New evidence that physician attitudes and stereotypes about race, even if unconscious, affect the doctor-patient relationship in ways that may contribute to racial disparities in health care
Primary care physicians who hold unconscious racial biases tend to dominate conversations with African-American patients during routine visits, paying less attention to patients' social and emotional needs and making these patients feel less involved in decision making related to their health, Johns Hopkins researchers report.
The patients also reported reduced trust in their doctors, less respectful treatment and a lower likelihood of recommending the biased doctor to a friend.
In a report published in the American Journal of Public Health, the researchers say the findings provide new evidence that even when racial bias is not overt, it can have a negative impact on the way care is delivered and the quality of the doctor-patient relationship. It reinforces the idea that there may be a link between racial biases and stereotypes playing out in the doctor-patient relationship and the racial disparities found across health care settings in the United States.
"If patients have good patient-centered interactions with their doctors, we know they're more likely to follow through with care, make follow-up appointments and better control diseases such as diabetes and depression," says study leader Lisa A. Cooper, M.D., M.P.H., a professor in the Division of General Internal Medicine at the Johns Hopkins University School of Medicine. "This study suggests that unconscious racial attitudes may be standing in the way of positive interactions to the detriment of patient health."
Acknowledging that the problem exists, Cooper adds, is half the battle. "It's hard to change subconscious attitudes, but we can change how we behave once we are made aware of them. Researchers, educators and health professionals need to work together on ways to reduce the negative influences of these attitudes on behaviors in health care," she says.
She says it is important to note that there are some negative consequences of racial bias for white patients as well.
In the new study, Cooper and her team investigated the association between physicians' racial attitudes and stereotypes they have about whether patients of different races are compliant with medical advice and how doctors and patients communicated during medical visits. They examined audio recordings of interactions among 40 primary care doctors and 269 patients in community-based medical practices in Baltimore, collected as part of their earlier studies investigating routine care of patients who had hypertension or depression, often along with other chronic conditions. The patients were primarily middle-aged women, and 80 percent were African-Americans. Forty-eight percent of the physicians were white, 30 percent were Asian and 22 percent were African-American. Roughly two-thirds of the doctors were women.
The researchers also assessed the physicians' unconscious racial attitudes using the Implicit Association Test (IAT), a widely used tool that measures reaction times to words and pictures to uncover biases and preferences. For example, a photo of a white or black individual is presented along with words that have good and bad connotations. The test measures how quickly the participant associates good or bad words with people from each race, rating the extent to which these concepts are linked in the brain. If a participant is quicker at associating the good words with a particular race, then that person is thought to have a subconscious preference toward that race. The doctors in the study completed two versions of the IAT. The first related to general race bias, while the second was specific to the medical context by assessing whether doctors held racial stereotypes with regard to whether they believed patients of different races are compliant with medical advice.
The researchers found that the physicians in the study held varying attitudes in regard to general race bias (as do most members of the general public) and that this was also true for a racial stereotype of the compliant patient. White and Asian physicians overall held more pro-white attitudes on both measures than did African-American physicians, whose scores were largely neutral.
Based on detailed analysis of visit recordings using the Roter Interaction Analysis System (RIAS), a highly detailed, reliable and internationally validated system of communication coding, the researchers found several relationships between racial attitudes, medical visit communication, and patients' report of their experience with their physicians. Racial bias favoring whites was associated with greater clinician domination of the medical dialogue for both African-American and white patients and a less positive patient emotional tone in the visits of African-American patients. In addition, African-American patients expressed less confidence in their clinicians, perceived less respect from their doctors, liked their doctors less and were less inclined to recommend the doctor to their friends. The impact of bias was generally, but not entirely, positive for white patients; they reported feeling respected and liked by their physician but also felt their physician was less likely to involve them in medical decisions about their care.
The impact of racial stereotyping on communication was somewhat different than the impact of general racial bias. For African-American patients, it included longer visits (by about 20 percent) characterized by slower speech speed, physician-dominated dialogue, lower levels of patient-centeredness (time spent addressing the emotional, social and psychological aspects of the patient's illness and treatment challenges) and lower levels of positive emotional tone in contrast to visits with white patients. The researchers suggest that although longer visits with slower-paced dialogue might be seen as positive, the African-American patients responded to these visits negatively, reporting lower levels of trust and confidence in the physician and lower perceptions of being involved in treatment decisions. Thus, the researchers suggest that patients may interpret this pattern of communication as conveying an authoritarian and critical tone that creates an overall negative impression regardless of longer visit duration. White patients also rated doctors who had this stereotype negatively; they reported being less involved in treatment decisions and were less likely to recommend these doctors to others.
Cooper, director of the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, says she and her team found no overt racial bias among the physicians. "Over time, in our society, people have become more open to different races and ethnicities and for the most part, it's not considered socially acceptable to be negative against other racial or ethnic groups," she says. "But we have subconscious bias that we develop from our earliest experiences and are less subject to social pressures."
Although Cooper's study delved into established primary care relationships, the communications problems her team identified have implications for many other medical settings such as emergency rooms or intensive-care units where the situations are more urgent and the consequences more directly life-threatening. Research is needed into whether implicit bias plays a negative role in those situations as well, she says.
Notably, Cooper says, the study group consisted of patients and physicians who knew each other well, had agreed to participate in studies to improve care for African- Americans, and were willing to have their visits recorded. And yet researchers still found that biases had a negative impact. "If we are more aware of how our attitudes are affecting our behaviors," she says, "only then can we change what we do and ensure that all of our patients get the best care."
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