By Zane Dash
Introduction
Over the last several decades, the patient-provider relationship in American healthcare has been thoroughly transformed. In North Carolina, echoes of the Jim Crow South meld (Martin) with complex transitions in Americans’ comprehension of race, and such effects extend to the patient-provider relationship. In exploring how race alters the dynamic between patients and their medical professionals, we can examine dynamics of patient-provider trust on the basis of race and analyze potential remedies for the doctor-patient relationship. While patient-provider trust remains damaged, techniques including race-based pairing, language concordance, increased practitioner diversity, and other interventions present feasible means of repairing doctor-patient trust, particularly on the basis of race.
Issues of Trust
Changing dynamics of race-based trust are major mechanisms through which race continues to alter the patient-provider relationship. Research finds that trust in health care providers increases the adherence of Black women to prescribed antihypertensive medication (Abel and Efird), while, more broadly, doctor-patient trust is positively related to both patient satisfaction and perceived quality of health care services (Chandra et al.). Trust is thereby a key factor influencing the success of a medical interaction, and increased levels of trust can be life-changing for both doctor and patient.
Yet when levels of trust are examined on the basis of race, concerning patterns emerge. In her Stories to Save Lives interview, nurse Stephanie Atkinson describes a healthcare landscape scarred by the past:
I also do a cultural competency training, which opened my eyes to some things. They talked about how…people had a mistrust…back to the Tuskegee. And it, like, completely changed my perspective, because they said, ‘Guess who did this? The CDC. Guess who this targeted? Black males of a certain age. Guess who some of your hardest patients to get to trust physicians are? Black males of a certain age.’ (Atkinson 42:16-43:21)
Indeed, levels of trust in physicians among numerous minority patient populations are severely damaged. In North Carolina, Black men maintain a “distrust” and “underutilization” of prostate cancer care, largely due to “their own medical encounters,” “distorted” by their “economic and social circumstances” (Talcott et al. 1606). Nationally, minority patients feel decreased control over formal medical decision-making (Ratanawongsa et al. 65), leading many minority patients to explore informal decision-making – such as ignoring medication (Abel and Efird) – and to believe N.C. medical professionals offer them a “lower quality” of healthcare (Moore et al. 64); this inequitable care furthers “the development of mistrust” in Black populations (Moore et al. 64). Mistrust among minority patients is relatively widespread (Armstrong et al. 1283-1289), and it dramatically increases when such patients experience poor healthcare access (Do 31-40). In sum, minority patients are disproportionately barred from formal decision-making, medical professionals’ authority is largely unchecked, and such experiences blend with remnants of historical racism to weaken minority patients’ trust in and adherence to physicians’ care.
Relationships between Caucasian patients and providers of minority background are also affected by issues of damaged trust. Dr. Damon Tweedy, an African-American graduate of Duke University’s School of Medicine, grappled with a North Carolina patient named Chester who – using a Jim Crow-era racial slur – rejected his care (109). Numerous patients stereotypically inquired about his basketball skills, his Black colleagues were mistaken for menial workers, and a Yale study of Black physicians in New England revealed “recurring” discrimination from white patients (Tweedy 113-116). Shalila S. de Bourmont and her team outlined similar findings in a diverse group of North Carolina residents of minority background. If “communication” is most “effective” and “efficient” for “engendering trust” (Pellegrini 95-102), and the dialogue of Caucasian patients and minority providers is steeped in racism, how can trust ever be properly established? It cannot. Such discrimination is “trust-destroying bias,” weakening diagnosis, physician satisfaction, and overall provider-patient relationships (Grob et al. 1347-1348). Minority physicians have greater difficulty trusting Caucasian patients nationally, particularly in North Carolina, creating a systemic issue that demands repair. While less research is devoted to Caucasian patients’ sentiments of trust, Dr. Tweedy’s accounts emphasize that some White patients reject minority physicians’ care, an incriminating indicator of distrust.
