Cultural Context Is Important When Building Patient Trust
By Melinda Young
Recent research shows health inequities have worsened since the COVID-19 pandemic began.1 More work is needed to improve medical care and interactions between African American patients and mostly European American healthcare providers. This also means case managers, whose job is to build trust with patients, will have to work hard to bridge cultural divides and distrust.
“The greatest problem is racial interaction,” says R. Baxter Miller, PhD, professor emeritus of English and African American studies at the University of Georgia. Miller spoke about cultural sensitivity at a recent case management conference.
Black patients may question whether white healthcare professionals see their full humanity. Past atrocities validate their concerns. For example, for more than three decades, government doctors, nurses, and researchers enrolled and provided minimal symptom relief to poor Black male sharecroppers in Alabama after they contracted syphilis. This research, referred to as the Tuskegee Study, began before antibiotics were widely available for treatment, but it continued long after penicillin became the standard treatment. The research subjects were not offered penicillin or even told there was a cure for their illness.2,3
“How could you possibly do that? First, you don’t consider them to be fully human,” Miller says. “You wouldn’t have chosen white families with an earning capacity of over $200,000 to be in the experiment because they would have been seen as ‘real people.’”
The government’s failure and deplorable treatment of these men only stopped after an anonymous whistleblower led to a media investigation.2
Generational Mistrust Persists
Because of this and other cases, there is a generational distrust of the research and medical community. Medical exploitation from generations earlier may have contributed to young African Americans distrusting the COVID-19 vaccine, Miller notes. A young person may have a vague notion that Blacks were the subject of unethical experiments. “It’s even more difficult because they have no historical context of how things have changed since then,” he adds.
Miller gives these suggestions to case managers and other providers to improve their cultural literacy and to earn the trust of patients, regardless of their background:
• Take time to make eye contact. For many Black patients, it is important for a provider to meet the patient’s eyes with a direct gaze that expresses concern and compassion.
“It’s a simple matter, and it takes one second,” Miller says.
This is not a cookie-cutter formula for all patients. In some cultures, including some Native Americans, direct eye contact may be considered rude and disrespectful.4
Case managers should perform a quick search on a patient’s cultural norms to find any issues with direct gaze. But in most cases, warm, direct eye contact reassures the patient the case manager is ready to listen and cares about their concerns.
Once, when Miller met with a doctor who did not take time to look in his eyes and was hurried in the clinic visit, Miller was left with the impression that he was not a person to this doctor.
“There’s nothing as a medical professional you can ever do to make up for that. It’s done. It’s over,” Miller says. “You should have seen me as a human being even if I had been there in my jeans and T-shirt. You should have seen me.”
When a full-on gaze is not suitable, case managers could make a side glance, a smile, or some other slight indication they are with the patient and feel empathy for them as a person, Miller suggests.
Find Ways to Connect with Patients
• Build trust through time and connections. If the patient and care provider share a similar culture and background, building trust may be quick and easy. If not, it will take time — and probably more than one meeting.
Patients who trust their case manager or provider will overlook slight problems because they trust them. “Trust is the most important intercultural thing. Visibility is only a matter of trust,” Miller says. “You can’t trust someone who doesn’t see you.”
Nurses have an advantage over doctors when it comes to building trust. Patients might think nurses are not from a background of privilege. “The people who go into nursing tend to come from the school of sacrifice and hard knocks and struggle and so forth,” Miller says. “They understand and don’t come from privilege, so there’s a socioeconomic rapport there.”
Case managers could build trust by sharing small anecdotes or making comments that suggest they also have overcome obstacles in their lives. “Share parts about yourself that could show you identify with the patient,” Miller says. Class economics is a significant factor that helps nurses or doctors who also come from lower-income backgrounds more closely identify with patients who are in a lower income bracket, he notes.
Politics Can Be Damaging
• Avoid politics or any perception of politics. When visible in the healthcare setting, a provider’s political messaging can alienate patients.
For example, Miller recalls visiting his doctor’s office and seeing a sign that said, “Obamacare not accepted.” The sign seemed to be aggressively political because of its use of a slang term to refer to insurance under the Affordable Care Act. Miller questioned why it even needed to be posted. He told the office supervisor that the sign appeared to be politicizing something did not need to be politicized, and that the sign makes people of color feel unwelcome.
“Later, I saw the doctor and told him my gripe,” Miller says. The next time Miller visited the doctor’s office, the sign was gone.
• Avoid assumptions about a person’s ability to pay. If the healthcare provider makes assumptions about a patient’s ability to pay for services, it can create distrust and injure a patient’s pride.
For instance, when transitioning patients to a post-acute facility or skilled nursing facility, case managers could provide patients with information about the payment options at each possible site, and whether the sites accept the patient’s insurance. But they should not assume patients will reject transitions to places where the cost would be higher.
“Recommending medication or treatment on the basis of perceived economics is a dangerous thing — a slippery slope,” Miller says. “Rather than making assumptions, why don’t you just ask, ‘Is money an issue, or are you good with that?’”
- Bress AP, Cohen JB, Anstey DE, et al. Inequities in hypertension control in the United States exposed and exacerbated by COVID-19 and the role of home blood pressure and virtual health care during and after the COVID-19 pandemic. J Am Heart Assoc 2021;10:e020997.
- Tuskegee University. About the USPHS Syphilis Study.
- Breed AG. How an AP reporter broke the Tuskegee syphilis story. Associated Press. July 25, 2022.
- Richardson Jr WJ. Cultural awareness to help while serving native veterans. June 27, 2012.
Recent research shows health inequities have worsened since the COVID-19 pandemic began. More work is needed to improve medical care and interactions between African American patients and mostly European American healthcare providers. This also means case managers, whose job is to build trust with patients, will have to work hard to bridge cultural divides and distrust.
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