. Engaging in a perspective-taking exercise activated study participants' emotional processing centers. It also activated cognitive processing centers: a shared neural network between representations of self and other as well as a set of regions in the brain responsible for maintaining a distinction between and preventing confusion about self and other.19 This work provides a neurophysiologic basis for perspective-taking-induced empathy in which both cognitive and emotional components are essential parts.

In the context of medicine or medical education, researchers have explored several approaches to induce empathy. One such approach is experiential: Medical professionals “live” the experience of being a patient.20 A second approach is didactic: Medical professionals receive training in interpersonal,21 active listening,22 and communication3 skills. Such training has led to increases in performance on various empathy scales9 and, in some cases, improved patient satisfaction.23 Although perspective-taking is sometimes implicit in such medical communications training, to the best of our knowledge, it has never before been explicitly explored as a solo strategy to improve patient satisfaction in medical encounters. In this article, we examine the effect of perspective-taking in a medical context through the use of standardized patients (SPs) in clinical skills examinations (CSEs).

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Overview

We conducted three randomized, controlled experiments in which we used SP satisfaction with student–clinicians as the primary outcome of our perspective-taking intervention. Given perspective-taking's effectiveness in inducing empathy in nonmedical settings, we predicted that it would also be successful in inducing empathy in a medical setting and positively influence SP satisfaction. SP interaction provides an effective and feasible method for assessing the impact of perspective-taking in a controlled setting: Researchers have validated interaction with SPs in the assessment of interpersonal skills and patient satisfaction.24–28

For all three studies, our primary objective was to determine whether student–clinicians exposed to a perspective-taking intervention would receive higher patient satisfaction scores than would controls. In addition, in Studies 2 and 3, we explored the effect of perspective-taking on different subgroups: African American SPs and medical students with baseline differences in perspective-taking tendency.

Prior research has shown that perspective-taking is a powerful means to decrease stereotyping, but has not explored how perspective-taking affects the satisfaction of stereotyped group members.11,13 Because African Americans are often subject to stereotyping and disparate treatment in health care,29 in Study 2 we focused on whether the intervention would have an impact on the satisfaction of African American SPs.

We explored in Study 3 whether students who are more naturally inclined or disinclined toward perspective-taking (characterized by different baseline tendencies) would be differentially affected by the perspective-taking intervention. We used a well-validated questionnaire to define students with high and low baseline tendencies. We hypothesized that such a baseline characteristic could have a potentially strong effect on outcomes and, if demonstrated, could have important educational implications. Identifying individuals who do and do not respond to the intervention, for example, could help medical educators tailor their teaching of communications skills to the responsiveness of their students.

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Method

To increase generalizability, we assessed perspective-taking in as many settings as feasible within the constraints of our institutions. During 2006–2007, as part of our annual CSEs, we conducted three experiments across two disciplines, with students from two medical schools—the George Washington University School of Medicine and Health Sciences (GW) and the Howard University College of Medicine (Howard)—and with SPs of different ethnicities (Table 1). The instruments used in the three experiments, although different, all contained similar items to measure patients' satisfaction with their clinician. We used different instruments because of external contingencies—for example, the Baltimore–Washington Consortium of Medical Schools, to which GW and Howard belong, required medical schools to use a different instrument in 2007 than it had in 2006.

Table 1
Table 1
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We conducted Study 1 in 2006 with third-year medical students from GW and Howard. In Study 2, conducted in 2006–2007, we used first- and second-year physician assistant (PA) students from GW and African American SPs. In Study 3, conducted in 2007, we again used third-year medical students from GW and Howard. All studies were conducted at GW; Howard students took their exams in GW's simulation center.

GW has an ethnically diverse student population, but the majority of students are white; Howard is a historically black university. We describe demographic characteristics of the participating students in Table 2.

Table 2
Table 2
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We conducted all three experiments as randomized, controlled assessments in which we compared the performance of student–clinicians who were given a perspective-taking intervention with those who were given neutral instructions prior to a CSE using SPs. For each study, we randomized students, using a computer-generated schedule, to an intervention or control group. We stratified the randomization by gender and race (and, as appropriate, university [Study 1, Study 3] and program year [Study 2]) to achieve approximate balance between the intervention and control groups. Differences between the control and intervention groups in each study are generally small. In Study 1, there were more African American students in the control group than in the intervention group. (Stratification in Study 1 was imperfect because of scheduling issues.) All students within a study received the same cases. In all studies, the SPs were blind as to whether the students were in the control or intervention group.

