Physician-patient Concordance Research Articles

Mental health disparities in people living with human immunodeficiency virus: A cross-sectional study on physician-patient concordance and treatment regimens.

Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) can profoundly affect the mental health of the people living with HIV (PLWH), with higher rates of anxiety, depression, and sleep disturbances. The disparities in neuropsychological problems evaluated by physicians and self-assessed by patients are still unknown. A total of 5000 PLWH and 500 physicians from 167 hospitals were enrolled in this cross-sectional study from September 2022 to February 2023. 4-Item Patient Health Questionnaire (PHQ-4) was used for the evaluation of depressive issues and anxiety issues by PLWH. Each physician assessed 10 PLWH under their care for the presence of depressive or anxiety issues. The primary outcomes of this study are the concordance rates on the depressive issues and anxiety issues evaluation between physicians and PLWH. The Cohen's kappa test was used to assess the agreement between physicians and PLWH. The concordance rate for the evaluation of depressive issues is 73.84% (95% confidence interval [CI]: 72.60-75.04%), and it is significantly different from the expected rate of 80% (P<0.001). Similarly, the concordance rate for the evaluation of anxiety issues is 71.74% (95% CI: 70.47-72.97%), which is significantly different from the expected rate of 80% as per the null hypothesis (P<0.001). The overestimation rate by physicians on depressive issues is 12.20% (95% CI: 11.32-13.14%), and for anxiety issues is 12.76% (95% CI: 11.86-13.71%). The mismatch rate for depressive issues is 26.16% (95% CI: 24.96-27.40%), and for anxiety issues is 28.26% (95% CI: 27.02-29.53%). The underestimation rate by physicians on depressive issues is 13.96% (95% CI: 13.03-14.95%), and for anxiety issues is 15.50% (95% CI: 14.52-16.53%). For the treatment regiments, PLWH sustained on innovative treatment regimen (IR) related to a lower prevalence of depressive issues (odds ratio [OR]=0.71, 95% CI: 0.59-0.87, P=0.003) and a lower prevalence of anxiety issues (OR=0.63, 95% CI: 0.52-0.76, P<0.001). PLWH switch from conventional treatment regimen (CR) to IR also related to a lower prevalence of depressive issues (OR=0.79, 95% CI: 0.64-0.98) and a lower prevalence of anxiety issues (OR=0.81, 95% CI: 0.67-0.99). Nearly one in three PLWH had their condition misjudged by their physicians. The findings underscore the need for improved communication and standardized assessment protocols in the care of PLWH, especially during the acute phase of HIV infection.

Physician Estimates and Patient-Reported Health Status in Atrial Fibrillation

A primary objective in managing atrial fibrillation (AF) is to optimize patients' health status, which can be done only if physicians accurately quantify the outcomes associated with AF in patients' lives. To explore physicians' estimation of the health status of patients with AF and its association with subsequent care and outcomes. A multicenter, prospective cohort study was conducted in 2 outpatient practices in Tokyo, Japan. Participants included patients with newly diagnosed AF or those referred for initial treatment of AF at outpatient practices and treating physicians from November 8, 2018, to April 1, 2020. Data analysis was performed from December 22, 2022, to July 7, 2023. Participating patients completed the Atrial Fibrillation Effect on Quality-of-Life (AFEQT) questionnaire, a 20-item tool covering 4 domains with a 7-point Likert scale; 3 domains (symptoms, daily activities, and treatment concerns) were used in this study. Blinded to patients' responses, treating physicians answered a 3-item questionnaire quantifying each patient's AFEQT domain with a single item. Patients' mean Likert scale responses within each AFEQT domain were subtracted from the physicians' assessments so that higher scores (≥0.5 points) indicate physician underestimation, while lower scores (≤0.5 points) indicate physician overestimation of the health status of patients with AF. The independent association of physician-patient concordance with treatment escalation (alteration or initiation of antiarrhythmic drugs, cardioversion, or catheter ablation) and 1-year adjusted changes in AFEQT scores. Among 330 patients (238 [72.1%] men; mean [SD] age, 67.9 [11.9] years; 163 [49.4%] with paroxysmal AF), physicians correctly estimated health status in 112 patients (33.9%), underestimated it in 42 patients (12.7%), and overestimated it in 176 patients (53.3%). Treatment escalation occurred in 63.6% of patients whose health status was correctly estimated, 47.6% of those whose health status was underestimated, and 66.3% of patients whose health status was overestimated. After multivariable adjustment, underestimation of health status was independently associated with less treatment escalation (adjusted odds ratio, 0.43; 95% CI, 0.20-0.90) and less frequent AFEQT overall summary score improvement at 1 year (underestimated, 2.5 [95% CI, -1.6 to 6.7] vs correctly and overestimated health status, 8.4 [95% CI, 7.0-9.9] points; P = .01). In this cohort study, physician underestimation of the health status of patients with AF was common and associated with less aggressive treatment and less health status improvement at 1 year.

