The Effect of Race, Culture, and Values on the Patient- Physician Relationship
Abstract & Commentary
By Rahul Gupta, MD, MPH, FACP. Dr. Gupta is Assistant Professor, Department of Internal Medicine, Meharry Medical College, Nashville, TN; Assistant Clinical Professor, Division of General Internal Medicine and Public Health, Vanderbilt University Medical School, Nashville, TN; he reports no financial relationship relevant to this field of study.
Source: Street RL Jr, et al. Understanding concordance in patient-physician relationships: Personal and ethnic dimensions of shared identity. Ann Fam Med 2008;6:198-205.
One of the foremost goals for the healthy people 2010 program1 is the elimination of health disparities among different segments of the population. Reported data are clear that barriers in the patient-physician relationship contribute to racial disparities in the experience of health care.2,3 Since differences exist in patients' perceptions of their physicians, which can impact health care utilization, status, and outcomes, it would be prudent to identify and measure such differences in a manner such that those inequalities may be better understood.
Concordance is defined as a similarity, or shared identity, between the physician and patient based on a demographic attribute, such as race, sex, or age. Race concordance between the patient and physician is well established. Such race concordance leads to higher patient ratings of care and satisfaction.4,5 Much less evidence points toward gender or age concordance or the interactions thereof. Furthermore, it is yet unclear whether such concordance may lead to better outcomes rather than just improvements in patient satisfaction.
In their study, Street et al hypothesized that the link between concordance and outcomes is mediated through perceptions of relational similarity. Thus, when patients perceive a physician similar to themselves, they may feel more comfortable in trusting such a physician with recommendations, which may lead to more action on their part and better outcomes. The authors set out three main objectives for the study: 1) to create a self-report measure of perceived similarity, 2) to evaluate the influence of concordance by race and sex on perceived similarity alone and in the context of other factors, and 3) to examine the relationship of patients' perceptions of similarity to physicians to the quality of care outcomes.
The study included a total of 269 patients and 29 physicians recruited from 10 primary care clinics in the Houston area from private and Veterans Affairs/county hospital settings. Neither Asian patients nor Hispanic physicians participated. All spoke English and were older than 18 years of age. Patients answered a subjective set of questions, which were matched to physicians to determine traits of personal and ethnic similarity. Interaction with physicians was audio tape recorded and later coded. The data were analyzed into three groups: race concordant, race discordant (White), and race discordant (minority: Blacks and Hispanics).
Patients in racially concordant (patient and physician of same race) encounters reported more personal similarity to their doctors than did minority patients in racially discordant (patients are Hispanic or Black but physicians are of different race) interactions. Similarly, patients in racially concordant encounters saw themselves as more ethnically similar to their physicians than did minority or White patients in racially discordant visits. Also, older and more educated patients, as well as those whose physicians used more patient-centered communication, perceived themselves to be more personally similar to their physicians.
Patients who believed they were more similar to their physician with respect to personal beliefs, values, and ways of communicating reported more trust in the physician, more satisfaction with care, and a stronger intention to adhere to recommendations. On the other hand, patients' perceptions of being similar to the physician in terms of race, ethnicity, and community were not related to patient outcomes. The degree to which physicians were patient-centered in their communication not only was related to patients' perceptions of personal similarity to their doctors, but it also predicted outcomes. Regardless of race, when physicians were more informative, supportive, and facilitative, the patients were more active participants, were more satisfied with care, expressed greater trust, and had a stronger intention to adhere to recommendations.
This study is another example of the fact that while we may not have become an entirely racially liberated society, cultural competence plays a great role in the educational training of a physician. A physicians' communication style and perceptions do affect patient outcomes. A patient-physician relationship must build itself on the basic concept of partnership: mutual respect, support, trust, and proper dissemination of information. Data suggest that patients are able to perceive when they are respected by their physicians and are willing to give the benefit of doubt to their physicians.6
As a primary care physician, I take pride in the fact that I begin any such relationship by finding common ground rather than attempting to ram my personal philosophy through each patient. I treat each patient individually, looking for a different similarity for each person I come in contact with and duly note such in my progress notes for review on subsequent visits. This builds a life-long relationship with an individual who understands that I value his/her input into our conversation and provides abundant opportunity for us to come to a mutual informed decision on any issue. Often, this is all it takes to make our patients happy and content, resulting in improved outcomes and adherence to recommendations.
It is interesting that data have also shown that physicians who reported a patient-centered orientation to the doctor-patient relationship were also more patient-centered in their communication.7 In other words, it is basically a matter of setting your mind to it. While some may feel that current and past data could be justified to demand training more physicians from a certain ethnic group to "pair up" with patients of a similar ethnic group, what is imperative is that we emphasize the cultural competency and communication skills components of developing physicians.
1. Healthy People 2010 Program. Available at: www.healthypeople.gov/About/goals.htm. Accessed Sept. 26, 2008.
2. Saha S, et al. Patient-physician relationships and racial disparities in the quality of health care. Am J Public Health 2003;93:1713-1719.
3. Rawaf MM, Kressin NR. Exploring racial and sociodemographic trends in physician behavior, physician trust and their association with blood pressure control. J Natl Med Assoc 2007;99:1248-1254.
4. Cooper LA, et al. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med 2003;139:907-915.
5. Sohler NL, et al. Does patient-provider racial/ethnic concordance influence ratings of trust in people with HIV infection? AIDS Behav 2007;11:884-896.
6. Beach MC, et al. Are physicians' attitudes of respect accurately perceived by patients and associated with more positive communication behaviors? Patient Educ Couns 2006;62:347-354.
7. Street RL Jr, et al. Physicians' communication and perceptions of patients: Is it how they look, how they talk, or is it just the doctor? Soc Sci Med 2007;65:586-598.