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Patient-Provider Communication: The Effect of Race and Ethnicity on Process and Outcomes of Healthcare Lisa A. Cooper, M.D., M.P.H. and Debra L. Roter, Dr.P.H. Johns Hopkins University, Baltimore, Maryland ABSTRACT Compelling evidence documents racial, ethnic, and social disparities in healthcare in the United States. While many studies have focused on technical aspects of healthcare—including the receipt of certain tests, procedures, and thera- pies—a smaller number of studies have focused on differences in interpersonal aspects of healthcare that may contribute to disparities across a wide range of conditions. 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, health status, and the normative expectations that guide the therapeutic relation- ship—are not only relevant, but central to an understanding and appreciation of the role of ethnicity in the interpersonal dynamics of healthcare. Consequently, our review places issues of race and its consequence for patient-provider commu- nication within this broadened context. Recent empirical studies of communication reveal interesting and unexpected results. Actual use of patient-centered communication skills identified in audio- tape 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. We provide the following considerations for future research. First, more in- depth exploration of social cognitions and stereotyping behavior by patients, phy- 552
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553 PATIENT-PROVIDER COMMUNICATION sicians, and other healthcare providers is needed. The reciprocal nature of the patient-physician relationship is a critical factor that should be highlighted in future work. Studies of race-concordant, patient-provider relationships will pro- vide opportunities to increase our understanding of the constructs of cultural competence. Inasmuch as physician ethnicity is confounded with age and gender (minority physicians are more likely to be female and younger than white physi- cians), future research will require disentanglement of the complex interactions among patient and physician age, gender, and ethnicity, and their impact on patient-physician communication. Finally, future research should include health- care providers who are not physicians and ethnic minority groups other than African Americans. 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. Until we have more evi- dence as to the impact of institutional resources in improving cultural compe- tency we must rely on physician training in interpersonal skills that emphasize those aspects of communication identified with documented benefits on patient health (e.g., patient-centeredness) coupled with patient activation and empower- ment strategies as promising vehicles to improve quality of care and outcomes and reduce ethnic disparities in interpersonal aspects of healthcare. INTRODUCTION AND SCOPE OF TOPIC A compelling amount of evidence documents racial, ethnic, and social disparities in healthcare in United States (Ayanian et al., 1993; Blendon et al., 1989; Carlisle, Leake, and Shapiro, 1997; Conigliaro et al., 2000; Escarce et al., 1993; Lee et al., 1997; Makuc, Breen, and Freid, 1999; Wenneker and Epstein, 1989; Whittle et al., 1993). While many studies have focused on technical aspects of healthcare, such as the receipt of cer- tain tests, procedures, and therapies, a smaller number of studies have focused on differences in interpersonal aspects of healthcare. Recent work has pointed to the role of physician bias in understanding ethnic and ra- cial disparities in healthcare (Schulman et al., 1999; van Ryn and Burke, 2000; Weisse et al., 2001). Additionally, patient views about healthcare, including satisfaction, have emerged as important outcomes that differ by race, ethnicity, social class, language, and literacy level (Blendon et al., 1995; Gross et al., 1998; Carrasquillo et al., 1999; Murray-Garcia et al., 2000;
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554 UNEQUAL TREATMENT Sun et al., 2000; Baker et al., 1996). Moreover, ethnic minority patients, patients with poor health status, older patients, and patients with less than high school education rate their visits with physicians as less partici- patory (Kaplan et al., 1995; Cooper-Patrick et al., 1999). Specifically, re- cent work has shown that African Americans and other ethnic minority patients, in the common race-discordant relationship with their physi- cians, report less involvement in medical decisions, less partnership with physicians, and lower levels of satisfaction with care (Cooper-Patrick et al., 1999; Saha et al., 1999). Continued disparities in healthcare across a wide range of conditions suggest that fundamental components of healthcare delivery, like patient-provider communication, should be fur- ther investigated. Ethnic groups currently defined as minorities are expected to com- prise 40% of the U.S. population by 2035 and 47% by 2050 (U.S. Bureau of the Census, 1996). Addressing the healthcare needs of an increasingly diverse population has become a very important public health goal (Agency for Healthcare Policy and Research, 1999; U.S. Department of Health and Human Services [DHHS] Office for Civil Rights, 1998; U.S. DHHS, 1999; U.S. DHHS Office of the Secretary, 1999). Healthcare pro- viders, systems, and policy-makers will need to rise to the challenge of providing care that takes the cultural and linguistic needs of the U.S. population into account. Arthur Kleinman’s seminal article (Kleinman, Eisenberg, and Good, 1978) articulated the importance of culture in healthcare. Culture, de- fined as “the integrated pattern of human behavior that includes thoughts, communications, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social group” (Cross et al., 1989), is relevant to everyone’s healthcare. 