Paul Haidet

Racial and ethnic disparities in the use of health services: Bias, preferences, or poor communication?

African Americans and Latinos use services that require a doctor’s order at lower rates than do whites. Racial bias and patient preferences contribute to disparities, but their effects appear small. Communication during the medical interaction plays a central role in decision making about subsequent interventions and health behaviors. Research has shown that doctors have poorer communication with minority patients than with others, but problems in doctor-patient communication have received little attention as a potential cause, a remediable one, of health disparities. We evaluate the evidence that poor communication is a cause of disparities and propose some remedies drawn from the communication sciences.

The Role of the Student-Teacher Relationship in the Formation of Physicians: The Hidden Curriculum as Process

Relationship-Centered Care acknowledges the central importance of relationships in medical care. In a similar fashion, relationships hold a central position in medical education, and are critical for achieving favorable learning outcomes. However, there is little empirical work in the medical literature that explores the development and meaning of relationships in medical education. In this essay, we explore the growing body of work on the culture of medical school, often termed the “hidden curriculum.” We suggest that relationships are a critical mediating factor in the hidden curriculum. We explore evidence from the educational literature with respect to the student-teacher relationship, and the relevance that these studies hold for medical education. We conclude with suggestions for future research on student-teacher relationships in medical education settings.

Understanding Concordance in Patient-Physician Relationships: Personal and Ethnic Dimensions of Shared Identity

PURPOSE Although concordance by race and sex in physician-patient relationships has been associated with patient ratings of better care, mechanisms through which concordance leads to better outcomes remains unknown. This investigation examined (1) whether patients’ perceptions of similarity to their physicians predicted their ratings of quality of care and (2) whether perceived similarity was influenced by racial and sexual concordance and the physician’s communication. METHODS The research design was a cross-sectional study with 214 patients and 29 primary care physicians from 10 private and public outpatient clinics. Measures included postvisit patient ratings of similarity to the physician; satisfaction, trust, and intent to adhere; and audiotape analysis of patient involvement and physicians’ patient-centered communication. RESULTS Factor analysis revealed 2 dimensions of similarity, personal (in beliefs, values) and ethnic (in race, community). Black and white patients in racially concordant interactions reported more personal and ethnic similarity (mean score, 87.6 and 78.8, respectively, on a 100-point scale) to their physicians than did minority patients (mean score, 81.4 and 41.2, respectively) and white patients (mean score, 84.4 and 41.9, respectively) in racially discordant encounters. In multivariable models, perceived personal similarity was predicted by the patient’s age, education, and physicians’ patient-centered communication, but not by racial or sexual concordance. Perceived personal similarity and physicians’ patient-centered communication predicted patients’ trust, satisfaction, and intent to adhere. CONCLUSIONS The physician-patient relationship is strengthened when patients see themselves as similar to their physicians in personal beliefs, values, and communication. Perceived personal similarity is associated with higher ratings of trust, satisfaction, and intention to adhere. Race concordance is the primary predictor of perceived ethnic similarity, but several factors affect perceived personal similarity, including physicians’ use of patient-centered communication.

Medical student attitudes toward the doctor–patient relationship

Context  Medical educators have emphasized the importance of teaching patient‐centred care.

Team-based learning at ten medical schools: two years later

Purpose  In 2003, we described initial use of team‐based learning (TBL) at 10 medical schools. The purpose of the present study was to review progress and understand factors affecting the use of TBL at these schools during the subsequent 2 years.

Beliefs about control in the physician-patient relationship: Effect on communication in medical encounters

