EP. 69: ADDRESSING HEALTHCARE INEQUITIES THROUGH PATIENT RELATIONSHIPS
WITH LISA COOPER, MD, MPH
The Director of the Johns Hopkins Center for Health Equity shares her early pioneering research on how strong doctor-patient relationships can help overcome racial and ethnic disparities in healthcare.
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Episode Summary
It’s no longer a surprise that the race and ethnicity of a patient influence their health outcomes. But back in the 1990s, when Lisa Cooper, MD first documented and published findings that supported the role of patient race on the quality of physician-patient interactions, these were groundbreaking, even radical ideas. Today, Dr. Cooper, a physician and social epidemiologist, is the Director of the Johns Hopkins Center for Health Equity and a Bloomberg Distinguished professor at the Johns Hopkins University School of Medicine. She has designed innovative approaches to improve physician communication skills and the ability of healthcare organizations to address health disparities. She is a recipient of the MacArthur Fellowship and a member of the President's Council of Advisors on Science and Technology. In this conversation, we discuss her international upbringing, implicit bias in medicine, what good physician-patient relationships look like, and how we can more effectively prepare doctors to create a more equitable future.
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Lisa Cooper, MD is a Liberian-born general internist, social epidemiologist, and health services researcher. She was one of the first scientists to document disparities in the quality of relationships between physicians and patients from socially at-risk groups. She then designed innovative interventions targeting physicians’ communication skills, patients’ self-management skills, and healthcare organizations’ ability to address needs of populations experiencing health disparities. She is the author of over 200 publications and has been the principal investigator of more than 20 federal and private foundation grants. She has also been a devoted mentor to more than 75 individuals seeking careers in medicine, nursing, and public health.
Dr. Cooper has received several honors for her pioneering research, teaching, and mentoring. She has also been recognized by several community organizations for her community engagement and advocacy to address health disparities. Currently, Dr. Cooper directs The Johns Hopkins Center for Health Equity, where she and her transdisciplinary team work with stakeholders from healthcare and the community to implement rigorous clinical trials, identifying interventions that alleviate racial and income disparities in social determinants and health outcomes. The Center also provides training to a new generation of health equity scholars and advocates for social change with policymakers.
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In this episode, you will hear about:
• Dr. Cooper’s international upbringing and how an early understanding of privilege shaped her career path - 2:21
• How privilege can change based on community and culture, and how Dr. Cooper experienced this shift - 7:25
• The observations Dr. Cooper made early in her career that led her to study how race and class impacts health outcomes in America - 12:58
• Facing stereotypes in a culture that is not your culture of origin - 18:44
• How Dr. Cooper began her research on racial inequities in health and the findings from those initial studies - 26:48
• The unrecognized assumptions that doctors are taught to make when it comes to patient care - 32:56
• How physicians can learn to take better care of patients from all backgrounds - 38:36
• The current state of medical education around implicit bias training and racial disparities - 46:40
• Dr. Cooper’s advice to her younger self - 52:53
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Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:02] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to the Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and health care executives, those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] If we were to tell you that the race and ethnicity of a patient shapes the relationships they have with their doctors and affects their health outcomes, you probably wouldn't be too surprised. But back in the 1990s, when Dr. Lisa Cooper first documented and published findings that supported the role of race on physician patient interactions, these were groundbreaking and even radical ideas today. Dr. Cooper, a physician and social epidemiologist, is the director of the Johns Hopkins Center for Health Equity and a Bloomberg Distinguished professor at the Johns Hopkins University School of Medicine. She has designed innovative approaches to improve physicians communication skills and the ability of health care organizations to address health disparities. She is a recipient of the MacArthur Fellowship and a member of the President's Council of Advisors on Science and Technology. In this conversation, we discuss her international upbringing starting in Liberia. Implicit bias in medicine. What good physician patient relationships look like, and how we can more effectively prepare doctors to create a more equitable future. Dr. Cooper, thank you so much for taking the time to join us and welcome to the show.
Lisa Cooper: [00:02:19] Thank you for having me.
Henry Bair: [00:02:21] I'd like to start with your fascinating international journey. Can you take us through your childhood and formative years?
Lisa Cooper: [00:02:28] Well, I was born in Liberia. West Africa. Small country. Uh, on the West Coast, founded by freed American slaves and people who were free people of color who had never been enslaved, who returned to Africa in the 1800s. So it's a country that is sort of a blend of people from lots of parts of the African diaspora. And, you know, it was the first independent country on the on the continent of Africa. And so it was an interesting place growing up. My parents, both of them were born in Liberia, but had come to the United States for their training and education. And my father was a surgeon. My mother is -she's still alive- is a librarian. And so I grew up with the sense of the importance of education, of course. And but also because Liberia is a pretty poor country of low income country there. Most of the population there, I think lives in. Worse conditions than a lot of people in the developed world. And so my family and I were kind of privileged people in that country. So I was really aware at a pretty early age of the advantages I had. We lived in a nice, comfortable house overlooking the ocean, and I went to an international school and the kids I went to school with were the children of diplomats and business owners.
