Arch Fam Med
Institution: STANFORD Univ Med Center  | My Account | E-mail Alerts | Access Rights | Sign In
  Vol. 9 No. 10, November 2000 TABLE OF CONTENTS
  •  Online Features
  Original Contribution
 This Article
 •Send to a friend
 • Save in My Folder
 •Save to citation manager
 Citing Articles
 •Citation map
 •Citing articles on HighWire
 •Citing articles on Web of Science (193)
 •Contact me when this article is cited
 Related Content
 •Similar articles in this journal

Racial and Ethnic Disparities in Perceptions of Physician Style and Trust

Mark P. Doescher, MD, MSPH; Barry G. Saver, MD, MPH; Peter Franks, MD; Kevin Fiscella, MD, MPH

Arch Fam Med. 2000;9:1156-1163.


Context  While pervasive racial and ethnic inequalities in access to care and health status have been documented, potential underlying causes, such as patients' perceptions of their physicians, have not been explored as thoroughly.

Objective  To assess whether a person's race or ethnicity is associated with low trust in the physician.

Design, Setting, and Participants  Data were obtained from the 1996 through 1997 Community Tracking Survey, a nationally representative sample. Adults who identified a physician as their regular provider and had at least 1 physician visit in the preceding 12 months were included (N = 32 929).

Main Outcome Measure  Patients' ratings of their satisfaction with the style of their physician and their trust in physicians. The Satisfaction With Physician Style Scale measured respondents' perceptions of their physicians' listening skills, explanations, and thoroughness. The Trust in Physician Scale measured respondents' perceptions that their physicians placed the patients' needs above other considerations, referred the patient when needed, performed unnecessary tests or procedures, and were influenced by insurance rules.

Results  After adjustment for socioeconomic and other factors, minority group members reported less positive perceptions of physicians than whites on these 2 conceptually distinct scales. Minority group members who lacked physician continuity on repeat clinic visits reported even less positive perceptions of their physicians on these 2 scales than whites.

Conclusions  Patients from racial and ethnic minority groups have less positive perceptions of their physicians on at least 2 important dimensions. The reasons for these differences should be explored and addressed.

 Jump to Section
 •Materials and methods
 •Author information

WHILE pervasive racial and ethnic inequalities in health care1-21 and health status22-25 have been widely documented, the causes are not sufficiently understood. Financial barriers can affect the delivery of health care, but less is known about the influence of individual factors, such as patient perceptions and preferences. Do members of racial or ethnic minority groups feel that physicians listen to them? Do they feel physicians provide adequate explanations? Do they trust their physicians? Because there is a critical need to reduce racial and ethnic disparities in health care and health, assessment of the influence of individual factors merits no less rigor and attention than has been given to other public health problems of similar magnitude.26-27

Health care that is closely congruent with and responsive to patients' wants, needs, and preferences28-29 may lead to high levels of satisfaction with the physician. When patients are satisfied with their physicians' style, effective communication, leading to improved adherence and health outcomes, becomes more likely.30-31 For effective communication to occur, physicians must listen to and understand patients and then communicate their understanding back to patients. Physicians must also explain to patients, in clear language, the nature of their illness, their diagnostic and treatment options, and how alternatives might relate to their values.32

However, little empiric work assessing race or ethnicity and satisfaction with physician style currently exists. In one study, Cooper-Patrick et al33 found that African American patients rated their visits with physicians as less participatory than whites. In 2 studies of health maintenance organization (HMO) enrollees,34-35 African Americans reported relatively high levels of satisfaction compared with whites. However, other studies have found African Americans to be less satisfied than whites with various aspects of care.35-37 Latinos have been observed to have levels of satisfaction similar to whites,36-38 although in a recent study at northern California's Kaiser-Permanente,38 Latinos rated physicians' accessibility less favorably than did whites. Recent data suggest that Asian Americans have the lowest satisfaction of any ethnic or racial group.36, 38-39

Trust is a fundamental component of the patient-physician relationship.40-44 Because quantitative measurement of trust may provide an important means of assessing the quality of the patient-physician relationship, researchers have developed scales measuring trust in the physician.45-47 Trust in the physician is significantly related to continuity and adherence.48-49 Patients in fee-for-service, indemnity coverage settings in 3 metropolitan insurance markets reported greater trust than those in salaried, capitated, or fee-for-service managed care settings.50 In one study, nonwhite patients reported lower levels of trust in their physicians than white patients.51 However, the relationship between race or ethnicity and trust in the physician has not been explored using a nationally representative sample.

We analyzed a large, recent, nationally representative survey to determine how members of racial and ethnic minority groups fared compared with whites on ratings of satisfaction with physician style and trust in their physician. We hypothesized that members of racial and ethnic minority groups would report lower levels of satisfaction with physician style and trust than whites, even after adjustment for potentially confounding factors.

