The effect of patient race and socio-economic status on physicians' perceptions of patients

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Abstract

Despite its potential influence on quality of care, there has been little research on the way physicians perceptions of and beliefs about patients are affected by patient race or socio-economic status. The lack of research in this area creates a critical gap in our understanding of how patients' demographic characteristics influence encounter characteristics, diagnoses, treatment recommendations, and outcomes. This study uses survey data to examine the degree to which patient race and socio-economic status affected physicians' perceptions of patients during a post-angiogram encounter. A total of 842 patient encounters were sampled, out of which 193 physicians provided data on 618 (73%) of the encounters sampled.

The results of analyses of the effect of patient race and SES on physician perceptions of and attitude towards patients, controlling for patient age, sex, race, frailty/sickness, depression, mastery, social assertiveness and physician characteristics, are presented. These results supported the hypothesis that physicians' perceptions of patients were influenced by patients' socio-demographic characteristics. Physicians tended to perceive African-Americans and members of low and middle SES groups more negatively on a number of dimensions than they did Whites and upper SES patients. Patient race was associated with physicians' assessment of patient intelligence, feelings of affiliation toward the patient, and beliefs about patient's likelihood of risk behavior and adherence with medical advice; patient SES was associated with physicians' perceptions of patients' personality, abilities, behavioral tendencies and role demands. Implications are discussed in terms of further studies and potential interventions.

Introduction

There is considerable evidence that patient socio-demographic characteristics have an impact on both physician behavior during medical encounters (Armitage et al., 1979, Wallen et al., 1979, Ventres and Gordon, 1990, Bertakis et al., 1993) and on the diagnoses and treatments patients receive (Perkoff and Anderson, 1970, Tobin et al., 1987, Ayanian and Epstein, 1991, Hannan et al., 1991, Redman et al., 1991, Steingart, 1991, Majeroni et al., 1993, Martin et al., 1998, Todd et al., 1993, McKinlay, 1996, Hannan et al., 1998). Furthermore, these differences persist even when patient income, insurance coverage (payer), and disease severity are controlled (Wenneker and Epstein, 1989, Ayanian and Epstein, 1991, Hannan et al., 1991, Okelo et al., 1995, Peterson et al., 1996, Hannan et al., 1998). These studies suggest that the relationship between patient socio-demographic characteristics and physician behavior is at least partially mediated by differences in physicians' perceptions of and beliefs about patients. Physicians' perceptions of patients may systematically vary by patient race, socio-economic status, or other demographic characteristics. In turn, these differences in perceptions may explain some of the variance in physician behavior toward and treatment of patients. Despite their potential influence on quality of care, there has been little research on the way physicians' perceptions of and beliefs about patients varies with patient race or socio-economic status. The lack of research in this area creates a critical gap in our understanding of the mediating factors in the relationships between patient socio-demographic characteristics and encounter characteristics, diagnoses, treatment recommendations, and outcomes.

Physicians are generally expected and expect themselves to be unaffected by the patient's social or demographic characteristics in forming judgements of patients (Daniel, 1970, Hooper et al., 1982). Since perceptions of and beliefs about patients can have a significant impact on encounter characteristics and treatment recommendations, physicians are generally expected to view each patient objectively and impartially, using biomedical information obtained from physical examination and diagnostic test results to develop a diagnosis and effective treatment plan (Eisenberg, 1979). Unfortunately, the research on social categorization and stereotyping suggests that these expectations are unrealistic.

All humans share the generally adaptive strategy of making the world more manageable by using categorizing and generalizing techniques to simplify the massive amounts of complex information and stimuli to which they are exposed (Hamilton, 1981, Klopf, 1991). In order to make the social world more manageable, people often make judgements about categories or groups of people and generalize these judgements to all the individuals mentally assigned to that category or group (Hamilton, 1981, Hamilton and Trolier, 1986, Andersen et al., 1990). This categorization strategy can lead to stereotype usage (Lalonde and Gardner, 1989): the generation of a widely held image of a group of people through which specific individuals are perceived, or the application of an attitude set based on the group or class to which the person belongs (Vassiliou et al., 1972, Devito, 1982, Klopf, 1991). When individuals are mentally assigned to a particular class or group, the characteristics assigned to that group are unconsciously and automatically applied to the individual. Given that this type of strategy is common to all humans and cultures (Klopf, 1991), the expectation that physicians be immune is unrealistic. In addition, the very nature and context of physicians' work may enhance the likelihood of stereotype usage. There is evidence that time pressure, the need to make quick judgements, cognitive load, task complexity, and ā€˜busynessā€™ increase the likelihood of stereotype usage (Bodehausen and Lichtenstein, 1987, Gilbert and Hixon, 1991, Pratto and Bargh, 1991, Macrae et al., 1993, Macrae et al., 1994, Gordon and Anderson, 1995). Physicians may be especially vulnerable to the use of stereotypes in forming impressions of patients since time pressure, brief encounters, and the need to manage very complex cognitive tasks are common characteristics of their work.

This paper utilizes survey data provided by physicians on 618 post-angiogram1 physicianā€“patient encounters to examine the way physician beliefs about patient personal and psychosocial characteristics, behavior and likely role demands are affected by patient race and socio-economic status.

Section snippets

Sample

Physician survey data on patients and doctorā€“patient encounters were collected using a four stage sampling plan2. In the first stage, ten New York State hospitals that perform angiograms were selected by a weighted

Results

The effects of patient race and socio-economic status on physician perceptions of patients are presented in Table 2, Table 3, respectively. For each level of the independent variable, the bivariate response distribution and chi-square (Ļ‡2)test of statistical significance is presented. The last column in all tables present the odds ratio and statistical significance of each effect, controlling for the standard set of covariates (patient age, sex, race, SES, sickness/frailty, overall health

Summary of results

The results support the hypothesis that physicians' perceptions of patients are influenced by patients' race and socio-economic status. Black CAD patients were more likely to be seen as at risk for noncompliance with cardiac rehabilitation, substance abuse, and having inadequate social support. In addition, physicians rated Black patients as less intelligent than White patients, even when patient sex, age, income and education were controlled. Physicians also report less affiliative feelings

Discussion

The results support the hypothesis that physicians' perceptions of patients are influenced by patients' socio-demographic characteristics. Physicians tend to perceive African-Americans and members of low SES groups more negatively on a number of dimensions than they do Whites, or members of the middle and highest third in SES. Furthermore, although there is considerable shared variance, each characteristic is associated with a unique set of perceptions. Patient race is associated with

Limitations

There are a number of limitations that could suggest alternate interpretations of the findings presented. First, there is a possibility that social desirability effects biased physician ratings of patients. Physicians may have been mindful of the purpose of the research project, which was to identify factors associated with under-use of aggressive treatments for CAD among minorities and women. They received questionnaires on patients sporadically (as patients they treated were sampled) over a

Conclusion

In conclusion, the results of this study provide significant evidence for the effect of patient race and SES on physician perceptions of patients. These findings suggest that further exploration with multi-item measures and additional controls for physician perception accuracy is warranted. Most importantly, these results highlight the need for studies of variations in physician perceptions of patients in a wide variety of settings and with different physician and patient populations, as well

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