Race, gender, and partnership in the patient-physician relationship.
TL;DR: The data suggest that African American patients rate their visits with physicians as less participatory than whites, however, patients seeing physicians of their own race rate their physicians' decision-making styles as more participatory.
Abstract: ContextMany studies have documented race and gender differences in health care
received by patients. However, few studies have related differences in the
quality of interpersonal care to patient and physician race and gender.ObjectiveTo describe how the race/ethnicity and gender of patients and physicians
are associated with physicians' participatory decision-making (PDM) styles.Design, Setting, and ParticipantsTelephone survey conducted between November 1996 and June 1998 of 1816
adults aged 18 to 65 years (mean age, 41 years) who had recently attended
1 of 32 primary care practices associated with a large mixed-model managed
care organization in an urban setting. Sixty-six percent of patients surveyed
were female, 43% were white, and 45% were African American. The physician
sample (n=64) was 63% male, with 56% white, and 25% African American.Main Outcome MeasurePatients' ratings of their physicians' PDM style on a 100-point scale.ResultsAfrican American patients rated their visits as significantly less participatory
than whites in models adjusting for patient age, gender, education, marital
status, health status, and length of the patient-physician relationship (mean
[SE] PDM score, 58.0 [1.2] vs 60.6 [3.3]; P=.03).
Ratings of minority and white physicians did not differ with respect to PDM
style (adjusted mean [SE] PDM score for African Americans, 59.2 [1.7] vs whites,
61.7 [3.1]; P=.13). Patients in race-concordant relationships
with their physicians rated their visits as significantly more participatory
than patients in race-discordant relationships (difference [SE], 2.6 [1.1]; P=.02). Patients of female physicians had more participatory
visits (adjusted mean [SE] PDM score for female, 62.4 [1.3] vs male, 59.5
[3.1]; P=.03), but gender concordance between physicians
and patients was not significantly related to PDM score (unadjusted mean [SE]
PDM score, 76.0 [1.0] for concordant vs 74.5 [0.9] for discordant; P=.12). Patient satisfaction was highly associated with PDM score within
all race/ethnicity groups.ConclusionsOur data suggest that African American patients rate their visits with
physicians as less participatory than whites. However, patients seeing physicians
of their own race rate their physicians' decision-making styles as more participatory.
Improving cross-cultural communication between primary care physicians and
patients and providing patients with access to a diverse group of physicians
may lead to more patient involvement in care, higher levels of patient satisfaction,
and better health outcomes.
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01 Jan 2004
TL;DR: Health Literacy: Prescription to End Confusion examines the body of knowledge that applies to the field of health literacy, and recommends actions to promote a health literate society.
Abstract: To maintain their own health and the health of their families and communities, consumers rely heavily on the health information that is available to them. This information is at the core of the partnerships that patients and their families forge with today?s complex modern health systems. This information may be provided in a variety of forms ? ranging from a discussion between a patient and a health care provider to a health promotion advertisement, a consent form, or one of many other forms of health communication common in our society. Yet millions of Americans cannot understand or act upon this information. To address this problem, the field of health literacy brings together research and practice from diverse fields including education, health services, and social and cultural sciences, and the many organizations whose actions can improve or impede health literacy. Health Literacy: Prescription to End Confusion examines the body of knowledge that applies to the field of health literacy, and recommends actions to promote a health literate society. By examining the extent of limited health literacy and the ways to improve it, we can improve the health of individuals and populations.
4,107 citations
Cites background from "Race, gender, and partnership in th..."
...African-American patients frequently experience shorter physician–patient interactions and less patient-centered visits than Caucasian patients (Cooper and Roter, 2003; Cooper-Patrick et al., 1999)....
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01 Jan 2003
TL;DR: These “Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists” reflect knowledge and skills needed for the profession in the midst of dramatic historic sociopolitical changes in U.S. society, as well as needs of new constituencies, markets, and clients.
Abstract: Preface All individuals exist in social, political, historical, and economic contexts, and psychologists are increasingly called upon to understand the influence of these contexts on individuals’ behavior. The “Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists” reflect the continuing evolution of the study of psychology, changes in society at large, and emerging data about the different needs of particular individuals and groups historically marginalized or disenfranchised within and by psychology based on their ethnic/racial heritage and social group identity or membership. These “Guidelines on Multicultural Education, Training, Research, Practice, and Organizational Change for Psychologists” reflect knowledge and skills needed for the profession in the midst of dramatic historic sociopolitical changes in U.S. society, as well as needs of new constituencies, markets, and clients. The specific goals of these guidelines are to provide psychologists with (a) the rationale and needs for addressing multiculturalism and diversity in education, training, research, practice, and organizational change; (b) basic information, relevant terminology, current empirical research from psychology and related disciplines, and other data that support the proposed guidelines and underscore their importance; (c) references to enhance ongoing education, training, research, practice, and organizational change methodologies; and (d) paradigms that broaden the purview of psychology as a profession.