 Jump to Section
 •Materials and methods
 •Author information


Data are from the Community Tracking Study (CTS) Household Survey conducted in 1996 through 1997,52 a telephone survey of 60 446 individuals representing the US noninstitutionalized population. Sixty communities were randomly selected using stratified sampling with probability in proportion to population size to ensure representation of the US population. While random-digit dialing was used to select most households, a small sample was also included to represent households without telephones; these individuals were provided with cellular telephones for the interviews. The survey recorded information, including attitudes toward and satisfaction with health care, sociodemographics, health insurance, utilization of health services, health status, and preventive interventions. For this study, adults 18 years and older who identified a regular care physician and had at least 1 physician visit in the 12 months preceding the survey were included (N = 32 929).


We assessed summary scores for scales measuring satisfaction with physician style and trust in the physician.

Satisfaction With Physician Style

The Satisfaction With Physician Style items in the CTS included 3 questions measuring satisfaction with the thoroughness and completeness of the examination and treatment received, how well the physician listened, and how well the physician explained things in a way the respondent could understand. Each subject's average score (range, 1-5) was calculated, with higher scores indicating greater satisfaction with the style of their physician.

Trust in the Physician

Subjects were asked the following series of 4 questions: "I think my doctor may not refer me to a specialist when needed"; "I sometimes think that my doctor might perform unnecessary tests or procedures"; "I think my doctor is strongly influenced by health insurance company rules when making decisions about my medical care"; and "I trust my doctor to put my medical needs above all other considerations when treating my medical problems." We reverse coded the final item, so that higher scores indicated greater trust for all questions. Each subject's average score (range, 1-5) was calculated.


The Andersen-Newman model53-54 categorizes the numerous characteristics that influence access to health care into predisposing factors, need factors, and enabling factors. This framework includes characteristics of the population at risk, consideration of health policy, utilization of health services, and consumer satisfaction. Race or ethnicity is a predisposing factor. In the CTS, self-reported race and ethnicity were coded as African American, Hispanic (Latino), other, and white. Several sociodemographic variables were examined to adjust for potential confounding, including additional predisposing, factors: (1) level of education in years (<12, 12, 12-15, or >=16 years); age in years (18-44, 45-64, or >=65 years); sex; family structure (lives alone, single adult with children present, married with no children present, married with children present, or other); residence (urban or rural); and provider continuity (usually sees the same provider or usually sees a different provider); (2) enabling factors: household income as a percentage of poverty level for 1996 (<100%, 100%-199%, 200%-299%, 300%-399%, and >=400%); health insurance (none, Medicaid or other public coverage, military coverage, any Medicare coverage, private coverage and enrolled in an HMO, or private coverage and not enrolled in an HMO); usual care location (physician's office, HMO, other community clinic, hospital outpatient clinic, or emergency department or other place); (3) need factors: tobacco use (current, former, or never); and (4) health status (subjective health status was measured using the physical and mental component summary scales of the Medical Outcomes Study General Short-Form Health Survey for perceived health status, a measure of the health effects of chronic disease, with demonstrated reliability and validity).55 Because utilization rates are related to patients' race or ethnicity and because utilization may influence patients' perceptions of their physicians, adjustment for utilization over 12 months preceding the administration of the CTS includes number of physician visits (none, 1-2, 3-4, or >=5); emergency department visits (none, 1-2, or >=3); and hospitalizations (none or >=1).


To assess whether to report the scores for satisfaction with physician style and trust in the physician separately, we ran confirmatory factor analyses with items constituting the scales. Also, because the decision to report scales separately is supported when internal consistency is greater than the correlation between scales,47 we calculated Cronbach {alpha} coefficients56 for the Satisfaction With Physician Style and Trust in Physician scales to assess internal consistency, and also calculated the Pearson correlation coefficient to assess the degree of correlation between the 2 scales. We explored the relationships between the independent measures, including race or ethnicity and the other factors, and the dependent measures of perceptions of physicians with multivariate models. Weights provided on the public-use CTS files were used to adjust for survey oversampling and nonresponse to produce estimates representative of the US population. Because of the complex survey design of CTS, multivariate analyses were conducted with SUDAAN57 software, which uses the method of Taylor series linearization to produce appropriate SEs and 95% confidence intervals. Interaction between race or ethnicity and each covariate was assessed. Similarly, assessment of interaction between education and each covariate and also income and each covariate was performed.

To assess whether adjustment for satisfaction with physician style mediates the relationship between race or ethnicity and trust, we evaluated multivariate models with the Satisfaction With Physician Style Scale included as an independent variable.

 Jump to Section
 •Materials and methods
 •Author information

Factor analysis revealed that the summary scales for satisfaction with physician style and trust in the physician formed distinct domains. The Cronbach {alpha} for the 2 summary scales (satisfaction with physician style, {alpha} = .91, and trust in the physician, {alpha} = 0.62) were greater than the correlation between these 2 scales (r = 0.42). The removal of items from scales did not improve the value of the {alpha} coefficient.

Baseline characteristics of the sample are presented in Table 1. Unadjusted mean scores for the Satisfaction With Physician Style Scale and the Trust in Physician Scale were lower for subjects who were members of racial or ethnic minority groups. Lower scores on 1 or more of these measures were significantly associated with a number of factors, including being younger, male, less educated, poorer, in poorer health, uninsured, enrolled in Medicaid or other public health insurance coverage or an HMO, a current smoker, receiving regular care in a setting outside of a physician's office, lacking physician continuity for repeat visits, making fewer visits to physicians, making more visits to emergency departments, and not having been hospitalized in the previous year.

