Addressing racial healthcare disparities: how can we shift the focus from patients to providers?

“I n contrast to patients’ trust in clinicians, clinicians’ trust in patients has not been investigated.” So write Moskowitz et al., whose study, published in this issue of JGIM is the first to show that primary care providers’ trust in their patients (indigent patients with HIV who were part of a longitudinal study of pain) was lower for non-whites than whites, despite the fact that there were no actual racial differences in patient characteristics that might be expected to affect trust, such as patients’ self-reported illicit drug use and misuse of opioids. Trust in this study was assessed using a scale that asked providers to indicate how confident they were that the patient would engage in various behaviors indicating that the patient could be trusted (e.g., “will not manipulate the office visit for secondary gain” such as “inappropriate disability certification or prescription of controlled substances”; “will follow the treatment plan you recommend.”) Notably, in multivariate analyses, non-white race was the largest predictor of provider mistrust, followed by providers’ number of years in practice and patients’ current drug use, while patients’ reports of opioid analgesic misuse and lifetime alcohol abuse/ dependencewere not significant predictors. These results are troubling because lower levels of provider trust in their non-white patients with pain may contribute to racial disparities in pain treatment, particularly where opioid analgesics are concerned, since opioids require a certain amount of trust by physicians that the patient will not divert or abuse the prescription. Such racial disparities in pain treatment, in turn, may contribute to the greater prevalence of pain and greater functional impairments due to pain experienced by racial minorities, compared to whites. Although disturbing, the finding that non-white race was associated with lower levels of provider trust is not surprising, as it is consistent with numerous studies showing that many individuals in the United States, including healthcare providers, manifest a pro-white bias, at the conscious and unconscious level. In fact, the existence of racial bias among healthcare providers and its role as a potential contributor to racial healthcare disparities were discussed in the seminal Institute of Medicine report, Unequal Treatment, published in 2003. What is surprising, though, is that the Moskowitz et al. study, published in 2011, is the first to examine the effect of patient race on clinicians’ trust, in contrast to the many published studies examining patient trust. This imbalance underscores what is arguably the dominant way in which the problem of racial healthcare disparities is framed, in which the focus is on identifying and addressing the characteristics of racial minority patients, rather than the characteristics of providers, that contribute to disparities. The prevailing tendency to frame racial healthcare disparities in terms of patient race rather than providers’ racial stereotypes and biases is reflected in the prevailing training approaches aimed at improving the care of racial minority patients. Although it was almost a decade ago that Unequal Treatment recommended that providers receive training to understand and address ways in which they may unintentionally contribute to racial healthcare disparities, there are few programs aimed at helping providers overcome their own racerelated beliefs and stereotypes (such as the belief that white patients are more trustworthy than nonwhite patients), that contribute to racially disparate care. By contrast, the most popular training approach for reducing racial healthcare disparities focuses on improving providers’ “cultural competency,” defined as “the ability of individuals to establish effective interpersonal and working relationships that supersede cultural differences by recognizing the importance of social and cultural influences on patients.” Although some cultural competency programs do address issues of provider bias, the primary focus is on characteristics of the patient.” It is noteworthy that the number of cultural competency training programs is growing, despite the fact that there is a lack of evidence that cultural competency training reduces racial/ethnic healthcare disparities. This dominant framing of disparities is also consistent with the views of many providers, who believe that disparities are due mainly to patient factors rather than provider factors. For example, in a study of primary care clinicians by Sequist et al. published in JGIM in 2008, among the 52% who reported that racial disparities in the quality of diabetes care existed in their own health care system, less than 10% attributed these disparities to provider differences in prescribing medications and differences in referral to specialists and about 20% attributed disparities to providers’ miscommunication with patients. By contrast, about 40% attributed disparities to patient preferences; 45% to patient attitudes and beliefs about the provider; and over 70% to patient health behaviors. Presently there is a commitment by a number of researchers and educators to shift the focus away from patient race, as a cause of racial healthcare disparities, to provider-level and system-level factors. The National Institutes of Health and the National Cancer Institute, for instance, recently sponsored a Published online Ju , 2011