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. At the patient-provider level, it may be defined as a process in which the healthcare provider continuously strives to work effectively within the cultural context of a client, who may be an indi- vidual, a family, or community (Campinha-Bacote, 1999). There are three broad strategic approaches through which multicultural communication can be enhanced: 1) the provision of direct service designed to meet dis- parate language needs (interpreters and linguistic competency in health education materials); 2) the incorporation of cultural homophilly in the provision of care (use of staff who share cultural background, inclusion of
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555 PATIENT-PROVIDER COMMUNICATION family, inclusion of traditional healers or folk remedies, use of commu- nity health workers); and 3) institutional accommodation (clinic location, hours of operation, physical environment, increasing ability of profession- als to interact effectively within the culture of the patient population) (Brach and Fraser, 2000). Each of these strategies is likely to have an im- pact on the role of patient-provider communication in understanding and eliminating racial and ethnic disparities in healthcare. Our goal in writing this paper is to further our understanding of eth- nic disparities in health outcomes through an investigation of the inter- personal 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 thera- peutic relationship—are not only relevant, but central to an understand- ing and appreciation of the role of ethnicity in the interpersonal dynamics of healthcare. Consequently, our review has placed issues of race and its consequence for patient-provider communication within this broadened context (Figure 1). FIGURE 1. The effect of race and ethnicity on patient-physician communication.
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556 UNEQUAL TREATMENT Physician Role Obligations and Medicine’s Unwritten Social Contract It has been argued that the basis of trust between patients and their physicians lies in the physician’s dedication to “universalism,” that is, the responsibility to treat all patients alike without regard to particular at- tributes or ascribed traits (Parsons, 1951). It is reasoned that if patient care is not universalistic, suspicion and caution will prevail over trust and confidence in the patient-physician relationship. Fear that physicians might act upon ageist, class, or racist stereotypes could undermine the fabric of the social contract upon which the therapeutic relationship rests. In light of the significance of potential violations of physician universal- ism, investigation of the association between patient attributes and as- pects of care should be a research priority. However, this has not been the case. There have been relatively few methodologically sound studies de- signed 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). The Nature and Consequence of Broad Normative Expectations, Bias, and Racial Stereotyping by Providers and Patients There are three mechanisms by which one might hypothesize physi- cian behavior would relate to patient characteristics (Roter and Hall, 1992). First, there may be an unintended association between the care process and patient attributes that is produced by mutual ignorance of social or cultural norms. The marked differences that often exist between physi- cians and their patients (for example, patients who are poor, uneducated, and belong to an ethnic or racial minority group) may lead to very basic communication difficulties. For instance, citing sociolinguistic theorists, Waitzkin (1985) has generalized to the medical context the finding that middle-class subjects tend to be verbally explicit, while working-class sub- jects tend to communicate more implicitly through nonverbal signals. If not attuned to these nonverbal signals, physicians could easily miss or misinterpret patient requests for information or reassurance. A second explanation for an association between patients’ socio- demographic characteristics and the medical care process is that physi- cians may be consciously and quite appropriately addressing the varying responses to illness demanded by socially patterned expectations for care. These needs reflect the diverse attitudes, beliefs, and expectations of the groups to which the patients belong (Fox and Storms, 1981). For instance, in his classic study of ethnicity and pain, Zborowski (1952) found that patients’ interpretation of pain and expectations regarding pain control varied widely across ethnic groups and that members of these groups