View this table:
[in this window]
[in a new window]
Table 1. Relationships Between Summary Scores for Satisfaction With Physician Style and Trust in the Physician and Selected Characteristics

Sequential models using the Andersen-Newman classification are presented for the scales measuring satisfaction with physician style (Table 2) and trust in the physician (Table 3). These tables present unadjusted coefficients for race or ethnicity in the far left data columns and progress to fully saturated models in the far right columns. After adjustment for all covariates, members of each minority group identifiable in the CTS reported significantly lower summary scores for satisfaction with physician style and trust in the physician than did whites. For satisfaction with physician style, roughly one third of the difference between African Americans and whites and roughly half of the difference between Latinos and whites was explained by adjustment for all other factors. For trust in the physician, approximately half of the difference between African Americans and whites and between Latinos and whites was explained by adjustment for all other factors.

View this table:
[in this window]
[in a new window]
Table 2. Multivariate Relationships Between Race or Ethnicity and Summary Score for Satisfaction With Physician Style

View this table:
[in this window]
[in a new window]
Table 3. Multivariate Relationships Between Race or Ethnicity and Summary Score for Trust in the Physician

For the Satisfaction With Physician Style Scale, associations of similar magnitude and direction to those found for the race or ethnicity were observed with male sex, not having completed high school, lacking health insurance, and receiving care in HMOs (data not shown). Relationships of similar magnitude and direction as the race or ethnicity coefficients were observed for trust in the physician for being male, not having completed high school, having income below the federal poverty line, being enrolled in an HMO, and receiving care at an HMO clinic (data not shown). For both measures, the relationships with lacking physician continuity on repeat visits and with reporting poorer health status were of greater magnitude than the relationships for race or ethnicity (data not shown). Evaluation for interaction in the Satisfaction With Physician Style Scale revealed a significant interaction between race or ethnicity and health insurance (data not shown). The meaning of interaction is that satisfaction scores were particularly low for Latinos who lacked insurance and those who reported HMO insurance coverage. Assessment for interaction in the Trust in Physician Scale revealed significant interaction between race or ethnicity and sex (data not shown), indicating that trust scores were especially low for Latino and African American men. Also, for the trust scale, significant interaction between race or ethnicity and a lack of continuity on repeat visits was apparent (data not shown), indicating that the relationship between lacking of continuity and low trust scores was particularly pronounced for African Americans.

We evaluated whether the scale measuring satisfaction with physician style mediated relationships between subjects' race or ethnicity and their trust in their physician by adding the measure of satisfaction with physician style as an independent covariate in models examining trust in the physician. In these models, the association with minority group membership was attenuated by roughly one third for African Americans and Latinos and by about one tenth for other minority group members, but remained significant independent of the Satisfaction With Physician Style Scale and the other factors (data not shown).

 Jump to Section
 •Materials and methods
 •Author information

In this nationally representative sample, racial or ethnic minority group members reported less positive perceptions of physicians than whites on 2 conceptually distinct scales. A number of physician and patient factors could account for our observations. Many physicians may misunderstand racial or ethnic minority group members' views of symptoms and illness and some physicians may hold unconscious racial or ethnic biases that influence their interactions with minority patients.58 Also, physicians' expectations about patient visits may differ from the expectations of the minority group members they serve. Differences in minority group members' socioeconomic status partially explains worse perceptions of physicians, as models with income and education removed had more negative scores, but highly significant differences remained after adjusting for income and education. It is also possible that unmeasured patient factors, such as low self-efficacy regarding management of health or low health literacy, may be more prevalent among racial or ethnic minority groups and may account for some of the observed differences.

The small differences in summary scores for the perceptual scales evaluated in this study are likely to be meaningful, as previous research has demonstrated that small numeric differences on perceptual measures can have important effects on health care and health. In our study of medical skepticism, a 1-point change in the medical skepticism score (range, 1-5) was associated with an 11% increase in total mortality.59 In the Medical Outcomes Study, small changes in scores measuring physicians' participatory decision-making styles were associated with patients' reporting they planned to leave their physicians' practices within 12 months.60

This study is subject to several limitations. First, the CTS was not designed to assess racial and ethnic subgroups. The broad racial and ethnic groupings used in the CTS are heterogeneous and would not reveal any important differences for racial and ethnic subgroups within these broad categories. Second, we were not able to assess the race or ethnicity of subjects' physicians, or other potentially relevant physician characteristics. It is plausible that racial or ethnic congruence between patients and physicians would diminish disparities in minority group members' perceptions. For example, one study found that African American patients who visit African American physicians rated their physicians' decision-making styles as more participatory.33 Third, African Americans and Latinos have been observed to select extremes of Likert response scales more frequently than whites.61 How such a bias, if it occurred, would influence our findings is unclear. Fourth, while the items measuring satisfaction with physician style exhibited excellent internal reliability, supporting the grouping of perceptions of communication skills (listening and explaining) with perceptions of technical skills (thoroughness and completeness), the items measuring trust provided lower reliability than has been reported elsewhere,38-40 indicating that further refinement of items measuring trust in the physician is warranted. The reasons for this lower than expected reliability of the trust scale are not clear; while the overall composition of the scale that is available in the CTS is not identical to published, validated trust scales,45-47 the individual questionnaire items found in the CTS trust scale are virtually identical to questionnaire items used in these other trust scales.