Lisa Cooper: [00:04:09] And, you know, so in Liberia, we were fairly well-to-do. So I think I had this sense of like sort of how fortunate I was in many ways. But I also saw a lot of people around me who didn't have all those advantages. So I saw lots of children who were walking on the streets without shoes on and often like carrying water on their heads because they didn't have running water in their homes, taking care of their younger siblings and not being in school. So think I was really aware of the fact that. I had a lot. And my parents also kind of instilled this in me and my brother and sister that to those whom much is given, much is expected. So, you know, my parents also gave back a lot. They were involved in a lot of activities, civic activities. You know, my mother worked on the leprosy board, Leprosy control board. You know, my father was in the Rotary Club. So I grew up with a sense of the importance of service to community. And then also, you know, I grew up in a medical family, so my father's mother was also a nurse.
Henry Bair: [00:05:20] So did you plan to go into medicine yourself right from the start, or did you at some point kind of realize this was, after all, the right path for you as well?
Lisa Cooper: [00:05:31] Yeah. No, that's that's always an interesting question. I think as a little as a very small child, I was always interested in being a doctor. And I don't know if it's because I saw my father doing his work, you know, going back and forth. But I think that was part of it. I think the other part of it was that I always felt like I wanted to to help other people feel better. I think I've always been sort of a sensitive person and to the kind of the pain or the suffering of other people. So I always wanted to be somebody in medicine, probably a doctor, because I saw my dad, but I wasn't 100% sure that I would be really cut out for it. So, you know, I don't think I was a sure you know, as a young person, I always had that in the back of my mind and always tried to prepare for that. You know, taking science classes. I liked science and math, too. And but I also liked other things like music and art. And I played the piano wasn't decided. But when I did go to college, did a liberal arts degree at Emory College in Atlanta, Georgia, and and continued to take all the pre-med requirements. And and then at the end, sort of towards the end of college, I kind of made a firm decision that, yes, I was going to go to medical school because I considered lots of other things knowing because one of the reasons I did that was because my father worked really hard, very long hours. He wasn't always at home with us. He wasn't always on family vacations with us. So I knew that medicine required a lot of dedication and I might actually not have as much free time to do other things I wanted to do. So I tried to think of lots of other things that I might like doing, which I did, but at the end of the day, I still came back to medicine.
Tyler Johnson: [00:07:25] Listeners to this show may think that we've just gone around the country to find all of the doctors who are liberal arts majors in college because there is a preponderance of people who study the liberal arts in one fashion or another before they came into medicine. So you mentioned this awareness from a very young age about differences in you might well, I think you called it privilege or in other in another sense, differences in power, even when you were growing up. Can you talk a little bit about how that awareness then played into your developing sense that you wanted to be a helper and then eventually that you specifically wanted to do that by going into medicine?
Lisa Cooper: [00:08:11] Sure. Yeah. I mean, I think I saw actually I saw children who were sick, you know, and I saw adults who were sick who came from sort of poorer neighborhoods and things like that. And so I had the sense that, you know, it was due to them not having opportunities to be healthy, not having health care, not having healthy food, safe place to live, things like that. So I did connect those things to health. You know, as a young person and felt that, you know, if I did work in the area of health care, I could help people feel better. I didn't know at the time that there was a broader kind of field like public health that would actually bring all of those things together. But I had a sense that all those things were connected. So I think it started early on but think again it came back to me when I moved to the United State. After college, actually, when I went to medical school and was able to see in the health care system itself how people from sort of more advantaged backgrounds and areas of the country or the state seem to be healthier, seem to live longer than people that I saw who weren't in the same situation. And in a lot of cases, of course, in the United States, a lot of the people who were disadvantaged were people who were African American or Hispanics or recent immigrants or even American Indian patients.
Tyler Johnson: [00:09:52] What about and maybe I should have asked this question before the one I just asked. But you know what I heard you saying when you were talking about growing up in Liberia was that in some sense, sometimes even physically, but at least figuratively, that you felt a sense of being a part or almost set apart in a little bit, you know, in the sense that you had you were aware that your family had more than a lot of the people around you. When you then eventually moved to the United States, how did that dynamic change? Did you still feel that sense of being a part, but maybe for different reasons or in different ways, or did that go away when you moved here? Or how did that dynamic play out once you had moved?
Lisa Cooper: [00:10:38] Yeah, This is a whole a very complex kind of story for me. I think, you know, as a Liberian, I felt that I came from a relatively privileged background. And so from that standpoint, I did feel somewhat, you know, sort of set apart from a lot of people around me who didn't have those same opportunities. But I went to an international school where there were people from other countries who came from, you know, very privileged backgrounds. And I wasn't in the majority at that in that school. There weren't as many Liberians at that school. So I kind of had the sense of what it was like to be sort of in a more privileged group, but also the sense of what it's like to be in sort of a minority group or a group that doesn't have all the advantages and all the connections and all the power. And even once I left Liberia, I went to an international school in Geneva, Switzerland, where a lot of the people there were from European countries, many of them were from Arab countries and from the Far East. And there were a smaller number of people from Africa there.
