Focus Group Findings
We found three main themes. Overall, we found that both black and white physicians held similar views that the patient's medical information (e.g. past medical history, family history) is the most important factor for treatment decision-making. However, black and white physicians' views about the medical relevance of race differ, and are presented as separate themes. Among white physicians, patient race was viewed as relatively unimportant for treatment decisions. Instead, white physicians believed that the hypothetical patient should be treated aggressively regardless of her race. Conversely, black physicians in the study believed that race is important for treatment decision-making, provides useful information for choosing medication, understanding disease risk, and is associated with social determinants (socioeconomic factors and cultural beliefs about illness) for the patients' health. These findings are described in detail below.
Theme 1. Black and White Physicians Hold Similar Beliefs that Medical Information is the Most Important Factor for Medical Decision-Making
Both black and white physicians reported that the medical and clinical history of the patient was important for treatment decision-making. Specifically, physicians considered it a priority to know the patient's medical information, family history, and weight and body mass index. When asked by the moderator, "What kind of information would you like to know to treat Michelle, the hypothetical patient?," physicians immediately discussed details of the patient's medical history, such as disease history, her past diagnostic and treatment history, and her current or past medication regimen. For example, two physicians noted:
"...it would be nice to know what prescriptions she's on currently. And, if she's been on other medications previously and what's happened over the years." (Black physician, Detroit Focus Group)
"I'd want to know what's been done already and what hasn't been done, who is she seeing, what medicines she's tried, whether it's a compliance issue, whether it's a tolerance of medicine issue, whether she hasn't had healthcare." (White physician, Baltimore Focus Group)
Physicians also discussed wanting to complete further diagnostic testing, such as urinalysis, chest radiography, and electrocardiography. Physicians explained,
"My feeling is [that] I would need to see her and probably do a complete work up on her... from the basic history and everything... as well as doing EKG[electrocardiogram], doing blood work, additional blood work, other than what's there, to determine where her base line is." (Black physician, Philadelphia Focus Group)
"...Physical exam findings to suggest longstanding diabetes or hypertensive changes." (White physician, Atlanta Focus Group)
Family history of disease was also important to physicians. The majority of participants indicated that having knowledge of the patient's family history could help assess the aggressiveness of treatment. Representative comments include:
"Family history... In terms of the risk factors that you described -- hypertension, diabetes, lipidemia. Even more than that is the end results of these -- like heart attacks and strokes and at what ages the family may have had it. Is it first degree or distant, remote relatives?" (White physician, Los Angeles Focus Group)
"Well it kind of gives you an idea of severity, of how urgently [you] need to get at her problem because of the family history. ...where persons die early in her family from [the disease], then you have to think about be[ing] more aggressive in managing her diabetes and hypertension." (Black physician, Baltimore Focus Group)
Finally, physicians indicated that weight and body mass index were critical and had an impact on the patient's treatment.
"Did you [referring to the moderator who read the vignette] say what she weighs?" (White physician, Detroit Focus Group)
"I'd also like to know her weight."(Black physician, Philadelphia Focus Group)
Another agreed, saying, "Exactly, I think it [her weight] has an impact on all of her conditions." (Black physician, Philadelphia Focus Group)
Theme 2. White Physicians Reported That Patient Race is Not Important for Treatment Decision-Making, and That Medical History Should Drive Decision-Making
Physicians were asked to be explicit about the ways in which race might be medically relevant in their clinical practice to deliver appropriate care to their patients, using the example of the hypothetical patient vignette. The majority of black physicians in each focus group stated that knowing the hypothetical patient's race would affect treatment decisions. Among white physicians, however, few indicated that the patient's race was important for treatment decision-making.
There were marked differences regarding the importance of race between black and white physicians. Of the five focus groups among black physicians, all had extensive discussion regarding the importance of race for medical decision-making. However, only four white physicians discussed the importance of the patient's race for medical decision-making. Responses of white physicians who supported the use of race for treatment decision-making are below.
"Let's take African-Americans. I've always stressed to them that because they're African-American, for instance, treating hypertension, that they really have to pay attention and take their medications and let them be on the team with me. It's because they're African-American, we make them realize it that they really have to pay attention. I think it's a good thing that we go into their race." (White physician, Los Angeles Focus Group)
"I would want to know the race -- I'm not doing hospital work anymore, but if someone was presenting me a case, I'd want to know the race so you would have an idea of how they grew up. I mean what their diet was, what their socioeconomic and the milieu was as they were growing up." (White Physician, Philadelphia Focus Group)
During conversations regarding the importance of race for treatment decision-making, white physicians sometimes indicated that race and ethnicity were important for treatment of disease, but immediately followed by stating that race was not as important as other factors. For example, two physicians said,
"If she was Hispanic, diabetes seems to be more malignant in terms of its course. African-American hypertension seems to be a more difficult disease to treat, and obesity seems to be more prevalent. But in terms of overall, I think basic nutrition is really one of the key problems we see in our total culture. It's not raced based or ethnic based. It's pretty much the commercial world we live in." (White physician, Los Angeles Focus Group)
"My initial thought is that it [race] doesn't affect it [her treatment] very much, at least, initially. That the initial evaluation and the initial treatment is going to be pretty much the same. And race is a secondary or tertiary or farther on down the list than the other information that I need to have at hand in order to make the initial treatment decisions. Yes, it may be a factor. It may come into play more later on but not in the beginning on the first visit." (White physician, Atlanta Focus Group)
In the Los Angeles focus group only, white physicians warned one another regarding the use of race in clinical settings.
