- Email: [email protected]
Blacks’ and Whites’ Attitudes Toward Race and Nativity Concordance With Doctors
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Blacks’ and Whites’ Attitudes Toward Race and Nativity Concordance With Doctors Jennifer Malat, PhD; Michelle van Ryn, PhD, MPH; David Purcell, PhD
Financial Support: Funding for this research was provided by grants to Dr Malat from the Agency for Healthcare Research and Quality (R03 HS 13280-01A1) and the Taft Research Center at the University of Cincinnati. Previous Presentation: An earlier version of this paper was presented at the 2005 annual meetings of the American Sociological Association. While research shows that race is an important factor in patient-doctor interaction, very little is known about patients’ attitudes toward doctors’ race or nativity. This paper examines 2 specific components of these attitudes. We found that 16% of a Cincinnati, Ohio, sample believed that samerace doctors better understand their health problems, and 22% expected to be more at ease with same-race doctors. Blacks were more likely than whites to hold this belief and expectation, with the largest racial difference among those with college degrees. Looking at nativity, nearly one-third of the respondents believed that US-born doctors better understand their health problems and expected to be more at ease with US-born doctors. Again, blacks were more likely than whites to report a more positive view of US-born doctors compared to foreign-born doctors, with the effect of race varying by education. Future research should further explicate the nature of these attitudes and assess how these attitudes affect health care interactions. Keywords: patient-physician relationship n race/ethnicity n education n knowledge, attitudes, and beliefs J Natl Med Assoc. 2009;101:800-807 Author Affiliations: Department of Sociology, University of Cincinnati, Cincinnati, Ohio (Dr Malat); Department of Family Medicine and Community Health, Division of Epidemiology, University of Minnesota Minneapolis, Minnesota (Dr van Ryn); Department of Sociology, Kent State University, Kent, Ohio (Dr Purcell). Corresponding Author: Jennifer Malat, PhD, Department of Sociology, University of Cincinnati, PO Box 210378, Cincinnati, OH 45221-0378 ([email protected]).
INTRODUCTION
R
esearch on health care has increasingly given attention to the role of race in doctor-patient interactions. Yet while research demonstrates that race
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affects patients’ perceptions of doctor-patient interactions, very little is known about patients’ general attitudes toward doctor race. Further, the national origin of medical providers may influence the interpersonal dynamics of medical encounters as well. However, although international medical graduates make up 25% of the US physician workforce,1 there is very little empirical research on patients’ attitudes toward doctors’ nativity. This paper begins to fill the gaps in knowledge about patients’ thinking about doctors’ race and nativity by examining 2 specific components of patients’ attitudes toward interactions with race-concordant vs discordant providers, and foreign-born vs native-born providers: (1) patients’ beliefs regarding doctors’ knowledge about one’s health problems, and (2) patients’ expected ease with interpersonal interactions. Further, in order to expand understanding of these attitude dimensions, we examine whether these beliefs vary by patient race. Assessing the impact of race concordance and nativity on attitudes toward providers will improve our understanding of the complex dynamics involved in doctor-patient relationships for blacks and whites in the United States.
BACKGROUND
Black patients are much less likely than white patients to see a race-concordant doctor. For example, one study found that black patients most often saw white doctors (58.5%), followed by black doctors (21.7%) and Asian doctors (10.1%).2 This study found that whites most often saw white doctors (85.6%), with different-race doctors most often being of Asian origin (7.5%).2 In addition to race concordance among patients and providers, perceived social similarity or difference can be also be related to nativity. Approximately one-quarter of doctors in the United States are graduates of a foreign medical program, with only about 12% being US citizens who went abroad to study medicine; approximately 36% are from Asian countries, including 20% from India.1,3 Despite some fluctuations and variations within specialties, the proportion of international medical graduates in primary care residency programs was about the same in 2005 as it was a decade earlier.4 The importance of race and nativity of physicians in shaping patients’ evaluation of their care is highlighted VOL. 101, NO. 8, AUGUST 2009
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by research on patients’ ratings of care. Both blacks and whites give their providers higher average ratings when the patient-provider dyad is race concordant.5-7 While this correlation is clear, research has yet to document why this pattern exists. In contrast to the clear findings on the effect of racial concordance on patients’ rating of care, there is little research on how American-born patients evaluate care from foreign-born doctors. We located 2 relevant studies. Both found that patients rated international medical graduates, on at least some measures, more negatively than US medical graduates.8 Howard and colleagues9 also report that whites, not blacks, report less satisfaction with international medical graduates compared to US medical graduates. There are many dimensions of patients’ attitudes toward racial concordance with doctors and interactions with foreign-born doctors. We drew on research on patients’ evaluation of their health care providers to identify specific dimensions of attitude to examine.10,11 This research emphasizes the importance of 2 dimensions of evaluation: providers’ technical competence and interpersonal skills. Consequently, for this study 2 components of attitudes toward race concordance with doctors and doctors’ nativity were measured: (1) beliefs about doctors’ knowledge about respondents’ health problems (technical competence), and (2) respondents’ expectations for ease with interpersonal interaction. We hypothesized that patients believe that race-concordant and US-born doctors better understand their health problems and expect to feel more at ease with race concordant and US-born doctors. We also expected that this effect will be stronger among blacks, who are generally more negatively affected by racial inequality.
For the analyses we used data from the spring 2004 Greater Cincinnati Survey (GCS). The GCS is a telephone survey conducted by the Institute for Policy Research at the University of Cincinnati. The GCS is a random-digitdial sample of residents of Hamilton County, Ohio, which includes the city of Cincinnati and the surrounding area. In order to allow sufficient sample size to assess patterns among blacks, there was an oversample of black respondents. The final sample included 695 whites and 510 blacks. The study was approved by the institutional review board at the University of Cincinnati.
health problems better when they are the same race as me rather than a different race.” To measure expected comfort with different-race doctors, the respondents were asked whether they agreed or disagreed with the statement, “In general, I feel more at ease when the doctor is the same race as I am.” Similar questions were asked about nativity. Respondents were asked, “In general, doctors understand my health problems better when they are from the United States rather than from a different country,” and, “In general, I feel more at ease when the doctor is American born rather than from another country.” Race was measured by respondent report. Because there were very few persons in the surveyed population who were neither white nor black, the analysis for this paper included only blacks and whites. In order to clarify concordance on nativity, only persons born in the United States were included in the sample. This excluded only 16 cases (<2% of the sample). There were several control variables included in the multivariate analysis. First, in order to provide a clear assessment of the effect of race or nativity on the respondents’ expectations for ease and beliefs about health knowledge, the analyses controlled for general expectations and beliefs regarding doctors. The survey asked respondents whether they agreed or disagreed with the following statements, “In general, doctors understand my health problems,” and “In general, I feel at ease with doctors.” In the survey, these items preceded the raceand nativity-specific items described above. Because health status and access to care are related to race12 and may be related to the dependent variables, both were included as control variables. The survey measured health with the commonly used, and well-supported, self-rated health question;13 the self-rated health variable was dichotomized, with excellent and very good health contrasted with good, fair, and poor health. Access to care was indicated by having insurance coverage. Sex and age were included in the analyses as well. Education and income were also included in multivariate models. Both were measured in several categories, had rectangular distributions, and were implemented as continuous variables in the models in order to present more parsimonious models.14 More than 20% of the respondents refused or were unable to provide income information. The missing values were imputed using the “UVIS” Stata module based on a multiple regression with sex, age, race, and education as predictors.