We recruited SPs through the university and from local communities. They received six hours of training from an experienced trainer. We did not formally assess the interrater reliability of the SPs.

Each study was approved by the institutional review board of the university whose students participated. For Studies 1 and 3, both the GW and Howard IRBs classified the study as exempt, so students' consent was not required. For Study 2, which was approved by the GW IRB, students signed an informed consent form to allow their data to be used in a “study of student and SP interactions,” but they were unaware of the nature of the intervention and the purpose of the study.

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Statistical analysis

The encounter between the student–clinician and the SP was the unit of analysis for testing mean differences between the intervention and control conditions on the primary outcome variables. Because scores were not independent across encounters, we based hypotheses tests on mixed-model analysis of variance (ANOVA), where SP and case were included as random effects, and study group, as well as university for Study 1 and Study 3, were included as fixed effects. We conducted these analyses with SAS Proc Mixed version 9.1.3,30 using maximum likelihood estimation. For Study 3, a second ANOVA model was fitted by adding a group × perspective-taking tendency interaction term to the model. Perspective-taking tendency was based on a median split of that scale score for the analysis.

To facilitate comparisons across the three studies (which used different measures of patient satisfaction), we summarized intervention effects as standardized effect sizes (mean difference divided by standard deviation [SD]). This measure indicates the relative magnitude of a mean difference when the underlying metric of the measure is arbitrary. A rule of thumb suggests that an effect size of 0.10 to 0.20 is “small,” 0.50 is “medium,” and 0.80 or greater is “large.”

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Study 1: Perspective-taking intervention
Participants.

The entire third-year classes of medical students at GW and Howard participated (N = 245: GW, n = 157; Howard, n = 88). SPs represented a range of ethnic backgrounds.

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Procedure.

The study took place during a formative CSE that we conducted at the end of the students' third year (2006). The Baltimore–Washington Consortium of Medical Schools chose the CSE's six cases—to be used by all member schools—to test basic clinical skills representing the spectrum of third-year clinical experiences. The consortium selected the cases from a variety of case books developed at a number of different institutions and consortiums. The cases depicted patients presenting with acute shortness of breath, acute upper abdominal pain, acute lower abdominal pain, anxiety, stroke, or pediatric vomiting/diarrhea.

All students attended preexamination orientation sessions in small groups; students were assigned to groups according to their intervention status. We gave all students a standard orientation form that was also read aloud to them by the director of the GW simulation center. This form indicated that, like the National Board CSE, the examination would score them on history-taking, physical exam, patient communication, and written notes.

In addition, we gave and read aloud different supplemental instruction forms to students in the intervention and control groups. We gave the perspective-taking intervention group the following special instructions:

When you see your patient, imagine what the patient is experiencing as if you were that person, looking at the world through the patient's eyes and walking through the world in the patient's shoes.

We also instructed the intervention group to write a brief note (10 lines or less) after completing each case, describing what they imagined the patient was experiencing. We included the following example of a postcase note:

Sherry Jenkins, a 23 year old secretary with right foot swelling: If I were Sherry, I would be really angry that this happened to me.… I couldn't run in the Marine Corps marathon that I had been training for the past year.… I hate my job, and my daily run is what gets me through the day … and also being injured is really depressing … at the age of 23 I am hobbling around like an old woman!

We gave the control group different special instructions:

We are interested in knowing how well your third-year clerkships prepared you for each of the cases in this exam. During each encounter please keep this in mind.

We also instructed the control group to write a brief note (10 lines or less) after completing each case, describing how their third-year experience had prepared them for that particular case. We provided the following example:

My medicine attending at GW helped me a lot in preparing for this kind of case. She taught me how to do a really good heart murmur exam. She is a really fine cardiologist, who even took the time to listen to heart murmurs with me using the Harvey heart sound simulator.

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Instruments.

