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Race, Ethnicity and the Patient-Physician Relationship

Race, Ethnicity and the Patient-Physician Relationship. Mary Catherine Beach, MD, MPH Associate Professor of Medicine and Health, Behavior & Society Johns Hopkins University Schools of Medicine and Public Health. Dimensions of relationship with potential links to health disparities.

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Race, Ethnicity and the Patient-Physician Relationship

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  1. Race, Ethnicity and the Patient-Physician Relationship Mary Catherine Beach, MD, MPH Associate Professor of Medicine and Health, Behavior & Society Johns Hopkins University Schools of Medicine and Public Health

  2. Dimensions of relationship with potential links to health disparities • Partnership • Communication • Trust • Respect • Knowing • Concordance Cooper LA, Beach MC, Johnson RL, Inui TS. J Gen Intern Med 2006; 21(S1): S21–S27.

  3. Dimensions of relationship with potential links to health disparities Partnership Communication Trust Respect Knowing Concordance Cooper LA, Beach MC, Johnson RL, Inui TS. J Gen Intern Med 2006; 21(S1): S21–S27.

  4. Partnership or Participatory Style • Relating to patients in an approachable, friendly, or supportive manner • Soliciting and listening to the patient's views • Using a `participatory' or non-authoritarian manner of problem-solving and conflict resolution • Providing clear instructions and information about the treatment and its purpose • Giving the patient choice, control, and responsibility* B.L. Svarstad, Patient–practitioner relationships and compliance with prescribed medical regimens. In: L.H. Aiken and D. Mechanic (Eds), Applications of social science to clinical medicine and health policy. .Rutgers University Press, New Brunswick (1986); *Kaplan SH, Med Care 1995;33:1176-1187

  5. Participatory decision making style is related to better outcomes • Patient satisfaction, continuity of care Kaplan 1995 • Diabetes self-care behaviors Heisler 2007 • Adherence to antidepressant medicine Bultman 2000 • Resolution of depression Clever 2006 • Continuation of therapy with statins McGinnis 2007

  6. Ethnic minorities rate their visits with physicians as less participatory P=0.007 P=0.05 PDM scores range from 0-100. A higher score means visit is more participatory. Cooper-Patrick L , JAMA 1999;282:583-589

  7. Dimensions of relationship with potential links to health disparities Partnership Communication Trust Respect Knowing Concordance Cooper LA, Beach MC, Johnson RL, Inui TS. J Gen Intern Med 2006; 21(S1): S21–S27.

  8. Patient-physician communication is related to important outcomes • Patient recall of information • Patient adherence • Patient satisfaction • Clinical outcomes • Glycemic control • BP control • Pain reduction • Depression resolution Greenfield 1988, Kaplan 1989, Stewart 1995, Safran 2001,Clever 2006, Heisler 2007

  9. Patient Race, Ethnicity and Patient-Physician Communication • Patient race and ethnicity influence physician empathy, concern, courtesy, information-giving, and nonverbal attention1 • African American race associated with narrowly biomedical communication style2 • African Americans experience less patient-centered communication with physicians3 • African Americans and Asians report poor communication with providers4 • Hooper, Med Care 1982; 2. Roter, JAMA 1997; 3. Johnson, Am J Public Health 2004; 4. NHDR 2008

  10. Physicians communicate differently with black and white patients Adjusted for: patient age, gender, education level, and self-rated health status; and physician gender, race, time since completing training, and report of how well he/she knows each patient. *p-value from linear regression with GEE.** Patient and physician affect scores are derived from audiotape coders’ impressions of the overall emotional tone of the medical visit. Johnson RL, Roter DL, Powe NR, Cooper LA. Am J Public Health 2004;94:2084-2090.

  11. Language Barriers • In 2000, nearly 47 million US residents spoke a language other than English at home • 18% of population • Increased from 14% in 1990 and 11% in 1980 • Nearly one-half (21.4 million) had difficulty speaking English

  12. Patients with language barriers • Less satisfied with provider communication • Less likely to have a regular source of care • Less likely to receive preventive services • More likely to report medication complications • Greater risk of death Morales LS et al. JGIM 1999; 14: 409-17 Hu DJ et al. West J Med 1988; 144:490-3 Wolloshin S et al. JGIM 1997; 8:472-7 Ghandi TK et al. JGIM 2000; 15:149-54 Gardam M et al. J Immigr Minor Health 2009;11(6):437-45

  13. Dimensions of relationship with potential links to health disparities • Partnership • Communication • Trust • Respect • Knowing • Concordance Cooper LA, Beach MC, Johnson RL, Inui TS. J Gen Intern Med 2006; 21(S1): S21–S27.

  14. Trust is linked to quality of care and patient outcomes • patient adherence Thom 2002, McGinnis 2007 • satisfaction Safran 1998, Hall 2002 • continuity of care Kao 1998 • self-rated health Safran 1998 • use of preventive services O’Malley 2004

  15. Trust in physicians and hospitals is lower for African Americans ** * * p<0.05; ** p<0.01 Boulware et al. Public Health Rep 2003 Doescher et al. Arch Fam Med 2000

  16. Dimensions of relationship with potential links to health disparities Partnership Communication Trust Respect Knowing Concordance Cooper LA, Beach MC, Johnson RL, Inui TS. J Gen Intern Med 2006; 21(S1): S21–S27.