Review of the Disparities in Access to Pediatric Eye Care Among Low Socioeconomic Status and Underrepresented Racial Minority Groups Exacerbated by the Economic Downturn in Pediatric Ophthalmology.

To explore the association between race and socioeconomic status on health disparities in pediatric eye care, characterize the status of diversity within the pediatric ophthalmology workforce, and propose potential solutions to improve access to vision care, particularly for children from vulnerable populations. The major studies examining the socioeconomic and racial disparities in visual outcomes and the impact of diversity in the ophthalmology workforce were reviewed. Currently, the pediatric ophthalmology workforce has limited racial diversity, and increasing the number of underrepresented in medicine providers has potential to improve access to pediatric eye care, particularly for underserved populations. Mobile eye clinics, school-based vision programs, and health literacy initiatives may engage communities to bring eye care directly to children and enhance follow-up. Families with lower socioeconomic status may represent a vulnerable population facing significant access to pediatric eye care barriers, particularly for asymptomatic pediatric eye conditions. Emphasis on strategies that directly engage communities and bring free vision care to families should be given to improve disparities in visual health outcomes. Ophthalmologists and pediatric ophthalmologists should be aware of the current racial underrepresentation within the pediatric ophthalmology workforce, and the importance of workforce diversity in accelerating physician-patient concordance and access to eye care. [J Pediatr Ophthalmol Strabismus. 2024;61(3):172-178.].

Sex and Racial and Ethnic Diversity Among Ophthalmology Subspecialty Fellowship Applicants

Physician-patient concordance in sex and race is associated with improved patient outcomes. Studies have explored diversity among ophthalmology residents and faculty, but to our knowledge, not among ophthalmology fellows. To assess diversity by sex and race and ethnicity among fellowship applicants in ophthalmology subspecialties and compare match rates by applicants' sex and underrepresented in medicine (URiM) status. This cohort study examined ophthalmology subspecialty fellowship data from the 2021 San Francisco Match. Applicant characteristics were stratified by sex and URiM status and compared using χ2, Mann-Whitney U, and median tests. For applicants who matched, the percentages of female and URiM applicants were compared among the ophthalmic subspecialties. A multivariable logistic regression model was used to assess the association of applicant characteristics with their match outcomes. Included in the sample were 537 candidates who applied for an ophthalmology fellowship using the 2021 San Francisco Match; 224 applicants (42.6%) were female, and 60 applicants (12.9%) had URiM status. Females and males had similar match rates (70.5% [n = 158] and 69.2% [n = 209], respectively; P = .74), but females had a higher median (IQR) US Medical Licensing Examination (USMLE) Step 2 Clinical Knowledge (CK) score (248 [240-258] vs 245 [234-254]; P = .01). The pediatric ophthalmology subspecialty had the highest percentage of female matched applicants (67.5%; 27 of 40 matched applicants), while the retina subspecialty had the highest percentage of males (68.9%; 84 of 122 matched applicants). URiM applicants had lower match rates (55.0%, n = 33) than non-URiM applicants (72.2%, n = 293; P = .007). The URiM applicants had lower median (IQR) scores on the USMLE Step 1 (238 [227-247]) compared with Asian applicants (246 [235-254]) and White applicants (243 [231-252]; P = .04). Additionally, URIM applicants submitted fewer median (IQR) applications (10 [1-23]) than Asian (21 [8-37]) and White (17 [8-32]; P = .001) applicants and completed fewer interviews (median [IQR], 2 [0-11]) than Asian (median [IQR], 12 [3-18]) and White applicants (median [IQR], 8 [1-14]; P = .001). Among matched fellows in each subspecialty, URiM applicants comprised 13.9% (n = 11) in glaucoma, 10% (n = 4) in pediatric ophthalmology, 7.3% (n = 6) in cornea, and 6.6% (n = 8) in retina. Ophthalmology subspecialty fellowship match rates were lower for URiM vs non-URiM applicants in 2021. Underrepresentation of females exists in the retina subspecialty, while racial and ethnic differences exist in all ophthalmology subspecialty fellowships examined. Monitoring trends in fellowship diversity over time should help inform where targeted efforts could improve diversity.

