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Marc Imhotep Cray, M.D.

Link to the video enhanced version of this presentation

Goals of this Presentation

• To demonstrate/document racial disparities in health

care exist

• To show how trust is important to good health


• To explain why African Americans tend to mistrust the

medical profession (and this mistrust is not

• To emphasize why the medical profession needs to

demonstrate its trustworthiness. Some initial ideas... 2
Disparities Across
Health Care
• Disparities have been recognized among various
minority groups, but are best documented among
African Americans
• Adjusted for disease severity and socioeconomic
status, African Americans experience:
– Fewer referrals for renal transplant evaluation and
fewer transplants (Ayanian ‘99, Epstein ‘00)
– Less adequate pain medication for cancer (Cleeland ‘97)
– Inferior HIV Care (Moore ‘94, Shapiro ‘99)
– Fewer admissions to CCU and fewer revascularization
procedures, especially CABG (Ayanian ‘93, Peterson ‘97,
Schneider ‘01)
– Fewer eye examinations in DM, B-blockers after MI,
and follow-up after hosp. for mental illness (Schneider ‘02)
Due to Coverage?
Schneider et al. (2001,2002) found that among Medicare
recipients in managed care health plans, African
Americans were less likely than whites to receive:
• Breast cancer screenings
62.9% vs. 70.9% (P<.001)
• Eye examinations for diabetes patients
43.6% vs. 50.4% (P=.02)
• -blocker medication after myocardial infarction
64.1% vs. 73.8% (P<.005)
• Follow-up after hospitalization for mental illness
33.2% vs. 54.0% (P<.001)
• Influenza vaccinations
46.1% vs. 67.7% (AD 21.6%; 95% CI 18.2% to 25.0%)
Median Waiting Time (in Months) to Kidney Transplant By Race
Year Black Recipients White Recipients Difference
1988 20.1 11.3 8.8
1989 21.4 12.7 8.7
1990 24.9 13.3 11.6
1991 26.7 14.1 13.7
1992 29.8 16.0 13.8
1993 34.9 18.7 16.2
1994 39.7 20.1 19.6
Source of Data for 1998 HHS OIG Report: Organ Procurement and Transplantation Network (OPTN), 1997
Who You Are Influences
What You Think
 Do you think the average African American is better off,
worse off, or just as well off as the average white American
in terms of access to health care?
Worse Off: White Americans 35% African Americans 61%

 How much discrimination do African Americans face in our

society today?
A Lot: White Americans 20% African Americans 48%

 Do you feel that African Americans have more, less, or

about the same opportunities in life as white Americans
Less Opportunities: White Americans 27% African Americans 74% 74%

The Washington Post, the Henry J. Kaiser Family Foundation and Harvard University Racial Attitudes Survey (April 2001)
Unfair Treatment

• 25% of White physicians

• 29% of Physicians overall
• 33% of Asian physicians
• 52% of Latino physicians
• 77% of African American physicians
… believe that the health care system treats
people unfairly based on their racial or ethnic
background ―very‖ or ―somewhat often.‖

The Kaiser Family Foundation National Survey of Physicians (March 2002) 7

Views on Health Disparities
 Doctors say the health care system treats people unfairly ―very
often‖ or ―somewhat often‖ based on health insurance status
(72%) more than any other factor.
The Kaiser Family Foundation National Survey of Physicians (March 2002)

• Most whites (70%-76%) believe that African Americans and

Latinos receive the same quality of care as they do.
• 68% of whites, 75% of Latinos, 80% of African Americans
…say racism is a problem in health care
• 56% of Latinos, 64% of African Americans
…believe they receive lower quality health care than whites
Results of a Kaiser Family Foundation survey conducted in 1999 of 3,884 whites,
African Americans, and Latinos. (Lillie-Blanton et al. 2000) 8
Fueling Disparities
•Patient-Level Variables
–Patient preferences, mistrust, comfort level
–Seeking treatment (or not)
–Adherence to treatment (or not)
–Effectiveness of treatment
•Healthcare Systems-Level Factors
–Language barriers
–Availability and access to health care
–Ability to navigate clinical bureaucracies
–Lack of insurance, differences in insurance
–Managed care limitations
•Care Process-Level Variables
–Bias, prejudice, stereotyping, clinical uncertainty
–Decisions made with limited time and information
–Effect of patient response on physician
Institute of Medicine Report (2002) Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care 9
Importance of Trust
 Intrinsic value of trust in the Patient-Physician
– ―The physician-patient relationship often reflects
[intimate bonds] and contains strong elements of
transference, particularly during times of critical
illness when patients are vulnerable and frightened.‖
(Mechanic 1996)
 Instrumental Value of Trust in Health Care
– Trust predicts a patient‘s loyalty to their physician.
(Thom 1999, Safran 2001, Keating 2002)
– Higher levels of trust between patients and their
physicians are correlated with positive health
outcomes. (Thom 1999, Safran 1998)
Declining Trust
Eroding trust means that the health care system must work to maintain
not only trust in physicians, but trust in the health care system overall.

