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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 healthcareâincluding the receipt of certain tests, procedures, and thera- piesâa 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 raceâincluding gender, age, literacy, social class, health status, and the normative expectations that guide the therapeutic relation- shipâare 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
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 âdoctorâ 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;
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 Kleinmanâs seminal article (Kleinman, Eisenberg, and Good, 1978) articulated the importance of culture in healthcare. Culture, de- fined as âthe integrated pattern of human behavior that includes thoughts, communications, actions, customs, beliefs, values, and institutions of a racial, ethnic, religious, or social groupâ (Cross et al., 1989), is relevant to everyoneâs 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
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 raceâincluding gender, age, literacy, social class, and the normative expectations that guide the thera- peutic relationshipâare 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.
556 UNEQUAL TREATMENT Physician Role Obligations and Medicineâs Unwritten Social Contract It has been argued that the basis of trust between patients and their physicians lies in the physicianâs dedication to âuniversalism,â 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 patientsâ 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 patientsâ interpretation of pain and expectations regarding pain control varied widely across ethnic groups and that members of these groups
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 physiciansâ 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 physiciansâ 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 patientsâ racial or SES group or from patientsâ reports of their actual behaviors and tendencies. Physiciansâ negative attitudes or the assump- tions they make about a patientâs 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-
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 patientsâ race or ethnicity on physiciansâ 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 patientsâ 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 physicianâs 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-
559 PATIENT-PROVIDER COMMUNICATION ciated with patient ratings of physiciansâ 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 patientsâ 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 âmm-hmmâ which serve to facilitate a partnerâs 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).
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- siciansâ talk included less psychosocial discussion. Male physicians also asked fewer questions of all sorts, engaged in less partnership-building behaviors (enlisting the patientâs 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 patientâs 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 physiciansâ 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 patientsâ communication, it is also possible that social-class background relates to differences in physiciansâ communication. These differences might act to
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. Physiciansâ so- cial class background, as measured by their fathersâ occupations and the physicianâs 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 âOrientation 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 positionâ (Waitzkin, 1985, p. 92). Another example of the evidence of how social background affects physiciansâ styles of practice is found in Hollingshead and Redlichâs (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 psychiatristâs 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 âold American stock,â 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.
562 UNEQUAL TREATMENT Hollingshead and Redlich speculate that the analytic psychiatrists âlike 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, transformationâ (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 âtake chargeâ 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
563 PATIENT-PROVIDER COMMUNICATION norms or lack of confidence, such patients do not request or demand a high level of performance from their physicians (which would, of course, confirm whatever stereotypes the physicians may already have). All of these possibilities could be relevant, for example, to the finding that Asian- American patients in Hawaii report a lower degree of participation in their medical visits than mainland Americans do (Young and Klingle, 1996). An additional example is provided by preliminary data from our ongoing study of primary care physicians and patients in the Baltimore-Washing- ton, DC, metropolitan area showing that African-American patients expe- rience shorter, more physician verbally dominated, and less patient-cen- tered visits than white patients (Cooper-Patrick et al., 2000). Other studies of the role of patient ethnicity in the medical dialogue have been conducted in Eurocentric groups. 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) found that among pa- tients seeking medical care from several different outpatient clinics, those of Italian rather than Irish or Anglo-Saxon descent were much more likely to be labeled as having âpsychiatric problemsâ by their phy- sicians, despite the fact that there was no objective evidence that these problems were more frequent among this particular group. For instance, when the doctors could not identify any specific disease to explain the patientâs symptomsâwhich happened equally often in each of the eth- nic groupsâItalians almost always had their symptoms attributed to psychological problems; this almost never happened in the case of the Anglo Saxons and Irish. Differences were evident, however, in how the Italians presented their chief complaints. Italians reported more pain, more symptoms overall and in more bodily locations, and more consequent dysfunction, includ- ing interference with their social and personal relations. From these find- ings, the investigator (Zola, 1963) speculates that the Italians and Irish have ways of communicating illness that reflect different ways of han- dling problems within the culture itself. The Italians tend toward drama and exaggeration as a means of dissipating and coping with anxiety, whereas the Irish have a tradition in which control and denial are fore- most (Barzini, 1965). This became evident in the very different ways these patients presented their symptoms to their doctors. Similar findings were reported by Zborowski (1952) in describing ethnic variations in response to pain. Anglo-Saxon patients viewed pain in an âobjectiveâ and rather unemotional way, the Irish often denied pain, and Italian and Jewish pa- tients were highly emotional and exaggerated in their pain expression. Moreover, the Italian patients sought immediate relief from pain and were satisfied as soon as the pain ceased, but the Jewish patients were more
