Clashing cultures contribute to racial disparities in medical care

Clashing cultural cues – rather than discriminatory doctors – could cause at least part of the medical care gap between black and white Americans, according to a recent study of patient adherence by Jonathan D. Ketcham, a professor of health management and policy at the W. P. Carey School of Business, and Karen E. Lutfey of the New England Research Institutes in Watertown, Massachusetts. Ketcham said that his results indicated "no evidence of a negative stereotype against black patients. In fact, it seemed to be only about communication - the physicians and patients disagreed about how adherent they were."

Clashing cultural cues rather than discriminatory doctors could cause at least part of the medical care gap between black and white Americans, according to a recent study. The study, "Patient and Provider Assessments of Adherence and the Sources of Disparity: Evidence From Diabetes Care," by Jonathan D. Ketcham, a professor of health management and policy at the W. P. Carey School of Business, and Karen E. Lutfey of the New England Research Institutes in Watertown, Massachusetts, focused on patient adherence among Midwesterners suffering from diabetes.

Ketcham began the study knowing that "while some ascribe these disparities to stereotyping or bias against minority patients, problems in communication might actually be responsible" for minorities receiving worse healthcare than non-minorities. Example: a 2003 Institute of Medicine study that found blacks with cardiovascular disease got different medical treatment. Institute researchers pointed out that the medical-care gap was there regardless of factors such as disease severity. Other studies reported similar results for minority patients suffering from diabetes, HIV and cancer.

It's about communicating

Ketcham said that his results indicated "no evidence of a negative stereotype against black patients. In fact, it seemed to be only about communication — the physicians and patients disagreed about how adherent they were." Ketcham's findings make sense, says Mary Rimsza, M.D., co-director of the W. P. Carey School's Center for Health Information and Research. A pediatrician as well as a veteran researcher, Rimsza says she has observed that doctors who are of the same racial background as their patient are better able to communicate with them and pick up on non-verbal cues.

For instance, as a Caucasian physician, she chooses her words carefully when discussing future health complications with some Native American patients, "because I've learned my words are taken as indications that these bad things will happen." Some of her Hispanic patients feel that certain diseases are "hot" and others are "cold" and that the treatment thus needs to be based upon this. However, the influence of Hispanic cultural health beliefs varies and usually is stronger among new immigrants, she says.

Ketcham decided to look at diabetes because physicians choose from a range of options when treating patients. He hoped to find clues in how they take idiosyncratic patient factors into account when making inferences about the patient s adherence to treatment. He also wondered what role their conscious and non-conscious thoughts, including racial or ethnic bias, played in their recommendations.

For instance, there are a number of diabetes drugs on the market, some more expensive than others, or requiring more frequent dosing. And while some diabetic patients can control their disease through carbohydrate-counting diets, sweating through exercise sessions and other lifestyle modifications, others cannot, or will not.

But while Lutfey and Ketcham were investigating how physician beliefs about the patient's ability to follow a particular regime shapes his or her treatment plan, the authors also studied the patient's role in adherence. For the study, Ketcham and Lutfey asked 156 patients and their physicians at two endocrinology clinics the same, basic questions, centering on how well the patient adheres to the treatment regimen. Most of the study physicians were Caucasian. Patients at one clinic were mostly Caucasian, while the patient population at the second clinic was largely African-American.

Patients were interviewed over the phone within days of their last doctor's appointment. Doctors filled out surveys immediately after seeing each patient. Ketcham and Lutfey looked at four variables: the patient's self-rating of adherence; the provider's rating of the patient's adherence; the difference between the two and the absolute value of that difference.

The results show a statistically significant difference in how Caucasian physicians and their African-American patients rated adherence. Once other factors were taken into account, including the patient's age, sex, education, income and insurance coverage, black patients' views differed from their providers on average by 2.5 points on a scale of 1 to 10.

"The physicians rated some of the black patient's adherence above the patient's self-rating, but others below what the patient was thinking," Ketcham explains. "We found no evidence that physicians' systematically held more negative views of black patients' adherence." In comparison, white patients and their physicians differed by only 1.5 points on a scale of 1 to 10. This indicates the same-race physician/patient pairs were more in sync than the different-race physician/patient pairs.

One size fits all does not apply

Ketcham's research is intriguing but not surprising to Don Warne, a physician and a clinical professor at ASU's Sandra Day O'Connor College of Law, who said that "people are much more comfortable communicating with healthcare providers from their own culture."

"Communication styles are determined by culture. If there are two different cultures in the doctor-patient relationship, it will have an impact on the quality of communication. And subsequently, the quality of care," Warne continued. His medical school professors taught him to look each patient in the eye, to indicate sincerity and attention. But Warne, who is Native American, grew up in a tribal culture that considered direct eye contact a sign of disrespect or heralding a confrontation. "One cultural perspective is not appropriate for the whole world," he notes.

Warne has seen Ketcham's findings in action. Dozens of Native American patients whose relatives have diabetes have told him, "I don't have diabetes yet," indicating they believe the disease is in their future. It's tough to coach a person with this belief on how to avoid or mitigate diabetes, Warne explains, "because their beliefs impact how they behave, making the physician's frame of reference ineffective."

Ketcham ticks off several important implications emerging from the study. In the context of diabetes treatment at least, policies aiming to address negative stereotyping by health care providers would do little to improve racial disparities in care. Instead, Ketcham says, "physicians are less sure about whether minority patients are taking their medicine, exercising and eating right to take care of their diabetes due to poor communication, so we need to reduce that uncertainty. Unfortunately we don't yet know how this uncertainty affects decisions about how to treat patients."

He and other researchers suspect that this uncertainty drives physicians to be more conservative, because they don't want to make a big mistake. Related to this, for physician-patient pairs of different races, given the communication barrier, there may be a bigger mismatch between what the patient gets and what the patient should be getting. Ketcham proposes several practical changes to reduce the amount of uncertainty in the physician-patient communication about adherence.

First, boosting the number of minority doctors and other clinicians among healthcare providers could enhance the sharing of important information between physicians and minority patients. Second, objective tests might provide better information to physicians than relying on drawing out and understanding information from patients themselves. While health insurers might resist a call for further tests, improved management of chronic conditions such as diabetes can control spending down the road.

Bottom Line:

• Most Caucasian Americans interpret looking someone in the eye an indication of respect, even sincerity, but some Native Americans consider a direct gaze to be rude or worse.
• Physicians appear to have greater difficulty discerning minority patients' adherence to treatments but don't infer that those patients are less adherent.
• Steps that aim to improve communication, rather than addressing providers' stereotypes about patients, will be more effective at reducing racial disparities in health care.