After every encounter with a medical student, SPs completed two evaluation checklists: (1) medical skills, which was specific to each case, to assess history-taking and physical examination behaviors, and (2) patient satisfaction, which was identical for all cases. The Baltimore–Washington Consortium of Medical Schools created the patient satisfaction checklist based on published criteria that the National Board of Medical Examiners used to construct the communication checklist for its clinical skills licensure examination (Step 2 CS).31 The checklist used in this study consisted of five items—listening skills, caring, fostering patient participation in care, trust, and overall satisfaction—that are rated on a five-point scale (very dissatisfied to very satisfied).

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Study 2: Perspective-taking intervention, focusing on African American SPs
Participants.

The entire first- and second-year PA classes at GW participated (N = 105: first year, n = 55; second year, n = 50). All SPs were African American.

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Procedure.

We conducted Study 2 in the context of a formative CSE midway through academic year 2006–2007. Each student participated in three SP encounters—medical cases involving asthma, endocarditis, or diabetes.

All PA students attended preexamination orientation sessions in small groups; students were assigned to groups according to their intervention status. The same PA faculty member (S.F.L.) gave all instructions verbally prior to the first SP interaction. All students received standard CSE instructions. The intervention group also received two special instructions. First, we asked the students to “put themselves in the shoes” of the patients they were about to encounter. Then, to rehearse perspective-taking, we asked them to recall a recent personal interaction:

One aspect of the evaluation in your exam is your interaction with the patient, and a way to improve that interaction is to put yourself in the patient's shoes; that is, as you are talking with the patient, think about how you would feel if you were in their position and try to imagine their feelings. Take a moment now and think about a memorable patient you recently saw on your rotation. Put yourself in that patient's position and imagine how you would feel.

After a pause to allow the students time to reflect, the investigator asked them to “take a few moments and briefly write your patient's feelings down, seeing yourself in his or her position.” A few moments later, the investigator collected the students' writings and instructed them: “Now, when you see your patient, try to engage in this same process.” We did not ask the PA students, unlike the medical students, to write postencounter notes.

We did not give either group any further instructions during the series of SP encounters.

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Instruments.

We used the Education Commission for Foreign Medical Graduates' interpersonal skills questionnaire (IPS), which educators developed to evaluate international medical graduates (IMGs) on SP interactions.32,33 The IPS has been assessed for reliability in more than 37,000 IMGs, with Cronbach alpha ranging from 0.80 to 0.90.32 It consists of 17 questions in four areas—interviewing, counseling, rapport, and personal manner— evaluated on a four-point scale anchored by examples. For this study, we computed patient satisfaction as the mean score over the 17 items.

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Study 3: Perspective-taking intervention, considering student baseline tendency
Participants.

The entire third-year classes of medical students at GW and Howard participated (N = 258: GW, n = 157; Howard, n = 101). SPs represented a range of ethnic backgrounds.

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Procedure.

As in Study 1, we conducted this study during a formative CSE at the end of the students' third year (2007). We used similar cases and the same study design and procedure as in Study 1.

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Instruments.

After every encounter with a medical student, SPs completed two evaluation checklists: (1) medical skills, which was specific to each case, for history-taking and physical examination behaviors, and (2) patient satisfaction, which was identical for all cases. This patient satisfaction checklist was different from the checklist used in Study 1. For the 2007 consortium exam, the Baltimore–Washington Consortium of Medical Schools elected to adapt the East Tennessee State University Common Ground Rating Form.34 It uses a six-point scale (unacceptable to outstanding) to assess eight items: appearance of professional competence, information gathering skills, listening skills, rapport building, exploration of patient's perspective, addressing feelings, meeting patient's needs, and overall satisfaction.

At the end of the examination, students completed the perspective-taking subscale of the Interpersonal Reactivity Index (IRI), a validated questionnaire that assesses underlying perspective-taking tendencies. The IRI asks students to indicate the degree to which seven statements describe them, using a five-point scale.35–39 Two sample items appear below:

I sometimes try to understand my friends better by imagining how things look from their perspective.

Before criticizing somebody, I try to imagine how I would feel if I were in their place.

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Results

We summarize patient satisfaction ratings for each of the three studies in Table 3. We calculated Cronbach alpha for the satisfaction scores separately for each case in each study. Coefficient alpha values, averaged across cases, were 0.87, 0.85, and 0.94 for Studies 1, 2, and 3, respectively.