  17. Race/ethnicity and patient reports of respectful treatment • Latina mothers report professionals are rude, rush them through meetings, and treat them “like dirt”Shapiro 2004 • African Americans and Hispanics report being treated with disrespect; Asian Americans report being looked down on by doctors Collins 2003 • Minorities are more likely than whites to believe they were judged or treated unfairly based on raceJohnson 2004

  18. Dimensions of relationship with potential links to health disparities Partnership Communication Trust Respect Knowing Concordance Cooper LA, Beach MC, Johnson RL, Inui TS. J Gen Intern Med 2006; 21(S1): S21–S27.

  19. Race/ethnicity and physicians’ knowing of patients • Providers’ “knowing” of patients is associated with continuity and adherence Safran 1998, Beach 2006

  20. Race/ethnicity and physicians’ knowing of patients Physicians hold negative opinions about African Americans’ intelligence, compliance, and other health behaviors not corroborated by patients’ self-reports of these same factors van Ryn 2000 Hispanics and Asian Americans are less likely than whites to feel doctors know them or understand their background and values Shapiro 2004, Ngo-Metzger 2004

  21. Dimensions of relationship with potential links to health disparities Partnership Communication Trust Respect Knowing Concordance Cooper LA, Beach MC, Johnson RL, Inui TS. J Gen Intern Med 2006; 21(S1): S21–S27.

  22. Concordance • Shared identities between patients and physicians across various dimensions: • Visible (race/ethnicity, age, gender, education, language) • Less visible (beliefs, values, preferences) • Race concordance related to patient reports of satisfaction, participatory decision-making, timeliness of treatment, and trust in health system Cooper-Patrick 1999, Saha 1999, Cooper 2003, King 2004, Sohler 2007 • Concordance with regard to beliefs about care are important determinants of satisfaction and trust Krupat 2001 , Krupat 2000

  23. Patients in race-concordant relationships rate their physicians as more participatory P-value NS P=0.02 Mean PDM Style Score Adjusted for patients’ age, gender, education, marital status, health status, length of the patient-physician relationship, physician gender (race concordant analysis) and physician race (gender concordance analysis). Cooper-Patrick L, JAMA 1999;282:583-589

  24. Race-concordant visits are longer with more positive patient emotional tone *p<0.05. Adjusted for patient age, race, gender, and health status and physician gender and years in practice. Cooper LA et al, Ann Intern Med 2003;139:907-915

  25. Patients in Race-Concordant Relationships Rate Their Physicians Better Regardless of Communication † † * Mean Score/Probability *p<0.05, †p<0.01 from GEE. Analyses adjusted for patient gender, race, age, and health status, physician gender, years in practice, and patient-centered communication. Cooper LA et al, Ann Intern Med 2003;139:907-915

  26. How can we communicate better and build effective cross-cultural relationships?

  27. “The average American physician conducts between 140,000 – 160,000 medical interviews in a practice lifetime, making it the most frequently used medical procedure” - Lipkin et al. (1995)

  28. Communication Approaches • Patient-centeredness • Relationship-centeredness • Cultural and linguistic competence • Motivational Interviewing

  29. Key (Cross-Cultural) Communication Skills • Explore patient perspectives • Resist the righting reflex • Express empathy

  30. Overarching Goal Take 1-3 concrete skills to incorporate into your practice

  31. Key (Cross-Cultural) Communication Skills • Explore patient perspectives • Resist the righting reflex • Express empathy

  32. Exploring Patient Perspectives • Impact of illness on life and family/friends “How has this affected your relationship with your partner? Was it hard to tell your friends? You mentioned once that you felt guilty about having HIV – how are you thinking about that now?”

  33. Exploring Patient Perspectives • Impact of illness on life and family/friends • Explanatory framework for symptoms/illness “What do you think is going on? Causing the problem? What have you done to treat this illness so far? How does it work?”

  34. Exploring Patient Perspectives • Impact of illness on life and family/friends • Explanatory framework for symptoms/illness • Prior advice given to them “Have you seen other health professionals? What have they told you? What advice do your HIV-positive friends give you?”

  35. Exploring Patient Perspectives • Impact of illness on life and family/friends • Explanatory framework for symptoms/illness • Prior advice given to them • Worries/concerns/fears “What worries or concerns you most about this symptom? Is there anything you are particularly afraid of?”

  36. Exploring Patient Perspectives • Impact of illness on life and family/friends • Explanatory framework for symptoms/illness • Prior advice given to them • Worries/concerns/fears • Expectations “How were you hoping I could help you most?”

  37. Exploring Patient Perspectives • Impact of illness on life and family/friends • Explanatory framework for symptoms/illness • Prior advice given to them • Worries/concerns/fears • Expectations • Opinions “How do you think these medicines are working for you? What do you think we should do?”