Measures
Analytic Plan
As described earlier, we assessed 2 specific dimensions of attitudes about doctor race: belief about doctors’ knowledge about one’s health problems and expected comfort with interpersonal interaction. The survey asked respondents whether they agreed or disagreed with the following statement, “In general, doctors understand my
Except when noted, weights were applied to the data presented here. A probability weight adjusted for different likelihoods of selection into the sample due to multiple telephone numbers and number of adults in the household and to correct for potential sampling biases on age, race, sex, and education using US Census data.
methods Data
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All of the parameters estimates presented in this paper were estimated using Stata version 7.0 (StataCorp, College Station, Texas).15 Significance values for bivariate associations were determined using c2 tests of independence, which were adjusted using Stata’s svy commands to reflect nonrandom sampling. Multivariate models were estimated using logistic regression. Statistical significance for the Table 1. Weighted Percentage and Unweighted Frequency Distribution of All Variables
% Unweighted n Dependent Variables Understand (same race) Disagree 84.3 936 Agree 15.7 223 Ease (same race) Disagree 78.0 911 Agree 22.0 262 Understand (US born) Disagree 68.2 751 Agree 31.8 401 Ease (US born) Disagree 68.9 792 Agree 31.1 381 Race White 75.3 695 Black 24.7 510 Control Variables Understand (general) Disagree 11.3 149 Agree 88.7 1045 At ease (general) Disagree 14.5 164 Agree 85.5 1035 Self-rated health Good/fair/poor 46.4 562 Excellent/very good 53.6 643 Insurance coverage Have insurance 88.0 1057 No Insurance 12.0 147 Sex Male 45.2 391 Female 54.8 814 Age 18-29 24.8 241 30-45 28.7 360 46-64 24.6 382 ≥65 22.0 197 Education Less than high school 19.2 94 High school 27.4 306 Some college 27.7 411 College graduate 25.7 393 Income <$10 000 24.7 228 $10 000-$19 999 20.4 281 $20 000-$29 999 18.2 221 $30 000-$49 999 11.4 151 ≥$50 000 25.2 298
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coefficients was assessed with a z test using Stata’s robust command, which also adjusts standard errors for nonrandom sampling. Significance for race and the interaction terms was also tested by comparing nested models and assessing model improvement using the difference in the –2log likelihoods; the results supported the z test results. The tables present odds ratios. Because education and income may differently affect stated expectations and beliefs for interracial interactions depending on the race of the individual,16,17 an interaction between these variables and race was expected. To test for interactions between race and income, and race and education, we used multiplicative interaction terms. Because the interactions strained the statistical power of the sample, we presented significance values at .10 and below for the multivariate models. Preliminary analyses showed that the interaction between education and race was significant in all models. The interaction between race and income was significant in only 1 model—expectation for understanding of health problems with samerace vs different-race doctors. To facilitate interpretation of the results of the interactions, some findings are presented in terms of predicted probabilities, which were calculated in Stata by holding all variables at their mean except when noted.
Results
Table 1 presents the distribution of the variables. While a high proportion of respondents generally expected to feel at ease with doctors (85%) and believed that doctors generally understand their health problems (89%), respondents did have race- and nativity-specific beliefs and expectations. Looking at questions that asked about race specifically, 16% believed that race-concordant doctors better understand their health problems. Twenty-two percent expected to feel more at ease with a same-race doctor. Respondents had lower expectations for foreign-born doctors than native-born doctors. Thirty-two percent believed that American-born doctors better understand their health problems, and 31% expected to be more at ease with an American-born doctor. The distribution of the control variables can also be found in Table 1. Table 2 shows the relationship between dependent variables and the other variables. While significant relationships were not found (p >.05) between race and general perceptions of being at ease and doctors understanding health problems, differences were found for the race-specific questions. Blacks were more likely than whites (p < .01) to believe that race-concordant doctors understand their health problems (27% vs 12%) and expected to be more at ease with race-concordant doctors (27% vs 20%). In contrast, the bivariate analysis showed no difference between blacks and whites on their expectations and beliefs regarding doctors’ nativity. The belief that same-race doctors better understand health problems was not significantly associated with any of VOL. 101, NO. 8, AUGUST 2009
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the other variables in the table. Only age and income had a significant relationship with the other 3 dependent variables, and education was associated with only the 2 “at ease” variables. Table 3 provides the results from the multivariate analyses for the race- and nativity-specific variables. The results suggest that blacks were generally more likely than whites to believe that race concordant doctors better understand their health problems, but the effect varied by education and income. Note that while the coefficient for race does not have an asterisk indicating statistical significance, the inclusion of the interactions of race with education and race with income in this model means that the significance calculation for the race term is only the partial effect of race in this model. Figure 1 shows how the effect of race varied by education while holding the other variables at their mean. Among those with some college (the modal category), blacks were approximately 3 times more likely than
whites to believe that same-race doctors better understand one’s health problems (probability: .31 vs .12). Greater education decreased the probability of believing same-race doctors better understand one’s health problems among whites, but increased the effect among blacks. Income had a similar effect, such that higher income was associated with a lower probability of believing same-race doctors better understand one’s health problems among whites, but increased the effect among blacks (Figure 2). The second column of Table 3 shows the results of the analysis predicting expected greater ease with raceconcordant doctors compared to different-race doctors. The effects are similar to those for understanding of health problems, with 2 exceptions. First, there was not a significant interaction between race and income. Second, among those with less than a high school degree, whites were more likely than blacks to have a more positive expectation for race-concordant doctors. As shown
Table 2. Percentage Distribution of “Agree” on Dependent Variables by Independent Variables Race Concordant Understand Health Better More at Ease Race 20.3b White 11.8a a 27.1b Black 27.5 Understand (general) Agree 16.4 22.5 Disagree 11.7 18.1 At ease (general) Agree 15.8 22.0 Disagree 15.3 21.4 Self-rated health Good/fair/poor 17.9 23.8 Excellent/very good 13.9 20.3 Insurance coverage Have insurance 15.7 21.8 No Insurance 15.5 23.1 Sex Male 14.8 23.3 Female 16.5 20.9 Age 18-29 16.9 25.6a 30-45 12.0 14.8a 46-64 15.4 16.4a ≥65 19.7 33.4a Education Less than high school 20.4 35.6a High school 16.1 19.0a Some college 17.1 23.7a College graduate 10.4 13.1a Income <$10 000 18.4 31.3a $10,000-$19 999 21.0 25.2a $20,000-$29 999 13.8 20.0a $30,000-$49 999 15.3 17.6a ≥$50 000 10.4 13.7a a
p < .01 for adjusted c2 test of significance.
b
p < .05.