The CTS is a cross sectional survey; the associations observed here do not allow inferences about root causes. While a strength of the CTS is that future iterations will allow researchers to track minority group members' perceptions of physicians over time, longitudinal or interventional studies are needed to allow causal inferences.

While it is possible that the observed relationships could be the result of confounding by unmeasured or incompletely measured factors only incidentally associated with racial or ethnic background, the richness of our data source allowed us to control for a large number of potential confounding factors. The inferences that can be drawn from these results are further strengthened by the survey design and the recency of these data.

An overwhelming body of literature indicates that minority group members face disparities in health care1-21 and health status.22-25 Given these inequities, our findings, consistent with previous reports documenting minority group members' negative views about disparities in the health care system,33, 61-62 have implications for clinical practice, research, and health policy.63

Increasing the numbers of minority physicians might lead to improvements in perceptions of physicians,33 which might lead to better health outcomes. There is clearly a need for additional work examining racial and ethnic congruence between patients and providers and patients' perceptions of physicians. Also, interventions aimed at improving racial or ethnic minority group members' skills as effective consumers of health care could be developed and evaluated.

At the very least, physicians should be aware that, compared with whites, racial and ethnic minority group members report less positive perceptions of physicians. In a 1994 survey of medical schools, only 13 of 78 responding institutions offered cultural-sensitivity courses, and all but one of those courses were elective.64 Interventions aimed at teaching physicians to become more patient-centered need to be developed and assessed, especially because existing data suggest that physicians can be taught relevant skills.65-71 It seems reasonable to consider whether selection of medical students should be based, in part, on assessment of applicants' interpersonal skills and communication styles.

Effective patient-physician interactions require time to develop. Initially, the physician's attentiveness, responsiveness, and demeanor give the patient a first impression of what to expect,41, 66 but these early cues provide only rough indicators of how the relationship might evolve as the patient and the physician become more acquainted. The strong associations of trust and satisfaction with physician style with continuity likely are bidirectional: patients are more likely to continue to see physicians whose interactions are patient-centered and who inspire trust, and more positive perceptions of a physician are likely to develop over multiple encounters. While the effect of recent, large-scale changes in health care delivery, especially managed care, on continuity is not clear,41 strategies aimed at improving or at least preserving continuity of care should be evaluated.

Research is needed to determine how best to make providers, health plans, and health care delivery systems accountable for meeting the needs of their patients. The work reported herein suggests that measures of satisfaction with physician style and trust in the physician could become important indicators of health care quality, particularly if interventions can be developed to improve satisfaction with physician style and trust in the physician. Systematic monitoring of valid, easily administered measures of patients' perceptions of physicians might help us achieve the goal of Healthy People 201072 to eliminate racial and ethnic disparities in health in the United States.

 Jump to Section
 •Materials and methods
 •Author information

Accepted for publication September 14, 2000.

Funded in part by grant 36332, from the Robert Wood Johnson Foundation under its Changes in Health Care Financing and Organization Program (Drs Doescher and Saver).

Corresponding author: Mark P. Doescher, MD, MSPH, 4225 Roosevelt Way NE, Suite 308, Seattle, WA 98105-6099 (e-mail: mdoesche{at}u.washington.edu).

From the Department of Family Medicine, University of Washington School of Medicine, Seattle (Drs Doescher and Saver); and the Departments of Family Medicine (Dr Franks) and Community and Preventive Medicine (Dr Fiscella), University of Rochester School of Medicine, Rochester, NY.

