Achieving Health Care Equity Begins with Relationships
Jan 19, 2015, 9:00 AM
Lisa Cooper, MD, MPH, FACP, is the James F. Fries Professor of Medicine at Johns Hopkins University School of Medicine, Director of the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities, and an alumna of the Robert Wood Johnson Foundation (RWJF) Harold Amos Medical Faculty Development Program.
Have you ever had the experience of being sick and in need of help from a health professional? How about having a parent, child, other family member, or friend who had some health issue for which he or she was seeking answers? What was that like for you? How did you feel, and what were you looking for from that doctor, nurse, or therapist?
Did you ever feel afraid, and alone? Confused? That no one understood what you were going through? Or cared? Or even worse, that the health professionals may have made some assumptions about you or your family member that were wrong – even perhaps blamed you for having your condition or judged you for how you were dealing with it?
If so, you are not alone. Many people who find themselves in the role of a patient have felt these same feelings and had these same thoughts. And if you are poor, don’t have private health insurance, or if you are a person of color or belong to another minority group in our country, you are more likely than others to encounter these problems.
Don’t get me wrong. Most health professionals are good people. These are not excuses for us, but we have lots of challenges that contribute to these problems—uncertainty about which, among many, potential approaches to take with a particular patient; competing demands for our time in a complex and often inefficient health care system; difficulty understanding the needs of patients whose backgrounds differ from our own—often under highly stressful conditions.
So, inequities in health care persist, across race, ethnicity, gender, social class, and other social characteristics, including weight, sexual orientation, and physical disabilities. Patients come to clinicians for help and healing, wanting to trust and believe in the expertise of the person they see. Doctors and other health professionals pursue their careers out of a desire to uplift humanity, working long and hard to build their knowledge and skills and serve their patients. When patient and doctor make a strong positive connection, better health outcomes follow. But when the relationship falls short, poorer outcomes prevail.
Patients and providers must work together to call for a fair distribution of resources by administrators, payers, and policymakers.
Over the last several years, researchers have turned their scrutiny to the role of these key relationships in preserving or alleviating health care disparities. Investigations have evolved from simple surveys to analysis of recorded encounters to interventions designed to improved patient-physician partnerships. Through this research, we seek to discover the mechanisms that explain disparities in the relationships.
This work has identified several relevant factors among patients from disparity populations:
- mistrust of health professionals;
- avoidance of medical care;
- low health literacy;
- lower levels of engagement in medical visits; and
- lack of adherence to recommended treatments.
However, applying what we know to be true about a group to individual patients leads to stereotyping, and should be avoided. Each patient must be treated as an individual, and assumptions should not be made without examining these issues in a way that respects the individual patient. For many patients seeing clinicians who believe these stereotypes, it becomes a self-fulfilling prophecy as they begin to mistrust their doctor, avoid medical visits, talk as little as possible while at the clinic, and fail to follow through with healthy behaviors because they do not trust the advice and directions they receive.
Other research documents clinician factors that may perpetuate health care disparities:
- lack of sensitivity to patients’ cultural beliefs, preferences, needs and values;
- inability to communicate without using medical jargon;
- less participatory communication styles;
- implicit biases regarding race, social class, or physical appearance; and
- discomfort with uncertainty.
For many clinicians seeing patients from disparity populations, the struggle to maintain optimism about addressing the complex medical, social, and psychological needs of these patients becomes very real in the face of their own stressful working conditions as well as numerous barriers that patients face, both in the health system and in the places where they live and work.
As with most things, the problem is caused by many factors—both patient and clinician factors contribute to poor communication, and both sides must work to improve the relationship. There are also health system problems—such as inadequate staffing or training for staff, limited appointment availability, lack of culturally-appropriate materials, and lack of awareness of community resources that could support patient-clinician relationships and health system relationships with traditionally underserved communities.
As health care professionals, we are ethically bound to protect patients from harm, including harm that comes from how they are treated by those in our field, in our health care system, in our clinic, and even in our own exam room. The Charter on Medical Professionalism lays out a guide for us to follow: the primacy of patient welfare, patient autonomy, and social justice. Within these guideposts, clinicians have an obligation to provide the best care possible while avoiding stereotyping, and protect their patients from the harm a bad encounter with a doctor, a nurse, or other clinic staff member can cause. Patients must be viewed as—and become—partners in their care; actively participating in the decision making that determines what courses of action are pursued. If patients are wary or afraid of taking an active role in their health care, we must help them to be more engaged and activated. Patients and providers must also work together to call for a fair distribution of resources by administrators, payers, and policymakers.
The health of a population serves as a vital indicator of the evolution and civility of a society. We must continue to work to improve the resilience of both patients and clinicians to overcome barriers to positive health outcomes. And we must value and reward relationships, between patients and clinicians, and between health systems and their communities—as central to addressing health and health care disparities. As individuals, as communities, and as a society, we must establish strong partnerships, appreciating the unique strengths and contributions of diverse stakeholder groups, to end health care disparities. The urgent responsibility to build a healthier society is on all of our shoulders.
This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.