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US Born Understand Health Better More at Ease 30.6 35.8
30.8 32.0
31.3 37.0
31.2 30.9
32.6 27.7
31.5 29.2
35.1 29.1
31.5 30.7
32.4 27.7
31.5 28.2
29.6 33.7
28.1 33.6
22.7a 24.0a 36.3a 47.5a
26.9a 23.7a 35.7a 40.4a
38.7 31.6 34.9 23.7
40.1b 28.7b 35.2b 22.4b
39.2b 35.0b 31.5b 25.4b 24.9b
39.4b 29.8b 28.6b 35.9b 23.6b
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in Figure 3, increased education again had opposite effects for blacks and whites. Among blacks, increased education was associated with increased likelihood of expecting interpersonal ease to be positively influenced by having a same-race vs other-race doctor. Education had the opposite effect for whites; increased education was associated with lower likelihood of reporting that seeing a same-race doctor improved interpersonal ease. Table 3 also shows the results for nativity on these variables. Overall, we found that the results were in the same direction as those described for doctor race, but the gap between blacks and whites was not as wide. Also, the point at which blacks were more likely than whites to believe that US-born doctors better understand
their health problems, created by the interaction between race and education, was at a higher level of education for the nativity variables.
DISCUSSION
The goal of this paper was to assess 2 components of blacks’ and whites’ attitudes toward seeing same-race vs different-race doctors and toward seeing foreign-born vs US-born doctors. The 2 specific dimensions of attitude examined here were beliefs regarding doctors’ understanding of health problems and expected interpersonal ease with doctors. In addition to assessing these beliefs, the paper examined whether there were racial differences in such beliefs and expectations.
Table 3. Odds Ratios for Logistic Regression Models Race Concordant US Born Understand Health Better More at Ease Understand Health Better More at Ease 0.33b 0.37a Black race 0.49 0.14a Education 0.80 0.63a 0.84 0.78b a a a Race × education 1.54 2.57 1.74 1.51b Income 0.83a 0.82a 0.88b 0.90 Race × income 1.30a Age 1.07 1.11 1.48a 1.25b Male 0.95 1.33 0.92 0.87 Excellent/very good health 0.88 1.12 1.05 1.27 Have insurance 1.39 1.15 1.23 1.06 General—doctors understand health problems 1.58 0.79 General—ease with doctors 1.11 1.13 Observations 1112 1128 1106 1127 a
p < .01 for z test of significance.
b
p < .05.
a
p < .10.
Figure 1. Probability of Expectation that Same-Race Doctors Better Understand Health Problemsa Black
White 0.4
0.3
0.2
0.1
0 < High school
a
High school
Some college
College degree
Predicted probabilities based on model in Table 3.
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Overall we found that a very high proportion of people reported believing that doctors understand their health problems and expected to be at ease with doctors. However, for a minority of people, beliefs and expectations regarding doctors were differentiated based on the race and nativity of the doctor. Positive expectations for race concordance were stronger for interpersonal ease than for understanding of health problems. This difference was mainly due to whites’ low likelihood of stating that same-race doctors better understand their health problems. Because whites’ stated beliefs about doctors’ likely understanding of their health problems appeared to drive the difference in the distributions, we reserve discussion of this effect until racial differences in responses are discussed below.
Beliefs regarding doctors’ nativity suggested reservations about working with foreign-born doctors compared to US-born doctors. Nearly one-third of the respondents believed that US-born doctors better understand their health problems and expected to be more at ease with US-born doctors. Interpretation of this result requires some consideration. First, the specific national origin of doctors that respondents were considering when thinking of foreign-born doctors was unknown. Second, the stronger negative responses regarding doctors’ nativity compared to doctors’ race could have been due to real differences in strength of attitude. However, the difference could also have been due to taboos against speaking about race, especially among whites,18 compared to a generally greater acceptance of negative atti-
Figure 2. Probability of Expectation that Same-Race Doctors Better Understand Health Problemsa Black
White 0.4
0.3
0.2
0.1
0 Under $10 000 a
$10 000$19 999
$20 000$29 999
$30 000$49 999
≥$50 000
Predicted probabilities based on model in Table 3.
Figure 3. Probability of Expectation of Greater Interpersonal Ease with Same-Race Doctorsa Black
White 0. 5 0. 4 0. 3 0. 2 0. 1 0 < High school a
High school
Some college
College degree
Predicted probabilities based on model in Table 3.
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tudes toward persons who are foreign born. The next stage of the analysis compared blacks’ and whites’ beliefs and expectations regarding race concordance with doctors. For both understanding of health problems and interpersonal ease, blacks were more likely than whites to report a more positive attitude toward race concordance with doctors. The effect varied by education, so that the difference was more pronounced among those with college degrees, and for expected ease with different-race doctors, reversed among those with less than a high school degree. Social science research on how blacks and whites answer questions about race can help interpret this result. For blacks, greater education can be associated with greater reporting of racial discrimination.19-21 In part, this may be due to greater clarity of the cause of discrimination; for lesseducated people it is often not clear whether race or class bias is the source of discrimination. Also, blacks who have more education may have higher expectations for treatment with respect from whites.22 Finally, greater education may be related to more knowledge about inequality in medical treatment and health. Overall, greater sensitivity to unfair racial treatment may have led to more positive responses to race-concordant over race-discordant doctors among blacks with more education. In contrast, among whites higher socioeconomic status is associated with either more positive racial attitudes20 and/or a stronger social desirability bias,23,24 both of which increase the likelihood of reporting a positive regard for different-race doctors. Finally, racial differences in attitudes may result from actual experiences with race-discordant doctors; educated whites may be less likely than educated blacks to be underestimated by different-race doctors. Blacks and whites were more similar in their beliefs and expectations regarding US-born vs foreign-born doctors. However, as with race concordance with doctors, the effect of race varied by education. At lower levels of education, whites were more likely than blacks to state beliefs and expectations that favor US-born doctors, while at high levels of education blacks were more likely. At the midlevels of education, blacks and whites tended to be similar in their beliefs and expectations regarding doctors’ nativity. The effect of education was probably due, in part, to the reasons listed above regarding the possible influences on attitudes regarding race concordance with doctors. Clearly, nativity of doctors was something about which some patients have strong beliefs and expectations. Future research will need to be mindful that the effect of race and education depend on one another and measure the simultaneous effect of race and education on these attitudes. These findings have limitations. First, the sample as limited to a single metropolitan area. The greater Cincinnati area, however, includes urban areas similar to a
other larger cities as well as standard suburban areas and more rural areas. In addition, the sample population was similar to the US population on most basic demographic and economic measures (eg, age, education, proportion in the labor force), except that there is a higher proportion of blacks in Cincinnati area than in the United States overall.a Because blacks tend to be concentrated in particular geographic areas, the concentration factor does not threaten the generalizability of the sample. Second, the survey did not collect information about the degree of doctor choice that patients had, which may have influenced their experiences and attitudes. Third, the raceconcordance questions were generic in that they asked only about a doctor who was a “different race.” It is not known what doctor race respondents were thinking of when they responded to the questions. However, it is likely that they were thinking of the other-race doctors with whom they had had contact, which means the most prevalent doctor races for each racial group. Fourth, the effect of social desirability on responses to the survey was a potential limitation of these findings. Whites were hesitant to say how they feel about race, while blacks were more likely to speak frankly to interviewers about racial matters.18 This suggests that the degree of positive attitude toward race concordance with doctors presented here underestimates positive attitudes toward race concordance to the extent that whites understated their preference. At the same time, this may also mean that racial differences in attitude toward racial concordance with doctors may be inflated by whites’ hesitance to appear racist by stating a preference for white doctors. However, positive attitudes toward different-race doctors could also have been due to the cognitive strategy of group subtyping, which, in this case, would mean that common negative stereotypical attitudes toward blacks were less likely to be applied to the subtype of black doctors.25 Future research should use alternative methodological approaches in order to assess whether these factors influenced the findings presented here. This research had many implications. First, it is important to note that the vast majority of blacks and whites did not expect doctor race to influence care on the 2 dimensions measured. This is fairly encouraging, because it suggests that race matching to improve patient satisfaction may be necessary only among a relatively small portion of the patient population, and thus more feasible than many believe. At the same time, however, negative attitudes toward foreign-born doctors may become an increasingly pressing issue as the proportion of US physicians from other countries increase as demand for physicians increases.1 Second, negative expectations of doctors of a different race or nativity may influence quality of care in discordant encounters, although the actual effect is
Comparison based on 2000 Census data for the United States and Hamilton County, Ohio. Data available from www.census.gov.