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557 PATIENT-PROVIDER COMMUNICATION communicated these expectations to their physicians. In these instances, effective tailoring of pain management maximized medical care. Finally, it is possible that physicians, like others in our society, are negatively affected by stereotypes. Physicians have generally scored about the same as non-physicians in surveys reflecting attitudes toward the elderly or the poor (Marshal, 1981; Price, Desmond, Synder, and Kimmel, 1988). Further, the range in physicians’ political and ideological beliefs indicates a broad spectrum of response to patient groups (Waitzkin, 1985). Physicians appear to share the same negative stereotypes about physically unattractive people as do others in our society (Nordholm, 1980). Numerous studies indicate that patient race and ethnicity influ- ence physicians’ beliefs about and expectations of patients (Lewis, Croft- Jeffreys, and David, 1990; van Ryn and Burke, 2000; Porter and Beuf, 1994; Schulman et al., 1999). One recent study used survey data from patients and physicians during post-coronary angiogram encounters to examine the effect of patient race and socioeconomic status (SES) on physician per- ceptions of and attitudes towards patients (van Ryn and Burke, 2000). This study showed that even after adjustment for patient age, race, frailty/ sickness, depression, mastery, social assertiveness, and physician charac- teristics, physicians tended to perceive African Americans and members of low and middle SES groups more negatively on a number of dimen- sions than they did whites and upper SES patients. For example, African- American 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 phy- sicians. Patients in the lowest SES group were also perceived as having more negative personality attributes (lack of self-control, irrationality), less abilities, more negative behavioral tendencies, and fewer role de- mands (van Ryn and Burke, 2000). Patient SES appeared to have an even broader effect on physician perceptions than patient race. These percep- tions could not be completely explained by epidemiologic evidence about the patients’ racial or SES group or from patients’ reports of their actual behaviors and tendencies. Physicians’ negative attitudes or the assump- tions they make about a patient’s personality, motivation, or level of un- derstanding clearly have implications for the care they give. Correlates of Communication Individuals coming together in medical dialogue bring with them all of their personal characteristics, including their personalities, social atti- tudes and values, race, ethnicity, gender, sexual orientation, age, educa- tion, and physical and mental health. This applies to the physician as well as to the patient, though research on physician characteristics is less com-
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558 UNEQUAL TREATMENT mon, owing to typically small physician samples in communication stud- ies (Roter and Hall, 1992). Furthermore, the endpoints we might wish to measure, such as satisfaction or clinical outcomes, have many determi- nants. When interpreting non-experimental comparisons such as that comprising most of the literature on physician-patient communication, it is important not to make assumptions about the causal relations among variables. Even when potentially confounding variables (such as socio- demographic variables or health status) are statistically controlled, strong inferences of causality are often not justified. Causation may lie in vari- ables unrelated to those under study, and even when one has measured the right variables, complex paths of causation can exist. In the medical interaction for example, mutual (reciprocal) influence is possible. Al- though a given behavior may be produced by a quality of the person en- gaging in it, it may also be caused by how that person responds to the other person, or how that person is treated by the other. Therefore, while we tend to think of physicians as the active agents and patients as re- sponding to them, influence does not always flow from the physician to the patient (Roter and Hall, 1992). Physicians are influenced by patients, too. For example, one recent study shows that the effect of patients’ race or ethnicity on physicians’ beliefs about patients can be moderated by patient behavior. Krupat and colleagues (1999) conducted a study in which physicians observed randomly assigned videotapes of women seeking care for breast cancer. The videotapes varied patients’ sociodemo- graphic characteristics, general health status, and assertiveness. The study showed that assertive behavior among black and low SES patients, but not in white or upper SES patients, resulted in a greater likelihood that physicians would order full tumor staging. In the sections that follow we present research relating physician- patient communication to some of the antecedent and outcome variables that are relevant for understanding and eliminating racial and ethnic dis- parities in healthcare. The Role of Physician Sociodemographic Characteristics on the Medical Dialogue Physician race and ethnicity. Few studies have explored the impact of physician race and ethnicity on medical communication. Most of these studies have used patient ratings of the quality of the patient-physician relationship and the physician’s communication style, rather than actual measures of communication, such as audiotape, videotape, or direct ob- servation. A study of 1,816 adults and 64 primary care physicians in a large managed care organization in the Washington, DC, metropolitan area examined how race and gender of physicians and patients were asso-
