As a little girl, Monica Peek often went to the doctor with her grandmother, Mae Reather Long. On those visits to the clinic, she recalls, “my grandmother, who had diabetes, hypertension and high cholesterol, would listen patiently to her doctor’s advice. He would advise her to ‘eat healthy.’ She would politely answer that she had been doing so, and that was that." Her grandmother’s physician didn’t realize that “yes, I’m eating healthy” most likely meant vegetables prepared southern style—with smoked ham. Or that Peek’s grandmother really wanted more time to discuss her medications and how to take them, but she was afraid to ask.
At a presentation at the October 2012 American Public Health Association (APHA) meeting, Peek, who is now an MD, MPH, and diabetes specialist, taught other health care providers how to avoid this type of disconnect with their patients and harness the tremendous power of culturally appropriate communication. Peek’s research, along with her award-winning film on shared decision making (SDM) between physician and patient and her ongoing work at the South Side diabetes project in Chicago, grew, in part, out of those early lessons learned by her grandmother’s side.
“Growing up,” Peek says, “many of my family members struggled with illness. It contributed to my interest in patient impressions of physicians and how physicians can build trust with patients.” Peek, a Robert Wood Johnson Foundation (RWJF) Harold Amos Medical Faculty Development Program scholar (2006 to 2011), explains her goal has always been to learn more about how the social determinants of health affect African Americans.
What Influences Shared Decision Making?
Peek and her colleagues have been investigating the behaviors that encourage SDM since 2008, with a focus on African Americans, though Peek suggests her findings are also applicable to other ethnic or cultural groups struggling with diabetes. She found that while African American patients wanted to participate in SDM, they were much less likely to be asked by their physicians to engage in it than non-Hispanic Whites.
Addressing this gap is important because research has shown that SDM increases patient compliance with medication regimens, healthy lifestyle changes, and produces better diabetes outcomes such as improved glucose control and blood pressure. SDM has proven to be a powerful weapon against diabetes, a disease that costs the nation roughly $100 billion each year.
In her most recent work, “Patient Trust in Physicians and Shared Decision-Making
Among African-Americans with Diabetes,” published in the October 2012 issue of Health Communication, Peek reported: “We found that race, as a social construct, has the potential to influence the two key domains of patient trust—interpersonal relationships and medical skills and technical competence. For example, African Americans in our study were concerned that physicians might be biased or using them in medical experiments without their consent. This influenced their perceptions about their physicians’ overall competence, bedside manner and ability to provide them with high-quality care.”
The study also found that physician/patient trust did not always enhance SDM. Some patients who really trusted their doctors were willing to play more passive roles and let their health care providers make the decisions regarding treatment plans. Methods of building trust included enhanced patient education efforts, physician training in interpersonal skills, and cultural competence efforts to engage patients in SDM.
Bridging Cultural Barriers
In addition to her published work, Peek is a principal investigator of a multi-site intervention called Improving Diabetes Care and Outcomes on the South Side of Chicago (the South Side diabetes project) along with Marshall Chin, MD, MPH.
“The Harold Amos Medical Faculty Development award, along with my career development award from the National Institute of Diabetes and Digestive and Kidney Diseases, allowed me to design and pilot a program of patient empowerment classes at one of our South Side clinics that also led to our film,” explains Peek, a clinician in the department of general internal medicine, diabetes research and training center at the University of Chicago.
By working closely with the patients at the South Side diabetes project and testing various interventions to help them become comfortable with SDM, Peek has identified some of the greatest barriers to improved provider/patient relationships. “There are many complex factors involved, but certain problems rise to the top of the list,” Peek says. She advises clinicians to:
▪ Create a comfort zone: “One of the most consistent problems we found is that people do not feel comfortable saying ‘no’ to their physician,” Peek explains. “So they will say ‘yes,’ they agree with a treatment in the doctor’s office, but then leave and make a personal decision to say, not have a biopsy or try a newly prescribed medication.” Patients reported being more empowered to talk honestly with their doctors and engage in SDM when their doctors created a secure environment for them. Peek suggests that doctors tell their patients: “This is a safe space. You can tell me anything about your health—what you are and are not doing. I can only help you if we work together and talk about your preferences and what works best for you.”
By using behavior modeling techniques, Peek also encouraged SDM by using role playing and interactive games, including one based on the show Who Wants to be a Millionaire?
▪ Let them tell their story. “Patients really like to tell their stories,” Peek says. “Of course doctors often do not have time to listen, but this is a very important part of building a relationship with a patient and helping them feel that you genuinely care about them. When doctors do not listen, patients interpret that as not being cared about and they are less likely to trust the doctor’s recommendations.”
▪ Realize that race matters. “Our research shows that race continues to be a complicated, pernicious issue in our country. Perceptions of racism in the medical profession may impact the doctor/patient relationship, and physicians should be aware that patient perceptions about discrimination may affect their interpretation of what happens within clinical encounters. Cultural discordance poses problems if patients perceive that physicians do not understand their traditions, such as the African American diet and why, for example, they might find it difficult to give up certain foods,” Peek says.
▪ Build a supportive environment. “Overall, we found that African Americans did not feel cared about in the health care system,” Peek says. “But when they do, it makes a difference in how they care for themselves and their willingness to discuss care with their physicians. This is a simple, low-cost solution. Everyone—physicians, front office staff, should be trained to talk with people, ask them how they are and be supportive. You do not need a multi-billion dollar intervention to improve diabetes outcomes.”
▪ Debate, discuss and decide. “Physicians should try to engage their patients in this process,” Peek says. “Review the pros and cons of treatments and talk them over with patients. Discuss the patient’s questions and concerns and work with them to come to a decision.”
The Bottom Line
Peek’s findings repeatedly emphasize the benefits of health care providers building respectful, open and compassionate relationships with their patients. “It really comes down to this,” Peek says. “Love is free. Hugs cost nothing. Shared decision making is really just a very basic concept. It’s where patients and physicians come together to determine treatment. When it works, people take better control of their diabetes. Really tangible, hard outcomes can be traced back to better relationships between health care providers and their patients.”
Learn more about the RWJF Harold Amos Medical Faculty Development Program.
For an overview of RWJF scholar and fellow opportunities, visit www.RWJFLeaders.org.
Watch the award-winning film: Shared Decision Making: The Importance of being Actively Involved in Your Health Care.