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unknown. There are some reasonable hypotheses worth exploring. First, it is possible that the effect of negative expectations on verbal and nonverbal patient behavior will negatively affect the provider-patient dynamic and thus contribute to poor quality of care. At the same time, however, such expectations may result in a more highly activated patient who asks questions and seeks information that ultimately results in higher-quality diagnoses and treatment. In this way, it is possible that negative expectations will increase quality of care received and ultimately outcomes, especially among those at highest risks of lower-quality care. This research has clear significance for those who study doctor-patient interactions. Previous research suggests that patient sociodemographic characteristics influence doctors’ attitudes toward patients and the nature of the interaction.26-30 Few studies have evaluated patients’ attitudes toward doctors’ characteristics. The results presented here suggest that race as well as nativity of doctors affect some patients’ attitudes toward doctors. Future research should investigate why there are race and education differences in attitudes toward doctors’ race and nativity. In addition, future studies should examine attitudes among more racial and ethnic groups than were included in this study. Identification of the factors related to attitudes toward doctors’ race and nativity would advance interventions designed to improve doctor-patient interactions.
CONCLUSION
The analysis presented in this paper begins a needed process of examining patients’ attitudes toward doctors’ race and nativity. To date, research on race and health care has documented that race affects the doctor-patient relationship but has not addressed patients’ attitudes toward doctor race. How doctors’ national origin affects patients’ view of their care is rarely studied. This paper examined 2 components of patient attitude toward doctor race and nativity. The results suggest that both whites’ and blacks’ beliefs and expectations for medical encounters are influenced by the doctors’ race and nativity. Further, attitudes appear to vary by race and education. To improve understanding of the racial and national origin dynamics of the medical encounter, future research must further explicate the nature of patients’ attitudes toward doctors’ race and national origin. Furthermore, studies that explicate the impact of such expectations on interpersonal and technical aspects of care are greatly needed.
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5. LaVeist TA, Carroll T. Race of Physician and Satisfaction with Care Among African American Patients. J Natl Med Assoc. 2002;94:937-943. 6. Cooper-Patrick L, Gallo JJ, Gonzales JJ et al. Race, Gender, and Partnership in the Patient-Physician Relationship. JAMA. 1999;282:583-589. 7. Malat J. Social Distance and Patients’ Rating of Healthcare Providers. J Health Soc Behav. 2001;42:360-372. 8. Bertolino JG, Mainous AGI. Patient and physician characteristics associated with perceived quality of care. Fam Pract Research Journal. 1993;13:157-164. 9. Howard DL, Bunch CD, Mundia WO et al. Comparing United States versus international medical school graduate physicians who serve AfricanAmerican and White elderly. Health Serv Res. 2006;41:2155-2181. 10. Fung CH, Elliott MN, Hays RD et al. Patients’ Preferences for Technical versus Interpersonal Quality When Selecting a Primary Care Physician. Health Serv Res. 2005;40:957-977. 11. Montgomery JE, Irish JT, Wilson IB et al. Primary care experiences of Medicare beneficiaries, 1998 to 2000. J Gen Intern Med. 2004;19:991-998. 12. National Center for Health Statistics. Health, United States, 2004. Hyattsville, MD; 2004. 13. Idler EL, Benyamini Y. Self-Rated Health and Mortality: A Review of Twenty-Seven Community Studies. J Health Soc Behav. 1997;39:21-37. 14. Ritchey, FJ. The Statistical Imagination. New York, NY: McGraw-Hill; 1999. 15. Stata Statistical Software: Release 7.0 StataCorp. College Station, TX: Stata Corp; 2001. 16. Feagin JR. The Continuing Significance of Race: Antiblack Discrimination in Public Places. Am Sociol Rev. 1991;56:101-116. 17. Krysan M. Privacy and the Expression of White Racial Attitudes: A Comparison across Three Contexts. Public Opinion Q. 1998;62:506-544. 18. Bonilla-Silva E. Racism without racists : color-blind racism and the persistence of racial inequality in the United States. Lanham, MD: Rowman & Littlefield; 2003. 19. Broman CL, Mavaddat R, Hsu S. The experience and consequences of perceived racial discrimination: A study of African Americans. J Black Psychol. 2000;26:165-180. 20. Schuman H, Steeh C, Bobo L, Krysan M. Racial attitudes in America: Trends and interpretations. Cambridge, MA: Harvard University Press; 1997. 21. Bird ST, Bogart LM. Perceived race-based and socioeconomic status(SES)-based discrimination in interactions with healthcare providers. Ethn Dis. 2001;11:554-563. 22. Forman TA. The Social Psychological Costs of Racial Segmentation in the Workplace: a Study of African Americans’ Well-Being. J Health Soc Behav. 2003;44:332-352. 23. Krysan, M. Recent Trends in Racial Attitudes: A 2002 data update for the 1997 book Racial Attitudes in America: Trends and Interpretations, Revised Edition. tigger.cc.uic.edu/~krysan/t34a.htm. Accessed March 6, 2008. 24. Jackman MR, Muha MJ. Education and Intergroup Attitudes: Moral Enlightenment, Superficial Democratic Commitment, or Ideological Refinement? Am Sociol Rev. 1984;49:751-769. 25. Richards Z, Hewstone M. Subtyping and Subgrouping: Processes for the Prevention and Promotion of Stereotype Change. Pers Soc Psychol Rev. 2001;5:52-73. 26. McKinlay JB, Potter DA, Feldman HA. Non-medical influences on medical decision-making. Soc Sci Med. 1996;42:769-776. 27. Roter DL, Hall JA. Physician gender and patient-centered communication: a critical review of empirical research. Am J Public Health. 2004;25:497-519. 28. Schulman KA, Berlin JA, Harless W et al. The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization. N Engl J Med. 1999;340:618-626. 29. Shortt S. Venerable or vulnerable? Ageism in healthcare. J Health Serv Res Policy. 2001;6:1-2. 30. van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians’ perceptions of patients. Soc Sci Med. 2000;50:813-828. n
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Blacks’ and Whites’ Attitudes Toward Race and Nativity Concordance With Doctors Jennifer Malat, PhD; Michelle van Ryn, PhD, MPH; David Purcell, PhD
Financial Support: Funding for this research was provided by grants to Dr Malat from the Agency for Healthcare Research and Quality (R03 HS 13280-01A1) and the Taft Research Center at the University of Cincinnati. Previous Presentation: An earlier version of this paper was presented at the 2005 annual meetings of the American Sociological Association. While research shows that race is an important factor in patient-doctor interaction, very little is known about patients’ attitudes toward doctors’ race or nativity. This paper examines 2 specific components of these attitudes. We found that 16% of a Cincinnati, Ohio, sample believed that samerace doctors better understand their health problems, and 22% expected to be more at ease with same-race doctors. Blacks were more likely than whites to hold this belief and expectation, with the largest racial difference among those with college degrees. Looking at nativity, nearly one-third of the respondents believed that US-born doctors better understand their health problems and expected to be more at ease with US-born doctors. Again, blacks were more likely than whites to report a more positive view of US-born doctors compared to foreign-born doctors, with the effect of race varying by education. Future research should further explicate the nature of these attitudes and assess how these attitudes affect health care interactions. Keywords: patient-physician relationship n race/ethnicity n education n knowledge, attitudes, and beliefs J Natl Med Assoc. 2009;101:800-807 Author Affiliations: Department of Sociology, University of Cincinnati, Cincinnati, Ohio (Dr Malat); Department of Family Medicine and Community Health, Division of Epidemiology, University of Minnesota Minneapolis, Minnesota (Dr van Ryn); Department of Sociology, Kent State University, Kent, Ohio (Dr Purcell). Corresponding Author: Jennifer Malat, PhD, Department of Sociology, University of Cincinnati, PO Box 210378, Cincinnati, OH 45221-0378 ([email protected]).
