Tajwar Taher

Reem Hasan
18 December 2017
IMC Research Proposal

Background and Significance

In August 2017, Dr. Esther Choo – an Emergency Medicine physician at Oregon Health
and Science University – was finding it impossible to provide care to a patient. Her obstacle to
treatment was neither a lack of resources nor a lack of knowledge, but rather a lack of consent
from the patient. As reported in The Oregonian, even though Dr. Choo has “an impressive
resume…occasionally a patient will refuse her care and opt instead for an intern…some patients,
she said, will directly say they want a white doctor,” (Swindler, 1). Although patient autonomy is
of paramount importance in healthcare, this decision-making power should not extend to a
discrimination of providers based on race. Such discrimination violates the principles of total
inclusion that physicians and healthcare systems extend towards patients when providing care,
based on the expectation that patients will reciprocate with similar acceptance.

Indeed, Dr. Muhammad Tauseef remarks “‘As a physician, being a foreign medical
graduate, U.S. medical graduate, a Muslim doctor, a non-Muslim, we are trained to look for
signs and symptoms…We do not look at anybody's color; we are not trained to look at anybody's
religion or ethnicity,”’ (Silverman, 1). Tauseef is one of the many foreign-born physicians that
have filled the gaps in healthcare for the past 50 years, providing care that meets – if not exceeds
– the outcomes of their native colleagues. These outcomes were not affected by a physician’s
accent or nationality, but were solely rooted in the physician’s board certification (Chen, 1).
Tauseef’s situation is one in which the patient may not even have the ability to refuse care on the
basis of race because a physician of color is the only one available. While racial discordance may
not have an effect on the patient’s health outcomes long-term, it may prove a hindrance to
initially establishing the physician-patient relationship, with one study from the Annals of
Internal Medicine concluding “The significance of positive affect in race-concordant visits may
reflect such factors as mutual liking and respect, a sense of social or racial group affiliation and
enhanced trustworthiness, or positive expectations. These attributions are likely to influence both
the communication process and patient judgments of the medical visit,”’ (Cooper et al, 1).
However, implicit racial biases which prove hindrances to establishing a physician-
patient relationship based in mutual trust and respect – resulting in better patient outcomes – can
be overcome through inviting patients to take on the perspectives of their providers. Across the
literature a recurrent theme arises of biases against a group being negated through individuation,
with one study from the Annals of Family Medicine claiming that “patients who believed they
were more similar to their doctor with respect to personal beliefs, values, and ways of
communicating reported more trust in the physician, more satisfaction with care, and a stronger
intention to adhere to recommendations,” (Street Jr et al, 1). While so much medical education
focuses on establishing rapport with patients by inquiring and having some knowledge of their
personal lives (interests, hobbies, family concerns), very little is concerned with reciprocating
that process. If the aforementioned study demonstrates anything, it is that the physician-patient
relationship needs to be bidirectional in order to be complete and effective.
Given that numerous studies have demonstrated the amelioration of racial stereotypes by
training individuals on distinguishing faces of the racial other (so as to avoid “lumping” the
target of scrutiny with a larger group), and that taking on provider perspectives can neutralize
implicit racial biases, I propose a study to determine the efficacy of providing short films
profiling providers of color to patients prior to their clinic visit. After their appointment, patients
will be evaluated on the extent of their empathetic response to the provider using a questionnaire
including numerical and short answer assessment. If there is a significant difference between
patients exposed to these biographical short films and the control group of patients, the
consequences of implementing a quality improvement measure such as this range from the
narrow scope of the clinic to the broad scope of the healthcare system: patients may find a
meaningful use of their appointment wait time, the establishment of the patient-provider
relationship will be catalyzed, and the systemic discrimination based on race will be reduced.
Research Design and Methods
The study will be conducted at the Internal Medicine Clinic, focusing on their health care
professionals of color. Participants will be drawn from the physician and medical assistant pool
in order to have a larger sample than if physicians were investigated alone. Patient participation
will be voluntary, but those that identify as “white” or “Caucasian” will be selected for
juxtaposition with our staff of color. Much of the existing literature investigating patient-staff
race discordance almost only considers the situation in which the health care professional is
white or Asian while the patient is either black or Hispanic. This study would be one of the few
or first that investigates the inverse of this dynamic.
After patients check-in at reception, they will then have the opportunity to view the short
film about their health care professional at one of the TV’s already set up in the waiting room.
The short films may be running on a continuous loop, or patients themselves may have an option
to select the respective films of their health care professional from a menu. The benefits of the
former are that it most eases the burden on the patient, although there is a chance they won’t
even see their staff members’ film. Also, having a film continuously playing in the background
may irk other patients in the waiting room. The benefit of the latter is that there is almost
absolute certainty that the patient will see the film specific to their health care professional, but a
limitation is that patients not technologically competent may have difficulty playing their desired
film.
Another option would be for receptionist to provide patients with an iPad after checking-
in. A simple tap would be all it would take to start the film, and with headphones the bother to
other patients in the waiting room would be minimized. Providing an iPad would also allow for
an equal distribution of patients to the exposure (the short film) and control groups since the
receptionist would be determining which patients receive the iPad. The limitation to such a
system would be access to an iPad, while the TVs in the waiting room are already set up.
As far as the short film itself, health care professionals will be depicted in a simple
interview style giving the following information:

