Consider race-based risks, but treat patients individually


A 68-year-old Hispanic woman walks into your office with high blood pressure. Given that the risk factors and incidence rates for heart disease and diabetes are different for Hispanics than other ethnicities, how should you treat her?

Michael J. Bloch, ACP Member: “Culturally competent communication skills are important for all patients.”
Michael J. Bloch, ACP Member: “Culturally competent communication skills are important for all patients.”

The same as you would any other patient, at least in terms of therapy goals, said Michael J. Bloch, ACP Member, during a talk at Internal Medicine 2008 on racial and ethnic disparities in managing cardiometabolic risk.

Data on the prevalence of certain diseases and health risks among different populations should surely play a role in crafting public health screenings and education programs targeted to specific groups. Once in the doctor's office, though, a patient's treatment is an individual matter.

“It's not like we can say ‘Well, we've done a better job in recent years of controlling blood pressure in older, Hispanic women, so I don't need to concentrate on this woman's hypertension’,” Dr. Bloch said. “We have already identified this patient as having uncontrolled high blood pressure. The therapy goals, and the screening we do in the office for other cardiovascular risk factors, don't change by race and ethnicity.”

Communicating the risks and implications of disease is an area where a patient's background can come into play during a visit, however, he said.

“To deliver care effectively, you need to understand an individual's unique social and cultural environment—and that's not necessarily just his or her race and ethnicity,” Dr. Bloch said. “Culturally competent communication skills are important for all kinds of patients.”

Evidence of disparities

As most internists know, studies have indicated that race and ethnicity affect health care treatment, even when researchers control for patient income, education, occupation and insurance coverage. A 2003 Institute of Medicine study found, for example, that racial and ethnic minorities tend to get lower-quality care, regardless of income or insurance status, than non-minorities.

The root causes of the disparities are complex. Certainly, there are inequalities in access to health care, language barriers that affect health literacy and cultural differences in the way patients feel about treatment, which may decrease compliance. There may also be bias—whether conscious or unconscious—on the provider end which affects treatment, and ultimately, health outcomes.

A 2007 study in the Journal of General Internal Medicine found residents assigned different diagnoses and treatments to hypothetical black and white patient case studies that were presented with the same symptoms and medical history. And an observational study in the 2004 American Journal of Public Health found that physicians were 23% more verbally dominant, and engaged in 33% less patient-centered communication, with African-American patients than with white patients, regardless of the clinician's own race.

In an attempt to raise awareness and eliminate such bias, some have tried training physicians on specific values, customs and beliefs that are thought to be unique to different racial and ethnic groups. But this may not be the best solution to altering the provider and patient behavior that can lead to disparities, Dr. Bloch said.

“These training programs are well-meaning, but they run the risk of stereotypical oversimplification,” Dr. Bloch said. “I would suggest we don't actually know much about a patient based on her being 68 years old and Hispanic. She could be a governor, a recent immigrant who doesn't speak English or a business executive.”

A better approach is to use a communication model that is patient-centered and takes into account the complex interplay of a patient's social, cultural and economic background, he said. Such a model is especially important for racial and ethnic minorities, since research shows they have more difficulty communicating with physicians than whites (see sidebar), but it works for everyone.

Patient-centered communication

The ESFT (Explanatory, Social Risk, Fears, Therapeutic Contracting) Model, developed by Joseph Betancourt, MD, Alexander Green, MD, and J. Emilio Carrillo, MD, comprises a series of questions that can uncover factors that affect a patient's adherence to treatment—such as motivations, fears about medications, or economic struggles (see sidebar, “The ESFT model”).

The “explanatory model” element aims to reveal the patient's understanding and own experience of her medical condition, as well as how much she understands the doctor's concerns, Dr. Bloch said.

“It really gets to the question of ‘why.’ Why does the doctor care about blood pressure? Why does the patient care? How do we get those two to be congruous?” Dr. Bloch said.

The “social risk” aspect examines barriers to adherence, and includes questions about whether a patient's insurance will cover medications, how difficult it is for the patient to afford the drugs or to get to a pharmacy, and whether family members are helpful in managing medication. The “fears and concerns” element, meanwhile, looks at how a patient feels about taking medication, including concerns about side effects and dosage.

The last aspect, “therapeutic contracting,” may be the most important, Dr. Bloch said. It involves having the patient tell the physician how she plans to take the medications or handle treatments, and how she feels about the treatment plan. She and the doctor then come to an agreement about following the plan.

“You may not ask every single question in the model, but you can use it as a guide in deciding which questions are the most meaningful in a given situation,” Dr. Bloch said.

Studies have shown that the more satisfied a patient is with her health care, the more likely she will adhere to treatment. Research also has shown that good communication with a provider makes a patient more satisfied. All of this supports using a patient-centered model of communication, Dr. Bloch said.

“It stands to reason that if you are improving satisfaction by communicating better, and patients are then becoming more adherent, their outcomes will improve,” Dr. Bloch said.