Research

TheEffectofPatientPhysicianEthnicity andCommunicationonAdherence RatestoCardiovascularDisease Medications

JoseMaldonado JacquelineMayaSilva LarryMenefee,Jr. ShengXiong

ABSTRACT ailures in effective, culturally relevant communication correlates with lower rates of adherence to cardiovascular disease (CVD) medications. These failures include lack of patient satisfaction with physicians, lack of patient participation in conversation, and language barriers. Minority groups such as blacks and Hispanics experience these failures in communication more often and have lower adherence rates to CVD medications than whites. This problem can potentially be alleviated by encouraging patient participation and diversifying the health profession. INTRODUCTION The increasing number of people being diagnosed with cardiovascular diseases, including hypertension, stroke, heart attacks, and atherosclerosis, is reflected in the increase in deaths due to heart disease (Cene 2009). A big contributor to the high rates of CVD related deaths is the lack of adherence of patient or how much the patient takes his or her CVD medication. The low adherence rates of medications can be traced to the quality of the patientphysician relationship. The quality of patient-physician communication greatly affects patients outcome, including selfmanagement behaviors, satisfaction, trust, and adherence rates (Cene 2009). Patient-physician communication is the primary process by which medical decisions are made and patients are diagnosed and treated (Cene 2009). A big indicator of the quality of communication between physicians and their patients is their relative ethnicity. Concordance in patient-physician ethnicity, where the patient identifies as having the same ethnicity as the physician, leads to better communication and understanding because the patients feel more comfortable and have more trust in their physician (Traylor 2010). The

quality of patient-physician communication is associated with better outcomes for patients; the patients are able to build greater trust, which leads to higher adherence rates to their medications as (Cene et al 2009). Additionally, differences in patient and physician ethnicity often made the patients feel distant from their physician, leading to lessened participation in conversations during consult visits (Cene 2009). This paper will attempt to demonstrate the effects of racial discordance, where the patient and physician are of two different ethnicities, among patient-physician relationships and communication on patient adherence to cardiovascular disease medications. We will attempt to show that a patient who is ethically concordant with their physician, and has good communication with their physician has a higher adherence rate to their CVD medications than a patient who is ethically discordant with their physician and has minimal communication. Addressing the lack of diversity in the health care industry by increasing the number of minority physicians to reflect the ethnic composition of the United States, patients will be more likely to have better communication with their physician, better quality in their treatment, and a better experience overall. METHODS Sources used for this research were very useful in answering our topic question. One of the sources is a book titled Health Disparities in the United States, by Dr. Donald Barr. The book compares the rates of adherence in minorities to whites in the United States. Hispanics and blacks lack in participation, trust, and communication with their physicians. The five sources that we gathered from PubMed link to our main journal article source called Adherence to Cardiovascular Diseases Between Patients and Physicians. This article describes that by improving patient-physician race/ethnicity and language concordance will decrease disparities in cardiovascular diseases. RESULTS/DISCUSSION Blacks and Hispanics have a higher risk of developing cardiovascular disease, and are more likely to die from it

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(Traylor 2009). Blacks and Hispanics tend to receive lower quality care than whites due to the lack of understanding, trust, and satisfaction between patients and physicians (Saha 2003). Trust and satisfaction are among some factors that link to communication. Regardless of race, any miscommunications may lead to a bad adherence to medication. Ethnic discordance can cause a patient to have a lack of trust in a physician (Saha 2003). If a patient is uncomfortable with his or her physician, then there can be a failure in communication. 67% of black patients who are concordant with their physician are satisfied with their health care compared to 51% of those who are discordant with their physician (Saha 2003). 58% of Hispanic patients who are concordant with their physician are more satisfied with their health care compared to 54% of those who are discordant with their physicians (Saha 2003). Minorities prefer to have a physician with the same background as them (Saha 2003). Dr. Barr stated that patients and physicians with the same ethnicity have a reduced sense of social distance, which may result in higher levels of satisfaction and trust (Barr). Blacks and Hispanics that have the same ethnicity as their provider tend to feel more satisfied with their health care because the physician treats them with respect, explains all medical problems clearly, and listens to their concerns (Saha 2003). Adequate listening from a physician leads to a good decision-making (Saha 2003), which is very important because it will affect the patients health whether or not the patient will avoid a treatment (Barr). If the patient feels that the physician is doing his or her job, then satisfaction will be accomplished. Additional factors that contribute to miscommunication between patients and their physicians are language and cultural barriers. If a language barrier exists, important information can be lost in the process of interpretation. Studies have shown that patients of color are more likely than white patients to face these language barriers that lead to miscommunication with their physician (Traylor 2010). If the patient fails to understand what their physician emphasizes, the patients will be less likely to adhere to their medications because they might have been unable to perceive the importance of the intake of such medications. Cultural differences may also impact the amount of trust a patient has with their physician (Traylor 2010). The patients may feel uncertain about the physicians decisions due to the fact that physicians are not aware of their beliefs or preferences (Traylor 2010). A patientphysician relationship may be ethnically concordant but this does not guarantee that both the patient and physician share the same cultural. For example, the patient and physician may be concordant because they are Asian, but the physician may be Chinese while the patient is Hmong. Thus, cultural differences may still arise in ethically concordant patient-physician relationships.