Lisa Cooper: [00:11:48] So I knew what it was like there to be sort of not in the majority. And also because I didn't, you know, the language wasn't my my first language and I didn't know all of the. Norms and rules about living in Europe. I knew what it was like to be sort of like an outsider and not in a position of like kind of power and popularity as well. And so and then brought that. When I came to the US again, I saw that playing out. Interestingly at I went to school in Atlanta, Georgia, which is kind of like one of the. The main areas where the civil rights movement was born. So in that sense, there is a large African American population there, which was a good thing for me because I felt connected and identified, closely identified with African Americans because of the history of Liberia and indeed my own family. I have family on both sides of the ocean. But I also knew what was like to be in a smaller group of African American students at Emory College.
Henry Bair: [00:12:58] So as we briefly mentioned in the introduction to this episode, there is now a lot of conversation around the nation and in medical schools and hospitals everywhere about the role that race and ethnicity has on the quality of patient physician interactions and the actual tangible health outcomes. But back when you were doing this research in the 90s, you were one of the first people to take this seriously from an academic perspective and then eventually to try to translate this into policy and practice. Can you tell us more about what that experience was like? How much support did you get and how much pushback did you encounter?
Tyler Johnson: [00:13:39] And if you can also maybe talk to the front of that, how did you get to that point? Like what brought you to to want to look into that in a formal research oriented way?
Lisa Cooper: [00:13:51] So with this growing awareness I had of kind of the differences in experiences between being a black person and a white person or a person of color and and, you know, a person of European descent in America. When I was going through my training, I became increasingly aware of how people's backgrounds and specifically their racial and also sort of economic background influence their experiences in health care. So as a resident at University of Maryland Hospital, a large urban hospital, Baltimore City has a large African-American population. Many of whom live in neighborhoods that are have experienced disinvestment as a result of the history of redlining in those neighborhoods. And so. I saw the struggles that patients came in with. I saw the fact that they would come back over and over again because. They couldn't get their medications or prescriptions filled because they didn't have insurance or they couldn't afford it. They had lost their jobs. I saw people just affected by substance use disorders because they had become so sort of despondent about the situation they were in. They experienced family members being killed due to crime and violence in their neighborhoods, you know, struggling to make ends meet, to eat healthy. They couldn't go outside and exercise because of fear. And so I saw people struggling with a lot of those things. And I also saw on the other side, you know, many of us as health professionals, we're trained to sort of diagnose and treat medical conditions. But we in our education, at least at that time, we did not get a lot of training about all the other factors that kind of influence people's ability to be healthy.
Lisa Cooper: [00:15:49] So we would be there just basically asking people about their symptoms, examining them, and then trying to prescribe the treatments we were taught to prescribe in medical school. And and in some sense getting frustrated because people weren't doing those things. And so at a certain point, you know, because of the long hours and the the fatigue and everything, people just sort of start stereotyping. People sort of saying assuming that they're just not going to follow through on what we say and that they're here again, because, you know, here they are, they're drinking or they're using drugs again and and making assumptions about about people and their motives and then basically not giving them the kind of care that we ideally would be giving them. You know, we we all were sort of, I think, vulnerable to that because of the level of stress we have during our training. We had to see so many patients get so little sleep and, you know, and trying to do the right thing. But I was so aware of the fact that it was not helpful. Patients felt, you know, disrespected or they they didn't follow through on what we recommended because they didn't trust what we said. We made mistakes. We really didn't get the right diagnosis a lot of times because we were making assumptions that were simply incorrect. And so I really saw a lot of those things and I thought, wow, this is like a big problem. And somebody needs to to unpack this and do something about it.
Lisa Cooper: [00:17:24] I don't want to fall victim to this. I know a lot of my colleagues don't really want- they don't want to treat people poorly. But this is what is happening as a result of the lack of preparation on our part to deal with the problems and sometimes the lack of understanding of what other people are going through because we hadn't had similar life experiences. And then sort of all of that leading to this storm of people just not getting the quality of care they should be getting. So I saw that. And you know, when I was leaving residency, I thought, well, I could go out and practice medicine and try to make a difference one person at a time. But I feel like this is like a system problem. This is a problem with our whole system and I really want to. To see if I can address it on a broader level. So that's when I decided to go to Johns Hopkins and get training in public health, not realizing that I was actually going to end up doing research. I thought I was going to work in public health practice and try to change policies and things like that, which I am working on now. But I realized there was not a lot of data about the problems I was seeing, and so it really required me to use research methods to document the problem and to better understand it in order to be able to come up with the right solutions to it.