 Jump to Section
 •Materials and methods
 •Author information

1. Blustein J, Weiss LJ. Visits to specialists under Medicare: socioeconomic advantage and access to care. J Health Care Poor Underserved. 1998;9:153-169. ISI | PUBMED
2. Escarce JJ, Epstein KR, Colby DC, Schwartz JS. Racial differences in the elderly's use of medical procedures and diagnostic tests. Am J Public Health. 1993;83:948-954. FREE FULL TEXT
3. Ayanian JZ, Udvarhelyi IS, Gatsonis CA, Pashos CL, Epstein AM. Racial differences in the use of revascularization procedures after coronary angiography. JAMA. 1993;269:2642-2646. FREE FULL TEXT
4. Ferguson JA, Tierney WM, Westmoreland GR, et al. Examination of racial differences in management of cardiovascular disease. J Am Coll Cardiol. 1997;30:1707-1713. ABSTRACT
5. Peterson ED, Wright SM, Daley J, Thibault GE. Racial variation in cardiac procedure use and survival following acute myocardial infarction in the Department of Veterans Affairs. JAMA. 1994;271:1175-1180. FREE FULL TEXT
6. Goldberg KC, Hartz AJ, Jacobsen SJ, Krakauer H, Rimm AA. Racial and community factors influencing coronary artery bypass graft surgery rates for all 1986 Medicare patients. JAMA. 1992;267:1473-1477. FREE FULL TEXT
7. Peterson ED, Shaw LK, DeLong ER, Pryor DB, Califf RM, Mark DB. Racial variation in the use of coronary revascularization procedures: are the differences real? do they matter? N Engl J Med. 1997;336:480-486. FREE FULL TEXT
8. Delano BG, Macey L, Friedman EA. Gender and racial disparity in peritoneal dialysis patients undergoing kidney transplantation. ASAIO J. 1997;43:M861-M864.
9. Mitchell JM, Meehan KR, Kong J, Schulman KA. Access to bone marrow transplantation for leukemia and lymphoma: the role of sociodemographic factors. J Clin Oncol. 1997;15:2644-2651. FREE FULL TEXT
10. Stafford RS, Sullivan SD, Gardner LB. Trends in cesarean section use in California, 1983 to 1990. Am J Obstet Gynecol. 1993;168:1297-1302. ISI | PUBMED
11. Bright RA, Moore RM, Jeng LL, Sharkness CM, Hamburger SE, Hamilton PM. The prevalence of tympanostomy tubes in children in the United States, 1988. Am J Public Health. 1993;83:1026-1028. FREE FULL TEXT
12. Guadagnoli E, Ayanian JZ, Gibbons G, McNeil BJ, LoGerfo FW. The influence of race on the use of surgical procedures for treatment of peripheral vascular disease of the lower extremities. Arch Surg. 1995;130:381-386. FREE FULL TEXT
13. Romano PS, Campa DR, Rainwater JA. Elective cervical discectomy in California: postoperative inhospital complications and their risk factors. Spine. 1997;22:2677-2692. FULL TEXT | ISI | PUBMED
14. Klabunde CN, Potosky AL, Harlan LC, Kramer BS. Trends and black/white differences in treatment for nonmetastatic prostate cancer. Med Care. 1998;36:1337-1348. FULL TEXT | ISI | PUBMED
15. Moore RD, Stanton D, Gopalan R, Chaisson RE. Racial differences in the use of drug therapy for HIV disease in an urban community. N Engl J Med. 1994;330:763-768. FREE FULL TEXT
16. Sirey JA, Meyers BS, Bruce ML, Alexopoulos GS, Perlick DA, Raue P. Predictors of antidepressant prescription and early use among depressed outpatients. Am J Psychiatry. 1999;156:690-696. FREE FULL TEXT
17. Johnson PA, Lee TH, Cook EF, Rouan GW, Goldman L. Effect of race on the presentation and management of patients with acute chest pain. Ann Intern Med. 1993;118:593-601. FREE FULL TEXT
18. Kogan MD, Kotelchuck M, Johnson S. Racial differences in late prenatal care visits. J Perinatol. 1993;13:14-21. PUBMED
19. Fuentes-Afflick E, Korenbrot CC, Greene J. Ethnic disparity in the performance of prenatal nutrition risk assessment among Medicaid-eligible women. Public Health Rep. 1995;110:764-773. ISI | PUBMED
20. Cleeland CS, Gonin R, Baez L, Loehrer P, Pandya KJ. Pain and treatment of pain in minority patients with cancer: the Eastern Cooperative Oncology Group Minority Outpatient Pain Study. Ann Intern Med. 1997;127:813-816. FREE FULL TEXT
21. Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA. 1993;269:1537-1539. FREE FULL TEXT
22. Gornick ME, Eggers PW, Reilly TW, et al. Effects of race and income on mortality and use of services among Medicare beneficiaries. N Engl J Med. 1996;335:791-799. FREE FULL TEXT
23. Lopes AA, Port FK. Differences in the patterns of age-specific black/white comparisons between end-stage renal disease attributed and not attributed to diabetes. Am J Kidney Dis. 1995;25:714-721. ISI | PUBMED
24. Bindman AB, Grumbach K, Osmond D, et al. Preventable hospitalizations and access to health care. JAMA. 1995;274:305-311. FREE FULL TEXT
25. Shea S, Misra D, Ehrlich MH, Field L, Francis CK. Predisposing factors for severe, uncontrolled hypertension in an inner-city minority population. N Engl J Med. 1992;327:776-781. ABSTRACT
26. Cooper RS. Health and social status of blacks in the United States. Ann Epidemiol. 1993;3:137-144. PUBMED
27. Geiger HJ. Race and health care: an American dilemma? N Engl J Med. 1996;335:815-816 FREE FULL TEXT
28. Gerteis M, Edgman-Levitan S, Daley J, Delbanco T. Medicine and health from the patient's perspective. In: Gerteis M, Edgman-Levitan S, Daley J, Delbanco T, eds. Through the Patient's Eyes. San Francisco, Calif: Jossey-Bass Inc; 1993:1-15.
29. Laine C, Davidoff F. Patient-centered medicine: a professional evolution. JAMA. 1996;275:152-156. FREE FULL TEXT
30. Joos SK, Hickam DH, Gordon GH, Baker LH. Effects of a physician communication intervention on patient care outcomes. J Gen Intern Med. 1996;11:147-155. ISI | PUBMED
31. Brown JB, Boles M, Mullooly JB, Levinson W. Effect of clinician communication skills training on patient satisfaction: a randomized, controlled trial. Ann Intern Med. 1999;131:822-829. FREE FULL TEXT
32. Emanuel EJ, Dubler NN. Preserving the physician-patient relationship in the era of managed care. JAMA. 1995;273:323-329. FREE FULL TEXT
33. Cooper-Patrick L, Gallo JJ, Gonzales JJ, et al. Race, gender, and partnership in the patient-physician relationship. JAMA. 1999;282:583-589. FREE FULL TEXT
34. Bashshur RL, Metzner CA, Worden C. Consumer satisfaction with group practice: the CHA case. Am J Public Health Nations Health. 1967;57:1991-1999. ISI
35. Hulka BS, Kupper LL, Daly MD, Cassel JC, Schoen F. Correlates of satisfaction and dissatisfaction with medical care: a community perspective. Med Care. 1975;13:648-658. FULL TEXT | ISI | PUBMED
