The nature of conversations between physicians and their patients regarding HIV/AIDS medication varies with the race and ethnicity of the patient, according to a study published in the journal AIDS and Behavior last month. Michael Barton Laws, assistant professor of health services, policy and practice, who led the study, said the data suggests provider-patient communication plays a role in the quality of healthcare. The results also identify the variance in conversations between caregivers and patients as a potential factor contributing to disproportionately worse HIV outcomes in blacks and Hispanics.
‘The language of the community’
After discounting for “obvious” differences that explain poorer health outcomes, the causes of racial and ethnic disparities in health status are still unclear, said Ira Wilson, professor of health services, policy and practice and chair of the department. The framing question of the team’s study was “how do we explain the fact that blacks and Hispanics have worse HIV outcomes?” he said.
In prior research, the team discovered that, when speaking about HIV/AIDS medication regimens, doctors more frequently use directives — commands — rather than engage their patients in problem-solving solutions.
Laws and his colleagues studied the nature of doctor-patient discussions about HIV/AIDS medication adherence by recording 404 such interactions and analyzing them with the Generalized Medical Interaction Analysis. This approach works based on the idea that any utterance has two parts — a theme and an implied meaning or locution, Laws explained. His team classified recorded utterances by “elocutionary act and subject matter,” he said.
While the conversations between doctors and their patients were recorded with permission, research has found that knowledge of being recorded will not drastically change a subject’s behavior since social actions are habitual, Laws said.
Timothy Flanigan, professor of medicine, praised this methodology’s examination of the role of the community in contributing to how blacks disproportionately suffer from the disease. In order to understand this issue, “one has to use the language of the community,” Flanigan said.
Conversation disparities
While the study sought to identify and describe phenomena that may contribute to blacks’ and Hispanics’ poor HIV outcomes, “it was not designed to explain them,” Wilson said.
The results revealed that conversations with patients of all races and ethnicities were more provider-dominated, meaning that caregivers often steered the dialogue in their preferred direction. But the breakdown in doctor-patient communication was slightly more pronounced for patients of certain races and ethnicities. Fewer values and goals were discussed with black patients than in conversations with white patients. Discussions with Hispanic patients also included less humor and fewer open-ended questions, according to a University press release announcing the study’s results.
Drug adherence also emerged as a subject in a larger percentage of discussions between medical providers and black and Hispanic patients regardless of the actual adherence of the patient to an assigned treatment regimen. Even when conversations were longer, they did not contain more problem-solving strategies but rather more directives, according to the release.
“We’re not sure exactly what these data mean, but it is the case that (blacks and Hispanics) often have worse health outcomes and are often less satisfied with their relationship with their doctor,” Laws said.
Different methodologies would be necessary to understand deeper implications of the work, Flanigan said.
“This study raises more questions than it provides answers,” Laws said, adding that observers should not make broad generalizations from the data, as they were taken in only one setting with predominately white and Asian medical providers.
But the study “takes on a challenging area unexplored” by past research, Laws said.
A new medical approach
People often assume that a proper diagnosis and treatment is the key to overcoming a disease, but this is not the case, Wilson said. In order for treatment to be effective, one must implement treatment over time, especially in the case of HIV/AIDS, he added. Motivation to follow a medical regimen depends on the support patients have from the people around them — including the trust and relationships they have with their providers.
Proper trust and understanding between patients and their doctors is key in a successful diagnosis, Wilson said. The study may describe that a poor relationship with a medical provider could contribute to the greater rate of HIV developing into AIDS in black and Hispanic communities and could identify a cause of poor medical regimen adherence, he said.
Expanding the diversity of the health care workforce would change the industry’s environment to be more culturally competent so that doctors would have fewer cultural misunderstandings, and patients would feel more comfortable with their providers, Laws said.
“Doctors and patients speak different languages. Add to this different cultures, and you add another layer of complexity,” Laws said.
Cultural influences on healthcare delivery are an unfortunate obstacle to delivering equal care, Wilson said.
“But (race) shouldn’t matter,” Wilson said. “You should have the capacity to connect with and make connections with any patient you see.”
Reorganizing the system of teaching in medical school would be beneficial, Laws said. “In medical school, there is not enough about how to behave, how to communicate effectively.”
He added that the larger question at hand to improve health care for all patients may be “how can we get doctors up to speed?”
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