Tyler Johnson: [00:18:44] Before we get to the details of some of that research and what it showed and what it means, can I pause for a moment? So I want to tell a little bit of a story that I think has helped me to understand some things more broadly. And then I'd like to ask if you can speak to this a little bit. So during the pandemic, I'm not much of a fan of social media usually, but during the pandemic I spent a lot of time on social media, largely because I was trying to disseminate helpful information about vaccines and the virus masking and whatever. But I would also sometimes put up some posts on Facebook about just my personal experience during the pandemic. And I was writing a post one time, and the intent of the post was to was that I was trying to emphasize the heroic work that unseen people in the hospital do, unseen workers in the hospital do. Specifically in that particular post, I was trying to talk about people who do the sanitation work in the hospital. Right. Which during the pandemic, I think was that was one of the most harrowing jobs you could possibly have. Right. Like if you're the person who's like emptying the garbage liners that have all of the contaminated PPE in it. Right. That was mean to me personally as sort of a germaphobe. That feels like a terrifying job. So I was trying to write a post about how I had come to see them more, and I was so grateful for the work that they were doing. But in an attempt to try to highlight that fact, I began the post by talking about how I had realized that to many people, those workers in the hospital are effectively invisible. And to try to highlight that contrast, I talked about the fact that when I as an attending walk into a room, it is usually the case that every eye in the room turns toward me and that there is this sort of immediate recognition, like the doctors here.
Tyler Johnson: [00:20:40] And then, you know, and everyone is paying attention, everyone is listening, everyone is deferential. If there's any other person in the room, they usually stop whatever they're doing so that I can do what I'm there to do. Et cetera. So you may have already guessed where this is going, but what was so striking to me is that so I'm writing this post trying to highlight the the heroic work and the plight of these invisible workers. Then a friend of mine who's an infectious disease physician at our same hospital and who is a Hispanic woman, wrote and said, Oh, wait a minute, that's never my experience. When I walk in the room, people don't immediately stop and look at me and assume, Oh, there's the doctor. The doctor is here. Sometimes I walk into the room and people, even after I tell them that I'm the doctor, they don't know that I'm the doctor or they don't recognize that I'm the doctor or whatever. And then anyway, and you can imagine that. So then the conversation went on from there. So all of that is to say that I'm just wondering if during the training, when what you have described so far was this focus on look at how these patients are being treated differently. Did you also have any experiences where you as a training doctor felt like you were treated differently because of your appearance or the persona that you brought into the room? Could you talk about that a little bit?
Lisa Cooper: [00:22:00] Oh, certainly. I mean, I had lots of those experiences. I can't even tell you how many times I walk into the room to examine a patient or talk to them where family members ask me if I could go and get them something to drink or bring them food, or if I could clean up something because they had just assumed I couldn't possibly be. The doctor must be working in another another role. And even after I said who I was, there were times when I walked into the room with, you know, a whole team of medical students, and I might have been the senior resident at that point. And the patient and family members were all looking at the younger folks on the team who had less experience. For them to sort of speak and give the the final decision about what was happening when when was actually leading the team. So that happened often as well. I think one of the the advantages that I may have in coping with that kind of treatment over people who were born and grew up in this country is that I didn't grow up in a country where I was from a marginalized group.
Lisa Cooper: [00:23:16] So even though I experienced those things, I always saw them as well. That might be who you think I am. But I know who I am because I'm not treated that way. I haven't been treated that way my whole life. So on the one hand, I think that people who have grown up with that being their whole experience and that being the experience of their parents and grandparents, that that is even a more difficult kind of thing to cope with. So I think I experienced those things and I think for the most part, I, I still do experience them, but I've managed to sort of realize that, yes, I may be seen that way here, but I know that in other parts of the world I'm a very advantaged person and I know in many ways that I am still a much an advantage person. And so what I try to do is to focus on what power do I have, what privilege do I have and how can I use that. So yes, my answer to your question is yes.
Tyler Johnson: [00:24:19] That's a really interesting idea, though, that that because you didn't have that same level of sort of embedded stereotype threat that you had grown up with, you know, sort of that that was your experience from always that in a sense that inoculated you a little bit, gave you sort of a place to stand, to just say like, why are you you know, this doesn't make any sense. Instead of sort of feeling that that was somehow had some fundamental, you know, coherence to it or something. That's really interesting.
Lisa Cooper: [00:24:51] No, but I think I think the longer one lives in a society as a marginalized person, that's part of a marginalized group, that that sense of sort of internalizing the stereotypes and that increases over time. I do think that that happens.
Henry Bair: [00:25:08] Yeah, I think that's definitely actually my personal experience. I didn't grow up in the US. I people often comment that I sound like I grew up in the US, but I didn't. I spent the first 18 years of my life in Taiwan where very homogenous society there wasn't there weren't that many issues with minorities, no issues with minorities. I didn't grow up with that mindset. And then I came to the US. And then similar to you, I was surprised because at the same time I was, as Tyler described it, inoculated in the sense that people would have stereotypes. And sometimes I wouldn't even recognize that I was being treated differently. And in the moments when I did recognize it, it did genuinely didn't bother me because I was like, you know, nothing. It's like it's so obvious, you know, it's like, why should this affect me? Because I hadn't internalized it. At the same time, though, as you've mentioned, as I've I've been here ten years now, college, medical school. I have noticed how the more I spend time, the more I encounter elements of being treated differently. You I internalize some of that. You know, East Asians have stereotypes of being maybe more deferential, more quiet. And I think in some ways my behavior in groups where I am the lowest, you know, in a in an organization that has manifested like sometimes I will look back at my behavior and say, why did I say that? Why did I behave like that? Why didn't I speak up? And then maybe it's just because the expectation, you know, has compelled me to act that way. So hearing your experiences, definitely I resonate very much with that.
