Minority mistrust still haunts medical care

Physicians are urged to work harder to earn trust from minority patients.

By Damon Adams, amednews staff. Jan. 13, 2003.

To help him understand the mistrust minority patients have developed in doctors, Bruce Block, MD, imagined himself in post-World War II Germany.

Dr. Block, who is Jewish, pretended he was a Nazi concentration camp survivor who sought medical care. To his horror, the doctor was the physician from the death camp where he had been imprisoned.

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"That's the feeling I'm getting from well-educated minority patients and their stories. There are times when they are in the exam room when they feel like they're being treated by the enemy," said Dr. Block, a family physician at Shadyside Family Health Center in Pittsburgh, who is among doctors and educators working to wipe out that mistrust. He has conducted focus groups in the black community to hear patient concerns and teamed with churches to build health ministries -- two efforts that foster trust of the medical community.

Understanding his patients' cultural and racial backgrounds and being sensitive to them has enabled Dr. Block to build better relationships with his minority patients -- a key to providing the best possible care.

Minority health care has been under the spotlight since a March 2002 Institute of Medicine report found that racial and ethnic minorities received lower quality health care than whites. For example, minorities were less likely to undergo bypass surgery and to receive kidney dialysis or organ transplants than whites.

Some experts believe the best long-term solution to the disparities problem is to train more minority physicians. But the percentage of the population that is made up of minorities is growing at a much faster rate than the percentage of minorities in the physician work force. And medical school statistics indicate that isn't likely to change soon.

12.5% of the U.S. population is Hispanic, but only 3.4% of physicians are Hispanic.

Hispanics make up 12.5% of the U.S. population, and are expected to hit 24.3% in 2050, according to the U.S. Census Bureau. The black population will increase slightly from 12.3% to 14.7% during the same time. Blacks now make up 2.5% of the physician work force while 3.4% of physicians are Hispanic, according to the AMA.

And, during the past 10 years, the number of black and Hispanic medical school students and graduates has increased only slightly.

In 1992, 5.3% of U.S. medical school graduates were black, according to the Assn. of American Medical Colleges. In 2001, blacks made up 6.9% of graduates. The percentage of Hispanic graduates went from 5.5% in 1992 to 6% in 2001, the AAMC said.

Enrollment of blacks in medical schools went from 6.9% in 1992 to 7.2% in 2001, while Hispanic enrollment increased from 5.8% to 6.4%, the AAMC said.

All this means is that it's up to the medical profession to create a culture more comfortable for minorities, said physicians who see the mistrust issue as a barrier easier broken than some others.

"People are really eager to overcome distrust. We just have to be willing to help them overcome it," said Dr. Block, an associate clinical professor in family medicine at the University of Pittsburgh School of Medicine and director of the UPMC Shadyside Primary Care Institute, a research and service organization.

Reservations about research

A study in the Nov. 25, 2002, Archives of Internal Medicine spotlights concerns with clinical studies.

In a national telephone survey of 909 blacks and whites, researchers found that eight in 10 blacks feared they would be used as guinea pigs for medical research. The study also found that blacks were more likely than whites not to trust that their doctors would fully explain participation in clinical research.

12.3% of the U.S. population is black, but only 2.5% of physicians are black.

"Their perceptions are based on their experiences with the health care system. It does raise concern about how we are interacting," said lead study author Giselle Corbie-Smith, MD, assistant professor of social medicine and internal medicine at the University of North Carolina at Chapel Hill School of Medicine.

Some studies trace distrust in medicine and research to slavery. And more recently to the infamous Tuskegee syphilis study from 1932-1972, in which researchers withheld treatment from about 400 black men to study how the disease progressed.

New accreditation programs are intended to build public trust in clinical research, and government guidelines call for minority subjects in clinical trials. On the local level, the University of Pittsburgh Center for Minority Health two years ago started a community research advisory board that allows investigators to go over research findings with black community leaders.

Trust in the exam room

But researchers and physicians said trust must be addressed in the exam room, too.

Minority educators and physicians cite one key reason for distrust: unequal treatment among racial and ethnic groups.

In 2001, 7.2% of medical students were black, 6.4% were Hispanic.

The March 2002 Institute of Medicine report on racial disparities said some evidence suggests that bias and stereotyping by health care professionals may contribute to differences in care. The report recommended raising awareness among doctors.

The AMA and other medical organizations have developed "cultural competence" initiatives to sensitize physicians to needs of racial and ethnic groups. The National Medical Assn., which represents 25,000 black doctors, is working on a cultural competence curriculum for medical schools. The National Hispanic Medical Assn. is launching a Web site to create awareness about treating Hispanic patients.

"That's how you become a little more trusting, if you open up to patients and understand a little bit where they're coming from," said Elena Rios, MD, president of the National Hispanic Medical Assn.

In Baton Rouge, La., otolaryngologist Jon Traxler, MD, said his approach to patients, including the black patients who make up about one-third of his practice, is simple. "Sit and listen to what they're saying. Explain why you're doing things. Make them feel they are as important as anybody else in your practice, which they are."

Some doctors recommend learning key phrases in different languages and having a racially diverse office staff. Hiring interpreters is another possibility, though reimbursement issues have been a source of controversy for some physicians.

Showing respect can go a long way.

"One of the most incredible things you can do is treat [patients] like you would the president of the United States," said Neil Calman, MD, a family physician and president of the Institute for Urban Family Health in New York. "You wouldn't say, 'Step up on the scale.' You would say, 'Would you please step up on the scale so I can weigh you.' "

Losing the trust of a patient could mean losing that patient. And a bad review from the patient may be bad news for you.

"Trust is something that has to be earned," said Moon S. Chen Jr., PhD, professor of epidemiology and preventive medicine at University of California, Davis, School of Medicine. "We always remember the last restaurant we went to. If it's good food, the reputation is high. If it's bad, it sticks with you."

ADDITIONAL INFORMATION:

An AMA plan to bridge the gap

The AMA plans to create a new program to eliminate racial and ethnic disparities in health care.

The House of Delegates voted to establish the program last month during the AMA's 2002 Interim Meeting in New Orleans.

"Based on the available research, it is clear that racial and ethnic minority patients experience a lower quality and intensity of health care and receive fewer diagnostic and preventive health care services," AMA Immediate Past President Richard Corlin, MD, said in a statement. "We have a professional and moral obligation to aggressively confront this public health problem."

The AMA also will direct resources to help practitioners implement strategies and seek to work with national specialty and state medical associations and other organizations.

Research shows that disparities can result in disease complications, higher health care costs and poor health outcomes, the AMA said. An Institute of Medicine report released in March 2002 found that racial and ethnic minorities got lower quality care than whites.

The delegates' decision supports the goals of Healthy People 2010, a national effort to wipe out health disparities and increase quality care.

The AMA also is calling on federal agencies and other groups to help collect and develop evidence-based performance measures to identify socioeconomic, racial and ethnic disparities in quality.

"We know the problems exist, but we also must recognize there are clear needs for additional information on the nature, causes and implications of health care disparities," Dr. Corlin said.