African-American cancer patients are less likely to question and express concerns to their physicians than are white patients, a disparity that may lead to less informed medical decisions and negatively affect outcomes, researchers report.
“Black patients in the study were less participatory in their medical care, which resulted in them getting less information from their physicians,” said the chief investigator, Howard S. Gordon, MD, Visiting Associate Professor in the Department of Medicine at the University of Illinois and the Jesse Brown Veterans Affairs Medical Center in Chicago. “When communication is less effective, medical care may be less optimal.”
As reported in the September 15th issue of Cancer (2006;107:1313–1320), the study found no differences by race in the amount of self-initiated information provided by physicians.
But doctors were significantly less likely to provide additional information prompted by patients' questions or concerns during visits with black patients than with white patients, Dr. Gordon said.
Furthermore, when doctors and patients were of the same race, any gap in doctor-provided information to whites and blacks disappeared, he said.
“In other words, black patients and patients in racially concordant consultations in this study received less information overall because they less often engaged in communicative behaviors such as questions, concerns, and assertions that typically elicit more information from doctors.”
“These findings are notable because, while not directly negating the possibility that racial disparities in care are due to doctor bias or patient preferences, they suggest that disparities in medical care are related in part to the communicative dynamics of the encounter, particularly the degree to which patients are actively involved,” Dr. Gordon and his colleagues wrote.
Growing Number of Studies Linking Patterns of Communication to Outcomes of Care
While acknowledging that the study was small and involved only one hospital, Dr. Gordon said that potential racial variation in doctor-patient communications becomes an issue of concern when one considers the growing number of studies linking patterns of communication to outcomes of care.
The findings also suggest that problems in doctor-patient communication may account for at least some of the well-documented racial gap in cancer care, he added. In one study, for example, black patients were less likely to undergo surgery for early-stage potentially curable lung cancer than white patients were.
Carol L. Brown, MD, Director of the Office of Diversity Programs at Memorial Sloan-Kettering Medical Center, said the findings “add to the body of literature that tells us about the importance of communication in patient outcomes and underscore that some of the disparities we see in cancer outcomes may be related to differences in communication.”
K. Vish Viswanath, PhD, Associate Professor in the Department of Medical Oncology at Dana-Farber Cancer Institute and Associate Professor of Society, Human Development, and Health at the Harvard School of Public Health, said the research provides “more flesh to a long line of studies demonstrating quite consistently the differences in medical encounters between black and white patients.”
So what should be done?
Training—of patients as well as doctors—is key, all agreed.
“Studies have shown that if you train patients to ask question and to be more assertive, they get more information from the physicians. The satisfaction is huge,” Dr. Viswanath said.
Dr. Gordon pointed to one study that showed that patients who were coached to ask questions, negotiate medical decisions, and to overcome barriers when talking with their physicians became more active participants compared with patients who were educated with disease-specific information.
The problem: “Very little effort is placed on teaching patients to communicate with their doctors,” he said.
Proven communication aids include the use of pamphlets that prompt patients to write down questions before a visit and patient education videotapes that role-model active behaviors such as initiating a discussion of cancer, he said.
“Physicians have habits in how they communicate, and changing them can be difficult. But patients don't have as many habits. We have to teach them to be comfortable speaking up even if they think a question is stupid or that the physician is too busy.”
Dr. Viswanath said that habits or not, physicians too have to be taught better communication skills.
“Don't put the entire burden on the patient. We need to retrain our physicians to be sensitive to these types of issues, both through the medical school curricula and continuing education,” he said.
Also, teaching medical students and physicians about racial disparities in doctor-patient interactions may improve communication with patients from different cultural backgrounds, Dr. Gordon said.
At Memorial Sloan-Kettering Cancer Center, physicians are taught to use lay terms instead of scientific jargon when dealing with patients, Dr. Brown said.
Additionally, physicians are urged to encourage patients to bring companions to important consultations such as those involving a potential cancer diagnosis and treatment, she said.