564 UNEQUAL TREATMENT concerned about the significance of their pain for future health and re- sisted pain medication for fear that it would mask a significant symptom. It is also important to note that appropriate treatment was tied to the way in which patients presented their pain. For example, painkillers would be effective for the Italian patients, but not for the Jewish patients until reas- surance about future health was also provided. Only a physician sensi- tive to these distinctions could appropriately recognize these needs. A follow-up study, using the same clinics as in the Zborowski study some 20 years later (Koopman, Eisenthal, and Stoeckle, 1984) found simi- lar differences in pain reporting between Anglos and Italians. However, the effects of culture were most evident with patients over 60 years of age. Sex was also found to be important in this study; pain was most likely to be reported by older female Italians and least likely to be reported by older male Anglos. For younger patients, now second and third genera- tion in this country, the process of acculturation had diminished the eth- nic effects. Given the correlation between social class and ethnicity in our soci- ety, it is not surprising that doctorsâ treatment of patients in different eth- nic groups tends to parallel that for different social classes. Whites have been shown to receive care that is of higher technical and interpersonal quality than blacks or Hispanics receive, as well as to receive more posi- tive talk and more information, even within the same medical practices (Hall, Roter, and Katz, 1988; Tuckett et al., 1985). One study found that blacks received fewer recommendations for open-heart surgery, although they had equal clinical need; of all patients who received such a recom- mendation, blacks had surgery less often (Maynard, Fisher, Passamani, and Pullum, 1986). Another one of the few communication studies to address directly the issue of ethnicity found that physicians demonstrated better questioning and facilitating skills and more empathy skills when with Anglo-Ameri- can as compared to Spanish-American patients (Hooper et al., 1982). The investigators suggest that poorer performance is particularly evident in communication skills requiring listening. We believe that negative stereotypes of disadvantaged social groups affect the way doctors interact with these patients. We also believe this is unintentional and that doctors are only dimly aware of differences in their behavior, if at all. Like most people, doctors probably attribute any differ- ences 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). When oneâs own behavior can be construed as negative, one is particu- larly inclined to blame it on the other person. Attributing oneâs own be- havior to causes outside of oneself would greatly decrease the likelihood
565 PATIENT-PROVIDER COMMUNICATION that doctors recognize a connection between their own attitudes and be- havior (Roter and Hall, 1992). Patient gender. Among patients with chronic disease, females are more likely to prefer an active role in medical decision-making than males (Arora and McHorney, 2000). Indeed, this preference appears to be borne out in practice, as male patients report that they experience less opportu- nity for decision-making in their encounters with their physicians than female patients report (Kaplan et al., 1995). In that study, patient partici- pation in decision-making was particularly low when male patients inter- acted with male physicians, a finding consistent with the finding that in male patient-male physician interactions the contribution of the patient relative to the physician is the least of all gender combinations (Hall et al., 1994b). Waitzkin (1985) found that female patients were given more informa- tion than male patients, and that the information was given in a more comprehensible manner. The same data set also revealed that the greater amount of information directed toward women was largely in response to womenâs tendency to ask more questions in general and to ask more questions following the doctorâs explanation (Wallen, Waitzkin, and Stoeckle, 1979). Similar conclusions were reached in an English study by Pendleton and Bochner (1980), who found that female patients were given more information than males and that this information was in response to the womenâs more frequent questions. These findings are consistent with those relating to patient activation described above. Investigators have also found that female patients receive more posi- tive talk and more attempts to include them in discussion than males. In one study, physicians were more likely to express âtension releaseâ (mainly laughter) with female patients and to ask them more for their feelings (Stewart, 1983). Patient age. Patient age is associated with both the frequency of medi- cal contacts and the communication dynamic of these visits. Older pa- tients are plagued by multiple and complicated medical problems and are often required to make difficult decisions regarding the management of debilitating conditions. Moreover, it is the elderly who are most often required to confront fundamental choices at the end of life. While faced with these challenges, the elderly may be at a special disadvantage in fully understanding the complex choices they are asked to make. The elderly typically demonstrate lower levels of literacy and have had less exposure to formal education than younger birth-cohorts (Gazmararian et al., 1999). 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
566 UNEQUAL TREATMENT process. The Medical Outcomes Study (MOS) (Kaplan et al., 1995), based on surveys of over 8,000 patients sampled from the practices of 344 physi- cians, found that patients aged 75 and over reported significantly less par- ticipatory visits with their doctors than all but the youngest age cohorts of patients (those younger than 30 years). Interestingly, the most participa- tory visits were evident in the scores of only slightly younger patient groups including those aged 65 to 74, and the middle-aged group ranging from 45 to 64 years. In addition to age, ethnic minority status, poor health status and lower educational achievement were associated with lower re- ports of participatory visits. Thus, older ethnic minority patients may be at fourfold risk for low levels of participatory engagement with their doc- tors. All of the above factors may act alone or in concert to diminish the likelihood that full patient-physician partnerships will develop. Older patient visits are also distinguished from those of younger adults by the presence of a visit companion; estimates of the percentages of all visits that include a companion range between 20% and 57% (Prohaska and Glasser, 1996). There are only a few empirical studies of the effect of companions on the dynamics of exchanges in discussions, but their presence appears to change communication patterns. Greene et al. (1987) found that when a companion was present, older patients raised fewer topics, were less responsive to topics they did raise, and were less assertive and expressive. Moreover, patients were sometimes excluded completely from the conversation when a companion