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Thursday Review: “Racial and Ethnic Differences in a Patient Survey: Patients’ Values, Ratings, and Reports regarding Physician Primary Care Performance in a Large Health Maintenance Organization”

Research into race, ethnicity, and patient satisfaction is simultaneously clear and confounding. This alone makes this kind of work intriguing and tantalizing: there seem to be lessons to be drawn for the sake of improving care for broad populations of people. What those lessons are, though, seems illusive the closer we examine the trends in data.

Looking into the findings of Murray-García, et al. in this study of how race and ethnicity affect patients’ values and ratings of their physicians, there are striking similarities and also statistically significant differences among groups. For each one of the differences, there is instantly a complicating factor at hand. Trying to interpret what the similarities and differences mean for making health systems better able to serve diverse populations seems inconclusive.

Ultimately, knowing something about broad trends in racial and ethnic perceptions of care can’t be a bad thing. The challenge for front-line clinicians and staff is holding those tendencies in mind, and being patient-centric enough to abandon them when the needs and values of any individual don’t neatly conform to their given demographic.

One concrete mindset for being able to do this is the idea of “cultural humility”, proposed by Murray-García along with Melanie Tervalon.1 Even with knowledge of broad trends, every individual brings with them their own values. Staying humble and inquisitive about the individual’s values is more useful than asserting that everyone in a demographic behaves in a certain way. DasGupta took Tervalon and Murray-García’s idea and expanded it into “narrative humility”. After a physician colleague told DasGupta, You don’t have to say any more. I know exactly how your story ends, DasGupta insisted …we cannot ever claim to comprehend the totality of another’s story, which is only ever an approximation for the totality of another’s self.2

Murray-García and co-authors found that different demographics have some reported values in common. For example, prioritization of values was strikingly similar across the racial/ethnic groups, with technical skills being most highly valued for each group, followed by full explanations of diagnoses and treatments.

There were notable differences, though: For example, Asians consistently rated their physicians lower than whites on every dimension of performance. Although consistent and statistically significant, Murray-García et al. are careful to point out the limits of this as an actionable finding. The patient-reported performance may actually indicate a lower quality of care. The authors discuss that it may also reveal a difference of perception about the care, or a difference between high expectations and clinical reality. After reviewing previous studies of racial and ethnic differences in patient satisfaction reporting, the authors note interactions between these explanations may be quite complex.

It isn’t just theoretical differences that confound a straightforward interpretation of the authors’ findings, though. Murray-García et al. compared their findings with actual utilization data in the same health system. To stay with the example of Asian populations, although Asian patients rated physicians lower than white patients, they made more primary care visits than white patients. The complexity of why Asian patients appear to vote one way on paper, but another way with their feet, is a reminder that one, population-level understanding of a demographic isn’t a replacement for a culturally humble, narratively humble relationship with a patient.

The authors themselves also point out that convenient categories of “race” and “ethnicity” are artificial monoliths. Murray-García et al. were able to distinguish between subgroups of Asian patients, but not for other races or ethnicities. As one might expect, Pacific Islander was the smallest Asian subgroup. Pacific Islander patients, though, were far more satisfied with their physicians than not only the Asian identities as a whole (77% vs. 64.5% satisfied), Pacific Islanders were more satisfied than any other demographic.

Ultimately, knowing that there are apparent trends in perceptions and values for different populations might be most useful if it’s also known that those trends are complex. If health systems and clinicians of all kinds can’t pull easy answers from demographic data, we’ll have to make deliberate space to deal with individuals’ values, perceptions, and desires for their own care.


The article reviewed: Murray-García, Jann L., Joe V. Selby, Julie Schmittdiel, Kevin Grumbach, and Charles P. Quesenberry. “Racial and Ethnic Differences in a Patient Survey: Patients’ Values, Ratings, and Reports Regarding Physician Primary Care Performance in a Large Health Maintenance Organization.” Medical Care 38, no. 3 (2000): 300–310.

1 Tervalon, Melanie, and Jann Murray-García. “Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education.” Journal of Health Care for the Poor and Underserved 9, no. 2 (1998): 117–25.

2 DasGupta, Sayantani. “Narrative Humility.” The Lancet 371, no. 9617 (March 2008): 980–81.

Featured Image: Photo by Brock DuPont; used under Unsplash’s License