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Patient-doctor communication with patients who have high blood pressure is worse for blacks than for whites, study finds

September 01, 2009

Black patients with high blood pressure experience poorer communication with their doctors than white patients do, a study led by a University of North Carolina at Chapel Hill researcher has found.

CHAPEL HILL - Black patients with high blood pressure experience poorer communication with their doctors than white patients do, a study led by a University of North Carolina at Chapel Hill researcher has found.

"This is an important finding because poorer communication is associated with worse patient satisfaction, adherence to therapy and blood pressure control, which in turn may lead to worse disease outcomes for black patients compared to white patients," said Crystal Wiley Cené, M.D., M.P.H., an assistant professor in the UNC School of Medicine and lead author of the study.

The study is published in the September 2009 issue of the Journal of General Internal Medicine.

Cené, a native of Sneads Ferry, N.C. and a graduate of the Brody School of Medicine at East Carolina University, led the study while completing a fellowship in general internal medicine at Johns Hopkins University School of Medicine in Baltimore, Md.

In her study, Cené and colleagues analyzed audio recordings of patient visits with their primary care physician as part of a study of interventions aimed at improving patient adherence to high blood pressure therapy. The larger study was led by Cené's mentor, Lisa A. Cooper, M.D., M.P.H., a Hopkins professor who earned her M.D. at UNC in 1988. Cooper is also the corresponding author of Cené's article.

Previous studies have shown both that patients in poorer health report having worse interpersonal communication with their doctors, and that black patients report poorer patient-doctor communication than white patients. Cené's study was designed to examine whether having uncontrolled blood pressure, in addition to being black, had a greater negative impact on patient-doctor communication than just race alone.

Participants in Cené's study included 226 high blood pressure patients and 39 physicians from 15 primary care practices in Baltimore. Coders listened to recordings of the patient visits and measured several outcomes. These included, but were not limited to, the length of visits and the number of statements devoted to the communication functions of biomedical exchange, psychosocial exchange and rapport building.

The results showed that the black patients had shorter office visits, less biomedical and psychosocial exchange and less rapport building with their doctors than white patients. These differences were statistically significant for psychosocial exchange and rapport building but not for biomedical exchange. Blacks with uncontrolled high blood pressure fared somewhat worse than blacks whose blood pressure was controlled by medication, whereas there were no significant differences among whites based on blood pressure control status.

The researchers found that for each outcome blacks, regardless of whether their blood pressure was controlled or not, had worse communication with their doctors than whites, regardless of the white patients' blood pressure control. The only exception was for an outcome called "patient positive affect," which is a sum of ratings of patients' interest, friendliness, engagement, sympathy and assertiveness behaviors. For this outcome they found that blacks with uncontrolled blood pressure had less positive affect than any of the other groups.

"It seems that in general blacks talk less overall to their physicians than white patients," Cené said. "As a result, communication about specific topics occurs less often. There are several possible reasons why they may talk less to their physicians -- they might not trust the physician or feel that they are 'disconnected' from their doctors, for whatever reasons. This lack of communication by black patients may in turn make their physicians talk less to them." Cené said.

"We believe there also may be an 'unspoken subtext' that occurs in visits between patients and doctors that influences the communication that occurs during the visit," Cené said. "It's possible that black patients are more likely to pick up on that 'unspoken subtext' and it alters their communication with their doctor. This might explain why we found that black patients had less positive affect towards their doctors than white patients. Essentially they are more sensitized to 'cue' into things that the coders could not easily capture just by listening to the audiotapes."

The study concluded that patient race was more important than blood pressure control status in determining the quality of patient-doctor communication and recommended the testing of interventions designed to improve patient-doctor communication as a way to reduce racial disparities in the care of patients with high blood pressure.

UNC Health Care System