36. Meredith LS, Siu AL. Variation and quality of self-report health data: Asians and Pacific Islanders compared with other ethnic groups. Med Care. 1995;33:1120-1131. ISI | PUBMED
37. Harpole LH, Orav EJ, Hickey M, Posther KE, Brennan TA. Patient satisfaction in the ambulatory setting: influence of data collection methods and sociodemographic factors. J Gen Intern Med. 1996;11:431-434. ISI | PUBMED
38. Murray-Garcia JL, Selby JV, Schmittdiehl J, Grumbach K, Quesenberry CP. Racial and ethnic differences in a patient survey: patients' values, ratings and reports regarding physician primary care performance in a large health maintenance organization. Med Care. 2000;38:300-310. FULL TEXT | ISI | PUBMED
39. Taira DA, Safran DG, Seto TB, et al. Asian-American patient ratings of physician primary care performance. J Gen Intern Med. 1997;12:237-242. FULL TEXT | ISI | PUBMED
40. Beuachamp T, Childless J. Principles of Biomedical Ethics. 3rd ed. New York, NY: Oxford University Press; 1989.
41. Mechanic D. Changing medical organization and the erosion of trust. Milbank Q. 1996;74:171-189. FULL TEXT | ISI | PUBMED
42. Mechanic D, Schlesinger M. The impact of managed care on patients' trust in medical care and their physicians. JAMA. 1996;275:1693-1697. FREE FULL TEXT
43. Balint J, Shelton W. Regaining the initiative: forging a new model of the physician-patient relationship. JAMA. 1996;275:887-891. FREE FULL TEXT
44. Leopold N, Cooper J, Clancy C. Sustained partnership in primary care. J Fam Pract. 1996;42:129-137. ISI | PUBMED
45. Thom DH, Campbell B. Patient-physician trust: an exploratory study. J Fam Pract. 1997;44:169-176. ISI | PUBMED
46. Anderson LA, Dedrick RF. Development of the Trust in Physician Scale: a measure to assess interpersonal trust in physician-patient relationships. Psychol Rep. 1990;67:1091-1100.
47. Safran DG, Kosinski M, Tarlov AR, et al. The Primary Care Assessment Survey: tests of data quality and measurement performance. Med Care. 1998;36:728-739. FULL TEXT | ISI | PUBMED
48. Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract. 1998;47:213-220. ISI | PUBMED
49. Thom DH, Ribisl KM, Stewart AL, Luke DA, et al for the Stanford Trust Study Physicians. Further validation and reliability testing of the Trust in Physician Scale. Med Care. 1999;37:510-517. FULL TEXT | ISI | PUBMED
50. Kao AC, Green DC, Davis NA, Koplan JP, Cleary PD. Patients' trust in physicians: effects of choice, continuity, and payment method. J Gen Intern Med. 1998;13:681-686. FULL TEXT | ISI | PUBMED
51. Kao AC, Green DC, Zaslavsky AM, Koplan JP, Cleary PD. The relationship between method of physician payment and patient trust. JAMA. 1998;280:1708-1714. FREE FULL TEXT
52. Kemper P, Blumenthal D, Corrigan JM, et al. The design of the Community Tracking Study: a longitudinal study of health system change and its effects on people. Inquiry. 1996;33:195-206. ISI | PUBMED
53. Andersen RA. A Behavioral Model of Families' Use of Health Services. Chicago, Ill: University of Chicago Center for Health Administrative Studies; 1968.
54. Andersen R, Newman JF. Societal and individual determinants of medical care utilization in the United States. Milbank Mem Fund Q Health Soc. 1973;51:95-124. FULL TEXT | ISI | PUBMED
55. Ware J Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34:220-233. FULL TEXT | ISI | PUBMED
56. Cronbach L. Essential of Psychological Testing. New York, NY: Harper & Row Publishers; 1970.
57. Research Triangle Institute. SUDAAN: Professional Software for Survey Data Analysis. Version 7.5. Research Triangle Park, NC: Research Triangle Institute; 1997.
58. Schulman KA, Berlin JA, Harless W, et al. The effect of race and sex on physicians' recommendations for cardiac catheterization. N Engl J Med. 1999;340:618-626. FREE FULL TEXT
59. Fiscella K, Franks P, Clancy CM, Doescher MP, Banthin JS. Does skepticism towards medical care predict mortality? Med Care. 1999;37:409-414. FULL TEXT | ISI | PUBMED
60. Kaplan SH, Gandek PB, Greenfield S, Rogers W, Ware JE. Patient and visit characteristics related to physicians' participatory decision-making styles: results from the Medical Outcomes Study. Med Care. 1995;33:1176-1187. FULL TEXT | ISI | PUBMED
61. Kahn KL, Pearson ML, Harrison ER, et al. Health care for black and poor hospitalized Medicare patients. JAMA. 1994;271:1169-1174. FREE FULL TEXT
62. Blendon RJ, Scheck AC, Donelan K, et al. How white and African Americans view their health and social problems: different experiences, different expectations. JAMA. 1995;273:341-346. FREE FULL TEXT
63. Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in care. JAMA. 2000;283:2579-2584. FREE FULL TEXT
64. Lum CK, Korenman SG. Cultural-sensitivity training in U.S. medical schools. Acad Med. 1994;69:239-241. ISI | PUBMED
65. Wolf FM, Woolliscroft JO, Calhoun JG, Boxer GJ. A controlled experiment in teaching students to respond to patients' emotional concerns. J Med Educ. 1987;62:25-34. ISI | PUBMED
66. Putnam SM, Stiles WB, Casey JM, James SA. Teaching the medical interview: an intervention study. J Gen Intern Med. 1988;3:38-47. ISI | PUBMED
67. Maguire P, Fairbairn S, Fletcher C. Consultation skills of young doctors, I: benefits of feedback training in interviewing as students persist. Br Med J (Clin Res Ed). 1986;292:1573-1576.
68. Levinson W, Roter D. The effects of two continuing medical education programs on communication skills of practicing primary care physicians. J Gen Intern Med. 1993;8:318-324. ISI | PUBMED
69. Roter DL, Hall JA. Doctors Talking With Patients/Patients Talking With Doctors. Westport, Conn: Auburn House; 1992.
70. Vannatta JB, Smith KR, Crandall S, Fischer PC, Williams K. Comparison of standardized patients and faculty in teaching medical interviewing. Acad Med. 1996;71:1360-1362. ISI | PUBMED
71. Roter DL, Stewart M, Putnam S, Lipkin M, Stiles W, Inui TS. Communication patterns of primary care physicians. JAMA. 1997;277:350-356. FREE FULL TEXT
72. US Dept of Health and Human Services. Healthy People 2010, conference edition. Available at: http://www.health.gov/healthypeople/Document/tableofcontents.htm. Accessibility verified September 29, 2000.