- A greeting, followed by their name, country of origin, ethnicity, or any other cultural
identification they deem relevant to distinguishing them as a person of color.
- The institution where they received their degree, and when they were board certified.
They can also speak about any other certifications they have.
 - Why they chose to pursue medicine, or their favorite part of their job.
- Their life outside of the clinic: hobbies, interests, or family.
- Their experience as racially diverse

Although the film will mainly consist of the interview so that patients get the sense they are
having a face-to-face conversation with clinic staff, interspersed throughout the film can be
pictures complementing the story the health care professional tells in the film. The idea is that by
the end of the film, patients will be familiar with their health care professional’s face and have a
sense of their personal values. These short films will be at most 5 minutes.
After the patient has had their scheduled encounter with the health care professional, they
will be given the following questionnaire/survey regardless of whether they have seen the short
film or not. On the form, patients will first fill out their own racial identification, and then fill in
the name of their health care professional’s. There will then be a list of statements that patients
will rate on a 1 to 6 scale (1 = strongly disagree it is like me, 6 = strongly agree it is like me).
These statements are based on the Scale of Ethnocultural Empathy (SEE) developed by Wang et
al, with statements based on four criteria the developers distinguished within ethnocultural
empathy: Empathic Feeling and Expression (EFE), Empathic Perspective Taking (EPT),
Acceptance of Cultural Difference (ACD), and Empathic Awareness (EA). The questionnaire
would include the following statements:

1. I feel annoyed when people do not speak standard English (ACD)

2. I know what it feels like to be the only person of a certain race or ethnicity in a group
of people (EPT)
3. I get impatient when communicating with people from other racial or ethnic
backgrounds, regardless of how well they speak English (ACD)
4. I can relate to the frustrations some people feel about having fewer opportunities due
to their racial or ethnic background (EPT)
5. I don’t understand why people of different ethnic or racial backgrounds enjoy
wearing traditional clothes (ACD)
6. I seek opportunities to speak with individuals of other racial or ethnic backgrounds
about their experiences (EFE)
 7. When I know my friends are treated differently because of their racial or ethnic
backgrounds, I speak up for them (EFE)
8. When I interact with people of other racial or ethnic backgrounds, I show my
appreciation of their cultural norms (EFE)
9. I feel supportive of people of other racial or ethnic groups, if I think they are being
taken advantage of (EFE)
10. I get disturbed when other people experience misfortune due to their racial or ethnic
backgrounds (EFE)
11. I rarely think about the impact of a racist or ethnic joke on the people targeted (EFE)
12. I am not likely to participate in events that promote equal rights for people of all
ethnic or racial backgrounds (EFE)
13. I express my concern about discrimination to people from other racial or ethnic
groups (EFE)
14. It is easy for me to understand what it would feel like to be a person of another racial
or ethnic background other than my own (EPT)
15. When I see people who come from a different racial or ethnic background succeed in
a public arena, I share their pride (EFE)
16. I recognize that the media often portrays people based on racial or ethnic stereotypes
(EA)
17. I am aware of how society differentially treats racial or ethnic groups other than my
own (EA)
18. I do not understand why people want to keep their indigenous racial or ethnic cultural
traditions instead of trying to fit into the mainstream (ACD)
19. I feel uncomfortable when I am around people who are racially/ethnically different
than me (EPT)
20. It is difficult for me to put myself in the shoes of someone who is racially/ethnically
from me (EPT)

