Addressing microaggressions in racially charged patient-provider interactions: a pilot randomized trial

BACKGROUND

Racial bias in medical care is a significant public health issue, with increased focus on microaggressions and the quality of patient-provider interactions. Innovations in training interventions are needed to decrease microaggressions and improve provider communication and rapport with patients of color during medical encounters.

METHODS

This paper presents a pilot randomized trial of an innovative clinical workshop that employed a theoretical model from social and contextual behavioral sciences. The intervention specifically aimed to decrease providers' likelihood of expressing biases and negative stereotypes when interacting with patients of color in racially charged moments, such as when patients discuss past incidents of discrimination. Workshop exercises were informed by research on the importance of mindfulness and interracial contact involving reciprocal exchanges of vulnerability and responsiveness. Twenty-five medical student and recent graduate participants were randomized to a workshop intervention or no intervention. Outcomes were measured via provider self-report and observed changes in targeted provider behaviors. Specifically, two independent, blind teams of coders assessed provider emotional rapport and responsiveness during simulated interracial patient encounters with standardized Black patients who presented specific racial challenges to participants.

RESULTS

Greater improvements in observed emotional rapport and responsiveness (indexing fewer microaggressions), improved self-reported explicit attitudes toward minoritized groups, and improved self-reported working alliance and closeness with the Black standardized patients were observed and reported by intervention participants.

CONCLUSIONS

Medical providers may be more likely to exhibit bias with patients of color in specific racially charged moments during medical encounters. This small-sample pilot study suggests that interventions that directly intervene to help providers improve responding in these moments by incorporating mindfulness and interracial contact may be beneficial in reducing racial health disparities.

Perceptions of the working alliance among medical staff and cancer patients

OBJECTIVE

A working alliance (WA) is considered an essential factor in therapeutic relationships, relating to the mutual and interactive aspects of the relationship. In the medical setting, a WA has been found to be related to various positive outcomes; however, it has previously been investigated solely from the patient's perspective. The aim of the current study was to measure the concept from both sides of the patient-medical staff interaction.

METHOD

Physicians, nurses, and advanced cancer patients completed the Working Alliance Inventory-Short Revised.

RESULTS

Some 32 physicians, 39 nurses, and 52 advanced cancer patients completed the study. Senior staff members rated the WA higher than trainees, both among physicians and nurses. Physicians and nurses rated the "bonds" subscale highest, while patients rated "goals" at the highest level. In addition, a significant difference was demonstrated between physicians and patients, with patients rating the WA higher.

CONCLUSIONS

These preliminary findings demonstrate different perspectives among advanced cancer patients and medical staff interactions. Future studies should investigate the interactive aspects of the WA concept in the medical setting.

SIGNIFICANCE OF RESULTS

Awareness of the working alliance in patient-staff interactions may improve the quality of treatment given to patients confronting cancer.

The physician-patient working alliance

OBJECTIVE

Cognitive and emotional dimensions of the physician-patient relationship (working alliance) were examined in relation to patients' beliefs about the usefulness of treatment (perceived utility), patients' beliefs about being able to adhere to treatment (adherence self-efficacy beliefs), patients' follow through on their treatment plan (adherence), and patients' satisfaction.

METHODS

Participants were 51 men and 67 women who averaged 38.9 years of age (S.D.=12.28). Seventy-two were Euro-American, 23 African-American, 6 Asian-American, 11 Hispanic, and 6 "Other." They reported an average of 7.3 years (S.D.=7.48) since being diagnosed with a chronic medical illness and an average of 7.1 (S.D.=4.88) visits to their doctor within the last year. Patients' conditions included HIV+/AIDS, hypertension, diabetes, asthma, and cancer.

RESULTS

Results show moderate to strong relationships between working alliance and perceived utility (r=0.63, P<0.001), self-efficacy (r=0.47, P<0.001), adherence (r=0.53, P<0.001), and satisfaction (r=0.83, P<0.001). Regression analyses showed that ratings of the working alliance (SB=0.25, P<0.005) and self-efficacy beliefs (SB=0.48, P<0.001) predicted patient adherence and that working alliance ratings (SB=0.83, P<0.001) also predicted patient satisfaction.

CONCLUSION

The working alliance can be measured in medical care and appears to be strongly associated with patients' adherence to and satisfaction with treatment.

PRACTICE IMPLICATIONS

The working alliance is important in medical treatment, as it is associated with patient adherence and satisfaction. Patients' self-efficacy ought to be assessed and promoted as it is also associated with treatment adherence.