Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care (2003) / Chapter Skim
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Patient-Provider Communication: The Effect of Race and Ethnicity on Process and Outcomes of Healthcare
Patient-Provider Communication: The Effect of Race and Ethnicity on Process and Outcomes of Healthcare
Pages 552-593
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From page 552... ...
Actual use of patient-centered communication skills identified in audiotape analysis differs by patient and physician race and ethnicity. However, patient reports of the communication experience are inconsistent with the empirical record, suggesting that both provider beliefs and attitudes towards patients as well as patient expectations and judgments of physicians are in operation.
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From page 553... ...
The challenge in transforming the practice of medicine to more effectively meet the needs of ethnically diverse patients will include the generation of racial and ethnic-neutral social norms regarding patient expectations and judgments of physician conduct, as well as the establishment of medical practice norms that value communication skills, interpersonal sensitivity, and cultural competence. Increasing diversity in the physician workforce will help contribute to a societal norm that does not inherently define "doctor" in gender or race-linked terms, but this will not be sufficient to transform medical practice.
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From page 554... ...
However, the importance of race/ethnicity as a critical cultural indicator is perhaps especially salient for ethnic minority patients in the United States, who are almost always in race-discordant relationships with physicians. Cultural competence may be defined as the ability of individuals to establish effective interpersonal and working relationships that supersede cultural differences.
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From page 555... ...
Our goal in writing this paper is to further our understanding of ethnic disparities in health outcomes through an investigation of the interpersonal processes related to the provision of healthcare. We have found that an array of social factors in addition to race including gender, age, literacy, social class, and the normative expectations that guide the therapeutic relationship are not only relevant, but central to an understanding and appreciation of the role of ethnicity in the interpersonal dynamics of healthcare.
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From page 556... ...
However, this has not been the case. There have been relatively few methodologically sound studies designed specifically to investigate the role of sociologic factors in medical visits (Greene, Adelman, Charon, and Hoffman, 1986; Gerbert, 1984; Roter, Hall, and Katz, 1988; Roter and Hall, 1992~.
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From page 557... ...
For example, AfricanAmerican patients were perceived as being less intelligent, more likely to engage in high-risk behavior, and less likely to adhere to medical advice. These ethnic minority patients received lower ratings of affiliation by physicians.
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From page 558... ...
In the sections that follow we present research relating physicianpatient communication to some of the antecedent and outcome variables that are relevant for understanding and eliminating racial and ethnic disparities in healthcare. The Role of Physician Sociodemographic Characteristics on the Medical Dialogue Physician race and ethnicity.
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From page 559... ...
The physician sample was 56% white, 25% African American,15% Asian American, and 3% Hispanic. This study showed that there were no differences between ethnic minority and white physicians with respect to patient ratings of PDM style, even when adjustments were made for patients' age, gender, education, health status, and length of the patient-physician relationship (Cooper-Patrick et al., l999~.
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From page 560... ...
Considering that the gender differences among physicians closely mirror those found in the general population, it is likely that female physicians will have fewer barriers to overcome when learning to apply the biopsychosocial model in medical practice to reduce ethnic disparities in patient-physician communication. Physician social class (parental socioeconomic status)
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From page 561... ...
Physicians' social class background, as measured by their fathers' occupations and the physician's style of communication, was studied in audiotapes of 34 doctors in 336 medical visits (Waitzkin, 1985~. When compared with doctors from upper- or upper middle-class backgrounds, physicians from working-class backgrounds tended to spend more time informing their patients, giving more explanations, and providing responses that were at the same technical level as the questions asked.
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From page 562... ...
It is difficult to predict, based upon available evidence, what role physician social class might play in understanding racial and ethnic disparities in patient-physician communication. The Role and Impact of Patient Sociodemographics on Medical Communication In this section we will explore the extent to which the literature presents evidence of how patient characteristics, such as race and ethnicity, gender, social class, literacy, health status, and age cohort affect patientprovider communication.
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From page 563... ...
These studies provide a basis upon which studies may be designed and analyzed for patients belonging to traditionally underserved ethnic minority groups. One classic study of health and ethnicity (Zola, 1963)
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Like most people, doctors probably attribute any differences they do notice in their own behaviors to the character, aptitude, or needs of the other (in this case, the lower-class or ethnic minority patient)
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From page 565... ...
Particularly relevant to these decision-making demands is the fact that older patients appear to experience medical visits during which they are more passive and less actively engaged in the treatment decision-making
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In addition to age, ethnic minority status, poor health status and lower educational achievement were associated with lower reports of participatory visits. Thus, older ethnic minority patients may be at fourfold risk for low levels of participatory engagement with their doctors.
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In an earlier Scottish study, Bain (1976) found that patients of lowerclass backgrounds were less verbally active overall during medical visits than others.
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From page 568... ...
The opposite finding in regard to emotional support has been reported in several communication studies of pediatric visits wherein better-educated parents of patients received more emotional support than less-educated parents. The classic study by Korsch and associates (Korsch, Gozzi, and Francis, 1968)
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From page 569... ...