At the end of the questionnaire, patients will also be asked to rate their waiting time on a 1-10
scale (1 = extremely unpleasant, a waste of my time; 10 = extremely pleasant, a meaningful use
of my time). In addition, there will be a short response section in which they can provide any
additional feedback.
 The SEE portion of the survey will be scored based on a sum of the numerical responses
to each statement. Since there are both positively and negatively phrased statements, negative
scores will receive the reciprocal value of that reported (ie if a patient responds to “I rarely think
about the impact of a racist or ethnic joke on the people targeted” with a 2 – not much like me –
they would receive a 5). As evaluated in the original SEE study, higher scores correlate to higher
ethnocultural empathy. A simple t-test based on the mean scores of exposure and control groups
will be used to evaluate any measured differences between the two.

Preliminary Suppositions and Implications

Should there be a significant increase in ethnocultural empathy scores for those patients
exposed to the provider short film relative to the control group, there may be reason to extend
this practice to other clinics, and urgent or emergency care departments beyond this particular
Internal Medicine clinic. The potential benefits of such a quality improvement measure would be
to orient patients to their providers prior to seeing them so that the initial encounter is not as
shocking to the patient. With an orientation to the health care professional, patients will have the
time to mindfully plan their language and demeanor along cultural lines just as clinic staff
employs culturally competent care.
Such a quality improvement measure may be even more effective in emergency care
departments since there is a far greater incidence of initial encounters. In the primary care
setting, patients can develop a relationship with the clinic staff over a period of time, which
would minimize some of the shock related to seeing the racial other. Should this research project
prove fruitful, incorporating short films in waiting rooms may be a way to prevent incidents like
the one experienced by Dr. Esther Choo.
This project may also invite further study into the flipped race discordance within the
patient-professional relationship to be investigated within this research. While much of the
existing literature is concerned with white health care professionals working with patients of
color – looking into tools that providers can use to be more culturally competent or ethnically
aware – very little has considered how being a health care professional of color can affect the
patient-professional relationship. More research into this dynamic could investigate questions of
what expectations there should be for the patient with regard to cultural competence, how the
current political climate has shifted these expectations, and in gradually diversifying population
of health care professionals the kinds of barriers to practice that should be considered.
Should this research lead to effective quality improvement measures, it may result in a
more empowered health care professional population and a more informed or culturally
competent patient population. The combination of these consequences would ensure stronger
patient-professional relationships, thus resulting in greater patient outcomes and greater clinic
staff job satisfaction. This study may establish the feasibility of implementing a film based
waiting room intervention, from the time investment required by the clinic staff and film-makers
to develop the films to the ease with which patients can access and experience the film. By the
end of this study, the hope is that the results will be not only a significant outcome based on an
intervention, but also an effective and implementable design for such an intervention.

Conclusion
In order to ensure that health care professionals of color feel empowered and are not
targets of discrimination from their patients, the proposed study will attempt to expose patients to
short films about their health care professionals to elicit an empathic response. The decision for a
short film as an intervention arose from the literature demonstrating that implicit racial biases are
rooted in the visual: training individuals to recognize and distinguish the racial other as an
individual, not merely a member of a larger group, liberates that racial other from stereotype. In
addition, not only is there existing technology in place to implement such an intervention, there
is considerable sentiment on the patients’ parts to improve the quality of time spent waiting to
see their provider. As such, the implementation of a short film focusing on the provider’s
perspective may prove to be a quality improvement measure that functions bidirectionally:
empowerment of the provider, education of the patient.
With physicians like Dr. Esther Choo stepping forward to share their experiences and
investigations into empowering providers of color like this study, further research into racial
discordance within the provider-patient relationship may be sparked where it was once lacking.
While much has been established regarding patients of color receiving care from a white
physician, hardly any exists when such a dynamic is flipped. The ultimate goal of this nascent
movement – whether on the plane of social media or that of research – is preventing acts of
hatred and discrimination in an environment born out of compassion and hospitality so that our
resources can fully focus on simply healing to ensure the health of all humanity.

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