Racial and Ethnic Differences in Patient Perceptions of Bias and Cultural Competence in Healthcare (Distilled)

Journal of General Internal Medicine 2004;19:101–110.


Rachel L. Johnson, BA, Somnath Saha, MD, MPH, Jose J. Arbelaez, MD, MHS, Mary Catherine beach, MD, MPH, Lisa A. Cooper, MD, MP

To determine: 1) whether racial and ethnic differences exist in patients’ perceptions of primary care provider (PCP) and general health care system–related bias and cultural competence; and 2) whether these differences are explained by patient demographics, source of care, or patient-providercommunication variables. 

Racial and ethnic disparities in healthcare access and equality have been extensively documented. In 2003, the Institute of Medicine report; Unequal Treatment confirmed that racial and ethnic disparities in healthcare are not entirely explained by differences in access, clinical appropriateness or patient preferences. The report suggested that disparities in healthcare exist in the broader historical and contemporary context of social and economic inequality, prejudice and systemic bias.

Because most studies have focused on technical aspects of care, such as the receipt of certain tests, therapies, and procedures, less is known about interpersonal aspects of care that may contribute to observed disparities in healthcare quality.

Recent work shows that ethnic minorities, who are commonly in ethnic-discordant relationships with health professionals, rate the quality of interpersonal care by physicians and within the healthcare system in general more negatively than whites. Researchers have also provided evidence that bias and stereotyping exist among healthcare providers.

Moreover researchers assert that the cultural orientation of the medical care system is less congruent with the cultural perspectives of some patient groups than others. Given the important role that interpersonal processes, including manifestations of bias and cultural competences may play in the provision of healthcare to racial and ethnic minorities, measures of these phenomena might be important indicators of individual physician and healthcare system cultural competence.

To our knowledge, this is the first study that uses empiric measurements of several theoretical constructs of cultural competence in a nationally representative sample of adults in order to demonstrate racial and ethnic differences in patient ratings of care. Our results reveal troubling evidence that racial and ethnic minority respondents are more likely to perceive bias and lack of cultural competence when seeking treatment in the health care system overall than whites, and that these perceptions are somewhat diminished, but persist, even when controlling for demographic factors, health literacy, self-rated health status, source of care, and reports of medical communication.

In contrast, with the exception of the perception among Asian respondents that physicians look down on them and the way they live their lives, racial and ethnic differences in patient ratings of individual physician bias and cultural competence were explained, almost entirely, by demographics, health literacy, medical visit communication, and source of care.



            Spring 2011

Diversity: A Public Health Issue


      by James Z. Daniels, MSc., M.P.A.


It's no secret that health care professionals must identify, respect, and care about their patients' differences, values, preferences, and expressed needs. Some patients' backgrounds might be similar to those of the care provider and some may be different. It's the differences that cry out for attention.



It's no secret that health care professionals must identify, respect, and care about their patients' differences, values, preferences, and expressed needs. Nurses, physicians, allied health professionals: all need to be attentive when interacting with patients, and be sensitive to and respectful of their perspectives regarding health and wellness. The health care reform law currently being debated in Congress shifts some of the attention from how doctors are paid and how medical care is organized to how medical decisions are made and how those decisions affect care receivers. Some patients' backgrounds might be similar to those of the care provider and some may be different. It's the differences that cry out for attention.

More significantly, the differences, particularly the rampant socioeconomic disparities observed among racial and ethnic groups in the United States, can influence whether patients can even access high quality health care—perhaps care of any kind. The need for understanding, and for cultural competency training becomes clear when you look at the high incidence of diabetes and prostate cancer among African Americans; the high number of stress-related disorders among South Asian men; and the fact that Latinos have the highest median cholesterol level of any other group. Each of these facts impact communities and compounds aspects of public health. They affect the quality and vitality of, as well as exacerbate, public health issues.

