Sit it out or dance: representative bureaucracy contagion effects in health care

Abstract

The study of representative bureaucracy traces out multiple organizational and individual-level pathways through which identity-based representation contributes to improvements in bureaucratic processes, outcomes, and legitimacy. Leveraging a multi-level dataset of Florida emergency room visits, we simultaneously model aggregate (indirect) and individual (direct) forms of representation to shed light on what we term “contagion effects” in representative bureaucracy. Our theory of contagion argues that the presence of under-represented bureaucrats (in the aggregate) can change the behavior of other existing bureaucrats. An empirical test of physician-patient sex matching in heart attack outcomes finds that male physicians get better results for female patients when they work alongside more female physicians in their unit, that contagion effects are indicative of men changing their behavior to be more receptive to women’s symptoms, and that the quality of medical school is related to men’s susceptibility to contagion influences.