OBJECTIVES: Effective communication is a critical component of quality health care, and to improve it we must understand its dynamics. This investigation examined the extent to which physicians’ and patients’ preferences for control in their relationship (e.g., shared control vs doctor control) were related to their communications styles and adaptations (i.e., how they responded to the communication of the other participant).DESIGN: Stratified case-controlled study.PATIENTS/PARTICIPANTS: Twenty family medicine and internal medicine physicians and 135 patients.MEASUREMENTS: Based on scores from the Patient-Practitioner Orientation Scale, 10 patient-centered physicians (5 male, 5 female) and 10 doctor-centered physicians (5 male, 5 female) each interacted with 5 to 8 patients, roughly half of whom preferred shared control and the other half of whom were oriented toward doctor control. Audiotapes of 135 consultations were coded for behaviors indicative of physician partnership buidling and active patient participation.MAIN RESULTS: Patients who preferred shared control were more active participants (i.e., expressed more opinions, concerns, and questions) than were patients oriented toward doctor control. Physicians’ beliefs about control were not related to their use of partnership building. However, physicians did use more partnership building with male patients. Not only were active patient participation and physician partnership building mutually predictive of each other, but also approximately 14% of patient participation was prompted by physician partnership building and 33% of physician partnership building was in response to active patient participation.CONCLUSIONS: Communication in medical encounters is influenced by the physician’s and patient’s beliefs about control in their relationship as well as by one another’s behavior. The relationship between physicians’ partnership building and active patient participation is one of mutual influence such that increases in one often lead to increases in the other.

Role modeling humanistic behavior: Learning bedside manner from the experts

Purpose Humanistic care is regarded as important by patients and professional accrediting agencies, but little is known about how attitudes and behaviors in this domain are taught in clinical settings. To answer this question, the authors studied how excellent clinical teachers impart the behaviors and attitudes consistent with humanistic care to their learners. Method Using an observational, qualitative methodology, the authors studied 12 clinical faculty identified by the medical residents enrolled from 2003 to 2004 as excellent teachers of humanistic care on the inpatient medical services at four medical universities in the United States (University of Minnesota Medical School, Emory University, University of Rochester School of Medicine, and Baylor College of Medicine). Observations were conducted by the authors using standardized field notes. After each encounter, the authors debriefed patients, learners (residents and medical students), and the teaching physicians in semistructured interviews. Results Clinical teachers taught primarily by role modeling. Although they were highly aware of their significance as role models, they did not typically address the human dimensions of care overtly. Despite the common themes of role modeling identified, each clinical teacher exhibited unique teaching strategies. These clinical teachers identified self-reflection as the primary method by which they developed and refined their teaching strategies. Conclusions Role modeling is the primary method by which excellent clinical teachers try to teach medical residents humanistic aspects of medical care. Although clinical teachers develop unique teaching styles and strategies, common themes are shared and could be used for the future development of clinical faculty.

An initial experience with "team learning" in medical education.

Team learning is an approach to large-group teaching that combines the strengths of small-group interactive learning with teacher-driven content delivery. Team learning has been used successfully in professional disciplines other than medicine. The authors describe a field test of team learning in the setting of an internal medicine residency noontime lecture in the spring of 2000 at Baylor College of Medicine. They surveyed residents on their attitudes toward the usefulness of the lecture content before and after the session and surveyed them on their engagement in learning. Residents reported their engagement as high and demonstrated favorable changes in their attitudes about the usefulness of the lecture content to their daily medical practice. The authors describe their adaptation of the team-learning approach and conclude that team learning may be a useful new pedagogic tool in medical education.

How Well Do Doctors Know their Patients? Factors Affecting Physician Understanding of Patients' Health Beliefs