Harris and Associates Poll (1998) USA Today/CNN/Gallup Poll (2002)

Teachers 86% Teachers 84%
Clergymen or priests 85% Military officers 73%
Doctors 83% Police officers 71%
Scientists 79% Protestant ministers 68%
Judges 79% Doctors 66%
Professors 77% Catholic priests 45%
Police officers 75% Government officials 26%
Ordinary man or woman 71% Lawyers 25%
(The) President 54% CEOs of large corporations 23%
Business leaders 49% Managers of HMOs 20%
Members of Congress 46%
Journalists 43%
Trade union leaders 37% 11
Links to Health Outcomes
Decreased trust has been associated with:

• Lower patient and physician satisfaction

• Increased disenrollment
• Increased demand by patients for referrals and diagnostic
• Poorer patient adherence to treatment recommendations
• Increased litigation
• Possibly lower health status

Thom and Campbell 1997, Safran et al. 1998

Trust and
Patient Satisfaction
• Patients with 95th percentile trust scores
were about 5 times more likely than those
with median levels of trust to express
complete satisfaction with their physician.
(Safran et al. 1998)
• Thom et al. (1999) found trust to be a
significant predictor of patient‘s
satisfaction with care received from their

Mediator of the Placebo Effect?

• ―Trust may have therapeutic value, enhancing the

efficacy of prescribed treatment.‖ (Faden and
Beauchamp, in Goold 2002)

• ―Trust is important in reducing anxiety, increasing

a patient‘s sense of being cared for, which in turn
may improve the patient‘s sense of well-being and
improve functioning.‖ (Thom and Campbell 1997)

– Side query: What might be the economic cost

of losing the placebo effect?
Trust May Be Fragile
• Trust is easy to break
–―Trust is particularly fragile because negative events
are more visible, they carry greater psychological
weight, they are perceived as more credible.‖ (Slovac in
Mechanic 1996)

–―Trust can be disconfirmed at any time.

– Although patients discount small lapses because
they appreciate that doctors, like others, can have
good and bad days, a serious failure to be responsive
when needed can shatter even the strongest of
relationships‖. (Mechanic 1996)

Interpersonal  Institutional
Trust in the medical profession can be:
• Interpersonal: Patients trusting their physicians,
health care professionals.
• Institutional: Patients trusting their hospital, clinic,
or the medical profession.
(Mechanic and Schlesinger 1996)
Interpersonal and Institutional trust are related:
• Beginning a relationship with a new physician
requires some level of institutional trust.
• Institutional trust can be cultivated by building on
existing trust between patients and physicians.

American Minorities
Have Less Trust
• Interpersonal Trust
– Whites generally have higher levels of trust in
their physicians (Kao 1998)
– Trust scores are especially low for Latino and
African American men (Doescher 2000)
– When asked if they trust their primary
nephrologists' judgment about their medical care
African Americans responded ―somewhat‖ or ―not
at all‖ more often than whites (men 22% vs. 12%,
women 24% Vs 11%). (Ayanian 1999)
• Still, most patients trust their own physician a great
Less Institutional Trust
• Major Differences
– African American men and women are less trusting of
hospitals. (Boulware 2002)
– African Americans are less trusting of the reasons
physicians use or withdraw life sustaining therapies.
(Hauser 1997, Blackhall 1999)
– African Americans are less trusting of the organ donation
system. (Yuen 1998, Siminoff 1999)
– African Americans have less trust in the health care
system in general. (Gamble 1997, Freedman 1998, Minniefield 2001)
– African Americans have profound mistrust of medical
research. (Freedman 1998, Freimuth 2001, Shavers 2001, Corbie-
Smith 1999 and 2002)

Trust vs. Trustworthiness

Physicians should be concerned with demonstrating that

they are trustworthy; the trust of patients will follow.

There is a difference between a physician who is trusted

and one who is trustworthy. Patients are often the most
vulnerable when they are most in need of health care
services, and granting too much trust to a physician can
limit their ability to discern what is in their own best interest.
 ―Unquestioned trust in clinicians may discourage or
hinder patients from acting autonomously and taking
an active role in their own health care.‖ (Waterman in
Anderson and Dedrick 1990)

Extreme Mistrust
• The government introduced drugs into African American
• AIDS/HIV is a man made form of genocide.
• African Americans are used as guinea pigs in medical
• Physicians withdraw life-support to African Americans for
financial/racial reasons over medical reasons.
• Gamble 1997, Freedman 1998, Freimuth 2001

• The Tuskegee Study (―USPHS Study of Untreated Syphilis in

the Negro Male‖) involved deliberate infection with Syphilis.
(Gamble 1997, Freimuth 2001)
Guinea Pigs & Unethical Tests
• ―They always use our race as guinea pigs.‖ (Corbie-Smith 1999)