Table 3
Table 3
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In Study 1, we found a statistically significant difference between the control and the intervention groups. Third-year medical students exposed to a perspective-taking intervention achieved a mean patient satisfaction score of 4.04 (SD 0.62) on a five-point scale, compared with a mean score of 3.94 (SD 0.63) for the control group (P = .01); effect size = 0.16. As we noted earlier, the effect size enables us to compare the results across the three studies, which used different satisfaction instruments.

In Study 2, the intervention group showed a statistically significant higher mean patient satisfaction score than did the control group. Those first- and second-year PA students who were exposed to a perspective-taking intervention achieved a mean patient satisfaction score from the African American SPs of 3.38 (SD 0.35) on a four-point scale, compared with 3.26 (SD 0.42) for the control group (P = .001); effect size = 0.31.

In Study 3, the intervention group also outperformed the control group on patient satisfaction, with results similar to those of Study 1: 3.43 (SD 0.69) versus 3.34 (SD 0.68) on a six-point scale (P = .009); effect size = 0.13.

In addition to confirming the findings in Study 1, the results of Study 3 suggest that the effectiveness of the perspective-taking intervention depends in part on the preexisting perspective-taking tendencies of the medical students. We conducted separate analyses in Study 3, dividing students according to whether they scored above or below the median on the IRI perspective-taking subscale (Table 4). We identified a positive intervention effect (effect size = 0.25) among students who scored above the median on the scale. A test of the interaction of perspective-taking tendency by the intervention condition was statistically significant (P = .0004). However, we did not find a difference between the control and intervention groups among students who scored below the median.

Table 4
Table 4
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Discussion

In three randomized, controlled studies (N = 608), student–clinicians who were given a perspective-taking intervention received significantly better patient satisfaction scores from SPs than did controls. Although the effect size was small, these results suggest that our perspective-taking intervention may be an effective and generalizable strategy to improve patient satisfaction, given its consistent effectiveness across two medical schools, two clinical disciplines, and across SPs' racial groups. To the best of our knowledge, the experiments reported here represent the first studies of perspective-taking as a solo intervention in a medical context. Our results are consistent with findings derived from different populations in the social psychology literature,10–13 which provides further evidence for the intervention's generalizability and validity.

Studies 2 and 3 build on and clarify the results of Study 1. In Study 2, PA students interacted exclusively with African American SPs. The intervention not only succeeded, but the effect size (0.31), though still small, was greater than that in Studies 1 and 3 (0.16 and 0.13, respectively). Increased sensitivity on the part of African American SPs to the patient focus displayed by their clinician may have contributed to this difference. This possibility is supported by Beach and colleagues'4 finding that patient-centeredness improved the patient satisfaction scores of student–clinicians interacting with African American SPs but not with European American SPs. The greater effect size may also be related to a power differential between PA and medical students. In clinical practice, PAs are likely to have less power, defined as the ability to control important resources, than physicians do. Galinsky and colleagues'40 work indicates that those with lower power are more likely to effectively take the perspective of others. It seems possible, therefore, that among student–clinicians, PA students will be more likely than medical students to have high perspective-taking tendencies.

The increased effect size in Study 2 may also have been influenced by the additional intervention instruction that the PA students received. Both medical students and PA students were asked to imagine themselves in the patients' shoes. However, PA students were also instructed to rehearse this process—prior to the encounter—by writing about a recent personal interaction, describing what they believed the other person was thinking or feeling. This step may have created a more powerful intervention and may have contributed to the stronger effect.

In Study 3, we divided student–clinicians into those with high and low perspective-taking tendencies, as indicated by their responses to the IRI questionnaire, to explore the influence of baseline characteristics on the effect of the intervention. The pattern of SP satisfaction results suggests that high-tendency students responded to the intervention whereas low-tendency students did not. Study 3 supports a precept that is well established in the program evaluation literature: Baseline predisposition to achieving benefit from an intervention may exert a considerable influence on the intervention's effectiveness.41 We did not measure predisposition to perspective-taking in Studies 1 and 2, but it may have also influenced those results. Given that low-tendency students seemed not to respond to the intervention, Study 3 also supports the argument that educators should alter training methods to increase such students' perspective-taking tendencies or develop novel interventions to which they might respond.

