Addressing Disparities Starts With Rebuilding Trust, Connecting Better With Patients

Trust between patients and physicians is crucial; however, biases can impact that relationship and patient outcomes if they are not addressed. The first 5 minutes of a patient’s visit with a doctor can help improve communication and build more trusting relationships, explained panelists during a session on lung health disparities in America at CHEST 2022.

The session focused on what was learned from a listening tour, what those findings mean, and what can be done to address the issues raised.

The CHEST Foundation funded a listening tour across 5 cities/metropolitan areas:

• Jackson, Mississippi
• New York, New York
• Chicago, Illinois
• Southeast Texas (covering San Antonio, Corpus Christi, and Houston)
• Phoenix, Arizona

According to Ian Nathanson, MD, FCCP, vice president, Humana, these chosen cities/metropolitan areas cover a large segment of marginalized communities in the United States.

He played a video with some of the soundbites from the listening tour, which brought together community leaders, physicians, and patients. Among the many stories, what one Black man, Aldolphus, said stood out: “If I wear a suit to a doctor’s appointment, I get a different level of respect from the nurses and from the other people as I walk in the room.”

Another woman, who was a practicing nurse, recounted her 9-day experience in the hospital, and how the treatment she received the first 4 days was very different than what she received starting on day 5, when the hospital staff found out she had been a practicing nurse of 25 years. “When they found out I was a clinician…things started to change….People started to come in, people started to talk to me, look at me, examine me differently.”

At the end of the video, Nathanson highlighted the message coming through after listening to all these experiences and stories: physicians are still not doing as good of a job as they think they are.

The 5 cities/metropolitan areas chosen were not selected at random, noted Paul Thurman, DBA, MBA, associate professor of health policy and management at the Columbia University Medical Center. These cities were selected based on their compositions and that they do not look like the national average despite being huge parts of the country.

Using the 2010 Census data, the median age of these cities was slightly younger than the US national average. While the national composition is 60% non-Hispanic White, 13% Black, 19% Hispanic, 8.5% uninsured, and 13% of the population living below the Federal Poverty Line (FPL), these cities/metropolitan areas look very different.

In Jackson, 82% of the population is Black. In Chicago and New York, 29% of the population is Hispanic, with even higher proportions in Phoenix (42%) and Southeast Texas (46%). While 8.5% of the US population is uninsured, every city had much higher rates, ranging from 10% in New York to 16% in Southeast Texas, Phoenix, and Jackson. Finally, every city had a much larger proportion of the population living below the FPL ranging from 15% in Texas to 27% in Jackson.

“So, what does that mean, as physicians, clinicians, as public health professionals? Do we treat the United States? Or do we treat these 5 cities?” Thurman asked. “And the answer is we tend to treat the United States.”

Thinking about public health interventions done prior to the COVID-19 pandemic, there have been 3 main areas of focus: smoking cessation, vaccinations, and chronic diseases.

Smoking cessation campaigns have largely been based on education and shock tactics to get people to stop smoking. Initially these efforts focused on the hardcore smokers, but that pendulum has swung to the opposite direction and now focuses on preventing people from starting.

“What about all those people kind of in the middle? We're pretty good at the tails of the distribution, not so much the other 68% to 95%,” Thurman noted.

For vaccinations and chronic diseases, in addition to education, community inserts are a popular intervention. For vaccinations, these might be pop-up flu shot tents or church groups who bring in a clinician. For chronic diseases, doctor and nurse vans that go out to the community are popular.

However, for both, they have a limited reach and they are a point-in-time intervention—someone has to be there at the right time to get the benefit.

“If we're good at going out to these communities and doing things, why do we leave?” Thurman asked. “Why can't we stay there and do more with those patients that are not so average in terms of the United States?”

He circled back to Aldolphus, the Black patient from the listening tour who wears suits to his doctor’s appointments. “I don’t have to wear that to go to the doctor,” said Thurman, who is white.

Aldolphus has asthma and needs time with a physician, but he works a per-hour job and time off is income lost. If he can only go see someone on nights and weekends, that means he has to go to urgent care or the emergency department (ED), which costs more money and time not only from Aldolphus’ standpoint but also for the health system.