Restitution Through Equity-Focused Mentoring: A Solution to Diversify the Physician Workforce.

Minoritized and marginalized physicians who identify as Black, Latino/a/x and Native American (BLNA) remain unacceptably underrepresented in medicine. Multiple studies provide a compelling argument for prioritizing racial/ethnic diversification of the physician workforce to improve racial/ethnic physician-patient concordance and assist in achieving more equitable health outcomes. Despite a growing awareness for the tangible benefits of a diversified physician workforce, the number of physicians from minoritized and marginalized groups remains relatively stagnant or worsening in certain demographics. The 5:1 ratio of Black students and trainees to Black faculty exemplifies and exacerbates the increased risk for harmful isolation particularly experienced by many BLNA mentees. They too need and deserve the benefits produced by concordant racial/ethnic faculty mentoring and support. However, these demands on time, resources and bandwidth can lead to negative consequences for BLNA faculty engaged in these efforts by contributing to their emotional, mental and physical exhaustion. Given the perpetual paucity of BLNA physicians in academic medicine, immediate interventions to prevent attrition of BLNA faculty, trainees and students journeying along the physician career pathway are urgently needed. Requiring the implementation of mentoring programs explicitly focused on increasing the number of physicians from groups underrepresented in medicine must happen at every point of the education and training process.

The Care Children Deserve

The Care Children Deserve

Physician–Patient Concordance in the Assessment of Asthma Control

Discordance between physicians' and patients' perceptions of asthma control may negatively impact symptom control, treatment, and outcomes. To evaluate concordance between physicians' and patients' perceptions of overall asthma control and the association between perceived overall control and individual components of control. U.S. survey data (Dec 2015-Feb 2016; Apr-Aug 2018) from the Respiratory Disease Specific Programme were analyzed. Physicians recorded patient disease characteristics and their perception of patients' asthma control. Patients' perception of control was assessed using the Asthma Control Test; responses were compared with level of symptom control per the Global Initiative for Asthma criteria and Work Productivity and Impairment questionnaire responses. Agreement and association were assessed by weighted kappa (κ) and Spearman rho (ρ), respectively. The study included 1,288 patients. Concordance between physician-perceived and patient-perceived asthma control in the prior 4 weeks was moderate (κ= 0.4951). Association between physicians' overall perception of asthma control and patients' overall Asthma Control Test score was also moderate (ρ= 0.5450). However, 61.5% of patients with self-reported, well-controlled asthma had shortness of breath 1 to 2 times/wk, 45.6% had 1 to 2 night-time awakenings/wk, and patients reported a mean (SD) daily activity impairment of 17.5% (16.2%). Only 21.8% of patients with self-reported, well-controlled asthma were classified as such by Global Initiative for Asthma symptom criteria. Patients' self-assessment of overall control does not accurately characterize the true level of control; thus, patients and physicians may benefit from working together to assess the individual components of asthma control to achieve better disease management, treatment decisions, and improvedoutcomes.

Impact of Physician-Patient Communication in Online Health Communities on Patient Compliance: Cross-Sectional Questionnaire Study.