was present. Additional communication difficulties have been identified, including a tendency for a family member to take on the information-giving role in the visit, sometimes contradicting the patient or disclosing information the patient had not wanted revealed (Hasselkus, 1994). It appears that the content, tone, and nature of the medical discussion may be shaped by the roles adopted by the patient companion, and these may range from advocate and supporter to antagonist (Adelman, Greene, and Charon, 1987; Greene, Adelman, Friedman, and Charon, 1994). We know little about moderating effects such as the visit companionâs ethnicity and culture, age cohort, and the nature of familial relationships on communication dynamics. An intriguing question is the effect on com- munication when âbaby boomersâ serve as companions in the medical visits of their aging parents, compared with spouses or contemporaries acting as visit companions. We might speculate that these adult children bring an assertiveness to their medical encounters that can dominate the visit and perhaps contribute to a verbal withdrawal by the patient from the medical dialogue (as described by Greene et al., 1987, above). Alter- natively, the presence of a consumerist companion may spur assertive behavior on the part of some patients. These dynamics are made all the more complicated when consideration is given to the impact of changing
567 PATIENT-PROVIDER COMMUNICATION social norms for communication across racial groups, particularly for Af- rican-American birth cohorts (Satcher, 1973). Patient social class. The effect of social class on patientsâ presentation of themselves and their problems also has relevance for the medical treat- ment patients receive. Doctors talk more with patients who are higher in social class. This has been found in Florida, Massachusetts, California, England, and Scotland (Roter and Hall, 1992). How does such treatment affect the patient and what accounts for such findings? Does the higher social class patient have more to say? Or does this patient not have more to say, but instead, has the assertiveness to say it? Does the doctor give more opportunity for such a patient to talk by nonverbal indications of interest and by asking more inviting questions? Doctors give more information to the higher-class patients, even though, when asked later, patients of different classes do not differ in how much information they say they want. In their English videotape study of 79 general consultations, Pendleton and Bochner (1980) found that patientsâ social class was a significant predictor of how many expla- nations were volunteered by doctors. Physicians spontaneously offered more explanations to patients of higher-class backgrounds during visits than to other patients. The investigators suggest that physician explana- tions are less likely to be volunteered to patients of lower-class back- grounds because they are perceived as less interested in information and more diffident in question-asking. In an earlier Scottish study, Bain (1976) found that patients of lower- class backgrounds were less verbally active overall during medical visits than others. This was especially evident in areas such as patient presenta- tion of their symptoms, question-asking, and social talk. Physicians were much more likely to give higher-class patients information regarding prob- lem resolution and to engage in social talk with them than with lower-class patients. In further analysis of these data, Bain (1977) found that communi- cation regarding drugs was significantly less successful with patients of lower-socioeconomic backgrounds as their recall of diagnosis, drugs pre- scribed, and advice given regarding how often drugs should be taken and the duration of treatment was less than other patients. Bainâs later U.S. study (1979) involving 22 physicians and a total of 556 patients, confirmed similar differences in the overall content of communications for patients from different socioeconomic groups. Patients with higher socioeconomic class backgrounds engaged in nearly 60% more talk with the physician dur- ing the visit than patients of lower socioeconomic groups. Work by Cartwright and others appears to support the contention that patients of lower-class backgrounds appear diffident in asking ques- tions, not because they do not wish to know about medical matters, but rather because the social distance between themselves and their physi-
568 UNEQUAL TREATMENT cians discourages verbal assertiveness (Cartwright, 1967). Waitzkin (1985) attributes the paucity of direct question-asking by working-class patients to their sociolinguistic culture, which tends to be less verbal than that of the middle class. Because of the tendency away from direct (verbal) com- munication, working-class patients may be communicating their desire for information in ways physicians are likely to miss. Doctors, like other members of the middle class, expect communication to be verbal and ex- plicit; if patients have questions, physicians expect that they will be asked. Consequently, non-solicited information is not offered and reticence is taken as an indication of disinterest. Waitzkinâs (1985) large study in the United States found that better educated patients and patients of higher socioeconomic backgrounds re- ceived more physician time, more total explanations, and more explana- tions in comprehensible language than other patients. Ironically, physi- cians not only gave more information to higher-class patients, they also appeared to go out of their way to offer these explanations in clear, non- technical language. Multivariate analysis of these data further demon- strated that patientsâ level of education was more important than social class in general in explaining information transmittal. Thus, Waitzkin concludes that the educational aspect of social class determination is a particularly strong factor in doctor-patient communication. In a similar vein, Stewart (1983) reports that better-educated patients were much more likely to receive a justification for their treatment regi- mens from their physicians than less-educated patients. In this study, however, more information came at the price of communication, which offered emotional support. The better-educated patients in this study re- ceived less âsolidarityâ from their physicians than did those patients with- out some university level training. The opposite finding in regard to emotional support has been re- ported in several communication studies of pediatric visits wherein bet- ter-educated parents of patients received more emotional support than less-educated parents. The classic study by Korsch and associates (Korsch, Gozzi, and Francis, 1968) of pediatric encounters in an emergency walk-in clinic found that better-educated parents of patients were more likely to express their fears and hopes to the doctor and that they had a better chance of having these responded to or dealt with than less-educated par- ents. Similarly, the pediatric study by Wasserman and associates (Wasser- man, Inui, Barriatua, Carter, and Lippincott, 1983) found that better-edu- cated mothers received more reassurance, encouragement, and empathy during pediatric visits than less-educated mothers. Finally, in the most extensive observational study of pediatric practice, Ross and Duff (1982) observed indicators of performance quality, both technical and interper- sonal, in over 400 pediatric visits and reported that poorly educated par-