1,711 citations
TL;DR: A framework of organizational, structural, and clinical cultural competence interventions can facilitate the elimination of racial/ethnic disparities in health and improve care for all Americans.
Abstract: OBJECTIVES: Racial/ethnic disparities in health in the U.S. have been well described. The field of "cultural competence" has emerged as one strategy to address these disparities. Based on a review of the relevant literature, the authors develop a definition of cultural competence, identify key components for intervention, and describe a practical framework for implementation of measures to address racial/ethnic disparities in health and health care.
METHODS: The authors conducted a literature review of academic, foundation, and government publications focusing on sociocultural barriers to care, the level of the health care system at which a given barrier occurs, and cultural competence efforts that address these barriers.
RESULTS: Sociocultural barriers to care were identified at the organizational (leadership/workforce), structural (processes of care), and clinical (provider-patient encounter) levels. A framework of cultural competence interventions--including minority recruitment into the health professions, development of interpreter services and language-appropriate health educational materials, and provider education on cross-cultural issues--emerged to categorize strategies to address racial/ethnic disparities in health and health care.
CONCLUSIONS: Demographic changes anticipated over the next decade magnify the importance of addressing racial/ethnic disparities in health and health care. A framework of organizational, structural, and clinical cultural competence interventions can facilitate the elimination of these disparities and improve care for all Americans.
1,709 citations
TL;DR: It is hypothesized that race concordance is associated with higher levels of communication behaviors that are considered patient centered, higher patient ratings of physicians' participatory decision making, and higher ratings of patient satisfaction.
Abstract: When patients and physicians are of the same race, patients are more satisfied with care in the office setting. The authors found that having the same race did not affect patient-centered communica...
1,198 citations
Cites background from "Race, gender, and partnership in th..."
...2 Female 173 (69) 50 (67) 76 (73) 21 (60) 26 (68) Level of education, n (%) Less than high school 41 (16) 14 (19) 13 (13) 9 (26) 5 (14) 0....
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...In our study and previous studies (13, 14), race-concordant visits were characterized by higher patient ratings of satisfaction and more positive judgments of physicians’ participatory decision-making style....
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...Given that participatory decision making receives average ratings of approximately 75 on a 100-point scale in primary care studies (12, 13) and that a 2-point difference is related to a 10–percentage point difference in the likelihood that a patient would leave a physician’s practice in the next 12 months (47), these findings probably have clinical importance....
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TL;DR: 5 principles to address disparities in health care through modifications in quality performance measures are proposed: disparities represent a significant quality problem and clinical performance measures should be stratified by race/ethnicity and socioeconomic position for public reporting.
Abstract: Socioeconomic and racial/ethnic disparities in health care quality have been extensively documented. Recently, the elimination of disparities in health care has become the focus of a national initiative. Yet, there is little effort to monitor and address disparities in health care through organizational quality improvement. After reviewing literature on disparities in health care, we discuss the limitations in existing quality assessment for identifying and addressing these disparities. We propose 5 principles to address these disparities through modifications in quality performance measures: disparities represent a significant quality problem; current data collection efforts are inadequate to identify and address disparities; clinical performance measures should be stratified by race/ethnicity and socioeconomic position for public reporting; population-wide monitoring should incorporate adjustment for race/ethnicity and socioeconomic position; and strategies to adjust payment for race/ethnicity and socioeconomic position should be considered to reflect the known effects of both on morbidity. JAMA. 2000;283:2579-2584
1,170 citations
References
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TL;DR: In this article, an extension of generalized linear models to the analysis of longitudinal data is proposed, which gives consistent estimates of the regression parameters and of their variance under mild assumptions about the time dependence.
Abstract: SUMMARY This paper proposes an extension of generalized linear models to the analysis of longitudinal data. We introduce a class of estimating equations that give consistent estimates of the regression parameters and of their variance under mild assumptions about the time dependence. The estimating equations are derived without specifying the joint distribution of a subject's observations yet they reduce to the score equations for multivariate Gaussian outcomes. Asymptotic theory is presented for the general class of estimators. Specific cases in which we assume independence, m-dependence and exchangeable correlation structures from each subject are discussed. Efficiency of the proposed estimators in two simple situations is considered. The approach is closely related to quasi-likelih ood. Some key ironh: Estimating equation; Generalized linear model; Longitudinal data; Quasi-likelihood; Repeated measures.
17,111 citations
TL;DR: A class of generalized estimating equations (GEEs) for the regression parameters is proposed, extensions of those used in quasi-likelihood methods which have solutions which are consistent and asymptotically Gaussian even when the time dependence is misspecified as the authors often expect.
