Cooper: Doctor-patient relations cause health disparities

5 min read

In the United States, a black man can expect to die, on average, 10 years earlier than his white counterpart. For black women, that racial gap in life expectancy is five years.

Similar disparities along racial and ethnic lines are manifest in rates of illness and infant mortality.

“It’s no secret this has been going on for centuries,” said Liberian-born physician and health care researcher Lisa A. Cooper, a Johns Hopkins University professor of medicine. She explored how health care disparities arise out of the doctor-patient relationship in the first talk in the 2008-09 Dean’s Lecture Series at the Radcliffe Institute for Advanced Study.

“Eliminating Disparities in Healthcare: The Role of Healthcare Professionals” — with an audience of 75 listening in at the Radcliffe Gymnasium — was also the first of the institute’s traditional science lectures.

Cooper contributed to the Institute of Medicine’s landmark 2003 report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.”

Scientists, policymakers, and social scientists have debated the origins of health care disparities for years. Biological differences took center stage for a while, she said, along with class, income, and environmental factors like crowding and pollutants.

There were also debates about the effects of stress and discrimination on health care disparities, and behaviors related to exercise and diet.

Now at the forefront, said Cooper, are two newer issues: access to health care, and the quality of health care. How are those influenced by race and ethnicity?

That question gets to the heart of Cooper’s scholarly pursuits as a social scientist. She and her team of researchers acknowledge the traditional barriers to care, including long-distance travel or gaps in insurance coverage.

But they expanded the list of barriers to include cultural beliefs, language, and literacy. She asked, How “culturally competent” are health care providers? How well do they communicate? And what about bias and stereotyping that might — even unconsciously — affect the quality of health care?

The Institute of Medicine report surveyed decades of literature on health care disparities. It concluded that clinical care for all races was equal, said Cooper, but that disparities in health outcomes were still “pervasive” — for every illness, every patient population (young, old, male, female, urban, rural), and for every level of care, from expensive acute care to relatively inexpensive preventive care.

Her conclusion: We need to study more closely what happens between a doctor and a patient. There have been many investigations of “technical care” in medicine, said Cooper, but few studies of “interpersonal care.”

Prompted by the gaps in research, Cooper and her team in the past few years have used a variety of ways to penetrate and examine what happens in those little rooms where a patient and a doctor meet and talk.

One of Cooper’s early studies was conducted over the telephone. With the agreement of 65 doctors in 32 primary care practices in Maryland and the District of Columbia, more than 1,800 patients — roughly half white and half black — were surveyed about their perceptions of choice, control, and personal responsibility during consultations with doctors.

Not surprisingly, the better the communication, the better the health outcomes. Cooper also uncovered a factor that has emerged in every study since: “racial concordance.” The more a patient identifies with a doctor racially (and visa versa), the better the perception of health care, and the better the health care outcomes.

A later study used audiotapes to probe doctor-patient interactions. Researchers timed the visits, and measured factors like tone of voice and the speed of talk (faster is more aggressive). Among the findings: White doctors seem less interested and more hurried with patients of a different race. But “race-concordant” visits were longer, involved slower speech, and involved “a more positive emotional tone,” said Cooper.

Was something else going on?

Maybe. Cooper was the first researcher to measure implicit bias among doctors, and then blend those findings with how they were perceived by their patients. She measured bias she called so “unconscious” as to be “unavailable to introspection.”

Cooper used a modified version of the Implicit Association Test (IAT), developed at Harvard’s Project Implicit. The Web-based test, requiring a rapid-fire pairing of images and words, is the brainchild of Harvard social psychologist Mahzarin Banaji.

The bottom line: Despite professed liberal preferences, the doctors scored with the general U.S. population. Around 70 percent revealed preferences for same-race interactions.

“There hasn’t been a lot of work in this area at all,” said Cooper, who called for more research on the cultural and racial friction that may negatively affect health care.

“You can’t necessarily change an unconscious attitude,” she said. “But you can change what you do about it.”

Doctors need better communications skills, Cooper said. Clinical practices need to build more time into visits, for the sake of doctor-patient rapport. And — somehow, she added — more minorities have to be drawn into health care practice.