Racial Concordance as a method to decrease healthcare disparities among African Americans By Jarvis S. Joiner This chapter will examine the differences between race and attitudes toward the health care delivery system and answer the research questions, Do African Americans prefer healthcare providers that look as they do? And are African Americans’ beliefs about racism in the healthcare system linked to how healthcare is accessed and experienced? For example there is a well-documented history of racial discrimination toward African Americans in medical research and in the clinical settings. Most notably is the 1932 U.S. Public Health Service Tuskegee Syphilis Study on Untreated Syphilis in the Negro Male. (Gamble, 1997). Recent research has illustrated that African Americans are aware of this discrimination and are reluctant to participate in clinical trials and distrustful of medical researchers and clinicians. (Shavers, Lynch & Burmeister, 2002). This distrust has been associated with racial disparities in health and lower rates of satisfaction with physician visits among African Americans than among other population groups. (Doescher, Saver, Franks & Fiscella, 2000). Definition Concordance is defined as a state of agreement such as harmony. (Merriam-Webster, 2003). In healthcare, the meaning is basically the same, healthcare providers in racial concordance as the people they care for. This concept of concordance has been extensively studied in healthcare and has lead to several published studies. What we know Data from the 2000 census document that African Americans (AA) make up about 13% of the US population, but less than 3% of practicing physicians are African American. (US Census Bureau, 2000). These disparities in AA physician numbers mirror the health disparities prevalent in AA populations. The Institute of Medicine report Unequal Treatment confirmed that racial and ethnic disparities are not entirely explained by differences in access and that disparities in healthcare exist in broader contexts such as social, economic and systematic bias. (Institute of Medicine, 2003). This report has generated new hypotheses and models of understanding healthcare disparities. Concordance is a new concept in the complex disparity arena. Recent studies have shown that ethnic-concordant relationships with healthcare providers are documented as being longer and more satisfying than ethnic-discordant relationships. This finding was independent of patient-centered communication suggesting that patient/physician attitude and bias may contribute to the relationship. (Cooper, Roter, Johnson, Ford, Steinwachs &Powe, 2003). Boulware, Cooper, Ratner, Laveist & Powe (2003) in a separate study, reported that 43% of AA respondents trusted their physician compared to 80% of White respondents. A majority of all respondents trusted their physicians (71%) and trusted hospitals (70%). After adjustment for potential confounders, black respondents were less likely to trust their physicians (37%, p=0.01). Boulware et al. concluded that patterns of trust in healthcare reflect cultural experiences and expectations of care among AA. We also know that few observational studies of healthcare use have report sufficient information to support the claim of provider bias; however a study conducted by Park et al. (2006) reported that most internal medicine residents gain cross-cultural skills through informal training and most stated that delivery of high-quality cross-cultural care was important, but were skeptical about the expectation of learning every little detail about all cultures. (Park, 2006). Barriers to cross-cultural care included lack of time, not knowing enough about the religion or ethnic group of the patient they were caring for and or dealing with beliefs systems which are different than their own. Van& Burke (2000) found that physicians rated minority patients more negatively than white patients; the study also reported that physicians viewed minorities as non-compliant and more likely to engage in risky health behaviors. These views can be perceived by AA via nonverbal and verbal cues. The American College of Physicians stated in a 2004 position paper that a diverse workforce of health professionals is an important part of eliminating disparities in the United States, (American College of Physicians, 2004). The paper also stated that concordance is associated with better patient-reported outcomes and that patients were more satisfied with their care. Concordance as an indicator of satisfaction A salient element of concordance is that the patients perceive the value of their relationship with their physician. Most patients are happy to discuss their health concerns when encouraged to do so by their healthcare provider. Cooper et al, in 2003 designed a cohort study to compare patient-physician communication in race-concordant visits and race-discordant visits to examine whether communication styles explained differences in patient ratings of satisfaction and participatory decision making. Figure 1 depicts the effect of race on patient-physician communication. From the model, one can see that the patient-provider communication is effected by social class of both the patient and the physician, and cultural competence of the institution. The outcomes of successful patient-physician communications are increased satisfaction and quality of life of the patient. The results of this study reported that race-concordant visits were longer [95% CI, 0.60 to 3.71] and had higher ratings of patient positive affect [95% CI, 0.04 to 1.05] compared with race-discordant visits. Patients in race-concordant visits were more satisfied and rated their physicians as more participatory. [95% CI, 3.23 to 13.60]. She concluded that race-concordant visits were longer, more satisfying and resulted in more positive patient outcomes. Patients reported greater ease in discussion problems and make healthcare decisions during longer medical visits. Ethnic-discordant visits were characterized by less social talk and had lower ratings of physician positive affect thanwere race-concordant visits. She added that increasing ethnic diversity among physicians may be the most direct strategy to improve healthcare experiences of minority groups. This supposition