INTRODUCTION
R
esearch on health care has increasingly given attention to the role of race in doctor-patient interactions. Yet while research demonstrates that race
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affects patients’ perceptions of doctor-patient interactions, very little is known about patients’ general attitudes toward doctor race. Further, the national origin of medical providers may influence the interpersonal dynamics of medical encounters as well. However, although international medical graduates make up 25% of the US physician workforce,1 there is very little empirical research on patients’ attitudes toward doctors’ nativity. This paper begins to fill the gaps in knowledge about patients’ thinking about doctors’ race and nativity by examining 2 specific components of patients’ attitudes toward interactions with race-concordant vs discordant providers, and foreign-born vs native-born providers: (1) patients’ beliefs regarding doctors’ knowledge about one’s health problems, and (2) patients’ expected ease with interpersonal interactions. Further, in order to expand understanding of these attitude dimensions, we examine whether these beliefs vary by patient race. Assessing the impact of race concordance and nativity on attitudes toward providers will improve our understanding of the complex dynamics involved in doctor-patient relationships for blacks and whites in the United States.
BACKGROUND
Black patients are much less likely than white patients to see a race-concordant doctor. For example, one study found that black patients most often saw white doctors (58.5%), followed by black doctors (21.7%) and Asian doctors (10.1%).2 This study found that whites most often saw white doctors (85.6%), with different-race doctors most often being of Asian origin (7.5%).2 In addition to race concordance among patients and providers, perceived social similarity or difference can be also be related to nativity. Approximately one-quarter of doctors in the United States are graduates of a foreign medical program, with only about 12% being US citizens who went abroad to study medicine; approximately 36% are from Asian countries, including 20% from India.1,3 Despite some fluctuations and variations within specialties, the proportion of international medical graduates in primary care residency programs was about the same in 2005 as it was a decade earlier.4 The importance of race and nativity of physicians in shaping patients’ evaluation of their care is highlighted VOL. 101, NO. 8, AUGUST 2009
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by research on patients’ ratings of care. Both blacks and whites give their providers higher average ratings when the patient-provider dyad is race concordant.5-7 While this correlation is clear, research has yet to document why this pattern exists. In contrast to the clear findings on the effect of racial concordance on patients’ rating of care, there is little research on how American-born patients evaluate care from foreign-born doctors. We located 2 relevant studies. Both found that patients rated international medical graduates, on at least some measures, more negatively than US medical graduates.8 Howard and colleagues9 also report that whites, not blacks, report less satisfaction with international medical graduates compared to US medical graduates. There are many dimensions of patients’ attitudes toward racial concordance with doctors and interactions with foreign-born doctors. We drew on research on patients’ evaluation of their health care providers to identify specific dimensions of attitude to examine.10,11 This research emphasizes the importance of 2 dimensions of evaluation: providers’ technical competence and interpersonal skills. Consequently, for this study 2 components of attitudes toward race concordance with doctors and doctors’ nativity were measured: (1) beliefs about doctors’ knowledge about respondents’ health problems (technical competence), and (2) respondents’ expectations for ease with interpersonal interaction. We hypothesized that patients believe that race-concordant and US-born doctors better understand their health problems and expect to feel more at ease with race concordant and US-born doctors. We also expected that this effect will be stronger among blacks, who are generally more negatively affected by racial inequality.
For the analyses we used data from the spring 2004 Greater Cincinnati Survey (GCS). The GCS is a telephone survey conducted by the Institute for Policy Research at the University of Cincinnati. The GCS is a random-digitdial sample of residents of Hamilton County, Ohio, which includes the city of Cincinnati and the surrounding area. In order to allow sufficient sample size to assess patterns among blacks, there was an oversample of black respondents. The final sample included 695 whites and 510 blacks. The study was approved by the institutional review board at the University of Cincinnati.
health problems better when they are the same race as me rather than a different race.” To measure expected comfort with different-race doctors, the respondents were asked whether they agreed or disagreed with the statement, “In general, I feel more at ease when the doctor is the same race as I am.” Similar questions were asked about nativity. Respondents were asked, “In general, doctors understand my health problems better when they are from the United States rather than from a different country,” and, “In general, I feel more at ease when the doctor is American born rather than from another country.” Race was measured by respondent report. Because there were very few persons in the surveyed population who were neither white nor black, the analysis for this paper included only blacks and whites. In order to clarify concordance on nativity, only persons born in the United States were included in the sample. This excluded only 16 cases (<2% of the sample). There were several control variables included in the multivariate analysis. First, in order to provide a clear assessment of the effect of race or nativity on the respondents’ expectations for ease and beliefs about health knowledge, the analyses controlled for general expectations and beliefs regarding doctors. The survey asked respondents whether they agreed or disagreed with the following statements, “In general, doctors understand my health problems,” and “In general, I feel at ease with doctors.” In the survey, these items preceded the raceand nativity-specific items described above. Because health status and access to care are related to race12 and may be related to the dependent variables, both were included as control variables. The survey measured health with the commonly used, and well-supported, self-rated health question;13 the self-rated health variable was dichotomized, with excellent and very good health contrasted with good, fair, and poor health. Access to care was indicated by having insurance coverage. Sex and age were included in the analyses as well. Education and income were also included in multivariate models. Both were measured in several categories, had rectangular distributions, and were implemented as continuous variables in the models in order to present more parsimonious models.14 More than 20% of the respondents refused or were unable to provide income information. The missing values were imputed using the “UVIS” Stata module based on a multiple regression with sex, age, race, and education as predictors.
