Opening the Door for All

Pathologists want to see our clinical colleagues effectively use the diagnoses and clinical guidance we provide. Over the past few months, this perspective – alongside my academic training in bioethics – has motivated me to explore healthcare disparities impacting the quality of care, particularly with respect to common diagnoses such as breast cancer. In my view, implicit bias may contribute significantly to race-based differences in information exchange during clinical encounters in breast cancer and to disparate dosing decisions noted in the literature.

Given the complexity of most cancers and their treatments, therapeutic decisions are rarely easy. Patients are often presented with multiple potential courses of treatment, which often involve difficult routes to administration, complicated dosing regiments, and uncertain outcomes. As a result, being properly informed is vital to successfully navigating diagnosis and treatment – so it’s no surprise that effective information exchange “increases involvement in the consultation and in decision-making, increases satisfaction with treatment choices, improves ability to cope at all stages of cancer, reduces anxiety and uncertainty, improves communication with family members, and reduces disruption in patient’s quality of life (1).” Patients are also enabled to make good treatment decisions when they are effectively provided with information relevant to their illness and understand the information they receive. It is therefore distressing that significant racial and ethnic disparities exist in the quality of information exchange during oncology interactions.

One key aspect of information exchange examined in the literature is the frequency with which patients ask questions in oncology interactions. The general findings are that African American patients ask fewer questions per interaction, even controlling for patients’ age, education, and income.  There is an additional source of disparity in information exchange that merits consideration – the impact of patients’ companions. Patients and companions together tend to ask over twice as many questions as patients alone (2,3) and African American patients are significantly less likely to bring a companion to oncology interactions than white patients. In a sample of 109 oncology encounters, 86 percent of white patients and 40 percent of African American patients brought a companion (3).

A significant disparity is also noted in the discussion of side effects when selecting a course of treatment. In one study, side effects were discussed in 97 percent of clinical interactions with white patients and only 62 percent of interactions with African American patients (4) In another trial, oncologists mentioned at least one side effect of the treatment regimen during 77 percent of interactions with white patients and only 44 percent of exchanges with African American patients (4). Additionally, oncologists provided significantly more information about side effects and other aspects of the trial to white patients and spent twice as much time talking about risks associated with the trial as they did with African American patients.

The quality of information exchange appears to correlate with treatment quality. Even after controlling for tumor characteristics, other medical conditions, obesity, socioeconomic status, and whether a patient had insurance, a study in almost 500 patients found that African American women were significantly more likely to be underdosed than their white counterparts. Only 61 percent of the African patients received a therapeutic dosage 80 percent of the recommended dose or greater, compared with 72 percent of white patients (5,6). Many oncologists, citing community distrust of medical authority, worry that their African American patients are less likely to feel comfortable reporting side effects of treatment and so prioritize preempting toxicity over clinically effective dosing – an approach that further underscores the need for effective communication and trust-building.

It is clear that new approaches are needed to ensure effective communication and high-quality care for patients of all ethnicities. I have come to perceive the development of positive emotion during the clinical encounter as central to improved physician-patient information exchange and shared decision-making. Positive emotion leads to more inclusive social categories, making people more likely to view themselves as being part of a larger group and facilitating empathy (7). Providers who experience higher levels of positive emotion during clinical encounters are less likely to categorize patients in terms of their racial, ethnic, or cultural group and more likely to view them, as individuals. Teaching techniques such as Balint groups (8) therefore represent appropriate methodology for training programs that aim to reduce provider bias. Balint groups also alleviate the “rebound effect,” in which the stereotype recurs at a higher rate among those instructed to suppress it (8,9). Methodologies focused on tackling bias directly through repression may also result in increased emotional distancing, thus potentially undermining the interpersonal quality of the encounter. Motivated by these thoughts, I propose a study to examine whether Balint groups offer a superior approach to information exchange in physician-patient interactions.

Click here to learn more about the proposed study.

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