569 PATIENT-PROVIDER COMMUNICATION ents received worse care on all accounts from their physicians. Also noted in this study was that low-income families did not have as consistently negative experiences as did the children of the poorly educated. These authors concluded, as did Waitzkin (1985), that education has more sig- nificance for health experience than other socioeconomic indicators. In sum, we can say that physicians engage in more talk overall, and especially more informative talk, with patients of higher as compared to lower social classes. Moreover, the evidence suggests that education may play a key role in the differential communication to patients of varying socioeconomic groups. The communication advantage for the better edu- cated is especially evident in socioemotional support expressed during pediatric encounters. It has long been known that poorer and less educated patients have trouble finding healthcare and get less of it. Now it appears that the prob- lems of these groups are not entirely structural. They suffer poorer treat- ment even after they gain access to the healthcare system. The poor also have worse health, and although this has usually been assumed to stem from lifestyle factors such as stress or poor nutrition or from difficulties in getting care, the possibility must also be raised that disadvantaged pa- tients may be sicker partly because of the way in which they and their doctors communicate. Patient health status. The state of a patientâs physical and mental health is related to both patient and physician communication (Bertakis, Calla- han, Helms, Rahman, and Robbins, 1993; Hall et al., 1996). When the patient is more distressed, either physically or mentally, both the patient and the physician engage in less social conversation and make more emo- tionally concerned statements, engage in more psychosocial discussion, and ask more biomedical questions. Sicker patients also provide more biomedical information. The research also suggests that physicians may respond ambivalently to sicker patients; physicians report less satisfac- tion after visits with sicker patients, and they report liking sicker patients less than more healthy patients (Hall et al., 1993, 1996). 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 dis- playing negative behaviors toward them. Hall, Milburn, Roter, and Daltroy (1998) used structural equation modeling to test this hypothesis and also to test whether the dissatisfaction stems directly from the sicker patientâs negative outlook. In general, the direct path was supported over the physician-mediation path, with one exception: physiciansâ curtailing of social conversation with sicker patients accounted for some of these patientsâ dissatisfaction. This is unfortunate, for in curtailing this âex-
570 UNEQUAL TREATMENT pendableâ category of interaction in the service of devoting time to more pressing medical issues, physicians may unknowingly undermine their relationships with the very patients to whom the quality of the relation- ship may matter most. To the extent that ethnic minority patients have poorer access to healthcare, present for care at later stages of disease, and have poorer health status, the impact of their health status may further exacerbate the communication problems they are already experiencing due to cultural or social class differences from their physicians (Hall and Roter, 2002). Patient literacy. Access to healthcare is traditionally assumed to occur once the patient walks through the examining room door. Yet, providing access to care is more than simply achieving patient presence; it also in- volves enabling patient engagement in the process of care. While not as obvious as cost and transportation barriers, low literacy skill is a signifi- cant obstacle to full access to effective medical care (Miles and Davis, 1995; Baker, Parker, and Clark, 1998). Even after adjusting for confounding sociodemographic variables such as ethnicity, gender, and age, Baker and his colleagues (1998) found that patients with low literacy skills have poorer health, higher rates of hospitalizations, and incur higher health- care costs than those patients with adequate literacy. The problem of poor literacy and its significance to patient care is made more meaningful when put within the health context. The Test of Functional Health Literacy Assessment âTOFHLA,â developed by Parker and colleagues, is based on specific measures that reflect a patientâs abil- ity to perform health-related tasks that require reading and computational skills. These tasks include taking medication, keeping appointments, ap- propriately preparing for tests and procedures, and giving adequate in- formed consent (Parker et al., 1995). Using the TOFHLA measure, Baker and colleagues have demonstrated that fully one-third of patients admit- ted to their inner-city hospital were functionally illiterate, while another 13 percent demonstrated marginally functional health literacy (Baker et al., 1998). These findings are consistent with prior research reporting in- adequate or marginal functional health literacy to be 35 percent among English-speaking patients and 62 percent among Spanish-speaking pa- tients seeking care at public inner-city hospitals. The prevalence of low literacy among elderly patients (more than 60 years of age) was greater than 80 percent for both English- and Spanish-speaking patients (Will- iams et al., 1995). With so high a prevalence of low literacy skills among the general population, physicians are likely to encounter patients with limited lit- eracy skills. 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-
571 PATIENT-PROVIDER COMMUNICATION ceptions surrounding illiteracy may hamper such recognition. In their comprehensive overview of challenges in teaching patients with low lit- eracy skills, Doak et al. broke several widespread myths associated with illiteracy: 1) that people with low literacy skills are intellectually impaired and slow learners; 2) that most adults with low literacy skills are poor, immigrants, and minorities; 3) that total years of schooling is a good mea- sure of literacy levels; and 4) that people will tell you if they cannot read or they will get help when they need it (Doak et al., 1996). In fact, most people with low literacy skills have an average IQ and function reasonably well by compensating in other ways for lack of read- ing skills (Doak et al., 1996; Jackson et al., 1991). The circumstances un- derlying low literacy are varied. Limited educational opportunity ac- counts 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). While low literacy is more frequent among persons of lower socioeconomic status, the poorly educated, the elderly, American-born ethnic minorities, immigrants, and the disabled, it is not limited to these groups. According to the U.S. Department