BACKGROUNDAn important feature of patient-centered care is physician understanding of their patients’ health beliefs and values.OBJECTIVEDetermine physicians’ awareness of patients’ health beliefs as well as communication, relationship, and demographic factors associated with better physician understanding of patients’ illness perspectives.DESIGNCross-sectional, observational study.RESEARCH PARTICIPANTSA convenience sample of 207 patients and 29 primary care physicians from 10 outpatient clinics.APPROACH AND MEASURESAfter their consultation, patients and physicians independently completed the CONNECT instrument, a measure that assesses beliefs about the degree to which the patient’s condition has a biological cause, is the patient’s fault, is one the patient can control, has meaning for the patient, can be treated with natural remedies, and patient preferences for a partnership with the physician. Physicians completed the measure again on how they thought the patient responded. Active patient participation (frequency of questions, concerns, acts of assertiveness) was coded from audio-recordings of the consultations. Physicians’ answers for how they thought the patient responded to the health belief measure were compared to their patients’ actual responses. Degree of physician understanding of patients’ health beliefs was computed as the absolute difference between patients’ health beliefs and physicians’ perception of patients’ health beliefs.KEY RESULTSPhysicians’ perceptions of their patients’ health beliefs differed significantly (P < 0.001) from patients’ actual beliefs. Physicians also thought patients’ beliefs were more aligned with their own. Physicians had a better understanding of the degree to which patients believed their health conditions had personal meaning (p = 0.001), would benefit from natural remedies (p = 0.049), were conditions the patient could control (p = 0.001), and wanted a partnership with the doctor (p = 0.014) when patients more often asked questions, expressed concerns, and stated their opinions. Physicians were poorer judges of patients’ beliefs when patients were African-American (desire for partnership) (p = 0.013), Hispanic (meaning) (p = 0.075), or of a different race (sense of control) (p = 0.024).CONCLUSIONSPhysicians were not good judges of patient’s health beliefs, but had a substantially better understanding when patients more actively participated in the consultation. Strategies for increasing physicians’ awareness of patients’ health beliefs include preconsultation assessment of patients’ beliefs, implementing culturally appropriate patient activation programs, and greater use of partnership-building to encourage active patient participation.An important feature of patient-centered care is physician understanding of their patients’ health beliefs and values. Determine physicians’ awareness of patients’ health beliefs as well as communication, relationship, and demographic factors associated with better physician understanding of patients’ illness perspectives. Cross-sectional, observational study. A convenience sample of 207 patients and 29 primary care physicians from 10 outpatient clinics. After their consultation, patients and physicians independently completed the CONNECT instrument, a measure that assesses beliefs about the degree to which the patient’s condition has a biological cause, is the patient’s fault, is one the patient can control, has meaning for the patient, can be treated with natural remedies, and patient preferences for a partnership with the physician. Physicians completed the measure again on how they thought the patient responded. Active patient participation (frequency of questions, concerns, acts of assertiveness) was coded from audio-recordings of the consultations. Physicians’ answers for how they thought the patient responded to the health belief measure were compared to their patients’ actual responses. Degree of physician understanding of patients’ health beliefs was computed as the absolute difference between patients’ health beliefs and physicians’ perception of patients’ health beliefs. Physicians’ perceptions of their patients’ health beliefs differed significantly (P < 0.001) from patients’ actual beliefs. Physicians also thought patients’ beliefs were more aligned with their own. Physicians had a better understanding of the degree to which patients believed their health conditions had personal meaning (p = 0.001), would benefit from natural remedies (p = 0.049), were conditions the patient could control (p = 0.001), and wanted a partnership with the doctor (p = 0.014) when patients more often asked questions, expressed concerns, and stated their opinions. Physicians were poorer judges of patients’ beliefs when patients were African-American (desire for partnership) (p = 0.013), Hispanic (meaning) (p = 0.075), or of a different race (sense of control) (p = 0.024). Physicians were not good judges of patient’s health beliefs, but had a substantially better understanding when patients more actively participated in the consultation. Strategies for increasing physicians’ awareness of patients’ health beliefs include preconsultation assessment of patients’ beliefs, implementing culturally appropriate patient activation programs, and greater use of partnership-building to encourage active patient participation.

Perspective: Guidelines for Reporting Team-Based Learning Activities in the Medical and Health Sciences Education Literature

Medical and health sciences educators are increasingly employing team-based learning (TBL) in their teaching activities. TBL is a comprehensive strategy for developing and using self-managed learning teams that has created a fertile area for medical education scholarship. However, because this method can be implemented in a variety of ways, published reports about TBL may be difficult to understand, critique, replicate, or compare unless authors fully describe their interventions. The authors of this article offer a conceptual model and propose a set of guidelines for standardizing the way that the results of TBL implementations are reported and critiqued. They identify and articulate the seven core design elements that underlie the TBL method and relate them to educational principles that maximize student engagement and learning within teams. The guidelines underscore important principles relevant to many forms of small-group learning. The authors suggest that following these guidelines when writing articles about TBL implementations should help standardize descriptive information in the medical and health sciences education literature about the essential aspects of TBL activities and allow authors and reviewers to successfully replicate TBL implementations and draw meaningful conclusions about observed outcomes.