Digest Commentator: Chad Hammond, PhD, Postdoctoral Fellow, School of Rehabilitation Sciences, University of Ottawa
Edited by: Mary Ann O’Brien, PhD, Department of Family and Community Medicine, University of Toronto
Indigenous peoples are often left behind other populations in terms of accessing quality healthcare. In the area of cancer care, for example, their survival rates have lagged behind those of non-Indigenous populations despite recent improvements in cancer screening techniques and treatments. A long, continuing history of institutional racism, dismissal, and mistreatment leaves many Indigenous peoples distrustful and fearful of ‘becoming a patient.’ In many ways, the article by Morris and colleagues captures the current status of Indigenous patient-provider relationships among American Indian and Alaskan Native (AI/AN) patients. Their investigation was sparked by a very appropriate and timely question: how do AI/AN patients and their surgeons perceive the decision-making process around cancer treatment?
Over three years, Dr. Morris and colleagues recruited AI/AN patients (multiple cancer sites) and their surgeons to rate their exchanges with each other. Although somewhat vaguely stated, the authors mention they abided by research protocols developed for respectful engagement with Indigenous communities—an essential ingredient toward developing trust between communities and institutions of research as well as of healthcare. A total of 49 AI/AN patients (62% response rate) completed a host of surveys, among them the Collaboration and Satisfaction about Care Decision scale, Ethnic Identity scale, Everyday Discrimination scale, and the Wake Forest Trust scale. Fourteen surgeons (37% response rate) were also surveyed and interviewed.
The results of this study presented a promising image of patient-provider collaboration. Several domains of trust in providers (including honesty, confidentiality, collaborative decision-making, etc.) were rated quite highly, especially the domain of competence with 78% of patients agreeing or strongly agreeing with a statement about physician competence. Provider fidelity (caring/advocating for patient) was rated the lowest with 53% of patients agreeing or strongly agreeing with a statement about physician fidelity. Without making any causal claims, the authors reported that patients’ higher satisfaction, perceived quality of care, and sense of collaboration were correlated with their adherence to treatment. Twenty-six percent of patients reported non-adherence to treatment and their reasons were mostly non-clinical, citing personal and socio-economic circumstances (e.g., poverty), lack of proper access, and mistrust as potential factors in reducing adherence. Importantly, in all domains providers rated the quality of interaction and collaboration higher than AI/AN patients.
This article is a hopeful gem, asking hard questions around Indigenous participation in healthcare and discovering that the default patient-provider relationship is not adversarial—many AI/AN patients give a vote of confidence in their providers. There are, however, domains needing improvement toward more cooperative, coordinated planning of treatments. The stark difference in patient ratings of provider competence versus fidelity is a powerful one; it suggests that Indigenous patients usually see their healthcare providers as effective healers but not always as loyal allies. The authors suggest that for AI/AN patients trust may matter more than satisfaction. Many Indigenous peoples, bearing the memories of trust betrayed by settler institutions and governments, know this intuitively.
Morris, A. M., Doorenbos, A. Z., Haozous, E., Meins, A., Javid, S., & Flum, D. R. (2016). Perceptions of cancer treatment decision making among American Indians/Alaska Natives and their physicians. Psycho‐Oncology 25,1050-6. doi: 10.1002/pon.4191. Epub 2016 Jul 6
Psycho-Oncology website: http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)1099-1611
Dr. Morris’ university webpage: http://surgery.med.umich.edu/general/patient/faculty/ammsurg.shtml
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