Tyler Johnson: [00:26:48] Well, let's go back though, now. So. Okay, so you get done with residency. You've noticed these what you at the time perceived to be pretty deeply ingrained differences about the way that people patients are coded and then treated, even if the practitioners were unaware of what they were doing, that they were nonetheless treated differently. And then you decided that. So then you go to Johns Hopkins, you decide to develop the research rigor to be able to go beyond having this be your perception, to actually demonstrating how this is playing out in practice. Where did things go from there?
Lisa Cooper: [00:27:25] So they started with me focusing on depression, people with depression. And this was like in large part because one of the faculty members who was doing a lot of primary care based research, he was he was focusing on depression. And I thought, you know what? This is like a really good kind of condition to focus on with this particular problem, because I had seen a lot of African American patients who came in with lots of different symptoms, which, you know, we went through a whole long medical workup for and that we didn't find anything but. It did turn out that more than likely they were depressed. But when we sort of talked about that with them, they were not as receptive to the idea. And so I started to wonder whether. This was actually a good condition to really look at. So what are the differences in how African American and white patients are treated for depression and differences in how they might be recognized as having depression or not? And so that's how my work started. And I was given some good advice by one of my mentors because I had all these different ideas, like I was going to develop this survey and I was going to ask patients what they thought. And and she said, How do you know that you're even asking the right questions? And I thought, wow, you know, that's, you know, incredible.
Lisa Cooper: [00:29:00] So she said, Why don't you just start by having focus groups like, you know, just asking people what's important to them? Like, what do they care about and see if any of this actually comes up and if there are other things that come up that you can include in your survey. So that's how my work started, is focus groups of patients with depression. And initially I was going to only do African American patients and then I was given the advice that I should also do white patients. And this is also an interesting thing is, you know, I think you mentioned before whether whether I had gotten pushback or discouraged from doing this work. And yes, I did. So there were lots of people who said, you don't want to just focus on a problem that affects African-Americans like you, you know, because it's too narrow. You you need to make sure that your research question is broader and that it has sort of broader like relevance and and implications, because otherwise you're not going to be successful. So you definitely need to include be broader about it and talk about the problem overall. And then you can also focus on like what's going on with African American patients. So I did that. And, you know, I think it was helpful in some ways because, you know, you don't if you focus only on one group, maybe you don't really get the sense of whether there are really differences or not.
Lisa Cooper: [00:30:25] And and plus, you can it's true. You can learn more about a problem if you if you cast a broader net. But my point is just that, you know that there was some pushback and and yeah. And I was actually told by lots of people that this was not a something that was like sort of a high priority in health care. And it's not a really urgent research question that that needed to be answered and that I was going to have a hard time getting funding and being successful. But I stuck to my initial intent. And pursued the question. And sure enough, it turned out that I found out some really important things from that initial work. Like I found out that almost all the patients felt like the thing that was most important to them in getting care for depression was having a good relationship with their doctor and having a doctor that actually listened to them, treated them as a person and not as like a medical problem, and that it was someone that they felt that they could trust and that that person really had their best interests at heart.
Lisa Cooper: [00:31:35] So everyone said that whether they were black or white. And then there were some other issues that that were different in the groups, you know. But again, these were small numbers of people. But African American patients tended to talk much more about the the role of spirituality and the fact that they felt like depression was like a spiritual illness, and they didn't really see it as a medical condition. And so that's why they really didn't even talk about it. And they went to see doctors. So that was one thing that we heard from African American patients that we didn't really hear as much from white patients. The other thing we heard more from African American patients was this concern that the medications used to treat depression and other mental health problems was not getting at the real problem, that it was just covering it up. So that was the one thing. And that also that they felt that it could be something that would cause them to become addicted. And they were afraid of that because they'd seen addiction in so many, you know, other sort of family members and friends. So that sort of led to my next series of studies, which then really focused a lot on the doctor patient relationship and on that communication process and what leads to patients having trust in their physicians.
Tyler Johnson: [00:32:56] Maybe it was just where I went to medical school. Or maybe it was the era when I went to medical school, which is about 10 to 15 years ago. But I remember this very strong emphasis on patient autonomy and individual autonomy. Right? And then the way that this was then applied when you're actually taking care of a patient. So as an oncologist, when I take care of patients in the hospital, a very sadly large number of them end up going to the ICU because they have very serious underlying problems from their cancer and what have you. And so then that often leads to very difficult discussions about what end of life care is going to look like and how aggressive, aggressive and invasive they want their care to be and etcetera. And I explained that to say that the impression that I had coming away from medical school was that if you were going to be making those kinds of life and death decisions where possible, in effect, what you were almost supposed to do was it was almost like you were supposed to get everybody else out of the room and have just the patient there. And then you were supposed to say to the patient, okay, now ignoring everything that anybody else wants, what do you want to do about whatever the decision is? And then furthermore, if there was any kind of conflict between what the patient said they wanted and what anybody else in the family or friends or broader social network said, then that was just tough for everybody else. But the only thing that you could think about or honor was what the patient wanted, Right? And, you know, as I think most good medical students do, I thought that was just gospel, right? That was just the way that it worked.
