As I explained in part one of this series of posts, minority racial and ethnic groups in the United States experience widespread and severe disparities in healthcare. Over the last few years, I have dedicated my time to researching health and treatment disparities in America that affect racial minorities. The COVID-19 pandemic has only exaggerated the issues, and I therefore feel that it is prudent to explore some of my research in multiple posts.
While structural barriers play a significant role in the decision to seek treatment, it is possible that interpersonal barriers may moderate the relationship between structural barriers and healthcare seeking behavior (Burgess et al., 2018; Betancourt et al., 2003; Mkandawire-Valhmu, 2018). For instance, after the state of Massachusetts implemented healthcare reform to decrease rates of uninsurance among racial and ethnic minorities, researchers found that the logistical reform alone was insufficient in decreasing health disparities; efforts beyond greater insurance coverage would be necessary to create real, lasting change (McCormick et al., 2015). Research on interpersonal barriers to healthcare has focused on factors (e.g. trust, representation, and cultural competence) affecting the quality of the physician-patient relationship. A good physician-patient relationship makes patients more likely to seek healthcare–leading to the idea that interpersonal factors may moderate the relationship between structural barriers and healthcare seeking.
A study by Betancourt et al. (2003) found that the quality of the physician-patient relationship is strongly correlated with patient satisfaction, adherence to medications and medical advice, and health outcomes. A factor contributing to the quality of physician-patient relationship is trust (Burgess et al., 2018). Powell et al., (2019) found that men with increased medical mistrust and exposure to perceived racism in health care were more likely to delay cholesterol and blood pressure screenings. In investigating factors that contributed to higher levels of trust within the physician-patient relationship, Jacobs et al. (2006) found that patients’ trust is determined by the interpersonal and technical competence of physicians, and contributing factors include lack of competence, perceived desire for profit, and patients’ expectations of racism and experimentation during routine healthcare. Without medical trust, patients of racial and ethnic minorities often will not seek healthcare, even if they have the financial means to do so. On the other hand, patients of low SES become more likely to seek healthcare if they score highly in medical trust and financial literacy (Powell et al., 2019). Therefore, the addition of medical trust is an example of how interpersonal factors may moderate the healthcare seeking schema.
In addition to mistrust, another factor contributing to the quality of the physician-patient relationship is the level of representation patients experience in the medical setting. Although African Americans, Hispanics, and Native Americans make up over a quarter of the nation’s population, in 2007 African Americans accounted for only 3.5%, Hispanics 5%, and Native Americans/Native Alaskans 0.2% of physicians (American College of Physicians, 2010). To examine the effects of racial concordance in medical treatment, Alsan et al. (2018) paired black men in Oakland with black or non-black doctors for a conversation about preventive care in order to under the effect of physician race on physician-patient relationship. They found that participants were much more likely to support every preventive service, especially invasive services, after meeting with a racially concordant doctor. While speaking with black doctors, participants were much more open, brought up more issues, and were more likely to seek advice. Unfortunately, the medical workforce is extremely lacking in diversity (Alsan et al., 2018). Faculty in medical schools and larger healthcare organizations are similarly lacking in diversity. In regards to increasing diversity of physicians alone, it is possible that an increase in black doctors in the workforce could reduce the black-white male gap in cardiovascular mortality by 19%, and the life expectancy gap by 8% (Alsan et al., 2018). Such a significant reduction is possible because racial concordance increases preventive care-seeking.
However, that is not to say that doctors who are not of the same race of their patients cannot deliver effective care. In a future post, I will delve into the issue of cultural competency, compassionate care, and how to strengthen the physician-patient relationship.