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559 PATIENT-PROVIDER COMMUNICATION ciated with patient ratings of physicians’ participatory decision-making (PDM) style. The physician sample was 56% white, 25% African Ameri- can, 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 pa- tient-physician relationship (Cooper-Patrick et al., 1999). This finding is in contrast to the Medical Outcomes Study, in which nonwhite physicians were rated as less participatory than white physicians. In this study, the ethnic mix of the nonwhite physician group was not reported. It is there- fore unclear which cultural or ethnic factors contributed to the lower par- ticipatory ratings by patients and whether the lower participatory ratings can be attributed to one specific ethnic or racial group of physicians (Kaplan et al., 1996). More research has been conducted to understand the role of physician gender in communication with patients. Methods used in these studies may provide a framework for how the role of physi- cian ethnicity and communication style in understanding racial and eth- nic disparities in healthcare might be further elucidated. Physician gender. A large amount of research conducted in non-clini- cal settings has found gender differences in communication style (Brody and Hall, 2000; Dindia and Allen, 1992; Eagly and Johnson, 1990; Hall, 1984). Indeed, the magnitude of gender differences in nonverbal expres- sion rivals or exceeds the gender differences found for a wide range of other psychological variables (Hall, 1998). As compared with women, men have been shown to engage in less smiling and laughing, less inter- personal gazing, greater interpersonal distances and less direct body ori- entation, less nodding, less hand gesturing, and fewer back-channel re- sponses (interjections such as “mm-hmm” which serve to facilitate a partner’s speech), and to have more restless lower bodies, more expan- sive arm movements, and weaker nonverbal communication skills (in terms of judging the meanings of cues and expressing emotions accurately through nonverbal cues). Men have also been found to use less verbal empathy, to be less democratic as leaders, and to engage in less personal self-disclosure than women. Also relevant is research suggesting that women experience many emotions more frequently and more intensely than men do, and refer more to emotions in their language. Observational studies of physician-patient communication typically have many fewer physicians than patients and a typical male-female phy- sician ratio of 2:1. This, plus the relative recency of interest in the role of gender on the process of care, has resulted in only two dozen or so studies that have systematically compared the communication styles of male ver- sus female physicians using audio or video recording or neutral third- party observers (Roter and Hall, 1998; Roter and Hall, 2001).
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560 UNEQUAL TREATMENT One study found that although male and female physicians did not differ in how much biomedical information they conveyed, the male phy- sicians’ talk included less psychosocial discussion. Male physicians also asked fewer questions of all sorts, engaged in less partnership-building behaviors (enlisting the patient’s active participation and reducing physi- cian dominance), produced less positively toned talk and less talk with emotional content, used less positive nonverbal behavior (e.g., smiling and nodding), and had overall shorter visits than female physicians. Con- sistent with these direct observational effects, male physicians report lik- ing their patients less than female physicians report (Hall et al., 1993) and hold less patient-centered values than female physicians (where a patient- centered response is the belief that the patient’s expectations, feelings, and life circumstances are critical elements in the treatment process) (Krupat et al., 2000). Based on a recent meta-analysis of the literature, the effect sizes for these gender differences are often small. However, they could have an important impact when generalized over many medical visits and many patients (Roter, Hall, and Aoki, 2001, manuscript under review). To the extent that male physicians’ behavior and attitudes are less patient-cen- tered than those of female physicians, there may be implications for over- all quality of care and health outcomes. Considering that the gender dif- ferences 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). Medicine is prac- ticed largely by members of the middle class and reflects middle-class ethics in