Measures
Analytic Plan
As described earlier, we assessed 2 specific dimensions of attitudes about doctor race: belief about doctors’ knowledge about one’s health problems and expected comfort with interpersonal interaction. The survey asked respondents whether they agreed or disagreed with the following statement, “In general, doctors understand my
Except when noted, weights were applied to the data presented here. A probability weight adjusted for different likelihoods of selection into the sample due to multiple telephone numbers and number of adults in the household and to correct for potential sampling biases on age, race, sex, and education using US Census data.
methods Data
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All of the parameters estimates presented in this paper were estimated using Stata version 7.0 (StataCorp, College Station, Texas).15 Significance values for bivariate associations were determined using c2 tests of independence, which were adjusted using Stata’s svy commands to reflect nonrandom sampling. Multivariate models were estimated using logistic regression. Statistical significance for the Table 1. Weighted Percentage and Unweighted Frequency Distribution of All Variables
% Unweighted n Dependent Variables Understand (same race) Disagree 84.3 936 Agree 15.7 223 Ease (same race) Disagree 78.0 911 Agree 22.0 262 Understand (US born) Disagree 68.2 751 Agree 31.8 401 Ease (US born) Disagree 68.9 792 Agree 31.1 381 Race White 75.3 695 Black 24.7 510 Control Variables Understand (general) Disagree 11.3 149 Agree 88.7 1045 At ease (general) Disagree 14.5 164 Agree 85.5 1035 Self-rated health Good/fair/poor 46.4 562 Excellent/very good 53.6 643 Insurance coverage Have insurance 88.0 1057 No Insurance 12.0 147 Sex Male 45.2 391 Female 54.8 814 Age 18-29 24.8 241 30-45 28.7 360 46-64 24.6 382 ≥65 22.0 197 Education Less than high school 19.2 94 High school 27.4 306 Some college 27.7 411 College graduate 25.7 393 Income <$10 000 24.7 228 $10 000-$19 999 20.4 281 $20 000-$29 999 18.2 221 $30 000-$49 999 11.4 151 ≥$50 000 25.2 298
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coefficients was assessed with a z test using Stata’s robust command, which also adjusts standard errors for nonrandom sampling. Significance for race and the interaction terms was also tested by comparing nested models and assessing model improvement using the difference in the –2log likelihoods; the results supported the z test results. The tables present odds ratios. Because education and income may differently affect stated expectations and beliefs for interracial interactions depending on the race of the individual,16,17 an interaction between these variables and race was expected. To test for interactions between race and income, and race and education, we used multiplicative interaction terms. Because the interactions strained the statistical power of the sample, we presented significance values at .10 and below for the multivariate models. Preliminary analyses showed that the interaction between education and race was significant in all models. The interaction between race and income was significant in only 1 model—expectation for understanding of health problems with samerace vs different-race doctors. To facilitate interpretation of the results of the interactions, some findings are presented in terms of predicted probabilities, which were calculated in Stata by holding all variables at their mean except when noted.
Results
Table 1 presents the distribution of the variables. While a high proportion of respondents generally expected to feel at ease with doctors (85%) and believed that doctors generally understand their health problems (89%), respondents did have race- and nativity-specific beliefs and expectations. Looking at questions that asked about race specifically, 16% believed that race-concordant doctors better understand their health problems. Twenty-two percent expected to feel more at ease with a same-race doctor. Respondents had lower expectations for foreign-born doctors than native-born doctors. Thirty-two percent believed that American-born doctors better understand their health problems, and 31% expected to be more at ease with an American-born doctor. The distribution of the control variables can also be found in Table 1. Table 2 shows the relationship between dependent variables and the other variables. While significant relationships were not found (p >.05) between race and general perceptions of being at ease and doctors understanding health problems, differences were found for the race-specific questions. Blacks were more likely than whites (p < .01) to believe that race-concordant doctors understand their health problems (27% vs 12%) and expected to be more at ease with race-concordant doctors (27% vs 20%). In contrast, the bivariate analysis showed no difference between blacks and whites on their expectations and beliefs regarding doctors’ nativity. The belief that same-race doctors better understand health problems was not significantly associated with any of VOL. 101, NO. 8, AUGUST 2009
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the other variables in the table. Only age and income had a significant relationship with the other 3 dependent variables, and education was associated with only the 2 “at ease” variables. Table 3 provides the results from the multivariate analyses for the race- and nativity-specific variables. The results suggest that blacks were generally more likely than whites to believe that race concordant doctors better understand their health problems, but the effect varied by education and income. Note that while the coefficient for race does not have an asterisk indicating statistical significance, the inclusion of the interactions of race with education and race with income in this model means that the significance calculation for the race term is only the partial effect of race in this model. Figure 1 shows how the effect of race varied by education while holding the other variables at their mean. Among those with some college (the modal category), blacks were approximately 3 times more likely than
whites to believe that same-race doctors better understand one’s health problems (probability: .31 vs .12). Greater education decreased the probability of believing same-race doctors better understand one’s health problems among whites, but increased the effect among blacks. Income had a similar effect, such that higher income was associated with a lower probability of believing same-race doctors better understand one’s health problems among whites, but increased the effect among blacks (Figure 2). The second column of Table 3 shows the results of the analysis predicting expected greater ease with raceconcordant doctors compared to different-race doctors. The effects are similar to those for understanding of health problems, with 2 exceptions. First, there was not a significant interaction between race and income. Second, among those with less than a high school degree, whites were more likely than blacks to have a more positive expectation for race-concordant doctors. As shown
Table 2. Percentage Distribution of “Agree” on Dependent Variables by Independent Variables Race Concordant Understand Health Better More at Ease Race 20.3b White 11.8a a 27.1b Black 27.5 Understand (general) Agree 16.4 22.5 Disagree 11.7 18.1 At ease (general) Agree 15.8 22.0 Disagree 15.3 21.4 Self-rated health Good/fair/poor 17.9 23.8 Excellent/very good 13.9 20.3 Insurance coverage Have insurance 15.7 21.8 No Insurance 15.5 23.1 Sex Male 14.8 23.3 Female 16.5 20.9 Age 18-29 16.9 25.6a 30-45 12.0 14.8a 46-64 15.4 16.4a ≥65 19.7 33.4a Education Less than high school 20.4 35.6a High school 16.1 19.0a Some college 17.1 23.7a College graduate 10.4 13.1a Income <$10 000 18.4 31.3a $10,000-$19 999 21.0 25.2a $20,000-$29 999 13.8 20.0a $30,000-$49 999 15.3 17.6a ≥$50 000 10.4 13.7a a
p < .01 for adjusted c2 test of significance.
b
p < .05.