Tyler Johnson: [00:34:29] And it wasn't until many years later in my training and then into my being an attending, that I started to notice that that way of approaching a problem is just loaded with cultural baggage, right? Like that is a particular way to think about medical decision making, but it reflects this very sort of individualized, hyper western, whatever you want to call it, societal assumptions that I just didn't I just thought that's how it was. Right. And it wasn't until I began to understand that in many cultural contexts, that just makes absolutely no sense, right? Like that kind of decision would never be made by one person by themselves. Because, I mean, that's almost at least illogical, if not almost immoral. Right? So I mentioned that only to say that I'm so struck that your focus groups demonstrated that for a lot of people who were coming in and being diagnosed with depression, in effect, they were saying, our doctors don't even have the vocabulary to talk about what we're here to talk about because we're not here to talk. We don't want to come here to get Prozac. We want to come here because there's this like existential dilemma in our lives that needs to be addressed in a much more sort of holistic and broad based way than just, oh, you're feeling sad, here's a pill.
Lisa Cooper: [00:35:58] Right, Absolutely. Yeah.
Tyler Johnson: [00:36:01] And which I guess all of that is just to say that I feel like it's such a potent reminder of how many assumptions are baked into the way that we teach doctors how to be doctors or even what it means to be a doctor.
Lisa Cooper: [00:36:19] No, I couldn't agree with you more. I think it did reflect like a basic sort of cultural difference in the way people saw their health and their illness and that that was it was just missing from the way we have been trained to approach that that set of problems or even to approach patients like you said.
Tyler Johnson: [00:36:44] And it's so it's so striking to me because- so when Henry and I launched this podcast a year and a little bit ago, in effect, the point of the podcast was to try to- you know, we know that there are many systemic issues driving burnout. That's clear. And we can all cite a bunch of statistics about corporatization and bureaucratization and the EMR and yada, yada, yada. Right? So we're not arguing with that, but we also feel like there is some more. We had this sort of hypothesis that there was a more that there was some element of that that was also deeper and more personal about the way that we approach medicine on a on a personal level. And and one way, I don't know that we've ever said it exactly this way, but one way of framing what our research, which is now nearing 80 hours of conversations with all different kinds of people across the health care world, one way of framing what our research has demonstrated is that we think that one of the drivers of burnout in medicine is precisely this hyper narrowed approach to trying to turn people into machines, right? And to try to address what's going wrong with them in the same way that you would address a car that needs a new carburetor or whatever. Like if we all just switch this out and then everything will be all better, right? And it's just really interesting from a completely different sort of vantage point and coming from a completely different place to hear that, in effect, what the people in your focus groups were telling you was a reflection of that same approach that is so, so narrowed. I just it sounds like a sort of a convergence in an unusual way that from two very different sources that I wouldn't have expected that would come together in this way. But it feels like they're telling sort of the same story.
Lisa Cooper: [00:38:34] Yeah.
Henry Bair: [00:38:36] So then you started really building your your career and your mission, if you will, to examining the race, gender, ethnic dynamics inherent in patient provider relationships and communication. Right? So after all this time, I'm wondering if you can share with us, well, maybe first of all, what does a good patient physician relationship even look like? What are the elements of that good relationship? And then tell us, what can we do to do better?
Lisa Cooper: [00:39:08] Yeah. Wow. Well, um.
Tyler Johnson: [00:39:13] Just fix the American health care system in ten minutes. No.
Lisa Cooper: [00:39:16] Yeah, really? You know, it's like, where does one start? But I think. One of the critical pieces of the patient physician relationship is communication, I have to say, like because I mean, one thing is that people need they need to hear. From their doctors. They need to feel heard. They need to, you know, people to listen to what they're saying. So and then they need to be able to understand what it is that's going on with them, at least from the medical perspective. They need to be a part of the decisions that take place because they they are the ones that have to act on those decisions and live with the the outcomes of those decisions. So I think it's communication. I think it's trust. I think it's feeling respected and heard. I think it's feeling known and I think it's feeling like you're a partnership, you know, where both people are sort of working together towards common goals. So these are things that I think but also things that have played out from from the research.
Henry Bair: [00:40:32] So I'm looking at one of your seminal papers from 1999 in the Journal of the American Medical Association. It's titled Race, Gender and Partnership in the Patient Physician Relationship. And we'll be sure to link that in the show notes. Fascinating findings. You know, you discover that African-American patients find that their interactions with Caucasian physicians tend to be significantly less use word participatory than their experiences with physicians of a similar race. So that, I think, leads me to my next question, which is what are the implications of this study? Does that devil's advocate here, does that mean that our African-American physicians best equipped to care for African-American patients, or is there something that other doctors can learn about what makes those interactions particularly effective? Right.
