What did “Unequal Treatment” say about communication 20 years ago?

It’s the 20th anniversary of the Institute of Medicine’s landmark report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare.” With communication top of mind for so many of us now, what did the report have to say about communication 20 years ago?

It’s the 20th anniversary of the Institute of Medicine’s landmark report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare.” I'd never read the report before so I've been taking the 20th anniversary as a chance to get into it and I invite you to join me. In this episode, I look for what Unequal Treatment had to say about communication.

Hi everybody. I'm Dr. Anne Marie Liebel, and this is 10 Minutes to Better Patient Communication from Health Communication Partners, your partners in health-equity focused education and communication. Visit healthcommunicationpartners.com.

It's exciting to have access to this text that's so important to so many people now, still, 20 years later. This is my first time reading the report. I still haven't read the whole thing. you'll find out I've cheated a bit, even for this one. But I’ve been taking notes as I read and that’s what I'm sharing with you. These are my largely unedited thoughts and questions and observations as I read the text. And I'm reading from my own position and history in equity-based approaches to language, to literacy, and education.

I invite you to listen along! Hopefully I can offer my reading in a way that’s helpful to you. Because having a text, holding up a text to reflect on can help us see our practices in a certain light.  So I invite you to reflect right along with me. How does what you're hearing hit your ears? When you think about your practice right now, what jumps out at you? What gets the wheels turning?

So if you wanted to search for communication in a traditional paper book, you would go to the index. So I went to the digital index and did a search for communication in the document. I got 261 hits, over half of them are from a single article in the paper contributions section. So I'm going to do that one first.

That paper is called “Patient provider communication: the effect of race and ethnicity on process and outcomes of healthcare” And of course I'm going to put text links in the notes. This paper is by Dr. Lisa Cooper and Dr. Debra Roter. This paper was helpful for me to read because it's a great kind of a state of the field of patient/provider communication research at the turn of the millennium. But it's a very specific view of the state of the field, because of course the authors are choosing which studies to highlight and which to background, which to omit, as they paint a specific picture that they want to paint of the field. One of the things I like about the way they handle this is that there are plenty of contradictions in the research they are reviewing and a lot of messy parts, and they don't attempt to gloss over them or tidy them up either.

A passage I especially appreciated was this one:

Individuals coming together in medical dialogue bring with them all of their personal characteristics, including their personalities, social attitudes and values, race, ethnicity, gender, sexual orientation, age, education, and physical and mental health. This applies to the physician as well as to the patient, though research on physician characteristics is less common, owing to typically small physician samples in communication studies (Hall & Roter, 1992).

I wonder how that first long sentence landed on readers 20 years ago, or the different responses different people might’ve had to it. I think it’s kind of telling that the authors have to point out that “This applies to the physician as well as to the patient” when we have that long list. Like people bring themselves with them to the medical dialogue. I don’t know if communication studies on physicians is less common than that on patients, but I'm gonna guess that it is. I wonder, how much, if at all, the balance has changed in the last 20 years?

One of the other things I like about this article overall is how it brings us down to earth a little bit. Reviews of research in general can be a little big-picture-y. But we do get the sense, the authors situate this in the interpersonal level. So we do get the sense of people actually being present. Because when you’re talking about communication, it's a thing that happens between people in specific contexts. So there’s only so far we can get in communication studies without getting down to the ground floor with people.

I will share another passage that I liked from this piece before I turn to the next one. The authors say, “It has long been known that poorer and less educated patients have trouble finding healthcare and get less of it. Now it appears that the problems of these groups are not entirely structural. They suffer poorer treatment even after they gain access to the healthcare system. The poor also have worse health The authors conclude that, disadvantaged patients may be sicker partly because of the way in which they and their doctors communicate.

And that was infuriating for me to read, now, 20 years after it was published. I wonder how it sounded to you. I wonder how it was taken at the time by different readers.

Ok I'm turning now to chapter 6 which is the next largest cluster of hits for communication.

This chapter is titled “Interventions: Cross-Cultural Education in the Health Professions”

Again this chapter is so helpful to me for the sense of field and the kind of selective history they gave me, some trends in research around culture specifically, a little less around communication,  how these were understood together, and also how they were brought into provider education–or at least some provider education–prior to 2003.

I was fascinated by the history they gave of trends, for instance, in the approaches to cross cultural education. One specific instance, something that’s really rankled me since I started getting into the health sector almost a decade ago now, was let’s call it an unanticipated side effect of a good-sounding policy. And that policy, or trend, was cultural competence. The unanticipated side effect as the authors put it is: “These efforts can lead to stereotyping and oversimplification of culture, without a respect for its fluidity (Donini-Lenhoff and Hedrick, 2000; Carrillo et al., 1999).” In that same section, they conclude that “learning as much as possible about the patient’s own sociocultural context and perspectives while minimizing the reliance on generalizations is ideal.” and I can tell you that is backed up in the knowledge base from the education sector, too.

In this section, we do get down to the individual level a few times, individual patients specifically. There’s not much on communication in this chapter, except to say more work in culture and communication is needed. But I'm almost ok with that because in this chapter there is so much about physician thinking about culture, and how to teach about culture, however culture is understood. And your thinking about culture is going to impact your communication. So I'm cool with that, I'll take that.

And I'll end with one of my favorite moments in this chapter. They repeat this moment, and I like it. It's in the beginning and then again at the end. So here it is: when sociocultural differences between patient and provider aren’t appreciated, explored, understood, or communicated in the medical encounter, the result is patient dissatisfaction, poor adherence, poorer health outcomes, and racial/ethnic disparities in care (Flores, 2000; Betancourt et al., 1999; Stewart et al., 1999; Morales et al., 1999; Cooper-Patrick et al., 1999; Langer, 1999). And it is not only the patient’s culture that matters; the provider culture is equally important (Nunez, 2000; Robins et al., 1998).

There is it again, that, Hey physicians, this includes you too, remember you too are communicating, you too are human, you too have culture, and all of that matters.

So I wonder what you're thinking.

How far have we come since then? What do we know now that was less well understood in 2003? What did we know then that's less well understood now? Where's the field as you see it? What conversations are you in?

I'm doing this reading, in part so that I can read the report to get a historical sense, to ground some of the more recent research, some of what I'm reading now, in this moment. And to also put my own work in context. There's something exciting I'll have to share soon that enters directly into this conversation, takes up some of these questions and issues and digs deep. So watch this space.

This has been 10 Minutes to Better Patient Communication from Health Communication Partners. Audio engineering and music by Joe Liebel. I'm Dr. Anne Marie Liebel.

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