Impact on care
Respondents who reported being treated with disrespect were significantly less likely to have had a physical exam within the prior year; those with diabetes, hypertension, or heart disease were less likely to have received optimal care. These respondents were also more likely to report not following the doctor’s advice and putting off needed care (Table 3). This relationship was not seen for optimal cancer screening.
Persons who believed they had been treated unfairly due to their race and who thought they would have received better care had they been of a different race were more likely to ignore the doctor’s advice and put off care when medically needed. Those who believed they would have received better care had they been of a different race were also less likely to receive optimal chronic disease care. In analyses not shown, we examined the independent effects of income and education, as well as interactions between these variables and insurance, and found the results basically unchanged.
TABLE 3
Relationship of negative perceptions to health care outcomes
| Exam within prior year (%) | Optimal chronic disease screening (%) | Optimal cancer screening (%) | Did not follow doctor’s advice (%) | Delayed care (%) | |
|---|---|---|---|---|---|
| Treated with disrespect or looked down on | n=6663 | n=1790 | n=4794 | n=6008 | n=6663 |
| Yes | 41.3§ | 58.9† | 52.9 | 32.3† | 31.1* |
| No | 48.6* | 76.0* | 54.1 | 23.6* | 18.6* |
| Treated unfairly because of…Race | n=6008 | n=1729 | 4500 | n=6008 | n=6008 |
| Yes | 52.5* | 50.7‡ | 64.9§ | 46.5* | 40.8† |
| No | 51.4* | 75.3* | 55.3* | 23.9* | 20.2* |
| Language | |||||
| Yes | 48.2* | 62.0* | 59.4* | 32.1* | 37.5‡ |
| No | 51.6* | 74.7* | 55.5* | 24.5* | 20.6* |
| Would have received better treatment if different race | n=6722 | n=1794 | n=4827 | n=6008 | n=6722 |
| Yes | 46.2* | 53.6‡ | 56.6* | 33.8‡ | 33.7* |
| No | 47.4* | 74.3* | 54.2* | 24.1* | 19.2* |
| This table reports predicted percentages derived from our multivariate regression analysis. Dependent variables: “exam within prior year,” “optimal chronic disease screening,” “optimal cancer screening,” “did not follow the doctor’s advice,” and “delayed care.” Principal independent variables: “treated with disrespect or looked down upon,” “treated unfairly because of race,” “treat ed unfairly because of language,” and “would have received better treatment if different race.” In each model, we examined the relationship of the dependent variable to each of our principal independent variables controlling for income, insurance, educa tion, presence of a primary physician, and chronic disease (excluded from the heart disease/diabetes screening regression.) | |||||
| * P≤.001 | |||||
| † P≤.01 | |||||
| ‡ P≤.05 | |||||
| § P≤.10 | |||||
Discussion
We hypothesized that patients who have negative perceptions of the patient-provider relationship would be less likely to seek needed care, and that reports of such feelings would be more prevalent among minority patients. As anticipated, large proportions of blacks, Hispanics, and Asians reported that they were treated with disrespect, were treated unfairly, or would have received better care if their race had been different. Male gender and lower educational attainment were also associated with perceived disrespect, particularly among minorities.
Negative experiences lead to suboptimal care
The finding of greater likelihood of perceived disrespect among minority groups, men, and those with lower levels of education is particularly important in light of the strong relationship between such reports and the quality of care that patients receive. Those who reported that they were treated unfairly because of race were less likely to get a routine physical exam, follow a doctor’s advice, or receive appropriate secondary preventive care for diabetes, heart disease, and hypertension. In other words, negative experiences within the health care environment may jeopardize care for medically needy patients. Receipt of suboptimal care, particularly in the context of chronic disease, is likely to be associated with worse health outcomes, and may contribute to disparities.
Cancer screening the exception
While the relationships between negative perceptions and receipt of care for chronic disease and receipt of a routine physical examination were strong, the correlation did not persist for cancer screening. Black and Hispanic respondents were more likely than whites to receive optimal cancer screening, a finding that has been reported elsewhere.14, 15
We hypothesize that this is in part because a wide array of community programs make special outreach efforts allowing patients to “bypass” the traditional office environment.16 These settings may be more likely to use culturally sensitive approaches or may be so transient that negative perceptions based on race or income may be less likely to form.
However, based on our finding that care requiring follow-up (eg, diabetes management) is less likely to occur with individuals who report negative perceptions of the patient-provider relationship, we would hypothesize that individuals who receive initial cancer screening might be less likely to follow up on abnormal results once screened. It may be that in situations requiring long term relationships, such as chronic disease care, perceptions of discrimination and disrespect may take the greatest toll. This hypothesis is supported by previous literature consistently reporting excess mortality despite higher cancer screening rates among blacks.17-20
Limitations
Our study has several limitations. Because we are relying on self-report, we could not assess which specific aspects of the patient-provider relationship may have influenced the reports of disrespect. Responses may have been affected by experiences completely outside of this relation ship, or outside of the health care system, that independently could have impacted health care utilization. We cannot disentangle how general life experience influences perceptions of the health care encounter or care-seeking; for example respondents who perceive racial bias in other environments such as the workplace may also be more likely to perceive it in the healthcare setting. In addition, self-reported utilization measures may not always be accurate, particularly regarding cancer screening.21,22