• ―They treat us like guinea pigs. They are trying stuff out on us -
stuff they learned in school.‖ (Corbie-Smith 1999)

• ―…We have always had a concern about what white people

have done to black people. Doing things without consent.
These are the things that make us back off even more. As
black people we become the guinea pig for white people. It is
as simple as that.‖ (Freedman 1998)

• ―Guinea Pigs. I have a strong belief that syphilis and AIDS

originated from a laboratory experiment. That‘s what they used
people for.‖ (Freimuth et al. 2001)

HIV & Genocide
• The AIDS virus was ―deliberately created in a laboratory in order
to infect black people.‖ (NY Times/WCBS Poll 1990)
– Believed to be true by 10% of African Americans
– Believed might be true by another 20%
• AZT is a plot to poison African American people.
• Urging condom use is a scheme to prevent African American
• Distributing clean needles is designed to encourage drug abuse.
• ―Well, this is just my opinion. The population is growing. People
are dying at slower rates. So they said, ‗let‘s see what happens if
we infect this (HIV) out there‘.‖ (Corbie-Smith 1999)
• ―I think [experimentation on Blacks] is still going on now. Like
AIDS, it was man-made but it kind of got out of hand.‖ (Freimuth
Views Reflect a History
These opinions did not arise from nowhere...
 ―Slavery, sharecropping, peonage, lynching, Jim Crow laws,
disfranchisement, residential segregation, and job
discrimination formed the substance to which many Black
Americans reduced all American history, forming a saga of
hatred, exploitation, and abuse.‖ (Jones 1991)

 ―For many blacks, the Tuskegee Study became a symbol of

their mistreatment by the medical establishment, a metaphor for
deceit, conspiracy, malpractice, and neglect, if not outright racial
genocide.‖ (Jones 1991)

 81% know something about the USPHS Study at Tuskegee

(Shavers 2001)

A Study of ‘Untreated’ Syphilis:
A Failure of Professional Ethics

• Begun in 1932, continued until 1972.

• Approximately 400 African American men in Alabama with
Syphilis were observed to autopsy.
• Most received some ineffective treatment(s), but no reliable
treatments were given, including after Penicillin was in
widespread use in the 1950‘s.
• Patients were not told of their diagnosis, but were told they
would receive ―free care‖ and a burial stipend.
• Patients remained infectious, underwent lumbar punctures and
other invasive testing.
• May 16, 1997, President Clinton apologizes on behalf of the
US Government. (Reverby 2000)
‘Untreated’ Syphilis
• ―It was difficult to hold the interest of the group of Negroes in
Macon County unless some treatment was given‖ Dr. R.
Vonderlehr, 1968. (Brandt 1978)

• In interviews with four survivors: (Department of Health, Education

and Welfare, 1973 - in Reverby 2000)
– All remembered receiving shots, ointments, pills, or

• The USPHS ensured that the subjects did not receive

treatment from other sources. (Brandt 1978)

• ―While the men did not get treated for syphilis, they did get
‗good medical‘ care—care they would not have received
otherwise because of their socioeconomic status.‖ (As perceived
by Nurse Rivers in Hammonds, 1994)

Contemporary Experience
―The legacy of the Tuskegee Study endures, in part, because the
racism and disrespect for black lives that it entailed mirror black
people‘s contemporary experiences with medicine.‖ (Blendon et al
Negative experiences cited by African American and Latino focus
groups (Thom and Campbell 1997)
– lack of respect
– lack of privacy
– deaths of friends or relatives due to what was perceived to be
poor medical care
Minorities report more communication problems with physicians
(Commonwealth Fund, 2002)
African American patients rate their visits with physicians as less
participatory than whites. (Cooper-Patrick et al. 1999)

Building Trust is the
Profession’s Responsibility
• Trust confers health benefits
• Minorities mistrust the profession
• There are reasons, both historic and contemporary for
this mistrust, which reflect failures of professional
• To reduce health disparities and improve outcomes,
the profession must build trust among minority
• How can the profession build trust that has been
Individual Physicians Can...
• Thoroughly Evaluate Problems
• Understand the Patient‘s Individual Experience
• Express Caring
• Provide Appropriate and Effective Treatment
• Communicate Clearly and Completely
• Build a Partnership
• Demonstrate Honesty and Respect for the
• Address Structural/Staffing Factors
Thom and Campbell 1997
Related Online iPapers by Dr. Cray

IVMS-Intro to Clinical Medicine-

Communication Skills

H1N1 Swine Flu 2009 Virus and Vaccination-

Historical and Political Considerations

IVMS -The Tuskegee Syphilis Experiment

IVMS-From the Tuskegee Syphilis Experiment to

Mandatory H1N1 Vaccinations

IVMS-H1N1 Swine Flu Virus2009 FAQ