of Educationâs National Adult Literacy Survey (NALS), in absolute terms, the majority of the low-literate population are white native-born Americans (Kirsch et al., 1993). Fur- thermore, more than 20 percent of adults tested in the NALS and 18 per- cent of patients in the study by Baker et al. who had demonstrated the lowest levels of literacy had earned a high school diploma. As noted by Baker et al., years of schooling reflect education completed, not skills at- tained, and is a rather insensitive measure of literacy (Baker et al., 1998). Indeed, adults typically read 3-5 grade levels lower than years of formal education completed (Jackson et al., 1991; Doak and Doak, 1980). Commonly held expectations about reading ability and social appro- bation that often follow discovery of literacy limitations may serve to in- hibit disclosure, silence patients, and further discourage efforts to seek information or request assistance. Parikh and colleagues report that one in three patients characterized by the TOFHLA as having low functional health literacy did not acknowledge difficulty reading or understanding what they read. Among those patients who admitted having trouble read- ing, 40% acknowledged feeling shame, and more than half of these pa- tients had never told their spouses or children about their difficulties read- ing (Parikh et al., 1996). Poor literacy may be a marker for an array of communication and infor- mation processing problems that go far beyond reading ability. Communica- tion difficulties faced by patients may be due in part to differences in vocabu- lary, but may also be attributed to differences in the structure and complexity
572 UNEQUAL TREATMENT of speech used by literate and low-literate populations (Roter, Rudd, and Comings, 1998). Some insight into the explanatory mechanisms linking lit- eracy to health outcomes is provided by LeVine and colleagues in several studies conducted in developing countries (LeVine et al., 1994). These inves- tigators have found a relationship between literacy skills level and compre- hension of oral communication. The authors suggest that literacy builds a cognitive process that facilitates comprehension of formal spoken language, such as that commonly included in health messages. Even further, Dexter et al. have demonstrated that poor literacy skills are linked to an individualâs ability to give adequate health-related descriptions (Dexter et al., 1998). This research suggests that low literacy not only presents obvious barriers to effec- tive 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 understand- ing physiciansâ oral communication. An analysis of focus groups and in- dividual interviews with low-literate patients revealed serious and wide- spread communication difficulties with their health providers (Baker et al., 1996). Patients complained that they felt they were neither listened to nor adequately informed about their medical problems and treatments in ways they could understand. Despite this frustration, few patients asked questions or otherwise revealed their difficulties to their providers. In- deed, few patients disclosed their poor literacy to providers at all. Though some patients concealed this information out of embarrassment, others simply did not think this was something the physician would be inter- ested in knowing. While better-designed, learner-centered materials are undoubtedly helpful to patients, there is little offered in the literature to help physi- cians better communicate with their low-literate patients. Consequently, it is not surprising that when patients with poor literacy skills are recog- nized, few physicians feel competent to adequately respond to their needs (Miles and Davis, 1995; Weiss and Coyne, 1997). The Consequence of Race Concordance on Patient Reports of Physician Participatory Decision-Making (PDM) Style and Other Aspects of Communication In our telephone survey study of 1,816 adult managed care enrollees attending primary care practices in a large urban area, we examined the association between race or ethnic concordance and discordance on pa- tient ratings of physiciansâ PDM style (Cooper-Patrick et al., 1999). The patient sample was 43% white, 45% African American, and 12% other race/ethnic groups (5% Asian, 5% Hispanic, and 2% Native American). To study the potential influence of race concordance or discordance be-
573 PATIENT-PROVIDER COMMUNICATION tween physicians and patients on PDM, we stratified patients according to the race/ethnicity of their physicians. We then measured the relation- ship between PDM style and patient race within each physician race group, adjusting for patient age, gender, education, marital status, health status, and length of the relationship. African-American patients had sig- nificantly less participatory visits with white physicians than white pa- tients ([beta] = â4.3, SE = 1.7, p < 0.02, adjusted). Asian and Hispanic patients had less participatory visits with African-American physicians than African-American patients; however, these results were based on very small sample sizes. There were no significant racial differences in PDM scores among patients seeing Asian or Hispanic doctors. However, there were only two Hispanic physicians in the study sample; therefore, reliable conclusions regarding the participatory decision-making style of Hispanic physicians could not be drawn. To explore the overall significance of racial and ethnic concordance in the physician-patient relationship, we conducted an analysis to assess the relationship between race/ethnic concordance between physicians and patients and PDM style. Patients in race-concordant relationships with their physicians rated their physicians as significantly more participatory than patients in race discordant relationships ([beta] = 2.6, SE = 1.1, p < 0.02, adjusted) (Cooper-Patrick et al., 1999). In another study of the impact of racial concordance on patient rat- ings of care by physicians, researchers used data from a nationwide tele- phone survey of 2,201 white, black, and Hispanic adults who reported having a regular physician (Saha et al., 1999). In this study, black respon- dents with black physicians were more likely than those with non-black physicians to rate their physicians as excellent overall, at treating them with respect, explaining problems, listening, and being accessible to them. Hispanic patients with Hispanic physicians were more likely than those with non-Hispanic physicians to be very satisfied with their healthcare overall, but not significantly more likely to rate their physicians as excel- lent. The Hispanic respondents were primarily of Mexican and Puerto Rican descent, and the majority of them were born in the United States. Studies have shown that ethnic minority physicians, particularly blacks and Hispanics, are more likely to provide healthcare to ethnic mi- nority, 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). Nevertheless, minority patients are far more likely to receive their care from white and Asian physicians than from physicians who are African American or Hispanic since the number of physicians from these ethnic groups is so small.