Enhancing Cultural and Contextual Intervention Strategies to Reduce HIV/AIDS Among African Americans
AJPH 2009;99:1941-1945.

Understanding Observed and Unobserved Health Care Access and Utilization Disparities Among U.S. Latino Adults
Vargas Bustamante et al.
Med Care Res Rev 2009;66:561-577.

A 41-Year-Old African American Man With Poorly Controlled Hypertension: Review of Patient and Physician Factors Related to Hypertension Treatment Adherence
JAMA 2009;301:1260-1272.

Barriers to Care and Primary Care for Vulnerable Children With Asthma
Pediatrics 2008;122:994-1002.

Racial/Ethnic Disparities And Consumer Activation In Health
Hibbard et al.
Health Aff (Millwood) 2008;27:1442-1453.

What Accounts for Differences or Disparities in Pediatric Palliative and End-of-Life Care? A Systematic Review Focusing on Possible Multilevel Mechanisms
Linton and Feudtner
Pediatrics 2008;122:574-582.

Racial/Ethnic Disparities and Culturally Competent Health Care Among Youth and Young Men
Vo and Park
Am J Mens Health 2008;2:192-205.

Can Language-Concordant Prevention Care Managers Improve Cancer Screening Rates?
Beach et al.
Cancer Epidemiol. Biomarkers Prev. 2007;16:2058-2064.

The Impact of the Adoption of Gag Laws on Trust in the Patient-Physician Relationship
Patel and Chernew
Journal of Health Politics, Policy and Law 2007;32:819-842.

Disparities In Health: Perspectives Of A Multi-Ethnic, Multi-Racial America
Blendon et al.
Health Aff (Millwood) 2007;26:1437-1447.

Disparities in Treatment and Outcome for Renal Cell Cancer Among Older Black and White Patients
Berndt et al.
JCO 2007;25:3589-3595.

Laboratory Abnormalities at the Onset of Treatment of End-Stage Renal Disease: Are There Racial or Socioeconomic Disparities in Care?
Arch Intern Med 2007;167:1083-1091.

Care at the End of Life: Focus on Communication and Race
Zapka et al.
J Aging Health 2006;18:791-813.

Development and Validation of a Patient-Reported Measure of Physician Cultural Competency
Thom and Tirado
Med Care Res Rev 2006;63:636-655.

The promise and limits of racial/ethnic concordance in physician-patient interaction.
Schnittker and Liang
Journal of Health Politics, Policy and Law 2006;31:811-838.

