To our knowledge, this is the first study to demonstrate that the attitudes of physicians-in-training are related to their performance on clinical exams, such that students with patient-centered attitudes performed better in encounters with African American SPs and not significantly different in encounters with white SPs. If patient-centered attitudes are stable over time, our study suggests that engendering a patient-centered approach in students may improve the quality of care for African American patients, and may reduce racial and ethnic disparities in some elements of medical care.
Although these findings are intriguing and potentially important, the absolute effects of patient-centeredness were modest. For example, the differences in history-taking performance with African American SPs between students with and without patient-centered attitudes (a mean difference of 2.7 points) amounts to an average loss of one history “fact” (or detail) on every one to four patients, depending on the scenario. Although this may not seem significant for any particular patient, this effect would compound over many patients. To the extent that we view the performance of certain details of the patient's history as important to appropriate diagnosis and treatment, these deletions could plausibly contribute to significant disparities in the health of populations. A similar case can be made for components of the interpersonal skills and counseling domains.
It is also worth noting that, although students with patient-centered attitudes performed better in interpersonal skills, history taking, and counseling with African American SPs than students without patient-centered attitudes, students with patient-centered attitudes still exhibited differences in their performance with white and African American SPs, as did students without patient-centered attitudes. This certainly suggests that a patient-centered approach will not eliminate all disparities in health care quality. Nonetheless, it is important to consider all means of disparity reduction, even modest means, because there is unlikely to be a single solution to the problem.
The measurement and correlation of attitudes with behaviors in physicians and physicians-in-training is a relatively undeveloped field of inquiry. In a study similar to ours, Haidet et al17
surveyed third-year medical students using the patient–practitioner orientation scale (PPOS) and found that higher PPOS scores (indicating a more patient-centered approach to medicine) were associated with higher SP ratings of humanism in students. Although that study did not examine differences across SPs' racial/ethnic groups or disparities in the care they received, its main implication, similar to ours, is that there was an association between students' attitudes and patients' experience of care. Further studies ought to explore this phenomenon, and enhance our understanding of which physician attitudes are associated with improved health care quality. As other studies have demonstrated the positive effects of cultural competence training on student attitudes,18
there is reason to be hopeful that patient-centered attitudes would be similarly susceptible to intervention.
One important source of potential bias in our study was that we relied on SPs' ratings of students' performance, and there were only eight total SPs (four African American and four white SPs). We believe that this threat to the validity of our study is somewhat moderated by the fact that our SPs were trained to rate students in a standardized manner and that the SPs were blinded as to how the students scored on the patient-centered attitude scale. We also used a clustering method to analyze our data that should minimize bias from potential differences in SP scoring. In addition, SP ratings are used widely in medical student assessments and have been found to be valid.19
Nevertheless, we believe that our data should be viewed in light of this limitation, and that efforts should be made to reproduce these findings in other settings.
Another potential limitation to our study was that our measure of patient-centeredness has not previously been validated. However, our measure was derived from a well-established conceptual framework and is associated with some of the same outcomes (such as intention to enter primary care) as are other measures of patient-centeredness.17
Therefore, our study provides preliminary data to assess the construct and predictive validity of the instrument. Finally, the generalizability of our study may be limited because we selected our participants from just two medical schools and because there was a higher proportion of African American students in our sample than in the overall population of U.S. medical students.
In conclusion, we believe that this study provides evidence that patient-centered attitudes may improve the quality of care for African American patients to a greater extent than it improves the quality of care for white patients, and, as such, that these attitudes may be important to consider in designing cultural competence training and other strategies to reduce disparities. Fostering such attitudes in students through techniques such as direct discussion, self-reflection and awareness exercises, and role modeling may contribute to a reduction in racial/ethnic disparities in health care quality. Future studies ought to explore the associations between the attitudes of health professionals and health care quality for racial/ethnic minority patients, and examine various educational strategies for engendering patient-centered attitudes in medical students.