The Intersection of the Patient-Doctor Relationship, Hypertension and Race

One of the most perplexing medical cases I saw as a medical student was a middle aged woman who was admitted to the hospital for symptoms of dizziness, and during her admission it was noted that her blood pressure was very elevated. Her personal physician, outside the hospital, had known about her high blood pressure for years and although a work up had been completed years ago without revealing an anomaly, for some reason or another or her high blood pressure was viewed as being "normal for her."

While doctors use a cutoff of 140/90 as signifying high blood pressure, a new clinical entity defined as pre-hypertension is defined as a blood pressure with a systolic number (or top number), between 120 and 139, and the diastolic number (or bottom number) between 80 and 89.

My patient had a blood pressure that was very much above both of these cutoffs as it hovered around 175/95. This was concerning for several reasons as, number one, her elevated blood pressure put her at risk for a variety of medical conditions including stroke and heart attack and number two, the perplexing part, why had her doctor failed to lower her blood pressure over the the years? While we never got an answer to this question, her story is perhaps repeated thousands of times a day in the United States as patients with poorly controlled blood pressure are seen by their doctors.

As America grapples with the obesity epidemic, hypertension and its side effects will become a much greater public health problem, and helping patients to lose weight and stay on their blood pressure medications will become an increasingly important part of the clinical care of patients.

Among African-American patients in particular, hypertension is an especially devastating and deadly disease. Rates of cardiovascular disease among African-Americans are 30 to 50% higher than what it is among whites, and this is due in large part to an excess prevalence of hypertension among African-Americans.

Are there effective treatments for hypertension in African-Americans?

The answer is a resounding yes. Certain blood pressure medications such as calcium channel blockers and diuretics or especially effective in African-American patients. And reducing sodium in the diet, which helps to lower the blood pressure of anybody of any race, is especially effective in African-Americans.

So why are African-Americans, and many other patients with high blood pressure, not getting the care they need?

It is often said that hypertension is a silent killer, and this is true as the damage it does to the body accumulates over time without any outward appearance that a person has a serious disease. This fact often works against doctors who wrestle with the difficulty of treating patients for a condition that won't kill them tomorrow or next week, but potentially decades in the future.

There is also an economic component to nonadherence, as the economy continues to do poorly, some patients may find it difficult to afford their antihypertensive medications. Stopping these medications will not result in any immediate adverse health consequences, and so they may decide to forgo buying the medication while the economy improves.

A lack of general healthcare knowledge may also lead a patient to conclude that their hypertension is not a serious medical condition, or that high blood pressure is actually a different disease from hypertension although they are two different names for the same thing. As patients research their diseases on the internet, and develop their own understanding of the disease, they may be more likely to discount what they doctors are telling them.

In addition, the patient-doctor relationship is important when it comes to encouraging the patient to take a medication for a disease that might not manifest itself for decades. Sadly, one study indicated that white doctors when caring for African-American patients use less empathy and are less likely to explain the disease process to their patient when compared to white patients. If patients are not communicated accurately the possible side effects of their antihypertensive medications, or are not told about the possible complications of hypertension, then they will be much less likely to adhere to their medication regime. An authoritarian approach is believed to be less beneficial than an engaging participatory decision-making style, yet authoritarian is the predominant style that many doctors adopt if only for superficial efficiency.

A patient who has depression, or anxiety, may be much less likely to take their medication regularly and identifying an underlying psychiatric condition in these patients is important. In addition, cultural sensitivity and awareness is an integral part of many doctors' practices who see patients from a variety of cultural backgrounds. Nonetheless, doctors bias is often evident as I learned as a medical student.

After observing senior doctors taking care of white and black patients in a clinic setting, I noticed the following patterns:

1. Doctors more easily enter a non-authoritarian conversational style with patients that are most like them in terms of socioeconomic background and race.

2. Some doctors who are not African-American appear to spend less time with African-American patients than with other patients.

3. Because doctors often spend less time with African-American patients, it almost seems paradoxically true that African Americans are expected to know more about their medical condition even though the doctor spends less time explaining it to them.

4. Very rarely has I seen a white doctor enter into a question and answer session with a black patient that lasted more than half a minute.

Conclusions

Researchers studying health disparities ascribe much importance to the quality to the patient-doctor relationship. Yet little is being done to teach medical students how to interact with, and more effectively understand and motivate, patients of a variety of different cultural backgrounds. This is not because it is impossible, but because the goal of the clinic visit for the medical student is to:

1. Gather the pertinent information to save the clinic preceptor time, and to practice doing a history and physical.

2. To evaluate the patient's symptoms and come up with a diagnosis, or the appropriate next step in treatment.

3. To quickly see a large number of patients in the clinic, thus improving efficiency so that as the doctor, the medical student can in the future see a large number of patients each day.

Very rarely is the medical student asked to consider how to relate to a given patient, or how they might have better opened a dialogue between the patient and themselves. Asking a patient about stress in his or her life, and the various psychosocial issues affecting him or her, has basically been restricted to the domain of psychiatry. Nonetheless, in the future medical students might be trained or rather encouraged to have more open and supportive relationships with their patients rather than focusing exclusively on changes in medication and other more mechanical issues to the exclusion of all else.

Sources:

A 41-Year-Old African American Man
With Poorly Controlled Hypertension
Review of Patient and Physician Factors Related
to Hypertension Treatment Adherence
JAMA, March 25, 2009-Vol 301, No. 12
JAMA. 2009;301(12):1260-1272.