Reducing Delay in Seeking Treatment by Patients With Acute Coronary Syndrome and Stroke: A Scientific Statement From the American Heart Association Council on Cardiovascular Nursing and Stroke Council
Moser et al.
Circulation 2006;114:168-182.

Patient preferences can be misleading as explanations for racial disparities in health care.
Armstrong et al.
Arch Intern Med 2006;166:950-954.

Racial Differences in Trust in Health Care Providers.
Halbert et al.
Arch Intern Med 2006;166:896-901.

Racial Differences in Trust and Lung Cancer Patients' Perceptions of Physician Communication
Gordon et al.
JCO 2006;24:904-909.

Doctor-Patient Communication, Cultural Competence, and Minority Health: Theoretical and Empirical Perspectives
Perloff et al.
American Behavioral Scientist 2006;49:835-852.

On Addressing Racial and Ethnic Health Disparities: The Potential Role of Patient Communication Skills Interventions
Cegala and Post
American Behavioral Scientist 2006;49:853-867.

Racial/Ethnic Variations in Veterans' Ambulatory Care Use
Washington et al.
AJPH 2005;95:2231-2237.

Evaluation of the Causes for Racial Disparity in Surgical Treatment of Early Stage Lung Cancer
McCann et al.
Chest 2005;128:3440-3446.

Access and equity to cancer care in the USA: a review and assessment
Siminoff and Ross
Postgrad. Med. J. 2005;81:674-679.

Patient Ethnicity and the Identification and Active Management of Depression in Late Life
Gallo et al.
Arch Intern Med 2005;165:1962-1968.

Trust in One's Physician: The Role of Ethnic Match, Autonomy, Acculturation, and Religiosity Among Japanese and Japanese Americans
Tarn et al.
Ann Fam Med 2005;3:339-347.

Pediatric Residents' Responses That Discourage Discussion of Psychosocial Problems in Primary Care
Wissow et al.
Pediatrics 2005;115:1569-1578.

Sufficiently Important Difference: Expanding the Framework of Clinical Significance
Barrett et al.
Med Decis Making 2005;25:250-261.

The Effect of Physician Disclosure of Financial Incentives on Trust
Levinson et al.
Arch Intern Med 2005;165:625-630.

Patients' Beliefs About Racism, Preferences for Physician Race, and Satisfaction With Care
Chen et al.
Ann Fam Med 2005;3:138-143.

Racial disparities in the use of surgical treatment for intractable temporal lobe epilepsy
Burneo et al.
Neurology 2005;64:50-54.

Update on the Health Disparities Literature
Long et al.
ANN INTERN MED 2004;141:805-812.

Ethnic Minority Older Adults Participating in Clinical Research: Developing Trust
Moreno-John et al.
J Aging Health 2004;16:93S-123S.

Barriers to Health Care Access Among the Elderly and Who Perceives Them
Fitzpatrick et al.
AJPH 2004;94:1788-1794.

Health Care in America -- Still Too Separate, Not Yet Equal
NEJM 2004;351:603-605.

Measuring Patients' Trust In Physicians When Assessing Quality Of Care
Thom et al.
Health Aff (Millwood) 2004;23:124-132.

Voting with Their Feet: Patient Exit and Intergroup Differences in Propensity for Switching Usual Source of Care
Journal of Health Politics, Policy and Law 2004;29:491-514.

Trust: Can We Create the Time?
Arch Intern Med 2004;164:930-932.

Patient Characteristics and Experiences Associated With Trust in Specialist Physicians
Keating et al.
Arch Intern Med 2004;164:1015-1020.

Patient-Centered Communication, Ratings of Care, and Concordance of Patient and Physician Race
Cooper et al.
ANN INTERN MED 2003;139:907-915.

Patient-Physician Relationships and Racial Disparities in the Quality of Health Care
Saha et al.
AJPH 2003;93:1713-1719.

On Being New to an Insurance Plan: Health Care Use Associated With the First Years in a Health Insurance Plan
Franks et al.
Ann Fam Med 2003;1:156-161.

Nature of Conflict in the Care of Pediatric Intensive Care Patients With Prolonged Stay
Studdert et al.
Pediatrics 2003;112:553-558.

What do patients value in their hospital care? An empirical perspective on autonomy centred bioethics
Joffe et al.
J. Med. Ethics 2003;29:103-108.

Physician Weight Counseling for Adolescents
Saelens et al.
CLIN PEDIATR 2002;41:575-585.

The Association Between Diabetes Metabolic Control and Drug Adherence in an Indigent Population
Schectman et al.
Diabetes Care 2002;25:1015-1021.

Strategies for Culturally Effective End-of-Life Care
Crawley et al.
ANN INTERN MED 2002;136:673-679.

Effect of Managed Care on Children's Relationships With Their Primary Care Physicians: Differences by Race
Stevens and Shi
Arch Pediatr Adolesc Med 2002;156:369-377.

Race and Ethnicity in Biomedical and Health Services Research
Arch Pediatr Adolesc Med 2001;155:972-973.

Racial Differences in the Use of Cardiac Catheterization after Acute Myocardial Infarction
Chen et al.
NEJM 2001;344:1443-1449.

© 2000 American Medical Association. All Rights Reserved.