Technologists Save Time but Physicians Lose Time in Digital Mammography
The use of digital mammography compared with screen-film mammography saves technologists' acquisition time but increases physicians' interpretation time, according to a study in American Journal of Roentgenology (2006;187:38–41).
In the study, researchers at Lynn Sage Comprehensive Breast Center of Northwestern Memorial Hospital, led by Eric A. Berns, PhD, a physicist and Research Assistant Professor, compared technologist study acquisition time from examination initiation to release of the patient for 100 screen-film and 100 digital mammography cases.
Also measured was the total interpretation time for screening mammography for 183 hard-copy screen-film cases and 181 soft-copy digital cases.
Technologists spent an average of 21.6 minutes acquiring screen-film mammograms and 14.1 minutes acquiring digital mammograms, which translated to a 35% time savings with digital mammography. The primary reason for this time savings was the elimination of film processing.
The use of digital mammography resulted in a 57% increase in physician interpretation time compared with screen-film mammography: 2.3 vs. 1.4 minutes.
“Interpretation takes longer with digital images because the physician reads on a soft-copy review workstation, which requires manual image manipulation, which isn't as efficient quite yet as reading a screen film study on a view box or alternator,” Dr. Berns said in a news release.
The results of the study suggest that digital mammography can increase patient “throughput” to meet a facility's financial goals, Dr. Berns added. However, the increased patient throughput must be balanced with the cost and capabilities of the physician reading the images.
“In addition, it must be balanced with what's realistic for the technologists,” he said. “More mammograms each day don't necessarily equate with better patient care.”
The researchers also noted that the results suggest that review workstation manufacturers should improve functionality to make soft-copy interpretation of digital mammography more efficient.
“In the meantime, because soft-copy interpretation of digital mammograms in clinical practice will incur longer interpretation times than screen-film screening studies, radiologists should adjust their time allocation for interpretation of digital studies,” the researchers wrote.
Black patients were somewhat less likely to bring a companion with them to the medical consultation, although the difference was not statistically significant.
As measured by the total number of utterances:
- Visits with black patients were significantly shorter than visits with white patients: 254 vs 403 mean total utterances.
- Black patients received significantly less information from their doctors: 49.3 vs 87.3 mean total utterances to whites.
- Physicians provided significantly less information to black patients in response to questions or concerns: 14.5 vs 34.6 mean total utterances to whites.
- There was no significant difference in the frequency of self-initiated information provided by the doctor to blacks and whites: 34.8 and 52.6 mean total utterances, respectively.
When the researchers performed mixed regression analyses that adjusted for patients' and companions' participation, patient and visit characteristics, and other factors, race no longer influenced the frequency of information provided by physicians.
However, the degree of patient engagement with the physician did affect physician-provided information, with each act of active participation by the patient associated with an increase of 1.1 statements of information from the doctor. If a companion was present, each act of active participation was associated with 18.2 additional physician statements.
Secondary analyses looking at doctor-patient racial concordance showed that patients in racially discordant interactions received significantly less information compared with patients in racially concordant interactions.
However, any disparity in doctor-provided information vanished when doctors and patients were of the same race, the researchers noted.
The researchers transcribed and analyzed audiotapes from consultations between medical staff and 137 patients, 30 of whom were black and 107 of whom were white. The African-American and white patients were similar with regard to age, gender, and self-reported mental and physical health status.
The patients, who had pulmonary nodules or lung cancer, consulted with one of five attendings, 10 fellows, or two physician assistants in oncology or thoracic surgery. Two of the staff members were white Hispanic, eight were white non-Hispanic, two were black, and five were Asian.
Using a system devised by the researchers, patients' participation was measured for three types of verbal communication that have the potential to influence doctors' behavior and treatment decisions:
- Asking questions.
- Being assertive.
- Expressing concerns.
Doctors' information-giving statements were coded into two categories depending on whether an utterance was self-initiated or prompted by a patient's communication.