574 UNEQUAL TREATMENT Another study by Saha and colleagues, using The Commonwealth Fund 1994 National Comparative Survey of Minority Healthcare, showed that black and Hispanic respondents who had the ability to choose their physician were more likely to choose a racially or ethnically concordant physician (Saha et al., 2000). About 42% of the Hispanic respondents who chose a Hispanic physician did so because of language. Other reasons for ethnic minority patient preference for and higher ratings of care in race- concordant relationships with physicians are unclear, but potential expla- nations 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 au- diotape analysis, we have examined the relationship between race con- cordance and actual patient and physician communication behaviors (252 adult patientsâ142 white, 110 African-American; 31 primary care physi- ciansâ13 white, 18 African-American). Our preliminary analysis shows significant differences in communication dynamics along several dimen- sions. Both African-American and white patients appear to have shorter visits (by about 2.0 minutes) when in race-discordant relationships with physicians. In addition to length of the visit, the strongest communication element that discriminated between race-concordant and discordant dy- ads was positive patient affect. When the same survey questions used in earlier research were used to determine patient ratings of PDM, the ratings were significantly associ- ated with audiotape measures of patient-centered interviewing (p < 0.01, Cooper, Roter, Ford, Steinwachs, Powe, published abstract, 2000). Pa- tients in race-concordant dyads rated their physicians as more participa- tory than patients in race-discordant dyads (consistent with previous work, Cooper-Patrick et al., 1999). Since African-American patients are more likely to be in race-discordant relationships with physicians than white patients, they are more likely to have shorter visits, less positive affect, and less perceived participatory decision-making. The Relationship Between Communication Style and Patient Satisfaction and Health Outcomes The physician-patient relationship and its expression through the medical dialogue has been described or alluded to in the history of medi-
575 PATIENT-PROVIDER COMMUNICATION cine since the time of the Greeks (Emanuel, 1961) and in the modern medi- cal and social sciences literature for the past 50 years (Engel, 1977; Freidson, 1970; Parsons, 1951; Szasz and Hollender, 1956). George Engelâs articulation of the biopsychosocial model of medical interviewing in the 1970s (Engel, 1977, 1988), later translated into a patient-centered clinical method by McWhinney (1988, 1989), has given substance to the promi- nence of a general reference to âpatient-centerednessâ in medical commu- nication curricula and research (Lipkin, Putnam, and Lazare, 1995; Mead and Bower, 2000). Patient-centered communication skills are not unlike the many other technical skills that comprise the basis of medical practice and for which proficiency is expected. Patient-centered care is defined as healthcare that is closely congruent with and responsive to patientsâ values, needs, and preferences (Delbanco, 1992; Gerteis, Edgman-Levitan, Daley, Delbanco, 1993). The corresponding communication behaviors include data-gather- ing skills (i.e., use of open-ended questions, particularly in the psychoso- cial domain), relationship skills (i.e., use of empathy, reassurance, sup- port, and emotional responsiveness), partnering skills (i.e., paraphrasing, asking for patient opinion, negotiation and joint problem solving) and counseling skills (i.e., informativeness) (Lazare, Putnam, and Lipkin, 1995; Roter, 2000a). Visits that include more patient questions and physician information giving, a higher proportion of psychosocial and emotional statements rela- tive to biomedical statements, and less verbal dominance by physicians are considered more patient-centered. Strong evidence links these com- munication behaviors to valued patient outcomes, including improve- ments in markers of disease control such as hemoglobin A1c and blood pressure, enhanced reports of physical and emotional health status, func- tioning, 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 asso- ciated with higher levels of patient satisfaction (Kaplan et al., 1995). Addi- tionally, a meta-analysis concluded that three dimensions of communica- tion (informativeness, interpersonal sensitivity, and partnership building) were consistently associated with patient satisfaction, compliance, and recall of information (Roter, Hall, and Katz, 1988). Implications for Physician Training and Patient Activation to Improve Patient-Physician Communication Within Culturally Diverse Populations Researchers have commented on the fact that physicians perform thousands of medical interviews during their career with virtually no for-
576 UNEQUAL TREATMENT mal training in communication skills (Epstein, Campbell, Cohen-Cole, McWhinney, and Smilkstein, 1993). For a long time, the assumption was that physicians naturally have adequate communication skill or that this skill inevitably develops through frequent experience. Now, medical edu- cators agree that training is necessary, that a solid foundation of behav- ioral science research exists to support training programs, and that train- ing 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). Despite variations in the length and format of training programs, all or most of these programs focus on the principles of relationship-centered medicine (e.g., Bensing and Sluijs, 1985; Cohen-Cole, 1991; Novack, Dube, and Goldstein, 1992; Putnam, Stiles, Jacob, and James, 1988; Roter et al., 1995). The study of Novack et al. (1992) found improvements in sensitiv- ity to psychosocial aspects of the patientâs illness, the ability to relate to patients, the ability to elicit information from patients, and the ability to communicate empathy. The training program of Roter et al. (1995) em- phasized physiciansâ ability to recognize and handle psychosocial prob- lems. After only eight hours of training, physicians did better with their actual patients (who were audiotaped several weeks post-training) in terms of emotion handling, recognizing psychological problems, and tak- ing a problem-solving approachâwith no increase in the overall length of the medical visit. Smith et al. (2000) have developed a standardized training program for primary care residents that has produced very encouraging results in terms of residentsâ knowledge, attitudes, self-confidence, skills in inter- viewing patients and dealing with relationships, skills in managing and communicating with somatizing patients, and skills in educating patients. Elements in Smithâs training program include setting the stage (welcom- ing the patient, using the patientâs name, introducing self, removing bar- riers to communication, putting the patient at ease), agenda setting (indi- cating time available, indicating own needs, obtaining list of all issues the patient wants to discuss, summarizing and finalizing the agenda), non- focused interviewing (appropriate use of open- and closed-ended ques- tions, observing the patientâs cues), and focused interviewing (symptom discovery, learning personal context of symptoms, addressing emotions). In contrast to the existence of many programs aimed at physicians and many published evaluations of such programs, relatively little re- search has tried to intervene with patients to improve the communication process. Classic is Roterâs (1977) waiting-room intervention to increase patientsâ question-asking. More striking still are the experimental studies showing that a brief waiting-room intervention to increase patientsâ par- ticipation in the medical visit can have significant effects on health out-
