Introduction:

Education status is a fundamental aspect of the social determinants of health, particularly in preventative health. In medical settings, having a strong education background as a patient is often associated with higher quality relationships with providers and better quality of care(Saha et al). A sufficient medical education, however, rarely lies in the hands of an average patient. In fact, studies show that 80% of North Carolina counties have populations below baseline health literacy(US Unite). Furthermore, in rural North Carolina, even with patients who’ve received a formal education, a doctor’s perception of their educational status – influenced by factors such as race and health literacy – holds greater influence on the care the patient receives and the doctor-patient relationship overall. 

Though Western biomedicine culture tends to emphasize concepts like “do no harm” and treating patients equally, in practice, the education status a doctor assumes a patient has, referred to as “perceived education status” throughout the essay, can alter this dynamic. This practice results in providers tending to be more aggressive, harmful, and dismissal to patients they perceive as “less educated”. When it comes to preventative healthcare, these actions–rooted in both personal biases and systemic discrimination–dictate much of the doctor-patient relationship and evidently, a patient’s health outcome. 

By examining interviews from the Southern Oral History Program, this essay aims to describe how perceived-education status alters the provider-patient relationship, and quality of care a patient receives.

Section I: Is It Really “Do No Harm” – Legitimate Education Status and the Doctor-Patient Relationship

The doctor-patient relationship has long been influenced by the idea of “do no harm” piloted by the Hippocratic Oath, which medical students recite prior to receiving their doctorate. Doing no harm is often referred to as avoiding physical harm, but about when harm is verbal and indirect? This is the case with Miranda Allende. When Allende, a Hispanic-American woman and health administrator with decades of experience enters the doctor’s office, she is confronted with a form of indirect verbal harm from her doctor. A native Puerto Rican and an experienced health worker assisting incoming immigrants in rural North Carolina, Allende was involved in providing utmost health administration to those with limited health literacy and English-language abilities. However, when she becomes the patient in the doctor’s office, discussing a cancer scare, her family’s history of cancer, and her -personal plans to maintain her health, she is met with a rather aggressive comment. Her doctor simply dismisses her plans and ideas, stating “I was the one that went to school for this”(Allende, 25 June, 2018). Even after trying to explain that she has knowledge for how to treat her own health, the doctor refused to collaborate. 

In her case, although Allende was knowledgeable and resourceful enough to switch providers, the doctor’s power assertion over Allende as the patient indicates a negative doctor-patient relationship which can result in poor health outcomes. If the doctor had seen Miranda as someone who looked as though she had an MD–white, male figure–as himself, would he have treated her the same? Though this may not seem as a form of harm, the doctor’s approach towards Allende could have resulted in delaying treatment and care given to her upon her cancer scare. Had Allende not switched doctors, she may not have received the care that she needed and appropriate knowledge for navigating through a cancer scare. After switching providers, Allende realized she had a tumor and needed immediate surgery — which would not have been taken into consideration as seriously with the previous doctor. This becomes more important to look at especially when examining patients who don’t have a sufficient educational background or opportunity to switch to better providers due to affordability(Tulane University). 

Allende’s situation however, isn’t a one-time scenario. Studies show that factors like education and education status in the social determinants of health account for about 50% of healthcare disparities seen, as in Allende’s case(US Unite). This statistic goes to show how critical education and perceived education status is in shaping the doctor-patient relationship and health outcomes.

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Section II: Race, Education, and Quality of Care

Sometimes, the first thing a provider sees and uses to form an opinion about a patient is looking at their race. In the US, specifically in North Carolina, minorities face more mortality and inequity in the healthcare setting(Baker, et al). Namely, Black women account for 43% of the state’s pregnancy related deaths, and are 2.3 times more likely to die of cancer than White women(Baker, et al). Terry Alston Jones, a Black woman, and a native of rural North Carolina describes multiple instances where being Black has affected her community and family members in terms of the care they receive, or rather lack thereof. With a large family working in cotton farms in rural North Carolina, Jones describes how diseases like diabetes, cancer, infant mortality, and more affected her community. Some of her closest family members died of illness, even though it could have been avoided. During her childhood, Jones describes a time when her grandmother(a then fifty-eight year old Black non-formally educated farmer) fell ill. The doctors’ diagnosed her for early onset dementia without looking closely at her condition, assuming her age would cause this kind of disease. Her education status was perceived low and therefore her care was not accounted for properly. Moreover, Due to the doctors not providing her with adequate treatment or investigating the cause further, her Grandmother passed away. 