BackgroundIn China, the utilization of medical resources is tense, and most hospitals are highly congested because of the large population and uneven distribution of medical resources. Online health communities (OHCs) play an important role in alleviating hospital congestions, thereby improving the utilization of medical resources and relieving medical resource shortages. OHCs have positive effects on physician-patient relationships and health outcomes. Moreover, as one of the main ways for patients to seek health-related information in OHCs, physician-patient communication may affect patient compliance in various ways. In consideration of the inevitable development of OHCs, although they have several shortcomings, identifying how physician-patient communication can impact patient compliance is important to improve patients’ health outcomes through OHCs.ObjectiveThis study aimed to investigate the impact of physician-patient communication on patient compliance in OHCs through the mediation of the perceived quality of internet health information, decision-making preference, and physician-patient concordance, using an empirical study based on the self-determination theory.MethodsA research model was established, including 1 independent variable (physician-patient communication), 3 mediators (perceived quality of internet health information, decision-making preference, and physician-patient concordance), 1 dependent variable (patient compliance), and 4 control variables (age, gender, living area, and education level). Furthermore, a Web-based survey involving 423 valid responses was conducted in China to collect data, and structural equation modeling and partial least squares were adopted to analyze data and test the hypotheses.ResultsThe questionnaire response rate was 79.2% (487/615) and the validity rate was 86.9% (423/487); reliability and validity are acceptable. The communication between physicians and patients in OHCs positively affects patient compliance through the mediation of the perceived quality of internet health information, decision-making preference, and physician-patient concordance. Moreover, physician-patient communication exhibits similar impacts on the perceived quality of internet health information, decision-making preference, and physician-patient concordance. Patients’ decision-making preference shows the weakest impact on patient compliance compared with the other 2 mediators. Ultimately, all 3 mediators play a partially mediating role between physician-patient communication and patient compliance.ConclusionsWe conclude that physician-patient communication in OHCs exhibits a positive impact on patient compliance; thus, patient compliance can be improved by guiding physician-patient communication in OHCs. Furthermore, our findings suggest that physicians can share high-quality health information with patients, discuss benefits, risks, and costs of treatment options with patients, encourage patients to express their attitudes and participate in health-related decision making, and strengthen the emotional connection with patients in OHCs, thereby decreasing patients’ misunderstanding of information and increasing concordance between physicians and patients. OHCs are required to not only strengthen the management of their published health information quality but also understand users’ actual attitudes toward information quality and then try to reduce the gap between the perceived and actual quality of information.

Is physician-patient concordance associated with greater trust for women of low socioeconomic status?

ABSTRACTThe authors examined the association between physician-patient concordance and patient trust for low socio-economic status women who were enrolled in Medicaid case management. The data were collected from October 2006 through March 2007 from a stratified random sample of 2,815 adult beneficiaries enrolled in North Carolina Medicaid’s primary care case management delivery system. We limited our analyses to women enrolled in primary care, hence controlling for gender and social class as well as access to care. We were also able to control for the availability of minority providers. The findings revealed that the enrollee’s race, education, and experiences seeking help with their health providers were significantly related to patient’s trust of their physicians. Neither race concordance nor gender concordance improved trust. This may be because relatively few minority providers were included in the sample. These results extend research on physician-patient concordance by examining the relationship of both racial and gender concordance with patient trust while controlling for access and social class. Research on physician-patient concordance needs to account for multiple measures of social status, as well as differences in culture and communication styles between physicians and their patients.