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US Born Understand Health Better More at Ease 30.6 35.8
30.8 32.0
31.3 37.0
31.2 30.9
32.6 27.7
31.5 29.2
35.1 29.1
31.5 30.7
32.4 27.7
31.5 28.2
29.6 33.7
28.1 33.6
22.7a 24.0a 36.3a 47.5a
26.9a 23.7a 35.7a 40.4a
38.7 31.6 34.9 23.7
40.1b 28.7b 35.2b 22.4b
39.2b 35.0b 31.5b 25.4b 24.9b
39.4b 29.8b 28.6b 35.9b 23.6b
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in Figure 3, increased education again had opposite effects for blacks and whites. Among blacks, increased education was associated with increased likelihood of expecting interpersonal ease to be positively influenced by having a same-race vs other-race doctor. Education had the opposite effect for whites; increased education was associated with lower likelihood of reporting that seeing a same-race doctor improved interpersonal ease. Table 3 also shows the results for nativity on these variables. Overall, we found that the results were in the same direction as those described for doctor race, but the gap between blacks and whites was not as wide. Also, the point at which blacks were more likely than whites to believe that US-born doctors better understand
their health problems, created by the interaction between race and education, was at a higher level of education for the nativity variables.
DISCUSSION
The goal of this paper was to assess 2 components of blacks’ and whites’ attitudes toward seeing same-race vs different-race doctors and toward seeing foreign-born vs US-born doctors. The 2 specific dimensions of attitude examined here were beliefs regarding doctors’ understanding of health problems and expected interpersonal ease with doctors. In addition to assessing these beliefs, the paper examined whether there were racial differences in such beliefs and expectations.
Table 3. Odds Ratios for Logistic Regression Models Race Concordant US Born Understand Health Better More at Ease Understand Health Better More at Ease 0.33b 0.37a Black race 0.49 0.14a Education 0.80 0.63a 0.84 0.78b a a a Race × education 1.54 2.57 1.74 1.51b Income 0.83a 0.82a 0.88b 0.90 Race × income 1.30a Age 1.07 1.11 1.48a 1.25b Male 0.95 1.33 0.92 0.87 Excellent/very good health 0.88 1.12 1.05 1.27 Have insurance 1.39 1.15 1.23 1.06 General—doctors understand health problems 1.58 0.79 General—ease with doctors 1.11 1.13 Observations 1112 1128 1106 1127 a
p < .01 for z test of significance.
b
p < .05.
a
p < .10.
Figure 1. Probability of Expectation that Same-Race Doctors Better Understand Health Problemsa Black
White 0.4
0.3
0.2
0.1
0 < High school
a
High school
Some college
College degree
Predicted probabilities based on model in Table 3.
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Overall we found that a very high proportion of people reported believing that doctors understand their health problems and expected to be at ease with doctors. However, for a minority of people, beliefs and expectations regarding doctors were differentiated based on the race and nativity of the doctor. Positive expectations for race concordance were stronger for interpersonal ease than for understanding of health problems. This difference was mainly due to whites’ low likelihood of stating that same-race doctors better understand their health problems. Because whites’ stated beliefs about doctors’ likely understanding of their health problems appeared to drive the difference in the distributions, we reserve discussion of this effect until racial differences in responses are discussed below.
Beliefs regarding doctors’ nativity suggested reservations about working with foreign-born doctors compared to US-born doctors. Nearly one-third of the respondents believed that US-born doctors better understand their health problems and expected to be more at ease with US-born doctors. Interpretation of this result requires some consideration. First, the specific national origin of doctors that respondents were considering when thinking of foreign-born doctors was unknown. Second, the stronger negative responses regarding doctors’ nativity compared to doctors’ race could have been due to real differences in strength of attitude. However, the difference could also have been due to taboos against speaking about race, especially among whites,18 compared to a generally greater acceptance of negative atti-
Figure 2. Probability of Expectation that Same-Race Doctors Better Understand Health Problemsa Black
White 0.4
0.3
0.2
0.1
0 Under $10 000 a
$10 000$19 999
$20 000$29 999
$30 000$49 999
≥$50 000
Predicted probabilities based on model in Table 3.
Figure 3. Probability of Expectation of Greater Interpersonal Ease with Same-Race Doctorsa Black
White 0. 5 0. 4 0. 3 0. 2 0. 1 0 < High school a
High school
Some college
College degree
Predicted probabilities based on model in Table 3.
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tudes toward persons who are foreign born. The next stage of the analysis compared blacks’ and whites’ beliefs and expectations regarding race concordance with doctors. For both understanding of health problems and interpersonal ease, blacks were more likely than whites to report a more positive attitude toward race concordance with doctors. The effect varied by education, so that the difference was more pronounced among those with college degrees, and for expected ease with different-race doctors, reversed among those with less than a high school degree. Social science research on how blacks and whites answer questions about race can help interpret this result. For blacks, greater education can be associated with greater reporting of racial discrimination.19-21 In part, this may be due to greater clarity of the cause of discrimination; for lesseducated people it is often not clear whether race or class bias is the source of discrimination. Also, blacks who have more education may have higher expectations for treatment with respect from whites.22 Finally, greater education may be related to more knowledge about inequality in medical treatment and health. Overall, greater sensitivity to unfair racial treatment may have led to more positive responses to race-concordant over race-discordant doctors among blacks with more education. In contrast, among whites higher socioeconomic status is associated with either more positive racial attitudes20 and/or a stronger social desirability bias,23,24 both of which increase the likelihood of reporting a positive regard for different-race doctors. Finally, racial differences in attitudes may result from actual experiences with race-discordant doctors; educated whites may be less likely than educated blacks to be underestimated by different-race doctors. Blacks and whites were more similar in their beliefs and expectations regarding US-born vs foreign-born doctors. However, as with race concordance with doctors, the effect of race varied by education. At lower levels of education, whites were more likely than blacks to state beliefs and expectations that favor US-born doctors, while at high levels of education blacks were more likely. At the midlevels of education, blacks and whites tended to be similar in their beliefs and expectations regarding doctors’ nativity. The effect of education was probably due, in part, to the reasons listed above regarding the possible influences on attitudes regarding race concordance with doctors. Clearly, nativity of doctors was something about which some patients have strong beliefs and expectations. Future research will need to be mindful that the effect of race and education depend on one another and measure the simultaneous effect of race and education on these attitudes. These findings have limitations. First, the sample as limited to a single metropolitan area. The greater Cincinnati area, however, includes urban areas similar to a
other larger cities as well as standard suburban areas and more rural areas. In addition, the sample population was similar to the US population on most basic demographic and economic measures (eg, age, education, proportion in the labor force), except that there is a higher proportion of blacks in Cincinnati area than in the United States overall.a Because blacks tend to be concentrated in particular geographic areas, the concentration factor does not threaten the generalizability of the sample. Second, the survey did not collect information about the degree of doctor choice that patients had, which may have influenced their experiences and attitudes. Third, the raceconcordance questions were generic in that they asked only about a doctor who was a “different race.” It is not known what doctor race respondents were thinking of when they responded to the questions. However, it is likely that they were thinking of the other-race doctors with whom they had had contact, which means the most prevalent doctor races for each racial group. Fourth, the effect of social desirability on responses to the survey was a potential limitation of these findings. Whites were hesitant to say how they feel about race, while blacks were more likely to speak frankly to interviewers about racial matters.18 This suggests that the degree of positive attitude toward race concordance with doctors presented here underestimates positive attitudes toward race concordance to the extent that whites understated their preference. At the same time, this may also mean that racial differences in attitude toward racial concordance with doctors may be inflated by whites’ hesitance to appear racist by stating a preference for white doctors. However, positive attitudes toward different-race doctors could also have been due to the cognitive strategy of group subtyping, which, in this case, would mean that common negative stereotypical attitudes toward blacks were less likely to be applied to the subtype of black doctors.25 Future research should use alternative methodological approaches in order to assess whether these factors influenced the findings presented here. This research had many implications. First, it is important to note that the vast majority of blacks and whites did not expect doctor race to influence care on the 2 dimensions measured. This is fairly encouraging, because it suggests that race matching to improve patient satisfaction may be necessary only among a relatively small portion of the patient population, and thus more feasible than many believe. At the same time, however, negative attitudes toward foreign-born doctors may become an increasingly pressing issue as the proportion of US physicians from other countries increase as demand for physicians increases.1 Second, negative expectations of doctors of a different race or nativity may influence quality of care in discordant encounters, although the actual effect is
Comparison based on 2000 Census data for the United States and Hamilton County, Ohio. Data available from www.census.gov.