The amount of patient participation in a conversation with a physician also affects their quality of communication. Communication at its worst is when his/her physician is dominating the entire conversation. The patient is either not asking questions or not contributing in the decision making process. Studies have shown that when the patient and physician are the same ethnicity, then the patient is more involved in the conversation (Cooper-Patrick 1999) Stevens data suggest that black patients rate their visits with physicians as less participatory than whites. (Cooper-Patrick 1999) Minorities are not as involved in their conversation with their doctors. Studies have shown that 58.0 of black patients are less participatory than 60.6 of white patients (Cooper-Patrick 1999). These numbers indicate blacks are not as involved in the patient-physician ethnicity relationship than whites. They would rather allow their health care provider to talk throughout the whole visits, which doesnt help the patient to understand or listen to the care provider. Patient participation is an essential factor that contributes to adherence to cardiovascular disease medications. When the patient and physician are the same ethnicity the patient is more comfortable and believes what his/her doctor is saying can help them in the long run. Patients with the same ethnicity are more likely to have a better relationship with their doctors than other minorities (Cooper- Patrick 1999). CONCLUSION Ethnic discordance among patient-physician relationships creates a disparity in the efficiency of communication that tends to decrease cardiovascular disease medication adherence in minority patients. On the other hand, ethnic concordance, especially among white patients, adherence rates to medications are higher. Ethnic concordance leads to better communication between patients and their physicians. Communication affects patient-physician relationships by building trust, satisfaction, and participation in patients that influence the patients into adhering to their medications at a higher rate. Factors that may impact communication include language and cultural differences. Hispanic and Asian concordance were not associated with good adherence to medications because there is still great diversity among these racial groups. This is mostly due to the fact that there exists many languages among these racial groups and still varying cultures that prevent patients from building trustful relationship with their physicians. Concordance in both language and culture improved patient communication and thus increased adherence rates in patients. The ethnic concordance between patients and their physicians may be increased if more minority youths were encouraged to go into the medical field. Early exposure to the medical field through youth programs that engage diverse high school students in the health system may encourage more

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minority students to seek a career in the medical field. By focusing on youth, we are insuring an increase in diversity among future physicians that will reflect the diversity that defines the United States population.
Additional Contributions: We thank Tim Dang for his critical reading andeditorialcommentaryonearlierdrafts. Presented in conjunction with an oral and poster presentation for the Stanford Medical Youth Science Program 2010 Summer Residential Program graduation ceremonies held at Leland Stanford Jr. University onJuly25,2010.

BIBLIOGRAPHY 1.BarrDA.HealthDisparitiesintheUnitedStates.Baltimore,Maryland: TheJohnsHopkinsUniversityPress,2008. 2. Cene CW, et al. The Effect of Patient Race and Blood Pressure Control on PatientPhysician Communication. Springer New York, Volume24,Number9(2009).10571064. 3. CooperPatrick L. Race, Gender, and Partnership in the Patient PhysicianRelationship.ThePatientPhysicianRelationship,Vol.282,No. 6:(2009)282,6:583589. 4. Johnson RL, et al. Patient Race/Ethnicity and Quality of Patient Physician Communication During Medical Visits. American Journal of PublicHealth,Vol.92No.12(2004):20842090. 5. Saha S, et al. PatientPhysician Relationships and Racial Disparitiesin the Quality of Health Care. American Journal of Public Health, Vol. 93 No.10(2003):17131719. 6. Taylor AH, et al. Adherence to Cardiovascular Disease Medications: Does Patient Provider Race/Ethnicity and Language Concordance Matter?JournalofGeneralInternalMedicine,(2010):16.

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