When he does get to see his doctor, how can the system ensure that he will get the time and attention he needs? The first 5 minutes of a doctor’s appointment will be crucial. During this time, the physician needs to get to know the patient and what their story is.

“As opposed to seeing him as a Black man in a tie, we see him as a patient with a condition and with a story,” Thurman said. “Stories take a lot more time than stereotyping. Stereotyping takes an instant; storytelling takes a little bit longer.”

In those first 5 minutes, it will be important to address any potential biases, said Nneka Sederstrom, PhD, MA, FCCP, chief health equity officer at Hennepin Healthcare in Minneapolis, Minnesota.

In those first seconds, what do you notice most about the patient and what do they notice about you, Sederstrom asked. Is it race, gender, or cultural clothing, such as a hijab?

“In that first 3 seconds of entering [the exam room], there is a dynamic and an opportunity for trust building that oftentimes gets ignored and leads to all the downstream effects that we see happening throughout how our patients engage with us,” she said.

Previous research backs this up. One study¹ found the patient’s first impression has a strong impact on positive and negative judgments on a doctor’s communication approach and “may facilitate or inhibit all further interactions.”

Nathanson provided some other research on the topic. One found that while no participating physician admitted to having an explicit bias, the results of clinical vignettes of patients presenting to the ED with acute coronary syndrome presented to them revealed something different.² While Black patients where more frequently diagnosed with coronary artery disease, the same proportion of Black patients and White patients received treatment. “No other explanation for this other than some sort of a bias,” he said.

The United States in particular has not done a good job of paying attention to historical traumas that come with patients and physicians into the exam room. The physician’s whiteness on its own can be an additional distress for patients who are not White, Sederstrom explained.

Addressing these issues, including that biases are there and are a barrier, will help that patient and physician move forward. Some people are stressed at the idea that addressing their race may change the dynamic for the negative, but Sederstrom doesn’t see it that way. She noted that it will change the dynamic for the positive, because a non-White patient has never had a White physician acknowledge that their race could impact care.

“That will be the initial trust-building block,” she said.

Nathanson rounded out the presentation by circling back to the listening tour and listens learned. He highlighted the 3 emerging themes:

1. Lack of access—patients like Aldolphus who work hourly wage jobs cannot get to their doctor during the day and the office likely isn’t open during the evening and on the weekends.
2. Lack of empathy—he acknowledged his own shortcomings in the past when he would get irritated at patients who admitted to not taking their medications instead of taking the time to find out why they weren’t. Often, it would turn out that the medication had copays that were too high.
3. Lack of trust in the health care system—the patients on the listening tour made it clear they don’t trust doctors, hospitals, or payers. “That was a message that came across loud and clear,” Nathanson said.

During the discussion period at the end with the audience, the issue of documentation in the medical record was raised. An audience member noted that with the ability to share electronic charts, physicians often form impressions of patients before ever meeting them.

Sederstrom shared that she had a meeting recently about instances of racist messaging being documented in the chart and how that can translate into outcomes. “It was an ‘aha moment’ for the people on the call that the bias that gets documented gets transferred,” she said.

The session closed out with Sederstrom providing an example of how biases go both ways. As a Black woman in Minnesota, she often has her guard up when she enters the exam room because almost everyone she sees is White. Taking the time in the first 5 minutes to really talk to the patient and build trust is crucial.

Recently, one White patient thought she was there to clean the room, and she addressed that confusion upfront by acknowledging he probably hadn’t seen another Black person there, let alone one who was a physician. She used it as a chance to communicate and create a safe space to discuss the issue.

“The next Black person who walks in that room, he may pause before he makes an assumption,” Sederstrom said.

References

1. Rimondini M, Mazzi MA, Busch IM, Bensing J. You only have one chance for a first impression! Impact of Patients' First Impression on the Global Quality Assessment of Doctors' Communication Approach. Health Commun. 2019;34(12):1413-1422. doi:10.1080/10410236.2018.1495159

2. Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231-1238. doi:10.1007/s11606-007-0258-5