Physician-Patient Concordance in Pharmacological Management of Patients with COPD

A retrospective analysis of a cross-sectional, multicenter survey was conducted in United States (US) medical practices to evaluate the concordance between patients with COPD and their physicians on disease-specific characteristics. Associations between patient and disease-related characteristics with monotherapy, dual therapy, or triple therapy prescribed as COPD maintenance regimens were also examined. Eligible physicians completed patient record forms (PRFs) for up to 6 consecutive patients with COPD. Patients for whom a PRF was completed were invited to complete a patient self-completion (PSC) survey consisting of questions similar to those on the PRF, as well as several validated measures to assess the impact of COPD on patients’ lives. A total of 469 patients completed a PSC that was matched with the PRF completed by their physician, forming the sample for the concordance analysis. Moderate agreement (kappa (κ) = 0.41–0.60) was observed for 79% of measures, with the lowest concordance rating corresponding to hemoptysis (κ = 0.22). There were few differences in demographic or clinical characteristics between patients prescribed monotherapy and dual therapy. Triple therapy rather than monotherapy or dual therapy was more often prescribed for patients with greater frequency of symptoms, negative impact of COPD on daily life and interpersonal relationships, and respiratory impairment based on the most recent FEV1. Diverse factors influence US physicians’ perceptions of disease and treatment choices, including patient symptoms, quality of life, and disease impact. Our results highlight that concordance between physicians and patients regarding symptoms and physical function may contribute to optimal management of COPD.

Differences between physician and patient in the perception of symptoms and their severity in COPD

Chronic Obstructive Pulmonary Disease (COPD) impairs quality of life and presents symptoms that affect the lives of patients. Our study analysed the degree of concordance between the patients and their pulmonologists in the perception of the severity of symptoms. A cross-sectional, descriptive, multicentre study was conducted in patients with COPD. From a list of 10 symptoms (cough, dry mouth, chest pain, expectoration, wheezing/whistling in the lungs, depression/sadness/discouragement, fatigue/tiredness/general lack of energy, anxiety/nervousness, breathlessness/shortness of breath upon exertion and difficulty sleeping/sleep disorders) each investigator and patient assessed those which, in their opinion, most concerned or affected the patient. A total of 450 patients were included in the study (91.3% males, 66.7 years old (SD = 10.2), FEV1(%) 51.7% (SD = 12.7%)). At an aggregate level, breathlessness/shortness of breath, fatigue/tiredness and coughing were identified by patients and physicians as being the most relevant symptoms. However, according to the concordance analysis conducted with individual pairs (each pulmonologist with his/her patient), only 52.8% coincided when identifying the symptom that most concerned or affected the life of the patient. The concordance analysed by the Kappa index between patients and physicians was poor (<0.42). The degree of physician-patient concordance was greater in patients with more severe COPD. The patients and their pulmonologists identified the same three main symptoms of COPD but showed low concordance when assessing the impact of the symptoms of the illness.

Physician-Patient Race Concordance from the Physician Perspective

The benefits of racial/ethnic physician-patient concordance have been cited to support increasing the number of minority physicians. Few studies have examined the rates at which physicians of different race/ethnicity groups or specialties see concordant visits. We aim to determine whether differences exist in rates at which physicians of different race/ethnicity groups and physician specialties see visits by patients of concordant race/ethnicity. We used data from the National Ambulatory Medical Care Survey, 2001-2006, a nationally representative survey of visits to private physician's offices. For physicians of each race/ethnicity group, the percentage of visits by patients in each race/ethnicity group was calculated. A concordant visit was defined as one in which a physician in a particular race/ethnicity group saw a patient of the some race/ethnicity group. Concordance rates were calculated overall, and for visits to primary care, medical specialties, and surgical specialties individually. White physicians see a higher percentage of concordant visits than any other race/ethnicity of physician (84.3%, p < 0.001 vs. all others), followed by Hispanic physicians and non-Hispanic black physicians, who had statistically similar rates (50.0%, and 46.8%, p > 0.05 for comparison), with non-Hispanic Asian physicians having the lowest rate of concordant visits (14.5%, p < 0.001 vs. all others). Minority surgical and medical specialists have significantly lower rates of concordant visits (33.4% and 33.6% respectively) compared to minority primary care physicians (49.5%, p < 0.001 for both comparisons). Concordance rates from the physician perspective differ by physician race/ethnicity and by physician specialty.