Lisa Cooper: [00:41:29] I think the answer is both things. In some ways. I think in many ways, African-Americans do better when seeing a physician of the same race. Because of that sort of common understanding and connection that can occur in those relationships. Of course, I would say that's like a generalized statement and it might not be true for any individual patient or, you know, clinician. So I think that that is true and that does have implications for diversifying our physician workforce. But I also think that there are things that can be learned. So at the time that I did that first study, I didn't know what exactly we could do, you know? All I knew was that that patients reported that when they saw a physician of their same race, that they felt that that physician gave them more of a choice, gave them more control, and allowed them to have more responsibility for the decisions that were made. Because didn't really know like what was driving that perception at that point. The main implication of that paper was that. In order to provide African American patients with greater partnership in their their relationships with doctors, we need to provide them with more of a choice of what whether they can see physicians who they feel that they can identify more closely with. Those were the implications, although we also suggested that there might be particular behaviors that could be gleaned from those race concordant relationships that could be then used to train other physicians. So that's why we went on and did the subsequent work where we actually recorded what was going on in those visits because we wanted to understand like, what is it that's making African American patients feel so much more engaged and, you know, involved in their care? And sure enough, we did find that in the visits where the doctor and the patient were of the same racial and ethnic background that African American patients were actually talking more.
Lisa Cooper: [00:43:37] They were sharing more about their concerns and their opinions about things, and the doctors were allowing them to do that. Whereas when they were seeing a white physician, those visits were more dominated verbally by the doctor. Doctor was sort of talking more about 25% more than they talked in sort of race, concordant relationships. And then they also the African American doctors and patients also sounded more relaxed and sounded happier and more interested and engaged. And this was sort of not something that we had necessarily expected, but that's what the independent readers had courted, was that in the race, discordant visits where the doctor and patient weren't of the same race that the visits were actually, they were about you know, they were shorter about two minutes, 2.5 minutes, and that the doctor and the patient sounded more rushed and hurried. And so we we had something there where we knew like, well, there are some pretty concrete things that we can share and train doctors to do that would sort of improve the situation.
Tyler Johnson: [00:44:49] Yeah. I mean, even listening to your description of that, it is I mean, for many complicated cultural, sociological and historical reasons that you referred to a little bit earlier. Right. It's not hard to imagine why many people of color would have a even if they're not aware of it. And often they probably are. But a sense of distrust or foreboding or at least not full trust. Right. That it if you if your family has been subject to redlining and discrimination and you know anyway whatever we could make a long list. It's it is I would imagine that it would be more difficult to have the kind of implicit trust that would allow you to be completely forthcoming with your physician. Right. Or to feel like you were completely comfortable in that sort of an interaction.
Lisa Cooper: [00:45:43] Now. That's true. I mean, think because the relationship is, you know, it's reciprocal, right? So part of it is whether somebody actually creates the space to allow the other person to speak and share their opinion or not. So it's a two way street. You know, it's you may come in feeling already hesitant about saying things. And then if the doctor's like sort of just talking and lecturing you, then you're less likely to, you know, interrupt and like, you know, give them like your thoughts and opinions, right? Whereas if they maybe you come in feeling a little bit. You know, unsure or not sure whether you can trust the person, but they invite that space by basically not talking as much, asking you more open ended questions and letting you tell your story. Then, you know, more of that comes out right?
Henry Bair: [00:46:40] So given all of your findings now, I'm thinking I believe medical education has changed quite a bit from when you were there to when Tyler was there and to when? Well, I graduated a few weeks ago when I was there. We now spend a lot of time in school on diversity and equity. We mostly use that time to examine studies such as yours and discussing the implications of implicit bias and cultural sensitivity and the rest of it. I'm wondering from your perspective, having seen the development of the academic and policy focus on these issues, do you think this is the best way for us to train future doctors, or is there something else we can do to better equip them with an ability to approach patients of all backgrounds?
Lisa Cooper: [00:47:26] Yeah, well, I mean, I think one thing we we could do better. I mean, I'm really pleased with the way medical education has evolved in that at least there's some acknowledgment of the importance of these issues now. And there are like now requirements that some of these topics have to be addressed within the curriculum. I think that there's room for improvement. I think in many ways sometimes the practice gets ahead of the science. So, you know, we discovered that there were these problems and now we're sort of trying to work to figure out like, well, what are the ways in which to really intervene in a successful way? And we don't have all of those answers yet. So we're doing things that we don't really know whether they actually work or not. So we know that you can train people how to communicate better, and we know that that does work, at least in the short term. We're not sure right now. Like how many times do you actually need to like boost that training? You know, how long should that training be? But so there are many aspects of training that we don't really have clear evidence to inform right now. We're trying to just use the best that we have. I think training in better communication skills, we have good evidence for the fact that it does work, you know, even though we don't know how much of it and how many times we need to boost it and all of that, we know that it does work to a certain extent.
