Race, Ethnicity and the Patient-Physician Relationship

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) S21S27.
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) S21S27.
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, Patientpractitioner 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 1995331176-1187
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
P0.007
P0.05
PDM scores range from 0-100. A higher score means
visit is more participatory. Cooper-Patrick L ,
JAMA 1999282583-589
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) S21S27.
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

1. 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
Communication measure Whites n202 Blacks n256 p-value
Physician verbal dominance 1.50 1.73 lt0.01
Physician positive affect 14.1 13.2 0.02
Patient positive affect 16.7 15.8 lt0.01
Patient-centeredness ratio 1.91 1.58 0.08
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 2004942084-2090.
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 144490-3 Wolloshin S et al.
JGIM 1997 8472-7 Ghandi TK et al. JGIM 2000
15149-54 Gardam M et al. J Immigr Minor Health
200911(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) S21S27.
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 OMalley 2004

15
Trust in physicians and hospitals is lower for
African Americans


plt0.05 plt0.01 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) S21S27.
17
(No Transcript)
18
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
  race Johnson 2004

19
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) S21S27.
20
Race/ethnicity and physicians knowing of
patients

• Providers knowing of patients is associated
  with continuity and adherence Safran 1998, Beach
  2006

21
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

22
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) S21S27.
23
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

24
Patients in race-concordant relationships rate
their physicians as more participatory
P-value NS
P0.02
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 1999282583-589
25
Race-concordant visits are longer with more
positive patient emotional tone
plt0.05. Adjusted for patient age, race, gender,
and health status and physician gender and years
in practice.


Cooper LA et al, Ann Intern Med 2003139907-915
26
Patients in Race-Concordant Relationships Rate
Their Physicians Better Regardless of
Communication



Mean Score/Probability
plt0.05, plt0.01 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 2003139907-915
27
How can we communicate better and build effective
cross-cultural relationships?
28
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)

29
Communication Approaches

• Patient-centeredness
• Relationship-centeredness
• Cultural and linguistic competence
• Motivational Interviewing

30
Key (Cross-Cultural) Communication Skills

• Explore patient perspectives
• Resist the righting reflex
• Express empathy

31
Overarching Goal

• Take 1-3 concrete skills to incorporate into your
  practice

32
Key (Cross-Cultural) Communication Skills

• Explore patient perspectives
• Resist the righting reflex
• Express empathy

33
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?

34
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?

35
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?

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
• What worries or concerns you most about this
  symptom? Is there anything you are particularly
  afraid of?

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
• How were you hoping I could help you most?

38
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?

39
Key (Cross-Cultural) Communication Skills

• Explore patient perspectives
• Resist the righting reflex
• Express empathy

40
Resist the Righting Reflex
41
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. Whats up?
• P-Ive been busy with the kidslooking for work
  because Im unemployed now.
• D- So what happens if you get sick and arent
  there to even look for work or be busy with the
  kids if you dont care for yourself.
• P- I promise I am going to be better.

42

• D Well, these have the time, you have pretty
  much chronology that youre taking them around
  the same time. Theyre 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
  dont 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 theres gonna be a time, when
  youre gonna, when these medications are gonna
  fail, when this happens and if they fail then
  theres nothing, you know theres nothing we can
  do.
• P Mmhmm
• D All of us who practice have patients that have
  so much drug resistance and that theres no
  drugs. You hafta take shots, you have to take
  T20 and that doesnt 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 youre 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
  its not a hundred percent or ninety-five percent
  its just gonna get worse because youre not
  dealing with me, youre not dealing with anybody
  else, youre dealing with nature. Mother nature.
  And Mother Nature is, is, is something you
  cant, you cannot deal with, you cannot change.
  The virus is not a living thing, you know its a
  pathogen. Its constantly making mutations,
  looking at ways to fool the body so it can grow
  and kill you and what youre doing is youre
  battling, that, that, that machine, that
  nonliving machine and thats what Natures doing
  to you and what you can, this is very, very good,
  were 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 cant
  deal with Nature.
• P Mmhmm.
• D You cant 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, its a mistake
  because at some point, youre gonna come back and
  youre gonna tell me, why didnt you tell me
  doctor, when I had the chance to take the
  medications. Why didnt you let me know the
  severity of the problem. Why didnt you make me
  take the meds one hundred percent. Well Im
  doing that now. Im just telling you cant do
  this.
• P Mmhmm.

43
Resist the Righting Reflex

• The situation
• Helping profession desire to set things right,
  heal, prevent harm, promote well-being
• Urge to correct anothers course is automatic,
  reflexive
• The problem
• All people have the tendency to resist persuasion
• Verbalization of counter argument, defend status
  quo

44
When you are listening, even if it is just for a
minute, you have no other immediate agenda than
to understand the other persons perspective and
experience.

• Rollnick et al.
• Motivational Interviewing in Healthcare

45
Key (Cross-Cultural) Communication Skills

• Explore patient perspectives
• Resist the righting reflex
• Express empathy

46
Empathy

• Empathy is a response that demonstrates an
  accurate understanding of the patients emotional
  state.

Wells, K. B., M. C. Benson, et al. (1985). "A
model for teaching the brief psychosocial
interview." Journal of Medical Education 60(3)
181-188.
47
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." Jama 277(8) 678-682.
48
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 20002841021-7
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

Levinson W et al. A study of patient clues and
physician responses in primary care and surgical
settings. JAMA 20002841021-7
50
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 20002841021-7
51
Why do we miss so many empathic opportunities?

• Provider barriers
• Failure to recognize opportunity
• Focus instead on solving underlying issue
• Sense that it will take too much time
• Sense of feeling unskilled
• Belief that detached concern is better

52
Why do we miss so many empathic opportunities?

• Patient cues can be more or less subtle
• Giving voice to emotion (This is pretty scary)
• Express challenge (This sounds complicated)
• Use hyperbole (Ive never been sick a day in my
  life)

53
Empathy in Practice

• Framing or sign-posting
• Let me see if I have this right,
• So it sounds like
• Reflecting the content
• So if Im hearing you right, comfort food during
  the winter would be the hardest to give up.
• Calibrating the emotion
• I have the sense that you feel strongly, but Im
  not sure I exactly understand what that feeling
  is. Can you tell me more?

54
Empathy vs. Reassurance
55
Empathy vs. Reassurance
56
Empathy vs. Reassurance
57
(No Transcript)
58
The Effect of Empathy on Outcomes of Care
Maternal Visit Outcomes by Exposure to Different
Levels of Empathy
High Empathy Low Empathy P-value
Visit Satisfaction 80.6 4.9 75.1 7.1 lt0.05
Reduction in Concern 8.1 3.6 5.6 1.9 lt0.05
Wasserman, R. C., T. S. Inui, et al. (1984).
"Pediatric clinicians' support for parents makes
a difference an outcome-based analysis of
clinician-parent interaction." Pediatrics 74(6)
1047-1053
59
Reflection of Understanding

• Can be related to emotion or not
• What to do when you are resisting the righting
  reflex
• It seems like youre life has just gotten so
  hectic for awhile that you havent been able to
  stay on top of all these appointments. Youve
  been so busy taking care of everyone else that
  you havent been able to make your own health a
  priority.

60
Key (Cross-Cultural) Communication Skills

• Explore patient perspectives
• Resist the righting reflex
• Express empathy

61
Overarching Goal

• Take 1-3 concrete skills to incorporate into your
  practice

62
I have learned that people will forget what you
said, people will forget what you did, but people
will never forget how you made them feel.

• - Maya Angelou