terms of hard work, delayed gratification, economic indepen- dence, and autonomy (Mechanic, 1974). Medicine is also a vehicle for social mobility, but only for those who have demonstrated mastery of middle-class values through academic performance (Kurtz and Chalfant, 1991). One effect of social class origin on the way physicians relate to pa- tients is in terms of class-based communication styles. Several studies have demonstrated sociolinguistic differences among members of vary- ing social classes. Reviewed by Waitzkin and Waterman (1974), the evi- dence suggests that there are indeed social class differences in linguistic skills. Most prominent is a tendency for middle-class subjects to be ver- bally explicit, while working-class subjects tend to communicate more implicitly through nonverbal signals. While most consideration of the consequences of these linguistic differences has been in terms of patients’ communication, it is also possible that social-class background relates to differences in physicians’ communication. These differences might act to
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561 PATIENT-PROVIDER COMMUNICATION enhance communication between physicians of lower social class origin with patients of similar social class backgrounds, or to impede the ability of physicians from poorer backgrounds to communicate with patients of higher social classes (Waitzkin and Waterman, 1974). While not well studied, this issue has been explored. Physicians’ so- cial class background, as measured by their fathers’ occupations and the physician’s style of communication, was studied in audiotapes of 34 doc- tors in 336 medical visits (Waitzkin, 1985). When compared with doctors from upper- or upper middle-class backgrounds, physicians from work- ing-class backgrounds tended to spend more time informing their pa- tients, giving more explanations, and providing responses that were at the same technical level as the questions asked. The study concluded that “Orientation to verbal behavior may be a class-linked phenomenon that affects doctors as well as patients. Thus, doctors from working-class back- grounds may differ in their verbal behavior from doctors who come from a higher class position” (Waitzkin, 1985, p. 92). Another example of the evidence of how social background affects physicians’ styles of practice is found in Hollingshead and Redlich’s (1958) classic study of psychiatrists in New Haven, Connecticut. The social back- ground of the 30 psychiatrists in the study was strongly associated with how they related to patients, as well as their therapeutic orientation. Therapeutic orientation was found to fall within two distinct approaches to the treatment of patients. The first approach is analytic and psycho- logical in orientation, with an emphasis on patient insight and as little physician directiveness as possible. These psychiatrists were almost pas- sive in relation to management of their patients and almost never per- formed physical or neurologic examinations. The second approach is much more active and biomedical in nature. These psychiatrists were very directive in their therapy, often combining suggestions and advice with medical procedures, drugs, and neurologic and physical tests. There were marked differences in the social and cultural backgrounds of the psychiatrists in these two treatment approach groups. As a group, the analytic psychiatrists had moved upward much farther in the class structure than the directive group. Almost three-quarters of the analytic group, compared with 42 percent of the directive group, moved upward one or more classes from the positions occupied by their fathers (Hollings- head and Redlich, 1958). The investigators also found that the number of generations the psychiatrist’s family had been in the United States was linked to his or her theoretical orientation. Only 8 percent of the analyti- cally oriented group were from “old American stock,” whereas 44 percent of the directive group were from that background. In contrast, 58 percent of the analytic group were first- and second-generation Americans, com- pared with 38 percent of the directive group.
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562 UNEQUAL TREATMENT Hollingshead and Redlich speculate that the analytic psychiatrists “like all phenomenal upward mobile persons, those who have achieved their present class positions largely through their own efforts and abilities have passed through a social, possibly also psychological, transformation” (Hollingshead and Redlich, 1958, p. 165), which accounts for their prac- tice style. While not specifically studied, it is interesting to speculate that the psychiatrist orientations described by Hollingshead and Redlich may also apply to primary care physicians and their tendency to relate to pa- tients in a more or less directive manner. Relevant to the point are the findings from a large survey of physi- cians (Haug and Lavin, 1983), which found that those who rose to the middle class reported greater attitudinal acceptance and behavioral ac- commodation to consumerist-type patient challenges than those who originally came from upper- and upper-middle-class backgrounds. This may reflect a more directive and “take charge” orientation of physicians from higher social class origins than those who are upwardly mobile. Haug and Lavin (1983) note that these findings are contrary to the theory that the upwardly mobile are more conforming to traditional norms. 