Differing Perceptions of Quality of Life in Patients With Prostate Cancer and Their Doctors

As the number of prostate cancer survivors increases, urologists must recognize their quality of life impairment. In the past physician ratings of patient symptoms did not correlate with patient self-assessments. We determined if urologists have improved their reporting of patient health related quality of life. We also investigated if urologists assessed health related quality of life more accurately in the short or long term. We identified 1,366 men from CaPSURE™, a national, prospective cohort, who had undergone prostatectomy, brachytherapy or external beam radiation therapy. At each visit urologists assessed fatigue, pain, and sexual, urinary and bowel dysfunction. Participants independently completed the SF-36™ and the UCLA-PCI. We contrasted the frequency of impairment reported by physicians and participants in select health related quality of life domains in the short (less than 1 year) and long (greater than 2 years) term. We also compared physician-patient concordance between the periods 1995 to 2000 and 2001 to 2007. In short-term and long-term followup, and for the 1995 to 2000 and 2001 to 2007 cohorts, physician and participant assessments differed in all analyzed domains. Urologists noted impairment in urinary and sexual function more often than fatigue or pain. Disagreement between physician and participant ratings did not vary dramatically from short-term to long-term followup, or from the earlier to the later cohort. In men treated for localized prostate cancer physician ratings of symptoms do not correlate well with patient self-assessments of health related quality of life. Physician reporting did not improve over time. It is increasingly important to recognize and address impairments in quality of life from prostate cancer and its treatment.

Dynamics of doctor-patient relationship: A cross-sectional study on concordance, trust, and patient enablement

Background:The rapid pace of medical advances coupled with specialization and super-specialization, is eroding the traditional doctor–patient relationship.Objective:(a) To study the determinants of core dimensions, such as, concordance, trust, and enablement in a doctor–patient relationship; (b) to explore associations, if any, among these core dimensions.Materials and Methods:A cross–sectional study design with both quantitative and qualitative methods was employed. One hundred and ninety-eight outdoor patients were interviewed as part of the quantitative study. Three dimensions of the doctor–patient relationship, that is, physician patient concordance, trust in physician, and patient enablement were assessed using validated tools. Focus group interviews using an open-ended format among few physicians was carried out as part of the qualitative study.Results:In the quantitative analysis most of the sociocultural factors did not show any significant association with the doctor–patient relationship. However, gender was significantly and strongly associated with trust in the physician. Female patients showed a much lower trust in the physician (50%) as compared to male patients (75%) (OR = 0.33, 95% CI 0.17 – 0.64, Chi Sq = 12.86, P = 0.0003). A qualitative study revealed language and culture, alternative medicines, commercialization of medicine, and crowding at specialist and super-specialist clinics as barriers to a good doctor–patient relationship. Better concordance was associated with improved trust in the doctor (OR = 5.30, 95% CI 2.06 – 13.98, Chi Sq = 14.46, P = 0.0001), which in turn was associated with improved patient enablement (OR = 3.89, 95% CI = 1.60 - 9.64, Chi Sq = 10.15, P = 0.001).Conclusion:Good doctor–patient concordance (agreement) leads to better trust in the physician, which in turn leads to better patient enablement, irrespective of the sociocultural determinants.

Differing Perceptions of Quality of Life in Patients With Prostate Cancer and Their Doctors

As the number of prostate cancer survivors increases, urologists must recognize their quality of life impairment. In the past physician ratings of patient symptoms did not correlate with patient self-assessments. We determined if urologists have improved their reporting of patient health related quality of life. We also investigated if urologists assessed health related quality of life more accurately in the short or long term. We identified 1,366 men from CaPSURE, a national, prospective cohort, who had undergone prostatectomy, brachytherapy or external beam radiation therapy. At each visit urologists assessed fatigue, pain, and sexual, urinary and bowel dysfunction. Participants independently completed the SF-36 and the UCLA-PCI. We contrasted the frequency of impairment reported by physicians and participants in select health related quality of life domains in the short (less than 1 year) and long (greater than 2 years) term. We also compared physician-patient concordance between the periods 1995 to 2000 and 2001 to 2007. In short-term and long-term followup, and for the 1995 to 2000 and 2001 to 2007 cohorts, physician and participant assessments differed in all analyzed domains. Urologists noted impairment in urinary and sexual function more often than fatigue or pain. Disagreement between physician and participant ratings did not vary dramatically from short-term to long-term followup, or from the earlier to the later cohort. In men treated for localized prostate cancer physician ratings of symptoms do not correlate well with patient self-assessments of health related quality of life. Physician reporting did not improve over time. It is increasingly important to recognize and address impairments in quality of life from prostate cancer and its treatment.

