The Patient's Role in Reducing Disparities

When the world's largest medical specialty society articulates 8 laudable and compelling position statements for reducing disparities in health care in the United States (1), the call for action must not get lost in niggling debates over the details of implementation. Yet the details are precisely where the difficulties lie. In dealing with these difficulties, the leadership of U.S. medicine must question whether some of the proposed solutions will actually produce better health care for minorities. Although some patients may prefer to see a physician of the same race, ethnicity, or sex, empirical evidence that this form of concordance alone improves the quality of interpersonal or technical care is, at best, mixed (2-7). In a carefully designed, multimethod study, for example, Cooper and colleagues (2) found that although patients were more satisfied when seen by physicians of the same race, actual audiotapes of their visits showed no increase in patient-centered communication compared with the audiotapes of visits in which the patient's race differed from the clinician's race. Earlier research suggests that minority patients seeing nonminority physicians may actually be more actively involved in treatment decisions than when the physician's race is the same as the patient's race (7). Greater diversity in the physician workforce is essential. However, the evidence suggests that relying on racial concordance to resolve communication problems between physicians and patients is unlikely to improve quality of care substantially. Training physicians in cultural competence is also unlikely to solve the problem of racial disparities. While cultural competence or cultural sensitivity should be an integral part of early physician training, practically, physicians cannot be taught the interior of every culture they could encounter in practice. How should we ensure that physicians are trained in the appropriate cultures once they are outside of the training environment? The cultural context of a physician's practice is a moving target. Physicians relocate. And the cultural face of major urban centers changes as the dominant minority cultures change with successive waves of immigration. A more appropriate focus for physician training is the specific skill sets that will help physicians to identify the discrete features of a patient's culture that may impede effective implementation of treatment or interfere with optimal health outcomes. Physicians can be taught certain elements of physicianpatient communicationsuch as using effective participatory decision-making styles, looking patients in the eye, and interrupting patients as infrequently as possiblethat produce better outcomes of care in patients of all socioeconomic backgrounds (7-10). Training physicians to focus on these elements of interpersonal communication is a more achievable goal than the far more daunting challenge of achieving universal cultural awareness and competence. Focusing solely on physicians and the clinical setting is meeting only half the challenge. Even the most culturally competent, racially or ethnically concordant physician who sees a patient with chronic disease every 2 to 3 months for 15 to 20 minutes cannot be expected to address the individual patient's complex and unique barriers to effective care. Preparing all patients to make the most of those brief office visits must be a major focus of future efforts to reduce disparities. Many tested patient training programs increase patient participation in treatment decisions. These programs are as effective in improving the outcomes of care among poor and minority populations (9-12) as they are in the general population. Minority patients could also be encouraged to bring advocates or family members to the office or hospital to be translators or negotiators for lifestyle-appropriate treatment decisions. Promising preliminary research suggests that using these patient advocates, navigators, or community-based coaches may be effective in improving the quality of chronic disease care for minorities (13). Calling for patients to be trained as meaningful, not just token, comanagers of their health care is far from a new notion. But its widespread implementation in ethnic and minority populations, while an enormous political, social, and economic challenge, may reduce disparities in the practice and effectiveness of U.S. medicine.