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 pre- sents evidence of how patient characteristics, such as race and ethnicity, gender, social class, literacy, health status, and age cohort affect patient- provider communication. Patient race and ethnicity. Ethnic origin and cultural background con- tribute not only to the definition of what symptoms are noteworthy, but are also responsible for how symptoms will be presented to the physician. Studies have found that physicians deliver less information, less support- ive talk, and less proficient clinical performance to black and Hispanic patients and patients of lower economic class than they do to more advantaged patients, even in the same care settings (Bartlett et al., 1984; Epstein, Taylor, and Sewage, 1985; Hooper, Comstock, Goodwin, and Goodwin, 1982; Ross, Mirowsky, and Duff, 1982; Waitzkin, 1985; Wasserman, Inui, Barriatua, Carter, and Lippincott, 1984). Various inter- pretations are possible. One is that physicians perform more poorly with such patients because they devalue them and their needs. Another is that the poor performance stems from stereotypes about the expectations, ca- pacities, and desires of such patients. Still another is that due to cultural
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583 PATIENT-PROVIDER COMMUNICATION Carlisle DM, Leake BD, Shapiro MF. 1997. Racial and ethnic disparities in the use of cardio- vascular procedures: Associations with type of health insurance. American Journal of Public Health, (87):263-267. Carrasquillo O, Orav EJ, Brennan TA, Burstin HR. 1999. Impact of language barriers on patient satisfaction in an emergency department. Journal of General Internal Medicine, (14):82-87. Carrillo JE, Green AR, Betancourt JR. 1999. Cross-cultural primary care: A patient-based approach. Annals of Internal Medicine, (130):829-34. Cartwright A. 1967. Patients and their doctors. London: Routledge, Kegan Paul. Cegala D J, Marinelli T, Post D. 2000. The effects of patient communication skills training on compliance. Archives of Family Medicine, (9):57-64. Cegala DJ, McClure L, Marinelli TM, Post DM. 2000. The effects of communication skills training on patients’ participation during medical interviews. Patient Education and Counseling, (41):209-222. Cleary PD, McNeil BJ. 1988. Patient satisfaction as an indicator of quality care. Inquiry, (25): 25-36. Coe RM. 1970. Sociology of medicine. New York: McGraw Hill. Cohen-Cole S. 1991. The medical interview: The three function approach. St. Louis, Missouri: Mosby. Colford JM, McPhee SJ. 1989. The ravelled sleeve of care: Managing the stresses of resi- dency training. Journal of the American Medical Association, (261):889-893. Conigliaro J, Whittle J, Good CB, Hanusa BH, Passman LJ, Lofgren RP, Allman R, Ubel PA, O’Connor M, Macpherson DS. 2000. Understanding racial variation in the use of coro- nary revascularization procedures: the role of clinical factors. Archives of Internal Medi- cine, (160):1329-1335. Cooper-Patrick L, Ford DE, Vu HT, Powe NR, Steinwachs DM, Roter DL. 2000. Patient- physician race concordance and communication in primary care. Journal of General In- ternal Medicine, (15):106. Cooper-Patrick L, Gallo JJ, Gonzales JJ, Vu HT, Powe NR, Nelson C, Ford DE. 1999. Race, gender, and partnership in the patient-physician relationship. Journal of the American Medical Association, (282):583-589. Cross TL, Bazron BJ, Dennis KW, Isaacs MR. 1989. Towards a culturally competent system of care: A monograph on effective services for minority children who are severely emotionally disturbed. Washington DC: CASSP Technical Assistance Center, Georgetown University Child Development Center. Cypress, BK. 1980. Characteristics of visits to female and male physicians. Vital and Health Statistics: Series 13, No. 49. Hyattsville, Maryland: U.S. Department of Health and Human Services. Davis M. 1969. Variations in patients’ compliance with doctors advice: An empirical analy- sis of patterns of communication. American Journal of Public Health, (58):274-288. Davis M. 1971. Variation in patients’ compliance with doctors’ orders: Medical practice and doctor-patient interaction. Psychiatry in Medicine, (2):31-54. Delbanco TL. 1992. Enriching the doctor-patient relationship by inviting the patient’s per- spective. Annals of Internal Medicine, (116):414-418. Delbanco TL, Stokes DM, Cleary PD, Edgman-Levitan S, Walker JD, Gerteis M, Daley J. 1995. Medical patients’ assessments of their care during hospitalization: Insights for internists. Journal of General Internal Medicine, (10):679-685. Dexter ER, LeVine SE, Velasco PM. Maternal schooling and health-related language and literacy skills in rural Mexico. 1998. Comparative Education Review, (42):139-162. DiMatteo, MR. 1994. Enhancing patient adherence to medical recommendations. Journal of the American Medical Association, (271):79-83.
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