Lisa Cooper: [00:48:55] So I think that makes sense. With regard to implicit bias, I think there's a lot less that's known about what really works to address that. So, you know, one would think intuitively that making people aware of the fact that they have a bias will help them. Right? But we've actually found that when you do that and you don't give people other skills to manage that knowledge and, you know, the sort of discomfort that comes with that, that it actually may make them behave worse. So so, you know, I think what we're working to. Identify now is like, what are the actual things that would actually help people manage that sort of discomfort and that anxiety that comes from an awareness that you have this implicit bias and how they can then use that more effectively. Some of it may be the same strategies we use to improve communication, you know, so we have certain tools we know work better. We know that like asking open ended questions allows people, patients to talk more.
Lisa Cooper: [00:49:58] We know that using more reflective listening, like checking back and telling people, you know, I've heard you say this and I'm just trying to make sure that I'm hearing you correctly. Or we know that using teach back, you know, things like saying, you know, I want you to tell me what your understanding is of what we've just talked about. We know that those things are effective. We know they're showing more empathy works. We know that talking less and listening more helps. So we should be focusing on those skills. The implicit bias awareness by itself is not helpful, but the real focus is on how to manage the anxiety or the discomfort that comes from that and how to behave in a different way. One of the things we know from behavioral science is that. You can get people to behave in a certain way, even if their attitudes aren't quite there yet, and their attitudes shift after they've begun to behave in a certain way over time. So I think we should focus on the behaviors because that's what we know the most about right now as we develop more understanding of how people's attitudes can be shaped or changed.
Henry Bair: [00:51:12] Yeah, towards the end there, you actually addressed one thing that I was going to just bring up, which is I was wondering as you were sharing to what degree this kind of training is external in the sense that they are tools, so to speak, that physicians can adopt to appear to be more effective to patients of different backgrounds, and how much of it is actually internalized as an attitude. As you mentioned, that was one question I had is do we know is there any information that shows that just because someone acts a certain way, are they actually changing? And, you know, I hope, of course, even the act of like even putting on the act of of better communication skills, even that is better than nothing. I think ultimately we're trying to get to a point where physicians do it not because they've been trained or taught or because they're being graded or rated on these behavior behaviors, But actually they internalize it such that they adopt these behaviors because this is what actually matters for their patients. This is what brings meaning to these interactions, to these relationships. Hopefully, that's the point we get to. And I'm heartened to hear that you're actually seeing some degree of data showing this is the case.
Lisa Cooper: [00:52:20] Yeah. Yeah. I mean, I do think that behaving in a certain way can shift, you know, attitudes over time, you know, because ideally we want people to behave in ways that are authentic. We know that, you know, patients can identify when when someone's not being authentic. But I think that you said it correctly. It's like engaging in the right behavior, even if it's not driven by like an authentic belief is better than not engaging in the behavior at all.
Tyler Johnson: [00:52:53] Well, Dr. Cooper, you have been so gracious and generous with your time. We as we're wrapping up, we would love to know sort of if you were looking back to your self when you were in medical school or in training however many years ago, and you were going to give yourself some hard earned wisdom that you've gotten along the way, What do you think would like what important things would you want your younger self to know?
Lisa Cooper: [00:53:21] Hmm. Wow. Wow, wow. Well, you know, I think a lot of people say this like with the benefit of like hindsight, you know, it's like. Be fearless, basically, even if you feel afraid. If you know it's what you really want to do or something you feel is really important, do it anyway. You know, the repercussions from doing those things are not nearly as. Bad as regret. Looking back and wishing that you had tried something or you had done something but that you didn't do it. So that's what I would say. Rather make mistakes because you will be able to recover from them. You are stronger than you think you are, and it's better to make a mistake doing something you strongly believe in than to be wishing that you had tried it and regretting that you didn't do it.
Tyler Johnson: [00:54:21] Yeah. The arc of your career reminds me a little bit of the aphorism that oftentimes those who blazed trails are scorned by everybody as being kind of crazy until everybody starts to assume that what they did was always inevitable anyway. Right. Because what what the kinds of questions that you were asking 25 years ago. Right. Are the ones that now are sort of de rigueur. Right. I mean, they've become almost sort of baked into the cultural consciousness. So. Well, we we thank you so much for joining us on the program today. And we thank you for your your many years of hard work and important causes. And we wish you all of the very best.
Lisa Cooper: [00:55:02] Thank you so much. Yeah, this was great.
Henry Bair: [00:55:06] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at www.thedoctorsart.com. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts or wherever you get your podcasts.
Tyler Johnson: [00:55:25] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:55:39] I'm Henry Bair.
Tyler Johnson: [00:55:40] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.
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LINKS
Dr. Cooper is the author of several highly-regarded medical research papers; in this episode we discussed Race, Gender, and Partnership in the Patient-Physician Relationship (1999), published by Journal of the American Medical Association.
You can follow Dr. Lisa Cooper on Twitter @LisaCooperMD.