In all three studies, we used patient satisfaction as the end point. This was supported by the wide “real-world” use of patient satisfaction as a measure for determining the effectiveness of the doctor–patient interaction42 and the link between patient satisfaction and positive health care outcomes (e.g., improved medication and dialysis adherence).43–45

As we noted above, the effect sizes of the intervention are not large. This may be due in part to the context of the studies. The participants were students on their best examination behavior encountering “patients” who presented with common medical problems but who were not interpersonally challenging. It is also possible that in the examination setting, other factors (test performance anxiety, poor clinical skills) may predominate over the intervention for some students. Further, if only students with high baseline perspective-taking tendencies are susceptible to the intervention (as suggested by Study 3), students with low tendencies may have diminished the overall effect size. Finally, it is worth noting that small effect size does not necessarily result in trivial consequences, as research has shown in other fields.46,47

We hypothesize that perspective-taking will become an important addition to the communications curriculum for clinical professions. Patient satisfaction is important to compliance and health outcomes, so even small increases in satisfaction can make large differences. Further, perspective-taking is feasible to incorporate into the curriculum because it takes minimal time and cost to implement.

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Future research

The work reported here points to avenues for further exploration. One of our studies suggests that perspective-taking could increase satisfaction among African American SPs, but the number of cases was small and the study did not include white SPs to serve as controls. The extent to which perspective-taking can increase satisfaction among African Americans and other high-risk and underserved populations needs further study. In addition, investigators should assess the potential of perspective-taking to reduce stereotyping of these populations, given the role bias and stereotyping play in health care disparities.48 Perspective-taking studies in other fields have shown reductions in stereotyping,12 indicating that the process might prove particularly helpful in assisting clinicians as they attempt to bridge differences between themselves and demographically diverse patients.

More work needs to be done to discover how to administer the intervention for maximum effect. To reinforce perspective-taking, participants in Studies 1 and 3 wrote short essays describing the patient's perspective after each patient encounter, whereas participants in Study 2 received only brief instructions at the beginning of the exam with no reinforcement. These modes were successful in our studies, but researchers should explore ways to boost the effect of the intervention while keeping it durable, simple, and efficient to implement. Additional issues important to research include the optimal way to integrate perspective-taking into communications skills teaching, the durability of the effects of perspective-taking training, and the impact of perspective-taking on improving clinician–patient communication in real-world clinical practice. Perspective-taking in clinical practice should prove useful across all specialties because empathetic communication is universally important when building trust between clinician and patient. As with student–clinicians, however, only physicians and PAs with high baseline perspective-taking tendencies may respond to interventions.

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Limitations

These studies have several limitations. First, we conducted them with medical and PA students in simulated situations; perspective-taking may be more or less effective with physicians, residents, and PAs in actual clinical practice. Second, we only looked at one of many important outcomes—patient satisfaction. We chose patient satisfaction because it is used in many studies as an important outcome of the doctor–patient interaction, it is a reasonable empathy indicator43–45 with which to measure the effect of perspective-taking, and it is feasible to use in a simulated clinical context. Third, these studies, though performed with students and SPs of different races and across two medical schools and two disciplines, were nonetheless limited to private institutions in the District of Columbia and may not generalize to other populations in other geographic areas. Finally, we measured patient satisfaction as an outcome of the effect of perspective-taking-induced empathy, but we did not directly measure empathetic behavior through analysis of video recordings of the encounters.

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Conclusions

In conclusion, our three studies provide evidence that very brief instruction in perspective-taking—a method of enhancing empathy—may play a valuable role in building the clinician–patient relationship. As clinician empathy is important to patient health outcomes, perspective-taking warrants further exploration in medical education and clinical practice settings.

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Acknowledgments:

The authors would like to give special thanks to Sheik Hassan, MD, associate dean for academic affairs and associate professor of medicine, Howard University College of Medicine, for his vital contributions to this project and his enthusiastic support. The authors would also like to acknowledge Richard Windsor, PhD, George Washington University School of Public Health and Health Services, for his methodological assistance.

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Funding/Support:

These studies were integrated into the standard education programs of the George Washington School of Medicine and Health Sciences and the Howard University College of Medicine. They received no outside support.

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Other disclosures:

None.

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Ethical approval:

Studies 1 and 3 were exempted by the IRBs of the George Washington School of Medicine and Health Sciences (GW) and the Howard University College of Medicine. Study 2 was approved by the GW IRB.

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