  38. Key (Cross-Cultural) Communication Skills • Explore patient perspectives • Resist the righting reflex • Express empathy

  39. Resist the Righting Reflex

  40. The Righting Reflex • D- What are you going to do with you? You keep on missing appointments • P-I came that day but I thought it was earlier in the day. • D- Well, you missed in August and July. My concern is that back when I saw you in June, we knew then that we pretty urgently needed to make some changes.… What’s up? • P-I’ve been busy with the kids…looking for work because I’m unemployed now. • D- So what happens if you get sick and aren’t there to even look for work or be busy with the kids if you don’t care for yourself. • P- I promise I am going to be better.

  41. D: Well, these have the time, you have pretty much chronology that you’re taking them around the same time. They’re a couple here that you took in the late, uh later. Uh, in May, the times are off. But this is the big, this is the big, you hafta be, you hafta do better and I don’t want to make this the focus of your life, when to take your medications and when not to take your medications, it should be routine. It should be part of the day, taking your medications because there’s gonna be a time, when you’re gonna, when these medications are gonna fail, when this happens and if they fail then there’s nothing, you know there’s nothing we can do. P: Mmhmm D: All of us who practice have patients that have so much drug resistance and that there’s no drugs. You hafta take shots, you have to take T20 and that doesn’t give you a very good lifetime. You know, my goal with you is to keep you healthy for as long as possible. P: Mmhmm. D: But you have to, you gotta, really hafta help me. P: Mmhmm. D: And I worry, I truly, truly, truly worry because I think that you’re 90% is good, I think there is a way that you could, you could do better. Total percent taken 91%. Percent taken on time 88%. Days with correct doses taken 82%. Total days with all doses taken on time 78%. If it’s not a hundred percent or ninety-five percent it’s just gonna get worse because you’re not dealing with me, you’re not dealing with anybody else, you’re dealing with nature. Mother nature. And Mother Nature is, is, is something you can’t, you cannot deal with, you cannot change. The virus is not a living thing, you know it’s a pathogen. It’s constantly making mutations, looking at ways to fool the body so it can grow and kill you and what you’re doing is you’re battling, that, that, that machine, that nonliving machine and that’s what Nature’s doing to you and what you can, this is very, very good, we’re checking this. You can get anything you want from me, you can get anything you want from a lot of people. You can deal with people, you can deal with, um, bad situations, you know the electric company and uh, you know, the insurance company this that and the other thing. You can’t deal with Nature. P: Mmhmm. D: You can’t deal with Nature. The only way to deal with nature is to take these medications and uh, I really truly am concerned. If you think you can go to bed and forget to take the medications. You think you can do all these things and still stay alive, it’s a mistake because at some point, you’re gonna come back and you’re gonna tell me, why didn’t you tell me doctor, when I had the chance to take the medications. Why didn’t you let me know the severity of the problem. Why didn’t you make me take the meds one hundred percent. Well I’m doing that now. I’m just telling you can’t do this. P: Mmhmm.

  42. Resist the Righting Reflex • The situation • Helping profession: desire to set things right, heal, prevent harm, promote well-being • Urge to correct another’s course is automatic, reflexive • The problem • All people have the tendency to resist persuasion • Verbalization of counter argument, defend status quo

  43. “When you are listening, even if it is just for a minute, you have no other immediate agenda than to understand the other person’s perspective and experience.” Rollnick et al. Motivational Interviewing in Healthcare

  44. Key (Cross-Cultural) Communication Skills • Explore patient perspectives • Resist the righting reflex • Express empathy

  45. Empathy Empathy is a response that demonstrates an accurate understanding of the patient’s emotional state. Wells, K. B., M. C. Benson, et al. (1985). "A model for teaching the brief psychosocial interview." Journal of Medical Education60(3): 181-188.

  46. MISSED EMPATHIC OPPORTUNITY (MEO) Patient: After I had my hysterectomy. I was taking estrogen, right? Physician: Yeah? Patient: You know how your breast get real hard and everything? You know how you get sorta scared? Physician: How long were you on the estrogen? MEO Patient: Oh, maybe about six months. Physician: Yeah, what, how, when were you, when did you have the, uh, hysterectomy? Suchman, A. L., K. Markakis, et al. (1997). "A model of empathic communication in the medical interview." Jama277(8): 678-682.

  47. Are we good at empathy? • Physicians ‘missed’ empathic opportunities in 72% patient visits Levinson W et al. A study of patient clues and physician responses in primary care and surgical settings. JAMA 2000;284:1021-7

  48. Are we good at empathy? • Physicians ‘missed’ empathic opportunities in 72% patient visits • Visits with ‘missed’ empathic opportunities averaged 3 minutes LONGER than visits in which empathy had been expressed Levinson W et al. A study of patient clues and physician responses in primary care and surgical settings. JAMA 2000;284:1021-7

  49. Are we good at empathy? • Physicians ‘missed’ empathic opportunities in 72% patient visits • Visits with ‘missed’ empathic opportunities averaged 3 minutes LONGER than visits in which empathy had been expressed • In 55% visits with missed opportunities, the patient brought up the same concern more than once Levinson W et al. A study of patient clues and physician responses in primary care and surgical settings. JAMA 2000;284:1021-7

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