Abstract: Longitudinal data sets are comprised of repeated observations of an outcome and a set of covariates for each of many subjects. One objective of statistical analysis is to describe the marginal expectation of the outcome variable as a function of the covariates while accounting for the correlation among the repeated observations for a given subject. This paper proposes a unifying approach to such analysis for a variety of discrete and continuous outcomes. A class of generalized estimating equations (GEEs) for the regression parameters is proposed. The equations are extensions of those used in quasi-likelihood (Wedderburn, 1974, Biometrika 61, 439-447) methods. The GEEs have solutions which are consistent and asymptotically Gaussian even when the time dependence is misspecified as we often expect. A consistent variance estimate is presented. We illustrate the use of the GEE approach with longitudinal data from a study of the effect of mothers' stress on children's morbidity.
7,080 citations
TL;DR: A limited set of concepts derived from anthropologic and cross-cultural research may provide an alternative framework for identifying issues that require resolution, including a fundamental distinction between disease and illness and the notion of the cultural construction of clinical reality.
Abstract: Major health care problems such as patient dissatisfaction, inequity of access to care, and spiraling costs no longer seem amenable to traditional biomedical solutions. Concepts derived from anthropologic and cross-cultural research may provide an alternative framework for identifying issues that require resolution. A limited set of such con- cepts is described and illustrated, including a fundamental distinction between disease and illness, and the notion of the cultural construction of clinical reality. These social science concepts can be developed into clinical strategies with direct application in practice and teaching. One such strategy is outlined as an example of a clinical social science capa- ble of translating concepts from cultural anthropology into clinical language for practical application. The implemen- tation of this approach in medical teaching and practice requires more support, both curricular and financial.
2,714 citations
"Race, gender, and partnership in th..." refers background or result in this paper
...This study adds to a growing body of research indicating that ethnic differences between physicians and patients are often barriers to partnership and effective communication.(19-22,30) A number of physician factors may account for these problems....
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...Race and ethnicity have been cited as important cultural barriers in patientphysician communication.(19-22) However, cross-cultural factors in patientphysician communication are largely unexplored....
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TL;DR: It is concluded that the physician-patient relationship may be an important influence on patients' health outcomes and must be taken into account in light of current changes in the health care delivery system that may place this relationship at risk.
Abstract: Growing interest in the doctor-patient relationship focuses attention on the specific elements of that relationship that affect patients' health outcomes. Data are presented for four clinical trials conducted in varied practice settings among chronically ill patients differing markedly in sociodemographic characteristics. These trials demonstrated that "better health" measured physiologically (blood pressure or blood sugar), behaviorally (functional status), or more subjectively (evaluations of overall health status) was consistently related to specific aspects of physician-patient communication. We conclude that the physician-patient relationship may be an important influence on patients' health outcomes and must be taken into account in light of current changes in the health care delivery system that may place this relationship at risk.
2,064 citations
"Race, gender, and partnership in th..." refers background in this paper
...Studies have shown that increasing patient involvement in care via negotiation and consensus-seeking improves patient satisfaction and outcomes.(37-39) Specifically, visits in which the physician uses a participatory decision-making (PDM) style are associated with higher levels of patient satisfaction....
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TL;DR: It is suggested that the race and sex of a patient independently influence how physicians manage chest pain.
Abstract: Background Epidemiologic studies have reported differences in the use of cardiovascular procedures according to the race and sex of the patient. Whether the differences stem from differences in the recommendations of physicians remains uncertain. Methods We developed a computerized survey instrument to assess physicians' recommendations for managing chest pain. Actors portrayed patients with particular characteristics in scripted interviews about their symptoms. A total of 720 physicians at two national meetings of organizations of primary care physicians participated in the survey. Each physician viewed a recorded interview and was given other data about a hypothetical patient. He or she then made recommendations about that patient's care. We used multivariate logistic-regression analysis to assess the effects of the race and sex of the patients on treatment recommendations, while controlling for the physicians' assessment of the probability of coronary artery disease as well as for the age of the patient, the level of coronary risk, the type of chest pain, and the results of an exercise stress test. Results The physicians' mean (±SD) estimates of the probability of coronary artery disease were lower for women (probability, 64.1±19.3 percent, vs. 69.2±18.2 percent for men; P<0.001), younger patients (63.8±19.5 percent for patients who were 55 years old, vs. 69.5±17.9 percent for patients who were 70 years old; P<0.001), and patients with nonanginal pain (58.3±19.0 percent, vs. 64.4±18.3 percent for patients with possible angina and 77.1±14.0 percent for those with definite angina; P<0.001). Logistic-regression analysis indicated that women (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) and blacks (odds ratio, 0.60; 95 percent confidence interval, 0.4 to 0.9; P=0.02) were less likely to be referred for cardiac catheterization than men and whites, respectively. Analysis of race–sex interactions showed that black women were significantly less likely to be referred for catheterization than white men (odds ratio, 0.4; 95 percent confidence interval, 0.2 to 0.7; P=0.004). Conclusions Our findings suggest that the race and sex of a patient independently influence how physicians manage chest pain.
1,852 citations
"Race, gender, and partnership in th..." refers background in this paper
...Previous work has shown that both physician and patient gender may be important determinants of PDM style, other aspects of interpersonal care, and medical decision making.(30-32,34,35,46-48)...
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