The Effects of Perceived Discrimination on Diabetes Management

We investigated whether self-reported racial/ethnic and gender discrimination were associated with lower rates of diabetes management. Analyses focused on 524 respondents with diabetes from the 2001 Commonwealth Health Care Quality Survey. Probit models estimated the marginal effect of self-reported racial/ethnic and gender discrimination on diabetes management, adjusting for racial/ethnic and gender concordance of the patient and physician, as well as a variety of health and sociodemographic indicators. Self-reported racial/ethnic discrimination was associated with a roughly 50% lower marginal probability of receiving a hemoglobin A1c test, foot exam, and blood pressure exam, when accounting for racial/ethnic and gender physician-patient concordance and other factors. Self-reported gender discrimination was associated with 22% lower marginal probability of conducting a hemoglobin test but not associated with the other management indicators. Evidence from this study suggests that racial/ethnic discrimination is an important barrier to diabetes management.

A Note from the Editor

A Note from the Editor Virginia M. Brennan Carter G. Woodson, whose work gave rise to Black History Month, wrote several invaluable histories of African Americans and, especially, the education of African Americans in the centuries before and the decades after Emancipation.1–4 Woodson documented the lives of individuals who achieved great things, against overwhelming odds. Among them are a number of physicians, including Dr. James Durham, born into slavery in 1762, who went on to prominence as a practitioner in New Orleans, where he saved more yellow fever victims during an epidemic than any other physician (he lost only 11 of 64 patients treated). Others were Dr. John V. DeGrasse, of New York, and Dr. Thomas J. White, of Brooklyn, who completed their medical studies at Bowdoin, in Maine, in 1849; Dr. William Taylor and Dr. John H. Fleet, who completed their medical education in Washington, D.C. prior to Emancipation; and two other African American physicians, who graduated from Berkshire Medical School in 1858. We are also reminded of Dr. James McCune Smith, who graduated as a physician from the University of Glasgow in 1837; Nurse Susie Baker (later known as Susie King Taylor), born into slavery in 1848, who became the first African American U.S. Army nurse during the Civil War; and Dr. Rebecca Lee Crumpler, the first African American woman to earn a medical degree, who graduated from New England Female Medical College in Boston in 1864. Woodson's captivating accounts serve as a welcome reminder of the importance of knowing the history of those who went before, especially those who, having stared down inconceivable adversity, dedicated themselves to the underserved. Happily, we have the opportunity to do that in JHCPU's Heroes and Great Ideas Column. This issue's column recounts the story of three generations of Black dentists, father, son, and grandson: Drs. Alexander Adolphus Dummett (1874–1949), Clifton O. Dummett Sr. (1919–present), and Clifton O. Dummett Jr. (1944–2006). Dr. J.W. Jamerson, of Savannah, Georgia, gives us a moving and detailed account of this extraordinary family's achievements. We also feature in this issue a commentary by Bailus Walker and Melvin Span on the importance of having under-represented minorities in the ranks of environmental health professionals, as well as on a long-term effort on the part of the National Library of Medicine to bring this about. Our second commentary also concerns environmental health. Nicholas Freudenberg and colleagues throw down the gauntlet for corporations to take at least some responsibility for reducing cancer health disparities by changing their practices in such areas as product design, marketing, retail distribution, and pricing. This rest of the issue continues by tracing a course through health matters in the lives of racial and ethnic minorities. This theme has two major tributaries. The first tributary carries the problem, establishing the persistence of differences, [End Page vii] disparities, and discrimination along racial and ethnic lines in large population studies in the North and Central American region of the world. Vijay Kumar Bhandari and colleagues evaluate the quality of anticoagulation control (important for traumas such as stroke) among people of low socioeconomic status, diverse racial and ethnic backgrounds, and/or limited English proficiency. They find that the time in therapeutic range (TTR) is significantly lower for African Americans than for Whites and also lower for Spanish-speaking Hispanics than for English-speaking Hispanics. Robert Levine and colleagues examine the relationship between the implementation of Medicare coverage for mammograms in 1991 and racial disparities in breast cancer mortality. They find that, post-implementation, breast cancer mortality declined faster among White than among Black elderly (65 years and older) women. No excess deaths occurred among Black elderly compared with White elderly through 1990; over 2,459 have occurred since. Andrew Ryan and colleagues investigate whether self-reported racial/ethnic and gender discrimination were associated with lower rates of diabetes management. They find that self-reported racial/ethnic discrimination is associated with a roughly 50% lower probability of receiving a hemoglobin A1c test, foot exam, and blood pressure exam, while accounting for physician-patient concordance (in gender and race/ethnicity) and other factors. Self-reported gender discrimination was...