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unknown. There are some reasonable hypotheses worth exploring. First, it is possible that the effect of negative expectations on verbal and nonverbal patient behavior will negatively affect the provider-patient dynamic and thus contribute to poor quality of care. At the same time, however, such expectations may result in a more highly activated patient who asks questions and seeks information that ultimately results in higher-quality diagnoses and treatment. In this way, it is possible that negative expectations will increase quality of care received and ultimately outcomes, especially among those at highest risks of lower-quality care. This research has clear significance for those who study doctor-patient interactions. Previous research suggests that patient sociodemographic characteristics influence doctors’ attitudes toward patients and the nature of the interaction.26-30 Few studies have evaluated patients’ attitudes toward doctors’ characteristics. The results presented here suggest that race as well as nativity of doctors affect some patients’ attitudes toward doctors. Future research should investigate why there are race and education differences in attitudes toward doctors’ race and nativity. In addition, future studies should examine attitudes among more racial and ethnic groups than were included in this study. Identification of the factors related to attitudes toward doctors’ race and nativity would advance interventions designed to improve doctor-patient interactions.
CONCLUSION
The analysis presented in this paper begins a needed process of examining patients’ attitudes toward doctors’ race and nativity. To date, research on race and health care has documented that race affects the doctor-patient relationship but has not addressed patients’ attitudes toward doctor race. How doctors’ national origin affects patients’ view of their care is rarely studied. This paper examined 2 components of patient attitude toward doctor race and nativity. The results suggest that both whites’ and blacks’ beliefs and expectations for medical encounters are influenced by the doctors’ race and nativity. Further, attitudes appear to vary by race and education. To improve understanding of the racial and national origin dynamics of the medical encounter, future research must further explicate the nature of patients’ attitudes toward doctors’ race and national origin. Furthermore, studies that explicate the impact of such expectations on interpersonal and technical aspects of care are greatly needed.
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5. LaVeist TA, Carroll T. Race of Physician and Satisfaction with Care Among African American Patients. J Natl Med Assoc. 2002;94:937-943. 6. Cooper-Patrick L, Gallo JJ, Gonzales JJ et al. Race, Gender, and Partnership in the Patient-Physician Relationship. JAMA. 1999;282:583-589. 7. Malat J. Social Distance and Patients’ Rating of Healthcare Providers. J Health Soc Behav. 2001;42:360-372. 8. Bertolino JG, Mainous AGI. Patient and physician characteristics associated with perceived quality of care. Fam Pract Research Journal. 1993;13:157-164. 9. Howard DL, Bunch CD, Mundia WO et al. Comparing United States versus international medical school graduate physicians who serve AfricanAmerican and White elderly. Health Serv Res. 2006;41:2155-2181. 10. Fung CH, Elliott MN, Hays RD et al. Patients’ Preferences for Technical versus Interpersonal Quality When Selecting a Primary Care Physician. Health Serv Res. 2005;40:957-977. 11. Montgomery JE, Irish JT, Wilson IB et al. Primary care experiences of Medicare beneficiaries, 1998 to 2000. J Gen Intern Med. 2004;19:991-998. 12. National Center for Health Statistics. Health, United States, 2004. Hyattsville, MD; 2004. 13. Idler EL, Benyamini Y. Self-Rated Health and Mortality: A Review of Twenty-Seven Community Studies. J Health Soc Behav. 1997;39:21-37. 14. Ritchey, FJ. The Statistical Imagination. New York, NY: McGraw-Hill; 1999. 15. Stata Statistical Software: Release 7.0 StataCorp. College Station, TX: Stata Corp; 2001. 16. Feagin JR. The Continuing Significance of Race: Antiblack Discrimination in Public Places. Am Sociol Rev. 1991;56:101-116. 17. Krysan M. Privacy and the Expression of White Racial Attitudes: A Comparison across Three Contexts. Public Opinion Q. 1998;62:506-544. 18. Bonilla-Silva E. Racism without racists : color-blind racism and the persistence of racial inequality in the United States. Lanham, MD: Rowman & Littlefield; 2003. 19. Broman CL, Mavaddat R, Hsu S. The experience and consequences of perceived racial discrimination: A study of African Americans. J Black Psychol. 2000;26:165-180. 20. Schuman H, Steeh C, Bobo L, Krysan M. Racial attitudes in America: Trends and interpretations. Cambridge, MA: Harvard University Press; 1997. 21. Bird ST, Bogart LM. Perceived race-based and socioeconomic status(SES)-based discrimination in interactions with healthcare providers. Ethn Dis. 2001;11:554-563. 22. Forman TA. The Social Psychological Costs of Racial Segmentation in the Workplace: a Study of African Americans’ Well-Being. J Health Soc Behav. 2003;44:332-352. 23. Krysan, M. Recent Trends in Racial Attitudes: A 2002 data update for the 1997 book Racial Attitudes in America: Trends and Interpretations, Revised Edition. tigger.cc.uic.edu/~krysan/t34a.htm. Accessed March 6, 2008. 24. Jackman MR, Muha MJ. Education and Intergroup Attitudes: Moral Enlightenment, Superficial Democratic Commitment, or Ideological Refinement? Am Sociol Rev. 1984;49:751-769. 25. Richards Z, Hewstone M. Subtyping and Subgrouping: Processes for the Prevention and Promotion of Stereotype Change. Pers Soc Psychol Rev. 2001;5:52-73. 26. McKinlay JB, Potter DA, Feldman HA. Non-medical influences on medical decision-making. Soc Sci Med. 1996;42:769-776. 27. Roter DL, Hall JA. Physician gender and patient-centered communication: a critical review of empirical research. Am J Public Health. 2004;25:497-519. 28. Schulman KA, Berlin JA, Harless W et al. The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization. N Engl J Med. 1999;340:618-626. 29. Shortt S. Venerable or vulnerable? Ageism in healthcare. J Health Serv Res Policy. 2001;6:1-2. 30. van Ryn M, Burke J. The effect of patient race and socio-economic status on physicians’ perceptions of patients. Soc Sci Med. 2000;50:813-828. n
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