Our study design using audiotapes of office visits is the first attempt to directly observe communication patterns of surgeons with patients of different races. Although we did not see statistically significant differences in the content of IDM discussions by race, we did observe striking differences between surgeons and their AA compared with white patients in our measures of relationship-building skills. Coders’ ratings of respect, listening, and responsiveness, identified by the Institute of Medicine as markers of patient centered care, were significantly higher for white patients than for comparable AA patients.
The differences in ratings for respect, listening, and responsiveness indicate that surgeons may be less effective in relationship building with AA as compared with white patients. Several models of communication9,17,23–26
indicate that effective interaction between physicians and patients, in any setting, requires physicians to be able to engage in building relationships with patients. The relationship-building skills include listening, expressing concern for patient’s emotions, expressing empathy, and understanding the impact of disease on patients’ lives. Although Cooper et al’s study of primary care visits found no significant differences in race concordant pairs (AA patients with AA physicians) compared with race discordant pairs, they did find that concordant pairs had higher levels of “positive affect” which was defined as ratings of interest, friendliness, responsiveness, and sympathy.17
Similarly, a Dutch study of racial minorities compared with native born Dutch found similar differences in positive affect.27
Siminoff et al found physicians spent more time in relationship building with white than non-white cancer patients.28
In our own previous studies of the relationship of communication to prior medical malpractice, we found that surgeons’ use of partnership-building statements was associated with fewer prior malpractice claims.29–30
We conclude that an equally if not more important dimension of racial disparities occurs in the process of relationship building in the surgical setting and that this difference may contribute to the differences in patient satisfaction with care that we observed.
In addition to coder ratings that differed by race, AA and white patients experienced their visits differently. AA patients rated their surgeons less well on all of the Consumer Assessment of Health Providers and Systems communication elements than did white patients. For example, 66% of AA patients thought that surgeons were excellent at “showing interest in you as a person” compared with 78% of white patients. In addition, we found that AA patients were less likely to be satisfied with their overall care and less likely to be willing to return to see the surgeon or recommend them to a friend. Our statistical models demonstrated that race was associated with patient satisfaction after controlling for other variables such as health status and gender. Although studies consistently report lower satisfaction with care among AA patients compared with white patients,31–33
our study indicates that both impartial coders and patients perceived a difference in the quality of communication with surgeons based on race.
In contrast, we did not find any differences in IDM across race. The content of conversations including the nature of the decision, alternative treatments, and discussing the pros and cons of decisions were equally presented to patients of both races. Levels of performance on some elements of IDM, like discussing the pros and cons, were lower than ideal,17,34
but these relative deficiencies were true for both AA and white patients. Although there are well documented disparities in the use of orthopedic surgical procedures by AA versus white patients,10–16
we found no evidence of differences in the content of conversations about these procedures. Surgical education focused only on teaching the content skills of IDM may improve the quality of information presented, but it is unlikely to decrease racial disparities in communication.
Our findings have important implications for educating orthopedic surgeons and other physician groups. Educational programs to enhance culturally sensitive communication competence are one component of efforts to decrease racial disparities. These programs often include communication skills training for physicians, but few have been designed for surgeons.35
Based on our findings, programs for surgeons must include efforts to enhance the relationship-building skills of listening, responsiveness, and demonstrating respect.
Our study has limitations. First, the orthopedic surgeons participating in the study might have had different communication patterns than either other surgeons in their field or than in other surgical specialties. As well, this is not a representative sample of orthopedic surgeons in the United States. However, we think this is a reasonable sample to study as a first effort to assess racial differences in actual surgical encounters in a mixed sample of community and academic surgeons. Second, we are not capturing all elements of communication and their complexity. Some elements of patient centered care, like empathy, are difficult to adequately measure without qualitative analysis. Third, the coders were blinded to race and were unaware of the subsequent plan to analyze the data for racial differences. However, it is possible that coders were not fully blinded, because accent or dialect may have given them clues as to participants’ race. Overall, we do not think this significantly biases our results, as we found racial differences for some measures of communication, yet not for others. Finally, it would be ideal to measure racial differences within individual surgeon practices. However, most of orthopedic surgeons are white and relatively few surgeons have a mix of both AA and white patients in their practice, limiting this analysis.
In conclusion, our study using audiotape analysis of visits with orthopedic surgeons confirms the critical importance of attending to the process of building relationships as well as content in clinical conversations with patients of different races. As organizations like the Agency for Health-care Research and Quality seek to decrease racial disparities in the quality of care, our findings suggest that interventions to improve communication between surgeons and patients should include content, and more importantly, process elements. The adage “It’s not what you say, but how you say it” is guidance that surgical and other medical educators should heed well in designing programs to improve communication and to decrease racial disparities in our care.