577 PATIENT-PROVIDER COMMUNICATION comes. In these studies, a research assistant reviewed the medical record with the patient, helped the patient identify decisions to be made, re- hearsed negotiation skills, encouraged the patient to ask questions, re- viewed obstacles such as embarrassment and intimidation, and after the visit gave the patient a copy of the medical record for that visit. In a sample of patients with diabetes, such an intervention reduced blood sugar, reduced patientsâ reports of functional limitations (mobility, role functions, physical activities), and improved patientsâ perceptions of their overall health (Greenfield, Kaplan, Ware, Yano, and Frank, 1988). Mecha- nisms accounting for these effects are not entirely understood because the intervention contained a number of different elements, but are likely re- lated both to information exchange and to feelings of empowerment. In that diabetes study, experimental patients elicited more information from physicians, talked more, and were more assertive. Encouraging results have occurred in similarly designed studies using different patient popu- lations, such as patients with ulcer disease (Kaplan, Greenfield, and Ware, 1989). Recently, an even simpler intervention, consisting of a mailed book- let designed to instruct patients in seeking, verifying, and providing in- formation during the medical visit and to give them the opportunity to write down their concerns and questions, had significant effects on pa- tientsâ information seeking and success in obtaining information. There was also a significant effect on how much information they gave to their physicians, and on self-reported adherence two weeks later (Cegala, McClure, Marinelli, and Post, 2000). Studies show that ethnic minority, low literate, and low SES patients experience lower levels of patient-centered communication and greater verbal passivity with physicians than whites and patients with higher levels of education. While health education programs often target disen- franchised populations, those groups are hard to reach and the least able to take advantage of innovations in educational and communication technology. Directions for Future Research Future research to better understand the contribution of patient-pro- vider communication to racial and ethnic disparities in care should be multifaceted, using combinations of clinical data, patient and provider surveys, audiotape and/or videotape analysis, and qualitative methods. Additionally, intervention studies that develop and test methods for im- proving patient-provider communication in encounters with ethnic mi- nority patients, as well as studies that evaluate the impact of such inter- ventions on processes and outcomes of care, are needed. Because most of the existing research focuses on African Americans, more studies includ-
578 UNEQUAL TREATMENT ing other ethnic minority groups, such as Hispanics and Asian Ameri- cans, are needed. Moreover, there is a paucity of research on the impact of using institutional resources (direct services, cultural homophilly, and institutional accommodations) to increase cultural competency. Issues identified in existing research that are of potential interest for future re- search include: 1) the degree to which physiciansâ cultural competence is explained by use of patient-centered communication; 2) the degree to which other attitudes and skills are necessary in order to achieve cultural competence in patient-physician communication; and 3) identifying which patient and provider attitudes and behaviors, in addition to patient- centeredness, explain higher patient ratings of partnership and satisfac- tion in race-concordant patient-physician relationships. For example, pre- liminary results from our study of race-concordance and communication show that race-concordance, while associated with better ratings of inter- personal care from physicians, particularly for African Americans, is not directly associated with patient-centeredness as measured by audiotape analysis, implying that other attitudes and perceptions on the part of pa- tients and physicians are in operation. In a recent review of the literature on the provider contribution to racial and ethnic disparities in healthcare, van Ryn (2002) discusses sev- eral studies that support a central hypothesis: that provider beliefs about patients and provider behavior during patient encounters are indepen- dently influenced by patient race/ethnicity. van Ryn goes on to suggest that a deeper understanding of automatic and social cognition processes involved in the patient-provider relationship will allow the development of better evidence-based interventions that target patient-provider com- munication to address racial and ethnic disparities in care. Our review of the literature supports the hypothesis put forth by van Ryn and ex- tends it to include the importance of reciprocity in the patient-physician relationship and the impact of patient expectations and judgments of physicians, placing all of these factors within the context of other patient and physician sociodemographic factors such as age, gender and social class. In summary, we provide the following considerations for future re- search. First, more in-depth exploration of social cognitions and stereo- typing behavior by patients and physicians is needed. Furthermore, 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 may provide opportunities to increase our understanding of the constructs of cultural competence. Finally, inasmuch as physician ethnicity is confounded with age and gender (minority phy- sicians are more likely to be female and younger than white physicians), future research will require disentanglement of the complex interactions
579 PATIENT-PROVIDER COMMUNICATION among patient and physician age, gender, and ethnicity and their impact on patient-physician communication. The Role of Cross-Cultural Training for Healthcare Professionals Researchers and medical educators have developed models for cross- cultural training of healthcare professionals (Sue, Zane, and Young, 1994; Gardenschwartz and Rowe, 1998; Carrillo, Green, and Betancourt, 1999; Loudon et al., 1999) that typically include the following objectives: 1) in- crease learnersâ awareness or mindfulness of the impact of culture and cultural differences on their own and othersâ behaviors during the pro- cess of communication between themselves and dissimilar others; 2) in- crease learnersâ knowledge of critical concepts useful in intercultural ad- justment, including knowledge that others find essential for success in their own culture; 3) challenge learnersâ emotional states engendered by intercultural interactions and facilitate their progression through devel- opmental stages of intercultural sensitivity (i.e., denial, defense, minimi- zation, acceptance, adaptation, and integration); and 4) develop culture- general (ability to manage stress, tolerate ambiguity, establish realistic expectations, acquire âantennaeâ for cultural differences in interpersonal interactions, develop empathy with emotions expressed by dissimilar oth- ers) and culture-specific skills (those that are unique to a given people or context) (Bennett, 1986; Brislin and Yoshida, 1994). These objectives have face validity; however, there is scant evidence that relates any of these objectives of cultural competence training to having an impact upon pa- tient outcomes. An alternative description of the cultural competence process incor- porates many dimensions of patient-centeredness. Campinha-Bacote (1999) describes cultural awareness, cultural knowledge, cultural skills, cultural encounters, and cultural desire as constructs of cultural compe- tence. Cultural awareness is the deliberate, cognitive process in which healthcare providers become appreciative and sensitive to the values, be- liefs, lifestyles, practices, and problem-solving strategies of clientsâ cul- tures. The cultural awareness process involves examination of oneâs own prejudices and biases toward other cultures and in-depth exploration of oneâs own cultural background. Cultural knowledge is the process of seeking and obtaining a sound edu- cational foundation concerning the worldviews of various cultures. The goal of cultural knowledge is to understand clientsâ worldviews, or the way indi- viduals or groups of people view the universe to form values about their lives and the world around them. Additionally, the process of cultural knowledge involves the process of obtaining knowledge regarding specific physical, bio- logical, and physiologic variations among ethnic groups.