"Diversity is our strength," rolls off the tongues of politicians, community activists, and academics; even consultants and the mass media spread the mantra. In health care, where patient-provider interactions, empirical and inferential research, and clinical procedures continue to illuminate the importance of diversity, these differences have, perhaps, the greatest impact. This can be clinically referred to as cultural health care competence—one aspect of the national health care sector that has taken on enormous significance as a public health concern.


CULTURAL COMPETENCY: Test Your Work Environment Have you ever examined your workplace's cultural competency— or your own? There are plenty of diversity and cultural competency assessments available online, or you can start with the questions below. Does your workplace... - Involve everyone on staff in developing more culturally competent practices? - Promote diverse hiring practices and leadership? - Use media, such as informational/educational films, that reflect diverse peoples? - Disseminate printed materials that take into account the average literacy levels of those the facility serves? - Feature posters, artwork, and other promotional materials representing diverse peoples? - Stock magazines and other reading materials in reception areas related to diverse peoples, including non-English publications? - Serve foods, including those used in research or clinical trials, that take into consideration the dietary restrictions and/ or preferences of diverse peoples? - Provide toys and playthings in reception areas and/or during research or clinical trials that reflect different cultures and feature diverse peoples?

It is estimated that in another 15 years, our country's demographic landscape will reflect a minority representation of roughly 40% of the U.S. population; already African Americans represent 13% and Hispanic Americans represent 16%. The National Institutes of Health are focused on how these statistics have galvanized the health care sector and are attempting to close the gap between the health status and health care of minorities versus the rest of the population.


Tackling this issue is not exactly new. What's missing is firm commitment. In 1999, physician Lisa Cooper-Patrick researched to understand the extent to which racial and ethnic disparities, in health status and use of health services, were related to the nuances within the physician-patient interaction. She examined how physicians' participatory decision-making style impacted the quality of care. Her findings provided evidence that physician bias was a significant contributor to the disparities in providing quality care to certain minorities and ethnic groups.

Other research has shown a discrepancy in patients' access to organ transplants. When changes to Medicare passed, also in 1999, African Americans and Hispanics were 28% and 31% less likely, respectively, to be recommended for kidney/pancreas transplants. These disparities are likely tied to the inordinately high numbers of diabetics in both African American and Hispanic communities.

Cooper-Patrick's research uncovered that African American patients described less participatory visits with their physician compared to Caucasian patients' visits. When the patient and the physician shared race or ethnicity, patients reported a more participatory experience. She concludes, in part, that physician factors such as "unintentional" (my emphasis) racial biases contributed qualitatively to the patient's experience and implicated the clinical outcomes. These results demonstrate how disparity affects patient care. Cooper-Patrick also studied a lack of physician capability regarding how to negotiate treatment and engage the patient across cultures.

When Kerry Watson, Chief Executive of Durham Regional Hospital in North Carolina, assumed leadership of the facility a few years ago, he addressed this issue after securing the support of the senior leadership of the Duke System. Watson then issued a directive that "every employee—every manager, every physician, every nurse, all 1,200 employees—would receive eight hours of cultural competency training, and this training was and remains the business case central to erasing the facility's reputation as providing substandard care."


Its impact was transformational. Employee morale and performance, community support, and the hospital's financial performance improved significantly. "It's about providing exceptional customer-patient service," he added. Watson tackled a tradition of care once tainted by bias. The transformation, as reflected in evolving patient satisfaction data, continues to validate the ongoing need for cultural health care competency training, essential to the hospital's integrated-care programs.

In short, diverse patient needs and race-related health disparities necessitate cultural competency training. If the treating physician is incapable of or lacking in cultural competence to engage these patients so that they may fully participate in their own wellness, the consequences are not only issues of disparity, but threats to the larger community as a public health issue.


James Z. Daniels, M.Sc., M.P.A., is the principal consultant for J Z Daniels Co. Ltd., a cultural healthcare competency practice.