Communication StudyPatient–physician social concordance, medical visit communication and patients’ perceptions of health care quality☆,☆☆
Introduction
The notion that disparities in health and health care may result from a combination of relational factors within the patient–physician relationship and contextual and structural factors that result in status differentials for social groups within society based on race, gender, age, or other shared social or cultural characteristics is gaining support [1], [2]. Patient social characteristics such as race, gender, age, and education are associated with disparities in health care [3]; are linked to treatment adherence [4], decision-making [5], and satisfaction [6], [7], [8], [9], [10]; and are also associated with health outcomes [11], [12], [13]. Research suggests physicians also bring expectations, biases, and values to medical visits [14], [15]. And, physicians’ own social characteristics influence the way they are perceived by patients [16], [17], [18], [19], [20].
Studies have found that physicians are more likely to view African–American patients as noncompliant or less intelligent than whites [14], and health care providers have more positive appraisals of patients who are better educated and employed [21]. Our previous work demonstrated differences in the content and tone of medical visit communication for African–American vs. white patients such that physicians are more verbally dominant with African Americans and have a less positive tone than with whites [22]. Differences in patient–provider communication are also associated with patients’ social class [23] and gender [24], and with physician gender [25]. Older patients also tend to have an expectation that the patient–physician relationship should be more dominated by physician expertise that do younger patients, which also has implications for medical visit communication [26].
Concordance is defined as the degree of patient and physician similarity or agreement across a given dimension. Sharing specific social characteristics (e.g. gender, race, socioeconomic status, education), expectations, beliefs, and perceptions impact health care quality [7], [8], [9], [10], [20], [23], [27], [27], [28], [28], [29], [30], [31], [32], [33], [34], [35], [36], [37], [38], [39], [40], [41]. Current literature on patient–physician concordance studies most often involves analyses that examine one shared characteristic in isolation from others. Therefore, the need to understand the cumulative impact of patient–physician concordance on communication and healthcare quality persists. We establish a framework for a multi-dimensional measure of shared social characteristics, called social concordance.
Social concordance (SC) is related to the concepts of homophily and interpersonal perceptions [42], [43], but it is a distinct construct. While homophily focuses on the probability of contact between people increasing with increasing similarity, SC is an evaluation of similarity with respect to social identity characteristics (e.g. race, gender, education, age) of participants in a specific interaction and does not evaluate the extent to which their social networks differ. While the concept of interpersonal perceptions applies directly to participants in a given interaction, it focuses on the extent to which participants (e.g. doctors and patients) share similar perceptions and values [43]. That values and perceptions among members of the same social groups often correspond more closely than among members of different social groups is not insignificant [42], yet it does represent an important distinction between SC and interpersonal perceptions. We define SC in relation to status homophily because it is based on similarities with respect to status related identity characteristics (e.g. race, gender, age, education) vs. an explicit set of shared values or beliefs [42], [43]. Our conceptualization of social concordance includes dimensions that are clearly visible (i.e. gender, ethnicity and age) and less immediately obvious identity characteristic (i.e. education). All of these relate to social status within interactions, which is what unifies them. As such, SC does not explicitly capture shared values, beliefs, or perceptions.
This study aims to determine whether SC is associated with differences in the quality of medical visit communication and patients’ perceptions of care. We hypothesized that lower patient–physician SC is associated with lower quality medical visit communication and less positive patient perceptions of care.
Section snippets
Study design and population
We used data from two brief cohort studies conducted from July 1998–June 1999 and January–November 2002. The details of data collection are summarized elsewhere [22], [32]. The protocols were reviewed and approved by the Johns Hopkins Medical Institutions Institutional Review Board and informed consent was obtained from all participants. Physicians were recruited from group practices and federally qualified health centers in the Baltimore/Washington, DC/northern Virginia area. Both studies
Results
Data was collected for a total of 548 patients. All patients who did not report their race/ethnicity were excluded from analyses (n = 9). Of the 539 patients who reported their race/ethnicity, those who reported membership in more than one racial/ethnic group (n = 9) or who did not identify as either African American/black or white (n = 9) were excluded from analyses in order to maximize the construct validity of the SC score. The final sample included 489 patients (255 African Americans and 234
Discussion and conclusion
Social identity often evokes images of status, power and privilege. In this regard, lower levels of social concordance in the doctor and patient relationship almost always reflect higher levels of patient vulnerability. But the construct of social concordance also embodies areas of commonality, and in this regard it provides a wider window into the nature of social relationships that develop between doctors and patients during medical visits. In fact, to the extent that shared social
Acknowledgements
This work was supported by research grants from the Commonwealth Fund and the Bayer Institute for Health Care Communication. In addition, the corresponding author, Dr. Thornton was supported in part by a National Research Service Award from the Agency for Healthcare Research and Quality (1 F31 HS 013265 0) in 2002-2003. Dr. Cooper is supported by a grant from the National Heart, Lung, and Blood Institute (K24HL083113).
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Disclaimer: The views presented here are those of the authors and not necessarily those of the Commonwealth Fund, its directors, officers, or staff.
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Prior presentations: An earlier version of this work was presented at the European Association for Communication in Health Care (EACH) International Conference on Communication in Health Care, September 16, 2004, Brugges, Belgium.