This apparent ambivalence, in conjunction with numerous findings showing that people with worse health status are less satisfied with their care (as reviewed by Hall, Feldstein, Fretwell, Rowe, and Epstein, 1990) , raises the question of whether physicians produce dissatisfaction in their sicker patients by displaying negative behaviors toward them.
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From page 570... ...
Nevertheless, physicians are unlikely to recognize patients with poor literacy skills or appreciate the negative consequences of low literacy on patient outcomes (Weiss and Coyne, 1997~. Common miscon
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From page 571... ...
The circumstances underlying low literacy are varied. Limited educational opportunity accounts for many of the poor literacy skills evident among the elderly and new immigrants, while undetected or inadequately addressed learning disabilities may account for a large proportion of the younger population who have poor literacy skills despite exposure to formal education (Kirsch et al., 1993~.
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From page 572... ...
This research suggests that low literacy not only presents obvious barriers to effective patient education, but may also complicate the process of history taking and establishment of the primary complaint. Patients in the United States have also noted difficulties understanding physicians' oral communication.
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From page 573... ...
Studies have shown that ethnic minority physicians, particularly blacks and Hispanics, are more likely to provide healthcare to ethnic minority, underserved, medically indigent, and sicker populations than are their white counterparts (Moy and Bartman, 1995; Komaromy et al., 1996; Xu et al., 1997~. Furthermore, ethnic minority patients are more likely than white patients to report having an ethnic minority physician as their regular doctor (Gray and Stoddard, 1997~.
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From page 574... ...
Other reasons for ethnic minority patient preference for and higher ratings of care in raceconcordant relationships with physicians are unclear, but potential explanations include more cultural sensitivity to the needs of these patients by race-concordant physicians and more shared cultural values, beliefs, and experiences in society between ethnic minority patients and physicians (Cooper-Patrick et al., 1999; Nickens, 1995~. Evidence of Race-Concordance Consequences for the Communication Process In an ongoing cross-sectional study using post-visit surveys and audiotape analysis, we have examined the relationship between race concordance and actual patient and physician communication behaviors (252 adult patients 142 white, 110 African-American; 31 primary care physicians 13 white, 18 African-American)
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From page 575... ...
Strong evidence links these communication behaviors to valued patient outcomes, including improvements in markers of disease control such as hemoglobin Alc and blood pressure, enhanced reports of physical and emotional health status, functioning, and pain control (Barsky et al., 1980; Greenfield et al., 1988; Kaplan et al., 1989; Giron et al., 1998; Stewart, 1995~. Specifically, visits in which the physician uses a participatory decision-making style have been associated with higher levels of patient satisfaction (Kaplan et al., 1995~.
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From page 576... ...
Now, medical educators agree that training is necessary, that a solid foundation of behavioral science research exists to support training programs, and that training improves the communication of physicians. Communication skills training during medical school has been shown to have effects lasting as long as five years (Maguire, Fairburn, and Fletcher, 1986~.
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From page 577... ...
Additionally, intervention studies that develop and test methods for improving patient-provider communication in encounters with ethnic minority patients, as well as studies that evaluate the impact of such interventions on processes and outcomes of care, are needed. Because most of the existing research focuses on African Americans, more studies includ
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From page 578... ...
In a recent review of the literature on the provider contribution to racial and ethnic disparities in healthcare, van Ryn (2002) discusses several studies that support a central hypothesis: that provider beliefs about patients and provider behavior during patient encounters are independently influenced by patient race/ethnicity.
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From page 579... ...
Campinha-Bacote (1999) describes cultural awareness, cultural knowledge, cultural skills, cultural encounters, and cultural desire as constructs of cultural competence.
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From page 580... ...
. Because strong evidence links these communication strategies to improved patient outcomes, intervention studies that target ethnic minority patients and incorporate communication skills training for physicians and empowerment strategies for patients should be conducted.
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From page 581... ...
The challenge of transforming the practice of medicine to more effectively meet the needs of ethnically diverse patients will include the generation of racial and ethnic-neutral social norms regarding patient expectations and judgments of physician conduct, as well as the establishment of medical practice norms that value communication skills, interpersonal sensitivity, and cultural competence. Increasing diversity in the physician workforce will help contribute to a societal norm that does not inherently define "doctor" in gender or race-linked terms, but this will not be sufficient to transform medical practice.
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From page 582... ...
1984. The effects of physician communication skills on patient satisfaction, recall, and adherence.
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2000. The effects of communication skills training on patients' participation during medical interviews.
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1980. Predicting patient satisfaction from physicians' nonverbal communication skills.
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1987. A communication skills programme for increasing patients' satisfaction with general practice consultations.
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1994. Older patient satisfaction with communication during an initial medical encounter.
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1998. Teaching and learning communication skills in medicine.
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Patient Education and Counseling, (39~:71-80. Mechanic D
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1995. The test of functional health literacy in adults: A new instrument for measuring patients' literacy skills.
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1991. Sex differences in patients' and physicians' communication during primary care medical visits.
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1996. The impact of patient-centered care on patient outcomes in family practice.
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Patient Education and Counseling, (30~:227-237.
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1998. Doctor-patient communication and patient satisfaction: A review.
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