Physicians’ communication and perceptions of patients: Is it how they look, how they talk, or is it just the doctor?

Although physicians’ communication style and perceptions affect outcomes, few studies have examined how these perceptions relate to the way physicians communicate with patients. Moreover, while any number of factors may affect the communication process, few studies have analyzed these effects collectively in order to identify the most powerful influences on physician communication and perceptions. Adopting an ecological approach, this investigation examined: (a) the relationships of physicians’ patient-centered communication (informative, supportive, partnership-building) and affect (positive, contentious) on their perceptions of the patient, and (b) the degree to which communication and perceptions were affected by the physicians’ characteristics, patients’ demographic characteristics, physician–patient concordance, and the patient's communication. Physicians ( N=29) and patients ( N=207) from 10 outpatient settings in the United States participated in the study. From audio-recordings of these visits, coders rated the physicians’ communication and affect as well as the patients’ participation and affect. Doctors were more patient-centered with patients they perceived as better communicators, more satisfied, and more likely to adhere. Physicians displayed more patient-centered communication and more favorably perceived patients who expressed positive affect, were more involved, and who were less contentious. Physicians were more contentious with black patients, whom they also perceived as less effective communicators and less satisfied. Finally, physicians who reported a patient-centered orientation to the doctor–patient relationship also were more patient-centered in their communication. The results suggest that reciprocity and mutual influence have a strong effect on these interactions in that more positive (or negative) communication from one participant leads to similar responses from the other. Physicians’ encounters with black patients revealed communicative difficulties that may lower quality of care for these patients.

Physician-Patient Relationship and Medication Compliance: A Primary Care Investigation

We assessed the relationship between 4 attributes of the physician-patient relationship and medication compliance. We conducted a waiting room survey of patients consulting 22 general practitioners in 14 randomly selected practices in Auckland, New Zealand (81% response rate). A total of 370 consecutive patients (75% response rate) completed survey instruments about 4 attributes of the physician-patient relationship. Continuity of care (assessed from use of a usual physician, length of continuity, and perceived importance of continuity) and trust in the physician were ascertained before the consultation. After the consultation the Patient Enablement Index measured the physician's ability to enable patients in self-care, and concordance between the patient and physician was measured by a 6-item inventory of perceived agreement about the presenting problem and management, were ascertained immediately after the consultation. Compliance with prescribed medication therapy was ascertained by telephone follow-up 4 days after the consultation. Overall, 220 patients (61%) received a prescription, and 79% of these patients were taking the medication at follow-up. In a univariate analysis adjusted for clustering, only trust and physician-patient concordance were significantly related to compliance. In analysis further adjusted for health and demographic factors, physician-patient concordance was independently related to compliance (odds ratio = 1.34, 95% confidence interval, 1.04-1.72). Primary care consultations with higher levels of patient-reported physician-patient concordance were associated with one-third greater medication compliance. An emphasis on understanding and facilitating agreement between physician and patient may benefit outcomes in primary care.