Race-Based Pairing: A Potential Solution?
While some patient populations may have reduced trust in physicians of specific races and broadly, a significant amount of recent medical literature has explored the potential benefits of racial concordance between patients and providers as a treatment for repairing the doctor-patient relationship. Initial results have been varied, yet they outline some encouraging findings. In a study of North Carolina Medicaid recipients, race concordance was linked to “significantly higher” levels of physicians’ trust of patients (Smith et al. 530), trends which could impact the authority ceded to patients in formal medical decision-making. Across patients of multiple racial groups nationally, satisfaction with care received from race-matched providers increased (Kennedy et al. 58), while race concordance increased Black patients’ adherence to treatment – with no effect on White patients (Smith 700, 715), likely given White patients’ access to better care. Improved mutual respect, health outcomes, patient comfort, and culturally-sensitive treatment are all associated with race concordance (Wilbur et al. 223-224). In regards to health outcomes, tremendous improvements may be possible – in Florida, racial concordance between Black newborns and their obstetric physicians halved the newborns’ mortality rates (Greenwood et al. 21194). Race is so deeply woven into medicine that even the care given to an unborn child depends on providers’ backgrounds.
The impacts of race-based pairing, until further studied, appear to be limited to specific patient and provider populations, a conclusion confirmed by Dr. Tweedy’s experiences in North Carolina healthcare and other research. In his review, Black patients tend to have “more positive interactions” with black physicians, yet some race-concordance research has found “no additional benefits to black patients,” while much of it excludes international medical graduates (Tweedy 199). A study of N.C. Medicaid recipients outlined scarce changes in trust through racial concordance (Scheid and Smith 631). Thorough research into racial concordance in medicine is required for more substantive conclusions, but the above studies emphasize that true gains of trust through racial concordance are possible.
Further analysis reveals that healthcare interventions rooted in racial similarities may be an oversimplification of a growing need in medicine: translators and language-fluent practitioners. North Carolina’s Hispanic and Latinx population has grown exponentially in recent years (Ordoñez), driving an increase in healthcare needs among the state’s Spanish-speaking population. Ana Maria Deaver, a bilingual CommWell Health CNA, identifies the crucial role of her racial identity within patient-provider relationships:
As an interpreter…it’s a blessing to help people that can’t speak the language, and a lot of time we see people that really cannot understand and cannot speak. (Deaver 25:25-25:40)
And I’m like, ‘No, I’m Latina, just like you. I’m from Panama.’ ‘Oh, I didn’t know you could speak Spanish.’ And I say, ‘Yeah, I speak Spanish. Yeah.’ So they would be amazed…because they see a black woman with kinky hair that speaks Spanish. Yeah, but it’s okay. (Deaver 35:36-36:56)
Deaver’s experiences reveal two ideas integral to race within modern patient-provider relationships: first, even in the absence of racial concordance, providers’ fluency in foreign languages can have a substantial effect on the experiences of minority populations. Second, we live in an increasingly diverse world, and patients’ and providers’ abilities to identify with one another on the basis of race may require dialogue surpassing a cursory examination of one’s skin color. It is thus heartening that racial concordance – here, observed by a healthcare professional and indicated to the patient – is a “consistent predictor” (Shen 137) of further improved patient-physician communication, which is key to patient-provider trust.