It was later identified during Jones’ adult years – after asking current doctors and doing a thorough dive into the family’s medical history – that her grandmother was more than likely to have Graves’ disease, which could have been treated had the doctors taken the time to identify and treat it effectively. In other words, Jones’ grandmother did not have to die. But, since the doctor’s were not caring enough to treat Jones’ grandmother – due to race and educational status – she died from a preventable misdiagnosis. Jones’ a current higher education administrator, needed to advocate for her family’s health in order to figure Studies show that in Black communities, misdiagnosis due to racial inequity, doctor biases, and educational statuses(like mentioned in Jones’ family’s story) leads to poor preventative care from a provider’s side(Saha, et all). 

Jones recounts painful stories of her dying grandmother by saying “I was very sad when I was around her…it was like she wanted to say something, but she couldn’t…It was just like, ‘Grandma, I don’t know what you want to say'”(Jones, 11 June 2019).  Not only does this story showcase one of racial inequity tied to educational status, but at large also highlights how the lack of equity when addressing the Black community’s health in the United States can affect families and the health outcomes of any Black patient.

Conclusion: 

Perceived education status is an integral aspect of the social determinants of health, influencing preventative health, as well as the doctor-patient relationship. The question of if a doctor should at all assume a patient’s education status becomes one to linger on. If using a patient’s education status is to assess their health literacy and adjust communication styles accordingly, doing so is important. But, to ensure the best healthcare experience and outcome for patients, perceived education status should not become a way for doctors to assume all authority of a patient and lessen the patient’s ability to make decisions and voice concerns regarding their health. Looking at these issues from a multifaceted approach–race and health literacy of a patient, for example–, is integral to addressing the core of disparities in preventive healthcare. Only then, will equitable healthcare-regardless of perceived education status–be possible.

Works Cited

Baker, Tamara A., et al. “Disparities and Social Inequities: Is the Health of African American Women Still in Peril?” Ethnicity & Disease, vol. 20, no. 3, 2010, pp. 304–9, pubmed.ncbi.nlm.nih.gov/20828107/.

Hironaka, L. K., and M. K. Paasche-Orlow. “The Implications of Health Literacy on Patient-Provider Communication.” Archives of Disease in Childhood, vol. 93, no. 5, May 2008, pp. 428–32, https://doi.org/10.1136/adc.2007.131516.

Hodkinson, Alexander, et al. “Preventable Medication Harm across Health Care Settings: A Systematic Review and Meta-Analysis.” BMC Medicine, vol. 18, no. 1, Nov. 2020, https://doi.org/10.1186/s12916-020-01774-9.

Panagioti, Maria, et al. “Prevalence, Severity, and Nature of Preventable Patient Harm across Medical Care Settings: Systematic Review and Meta-Analysis.” BMJ, vol. 366, no. 366, July 2019, https://doi.org/10.1136/bmj.l4185.

Saha, Somnath, et al. “Patient–Physician Relationships and Racial Disparities in the Quality of Health Care.” American Journal of Public Health, vol. 93, no. 10, Oct. 2003, pp. 1713–19, https://doi.org/10.2105/ajph.93.10.1713.

Southern. “Y-0001: Interview with Miranda Allende, Southern Oral History Program Interview Database.” Unc.edu, 2018, dc.lib.unc.edu/cdm/compoundobject/collection/sohp/id/27912/rec/1. Accessed 18 Apr. 2025.

Southern. “Y-0050: Interview with Terry Alston Jones, Southern Oral History Program Interview Database.” Unc.edu, 2019, dc.lib.unc.edu/cdm/compoundobject/collection/sohp/id/28660/rec/49. Accessed 19 Apr. 2025.

Tulane University. “Social Determinant of Health: Education Is Crucial.” Tulane University School of Public Health and Tropical Medicine, 27 Jan. 2021, publichealth.tulane.edu/blog/social-determinant-of-health-education-is-crucial/.

Us, Unite. “North Carolina by the Numbers: Top 5 Barriers to Care.” Uniteus.com, 5 Dec. 2018, uniteus.com/blog/nc-by-the-numbers/.