"But you still have to be careful. I mean if you tell somebody too many negatives about their race or something like that, they might take it the wrong way. That's what he's referring to." (White physician, Los Angeles Focus Group)
"I have some apprehension because there is a perception among some patients that you ask these probing questions, they might be sensitive to it. I mean I have this fear sometimes that I'm going to offend somebody by singling them out, their group." White physician, Los Angeles Focus Group)
Overall, the majority of white physicians stated that while race is sometimes important for understanding disease-risk, diet and socioeconomic status, race in the clinical vignette provided little information over medical history. Given the severity of Michelle's condition, knowing her race would not provide any additional helpful information, and most white physicians agreed that she should be treated aggressively regardless of her race. Some white physicians stated,
"I'm not sure that it's [race is] relevant in this woman's case...because of all the medical issues that you've described, she's going to need to be treated aggressively." (White physician, Philadelphia Focus Group)
"I'm more concerned with was she compliant in the past? Was she on medications at all and wasn't taking them for some reason rather than how her race factored into this?" (White physician, Atlanta Focus Group)
"I agree. I think your endpoints don't change and too, I think, just knowing their race, you have to avoid making generalizations about the race. Every individual is completely different. So, I kind of agree that it is not as important, at least to me." (White physician, Los Angeles Focus Group)
Theme 3. Black Physicians Reported That Patient Race is Medically Relevant and Can Be Useful in Treatment Decisions
Many black physicians explicitly indicated that patient race would be important. There was general consensus among black physicians that race is an important indicator that should be used in treatment decision-making. Some black physicians stated,
"I think being an African American is a risk factor in and of itself. And, I think that when you see an African American then you need to often be more aggressive than you would and use different standards than you would for the general white population." (Black physician, Philadelphia Focus Group)
"I think it's very significant to know what her race is because it will make some decisions... about what paths I'm going to use to treat her..." and "I mean [race] is important to choosing the medication." (Black physician, Atlanta Focus Group)
"[It is] important to choosing the medication, race and ethnicity... I think it's also important as [to] how you approach her." (Black physician, Detroit Focus Group)
Black physicians also stated that treating black patients more aggressively is necessary because of co-morbidities or increased risk for developing secondary conditions, saying,
"In African Americans, hypertension... [and] diabetes [are] more significant than that as compared to who is white or of a different race [because of] more severe problems with kidney control, kidney function." (Black physician, Baltimore Focus Group)
Black physicians also noted that patient race guides their ability to become aware of the patient's socio-cultural context. Specifically, black physicians discussed the importance of the patient's beliefs, health practices, and repeatedly inquired about the patient's socioeconomic position. Physicians were interested in the patient's ability to afford consistent care, maintain health insurance, and pay for prescription medications. Black physicians also noted that being aware of socio-cultural beliefs and practices that may affect health care would facilitate patient-physician communication and ultimately treatment decisions. One black physician stated,
"Cultural issues... are relevant no matter who you are. You know, [there is] no telling what this patient [is using to treat her illness]. I was thinking maybe they are treating their blood pressure with medicine or with some herbs..." (Black physician, Detroit Focus Group)
Black physicians also reported wanting to know about the patient's beliefs about illness, views on taking medication, experiences with disease and priorities with respect to disease management. As one black physician said,
"I'd be curious what she thinks about these issues [her health]. Does she think they're important? Does she think they're real? ...I need to know what she's thinking." (Black physician, Philadelphia Focus Group)
Physicians who deemed social attributes important in clinical decision-making discussed that knowing about the patient's beliefs could provide understanding into how the patient conceptualized her disease.
"[I want to know] her opinion on if she thinks this is important. And, it may be something low on her priority list... as far as being treated for hypertension or diabetes. She may not think it's important. That may be why she hasn't followed up. I think you need to explore that aspect of it as well."(Black physician, Detroit Focus Group)
In contrast, very few white physicians mentioned the importance of the patient's social characteristics. Out of all of the white physician focus groups, there were only four quotes regarding social determinants that might influence treatment decision-making. These four quotes are:
"You need to treat the person aggressively, but they may not be open to it. They may have a different view of the world." (White physician, Los Angeles Focus Group)
"I want to know her social history -- who is she living with. Is she the primary breadwinner? What are her psychosocial stressors." (White physician, Los Angeles Focus Group)
After being probed by the focus group moderator, two physicians stated,
"I'm thinking on the average, African-Americans are less likely to have insurance, less likely to have as many assets for paying for medications. And I've never really felt I'm doing somebody a great job if I come up with my brilliant idea on what they should do when I give them a prescription they can never pay for. So, you want to try to take that into account if your goal is to actually accomplish something rather than just give somebody a piece of paper." (White physician, Atlanta Focus Group)
"In your case report we started the conversation with, I think we all agreed that that patient was a walking time bomb. For me the interesting question may or may not be related to race -- it's why did she walk into the office at that point and still have no treatment. So, one of my goals is always to try to understand what motivates people -- you know, their paradigm of their own health. And that may or may not be a race-related issue. " (White physician, Los Angeles Focus Group)
Further analysis examined themes across other physician attributes, including age, sex, percentage of minority patients, number of years in clinical practice, practice setting and region where physicians practiced. We found no noteworthy differences in any focus group themes by these physician characteristics except one, a difference based upon practice setting for black physicians (academic vs. non-academic). Our analysis revealed that black physicians' practice setting - academic or non-academic - influenced their views about the importance of the patient's social attributes. While all black physician focus groups included discussion regarding the patients' social attributes, the majority of the discussion about affordability of medication and healthcare was among black physicians that practice in academic settings.