Diversity and Additional Remedies for Trust
The concordance of race and language between patients and providers and resulting gains in trust, however, cannot be accomplished without increased practitioner diversity. A physician workforce unrepresentative of the patient population is prone to “mistrust” and “misunderstanding,” and national (Clayborne et al.) and state-level (McGee and Fraher 1) physician diversity considerably lags patients’ racial and ethnic demographics. Even if racial and language concordance provide inconclusive benefits in trust and patients’ outcomes, the possibility of such benefits vanishes without improved provider diversity. Fortunately, pipeline, preprofessional, and enrichment programs for young minority learners; medical school recruitment efforts; emphases on resident and professional diversity; and numerous other methods (Clayborne et al.) are effective means of cultivating a diverse practitioner workforce. Numerous barriers inhibit these processes in North Carolina (McGee and Fraher 4), yet both statewide (Wynn and Phillips 155-158) and national (Wilbur et al. 225-228) interventions are encouraging: at Ohio State University, underrepresented minority (URM) medical school matriculation increased from 13 percent to 26 percent between 2009 and 2016 (Clayborne et al.). Increased healthcare diversity remains a “continuing need” (Wilbur et al. 222), yet strides towards a representative physician workforce, opportunities for patient-provider concordance, and enhanced healthcare are occurring.
Changes in medical professionals’ demographics will require immense investments of effort and time, and if strengthened trust on the basis of race is similarly slowed, generalized measures of improving patient-provider trust can be implemented. Numerous methodologies – distinct from improved physician diversity and patient-provider concordance – have been explored as potential remedies for improving minority patients’ health outcomes and trust in physicians. To prepare for a new era of intensive population-based research within “precision medicine,” research institutions seeking to develop trusting relationships with patients should address the impacts of “history and experience” on trust, engage issues of “group harm” such as racial discrimination, act on “cultural values and communication barriers,” and weave patients’ “values” and “expectations” into systems of oversight (Kraft et al. 3-20); these techniques can also be effectively applied in clinical settings. Such findings mirror aforementioned identifications of history, experience, and communication as key to patient-provider trust. More importantly, these proposals, while substantial, can be accomplished more efficiently than physician workforce changes or rigorous analysis into racial and language-based concordance.
Communication is indeed important: studies argue that if clinicians do not indicate their understanding of patients’ particular “expectations and concerns” about their medical encounters, the clinician will not be viewed as “trustworthy” and a “trusting relationship” will not be established (Sullivan 24). For physicians to gain minority patients’ trust, open dialogue about physicians’ understanding of patients’ values, concerns, and expectations is thus necessary. Ysaura Rodriguez, a Mexican-American immigrant, confirmed the importance of physicians’ understanding:
I think it’s the communication between us, and more than that, she gained my trust…communication is very important in how you make people feel… [She allows] me to explain things to her… [including] my problems [and] home remedies… She’s given me choices, which, it is very important for us to have choices. (Rodriguez 23:43-26:00)
Numerous presented interventions require significant resources for their success, but Ms. Rodriguez’s discussion presents an intrinsically simple solution. Most patients face limited options, and degraded trust between patients and providers partly arises from a lack of mutual understanding. With an emphasis on communication and physicians’ verbalization of patients’ preferences, physicians can tailor treatment, care, and conversation to their patients, just as Ms. Rodriguez’s doctor focused upon her patient’s reliance on home remedies. Admittedly, patients exhibiting racism, ignorance, or other biases may have difficulty trusting practitioners generally or based on specific characteristics. However, when more sophisticated options are not yet viable, a crucial remedy for trust exists at medicine’s core: communication and understanding.
Conclusion
While racial equity in healthcare has improved over the last several decades, significant opportunities for strengthening patient-provider trust remain. Past and present experiences, limited healthcare access, and the quality of healthcare received, among other factors, undermine patient-provider trust, patients’ adherence to and satisfaction with care, and shared medical decision-making. While such factors remain deeply intertwined and rooted in the North Carolina and American healthcare systems, various interventions have been proposed and explored for restoring patient-provider trust generally and on the basis of race. Race-based pairing, language-fluent providers, increased practitioner diversity, multifaceted macro-level approaches for research institutions and clinicians, and practitioners’ efforts to express their comprehension of patients’ experiences and preferences represent possible mechanisms for repairing the doctor-patient relationship. With repaired trust and careful attention to race in medicine, tremendous improvements in healthcare, clinical experiences, and patient outcomes are possible.
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