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April 25, 2006

Comments

Kevin T. Keith

[L]ow-income black patients in the metro area just don't trust the doctors, particularly at the ER, and often give false phone numbers and addresses, which makes follow up impossible. The UPenn study attributed much of the lack of trust to the fact that many blacks are uninsured and seek care in the ER, where the staff changes often. This makes perfect sense to me -- the experience of medical treatment chiefly through an ER setting, where you wait hours to see anyone, see a different doctor every time, and have an invasive, thorough medical history taken each visit, is quite different than visiting a consistent primary care doc.


Perhaps so, but I suspect much of that evasion is also an attempt to avoid payment.

ER fees typically run hundreds of dollars just to walk in, plus hundreds more for actual treatment (and god help you if you need an X-ray or invasive procedure). Paying ER fees out-of-pocket is simply out of the question for many uninsured patients, but private doctors, whose fees would still be high but much lower than for an ER visit, won't see them at all. So they are not only force to use ERs for primary care, but at rates they cannot possibly afford.

Doug Patton

The column above, the Kaiser Family Foundation column upon which it is based, and the Washington Post column which that column refers to, are all interesting not only for what they say but what they leave out. Looking at the original Archives of Internal Medicine study, we see that while race correlated significantly to trust, several other important factors did not. Annual salary (greater than versus less than $25,000) did not affect the results among blacks. Insurance status also made no difference. Even education level did not show an effect. As noted above, it was significant whether or not participants got their health care in a doctor’s office or “other source” (presumably an emergency department or community walk-in clinic), but this did not make nearly as much difference among white participants. Overall the picture seems pretty clear: black patients have trust issues with doctors.

The question is what to do with that information. A PR campaign? Public outreach program? Any large scale effort risks looking contrived and possibly defensive – the last thing physicians need. Dialog is important, but the solution, as always, is going to rest with care providers at the bedside. Physicians must be diligent with each patient interaction to establish the trust necessary to continue to being allowed the privilege of serving the population in their care. At the same time, it should be clear that patients will have a better experience and feel more comfortable with their primary care provider if they make the effort to find a provider they like, schedule regular appointments and develop a relationship with that physician so that he or she can provide continuity of care. Physicians and patients must both take responsibility for this trust gap if health care quality is going to improve for African-Americans.

Nicole

The idea that black patients do not trust doctors as much as their white counterparts is an interesting concept. The study by Halbert brings out the idea that the black population tends to receive their medical care in ER’s or walk-in clinics more than in primary care clinics. I can imagine that going into an ER where the patient does not have a relationship with the physician would make it difficult for the patient to feel that his/her “welfare is placed above other considerations” especially when the ER is busy and the patient is left in the waiting room for many hours. My question, just as Doug was alluded to, is why black patients are less likely to have a primary care doctor.
In class we watched a video of a black man who had been on dialysis for two years and was still waiting for a transplant. This patient stated that many elders in his community did not trust doctors because of past events, the most significant being the Tuskegee trial where medication to treat syphilis was withheld from many black men. It seems that this distrust continues to be passed down through generations especially as black members of society feel as though they are being treated unjustly by people in the medical arena. Could this distrust hinder the black population of the U.S. from seeking a primary care physician leaving them to visit the ER only when necessary?
The article by Halbert points out that “the interpersonal relationship between patients and health care providers is a critical component of patient trust.” This aspect of trust is absent for the patients who go to the ER or walk-in clinics which could further increase the distrust that the black population already has of the health care providers. There needs to be an intervention allowing the black population to have a primary care doctor whom they develop a relationship with in order for them to begin to receive appropriate medical care. Not only would this increase trust in the medical profession for black members of society, but it could easily impact their overall health if they begin to have routine, preventative medical care.

References:
Halbert C.H., Armstrong K., Oscar H., et al. Racial differences in trust in health care providers. Arch Intern Med. 2006; 166: 896-901.

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