Mitigating Racial Health Disparity with Patient-Centeredness

Kris English, PhD

Professor Emeritus of Audiology

The University of Akron

Relatively poorer health outcomes among racial and ethnic minorities have been documented in depth, for instance by the Institute of Medicine (2003) and the Journal of Racial and Ethnic Health Disparities. Reasons are understandably complex (National Academies of Science, Engineering and Medicine, 2017), but here we will focus on the clinician-patient dyad, communication styles, and clinical relationships.

When clinicians and patients are of the same race – racial concordance – disparities are less likely to occur (Cooper et al., 2003; Shen et al., 2018) although the evidence is mixed (Meghani et al. 2009; Rand & Berger, 2019). The more urgent concern is the documented consequences of racial discordance, wherein the clinician and patient are of differing races. As just one example, Cooper et al.’s (2012) results from racially discordant clinical appointments included more clinician verbal dominance, less patient-centered dialogue, lower patient positive affect, and poorer patient ratings of care – none of which support patient trust and acceptance of treatment recommendations (Dovidio et al., 2008; Zolnierek & DiMatteo, 2009).

Clinical Disparities: Not Inevitable

Racially discordant clinical encounters have been shown to be influenced by clinician bias (Maina et al., 2018; Schaa et al., 2015). Since up to 90% of audiologists in the United States are White (Tittle et al., 2020), we can expect a high likelihood of racially discordant clinical encounters in most areas of the country.

While we come to grips with implicit bias, audiologists can also draw upon the research indicating that clinicians can still strive for concordance within a racially discordant dyad.  “Concordance” as used here, per Pryce et al. (2018) means “an agreed plan between clinician and patient, replacing terms such as ‘adherence’ or ‘compliance’ with their connotations of authority led care… These discussions rely on rapport and trust in the clinical relationship” (p. 631).

Street et al. (2018) describe the impact of rapport-building, trust-earning discussions from data collected from 214 physician-patient consultations. Their study concluded that:

“Perceived personal similarity is associated with higher ratings of trust, satisfaction, and intention to adhere. Race concordance is the primary predictor of perceived ethnic similarity, but several factors affect perceived personal similarity, including physicians’ use of patient-centered communication.” (emphasis added) (p. 198)

In other words, when providers employed patient-centered communication in racially discordant consultations, they achieved cross-racial concordance: their patients were more active participants in the clinical encounters, were more satisfied with their care, expressed greater trust, and had a stronger intention to follow recommendations when their physicians were more informative and supportive.

Chu et al. (2019) recently reported similar outcomes, concluding: “Providers who are skilled in informing, showing respect, and supporting patient involvement could overcome perceived issues of being racially discordant with their patients and establish a connection with the patient that contributes to greater patient satisfaction” (emphasis added)(p. 5).

Establishing Connections

How encouraging to learn that racial discordance does not inevitably result in disparities in health care! Many factors are beyond an audiologist’s control, but at minimum, we can continue to increase our efforts to establish connections. Shen et al’s (2018) systematic review (consistent with seminal writings by Stewart et al., 2014) recommends focusing on the following skills, addressed in several essays on this web forum:

Communication Quality/Listening, Responding to Emotions

Talk Time Ratio

Information-Giving

Patient Participation

Participatory Decision-Making

Patient-Centeredness: Just the Beginning

The best patient-centered communication skills could still mask an audiologist’s implicit biases. A subsequent entry will explore evidence-based interventions to help us understand and address these personal issues. For now, let us develop pathways to cross-racial concordance and share our journeys with the profession.

Cross-Racial Concordance, COVID-19 Era


References

Chu, J., et al. (2019). The effect of patient-centered communication and racial concordant care on care satisfaction among U.S. immigrants. Medical Care Research and Review. Online ahead of print. doi: 10.1177/1077558719890988

Cooper, L. et al. (2003). Patient-centered communication, ratings of care, and concordance of patient and physician race. American College of Physicians, 139, 907-915.

Cooper, L. et al. (2012). The associations of clinicians’ implicit attitudes about race with medical visit communication and patient ratings of interpersonal care. American Journal of Public Health, 102(5), 979-987.

Dividio, J., et al. (2008). Disparities and distrust: The implications of psychological processes for understanding racial disparities in health and health care. Social Science and Medicine, 67, 478-486. doi: 10.1016/j.socscimed.2008.03.019

Institute of Medicine. (2003). Unequal treatment: Confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press.

Maina, I.W. et al. (2018) A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Social Science in Medicine, 199, 219-22. doi: 10.1016/j.socscimed.2017.05.009.

Meghani, S., et al. (2009). Patient–provider race-concordance: does it matter in improving minority patients’ health outcomes? Ethnic Health, 14(1), 107-130. doi:10.1080/13557850802227031

National Academies of Science, Engineering and Medicine. (2017). Communities in action: Pathways to health equity. Washington, DC: The National Academies Press. https://doi.org/10.17226/24624.

Pryce, H., et al. (2018). Shared decision-making in tinnitus care – An exploration of clinical encounters. British Journal of Health Psychology, 23, 630–645. doi:10.1111/bjhp.12308

Rand, L., & Berger, Z. (2019). Disentangling evidence and preference in patient-clinician concordance discussions. AMA Journal of Ethics, 21(6), S505-S512.

Schaa, K, et al. (2015). Genetic counselors’ implicit racial attitudes and their relationship to communication.  Health Psychology, 34(2), 111-119. doi:10.1037/hea0000155.

Shen, M., et al. (2018). The effects of race and racial concordance on patient-physician communication: A systematic review of the literature. Journal of Racial and Ethnic Health Disparities, 5(1), 117-140. doi:10.1007/s40615-017-0350-4

Stewart, M., et al. (2014). Patient-centered medicine: Transforming the clinical method. Abington, UK: Radcliffe Medical Press.

Street, R. et al. (2008). Understanding concordance in patient-physician relationships: Personal and ethnic dimensions of shared identity. Annals of Family Medicine, 6(3), 198-205.doi: 10.1370/afm.821

Tittle, S., Berry, S., Lewis, J & DeBacker, J.R. (2020). The count starts here: The 2020 audiology student census. Audiology Today, 32(4), 52-56.

Zolnierek, K.B., & DiMatteo, M.R. (2009). Physician communication and patient adherence to treatment: A meta-analysis. Medical Care, 47, 826–834. doi:10.1097/MLR.0b013e31819a5acc