580 UNEQUAL TREATMENT Cultural skill is the ability to collect relevant cultural data regarding clientsâ health histories and presenting problems, as well as accurately performing a culturally specific physical assessment. The literature offers several assessment tools that healthcare providers can use when conduct- ing cultural assessments (Berlin and Fowkes, 1983; Kleinman, Eisenberg, and Good, 1978; Buchwald et al., 1994). These tools essentially serve as reminders for physicians to use patient-centered communication skills when they are caring for patients from diverse cultural backgrounds. Cultural encounter is the process that encourages healthcare providers to engage directly in cross-cultural interactions with clients from culturally diverse backgrounds. The larger the number of cultural encounters a healthcare provider has with individuals from specific ethnic groups, the more likely he/she will gain an appreciation for intra-ethnic variations and the less likely he/she will be to engage in stereotyping behavior that might develop as a result of academic knowledge without direct experience. Cul- tural desire is the motivation and genuine desire of health providers to en- gage in the process of cultural competence. This is based on true caring (empathy), curiosity or interest, and respect regarding clients whose cul- tures differ from oneâs own. We believe cultural skills and cultural desire include most of the dimensions of patient-centeredness that have been shown to have positive and significant effects on patient outcomes. Conclusions To the extent that cultural skills and cultural desire are synonymous with patient centeredness, more broadly defined communication skills programs that prepare healthcare providers to deliver high quality inter- personal and technical healthcare to an ethnically diverse population are promising as a strategy to reduce ethnic disparities in healthcare, particu- larly when these programs are consistent with patient empowerment strategies. Patient empowerment strategies increase patientsâ ability to: 1) fully participate in the medical interview, 2) negotiate treatment plans by engaging in joint problem-solving and collaborative treatment decision- making with physicians, and 3) gain confidence and competence in illness self-management, including adherence to treatment and management rec- ommendations (Roter, 2000b). Because strong evidence links these com- munication 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. These studies should include rigorous measurement of healthcare processes and outcomes. The centrality of patient voice is all the more critical in recognition of the cultural diversity that often characterizes vulnerable populations and
581 PATIENT-PROVIDER COMMUNICATION distinguishes them from the majority culture. Ethnic minorities, the eld- erly, the poor, and the non-functionally literate are victims of disparities in health and the receipt of health services (Agency for Healthcare Policy and Research, 1999). This disparity appears to be growing and its elimina- tion constitutes a priority area for the future direction of both provider and patient education efforts. The progressive transformations of the patient-provider relationship will depend on its embracing a broad empowerment agenda (Roter et al., 2001). This will challenge the profession on many levels and test our com- mitment to serve patientsâ needs, and to empower patients themselves to define those needs. The broadening definition of quality in medical care of the past decade has called for systematic efforts to incorporate the patientâs perspective in defining their own medical goals and actively participating in management and treatment considerations, and to include patients in the judgment of their own functioning and well-being (Moloney and Paul, 1993). The challenge of transforming the practice of medicine to more effec- tively meet the needs of ethnically diverse patients will include the gen- eration of racial and ethnic-neutral social norms regarding patient expec- tations 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 physi- cian workforce will help contribute to a societal norm that does not inher- ently define âdoctorâ in gender or race-linked terms, but this will not be sufficient to transform medical practice. Until we have more evidence of the impact of institutional resources on improving cultural competency, physician training in interpersonal skill, emphasizing those aspects of communication identified with documented benefits on patient health (e.g., patient-centeredness), coupled with patient activation and empow- erment strategies, are promising as the vehicle by which the ethnic minor- ity patientâs voice and perspective will be enhanced. Interventions incor- porating these strategies will likely improve quality of care and outcomes for all patients, but those at highest riskâthe poor, elderly, chronically ill, low literate, and ethnic minority patients, may stand to benefit the most from these efforts. REFERENCES Adelman RD, Greene MG, Charon R. 1987. The physician elderly patient companion triad in the medical encounter. The Gerontologist, (27):729-734. Agency for Healthcare Policy and Research. 1999. Understanding and Eliminating Minority Health Disparities. (RFA: HS-00-003). Rockville, Maryland. Agency for Healthcare Policy and Research.
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