Effects of Patient Race and Sex on Orthodontic Communication:

A Pilot Study

S. Gajendra*, BDS, MPH, University of Illinois at Springfield, IL, USA

R. Fulford, DDS,MS, A. Koerber, DDS, PhD, E. BeGole, PhD and C. Evans, DDS, DMSc, University of Illinois at Chicago, IL, USA

Introduction• Effective verbal communication is an

important aspect of patient treatment

• Cultural competency and cross-cultural communication is important

• Communication has the potential to improve compliance

Objective

• To explore how differences in patients’ race and sex affect how orthodontic residents communicate with patients.

Literature Review

• Almost $52 billion are spent in the United States on dental services each year

• The Surgeon General’s Report in 2000 and Healthy People 2010 focus on reducing disparities in oral health status

Literature Review

• Patients care about communication (Gerbert, Bleecker and Saub (1994)

• Provider variables affect racial disparities (van Ryn, 2001)

• Dentist patient communication is complex

• Profoundly affected by race and sex (Ong et al, 1995)

Measurement of Communication

• RIAS method counts utterances

• Reliable and Valid (Sondell et al., 1998 & Levinson, Roter, et al., 1997)

• Useful in dental setting (Sondell et al., 1998)

Method• Urban Dental College, Orthodontic

Department, 1/99-1/01

• STUDY SAMPLE – Sixteen orthodontic residents

– Seventy new patients between the ages of 8-18 years

– Eighty-two sessions recorded

– Two types of sessions: records & consult

Method• Audio-taping of sessions

• Roter Interaction Analysis System (RIAS) used to analyze the utterances of the orthodontic residents

• Inter-rater reliability 0.80 (Cohen’s kappa)

Modifications of RIAS• Roter’s 40 utterance categories were

modified and grouped into 20 categories

• Only orthodontists’ utterances analyzed

• Raters count frequency of types of utterances (utterance=phrase)

• Examples: Giving Information, Encouraging, Agreeing with Patient

Variables

• Independent variables:– Patient race (white/non-white) – Patient gender – Records or Consult Session

• Dependent Variables:– 20 types of utterances – Frequencies measured– Time, Warmth, Time Spent Talking

with Others

Demographic Characteristics of Sessions

Session ConsultRecords

2557

PatientRace

WhiteNon-White

1951

Patient Sex MaleFemale

2644

Residents’ Information

• 6% of sessions with female residents

• 4 Female Residents

• 55% of sessions with non-white, mostly Asian residents

• 1 African-American resident

Statistical Analysis: MANOVA

Wilks’ Lambda F Value(23, 52 df)

P value

White 2.28 .009 *

Gender 1.32 .202

Session 6.42 .000 *

WhiteXSession 1.24 .256

GenderXSession 1.79 .041 *

WhiteXGender 1.20 .284

Significance Confirmed by Mann-Whitney Test

White Gender X Session

Agreement p=.006 Time (consult, p=.010)

AsksOpinion

p=.091 Time talkingto Others

(consult, p=.084)

Encourage p=.081 Concern (consult, p=.007)

Partnership p=.013 Empathy (records, p=.059)

Non Medical p=.017 Personal (records, p=.040)

Instructions (consult, p=.010)

Significant Differences in Types of Utterances Made to Whites

0

5

10

15

20

25

30

Nu

mb

er o

f U

tter

ance

s

White

Other

Examples of Communication With No Race Differences

0

5

10

15

20

25

30

35

40

45

50

Open Questions Empathy Concern Admonishment Give Information

Nu

mb

er o

f U

tter

ance

s

White

Other

Gender By Type of Session for Total Time

0

100

200

300

400

500

600

Consult Records

Type of Session

To

tal

Tim

e

male

female

Gender By Type of Session

Time Talking to Others

0

5

10

15

20

25

30

Consult Records

Personal Utterances

0

2

4

6

8

10

12

14

16

Consult Records

male female

Gender by Session Differences Concern Empathy

0

1

2

3

4

5

6

7

Consult Records

malefemale

0

0.5

1

1.5

2

2.5

Consult Records

Gender by Session Differences on Gives Instructions

0

5

10

15

20

25

Consult Records

male

female

Conclusions

• The types of differences in utterances found suggest that the residents were less comfortable talking to non-white patients

• Sex of the patient was also related to differences in communication.

Limitations of the Study• Small sample size

• Low number of orthodontists

• Residents may be different from general dentists and orthodontists

• Boys may have had worse malocclusal conditions than girls

• More sophisticated statistical analysis needed.

Strengths of the Study• New area of study in dentistry

• Important issues of –Compliance–Dentist patient relationships–Provider behavior and oral

health disparities

Suggestions for future studies

• Examine larger sample sizes of patients and dentists

• More specific racial dentist-patient pairings

• Examine communication and patient satisfaction & compliance

Suggestions for future studies

• Include other psychosocial factors such as socioeconomic status

• Match subjects for age and similarity in malocclusion conditions

BIBLIOGRAPHYBartsch A, Witt E & Marks M. (English Abstract). Wirkung von Information und Kommunikation im

kieferorthopadischen Beratungs-und Behandlungsgesprach. Teil II: Kommunikationsstil und Compliance. [The influence of information and communication in the orthodontic consultation and treatment visit. II. The communication style and compliance] Fortschr Kieferorthop, Jan 1995, 56(1), pp.7-15. 

Cooper-Patrick, L., Gallo, J.J., Gonzales, J.J., Vu, H.T., Powe, N.R., Nelson, C. and Ford, D.E.: Race, gender and partnership in the patient-physician relationship. JAMA. 282:583-589, 1999.

Gerbert, B., Bleecker, T., Saub, E. (1994, March). Dentists and the patients who love them: professional and patient views of dentistry. Journal of American Dental Association, 125, 265-274. 

Hall, J. A., Irish, J. T., Roter, D. L., Ehrlich, C. M., Miller, L. H. (1994a). Gender in medical encounters: an analysis of physician and patient communication in a primary care setting. Health Psychology, 13(5), 384-92. 

Levinson, W., Roter, D., Mullooly, J. P. (1997). The relationship with malpractice claims among primary care physicians and surgeons. Journal of American Medical Association. 277(7), 553-559. 

Lipkin, M., Putnam, S. M., Lazare, A. (1995). The Medical interview; clinical care, education and research, New York: Springer-Verlag. 

Ong, L. M., de Haes, C. J., Hoos, A. M., Lammes, F. B. (1995). Doctor-patient communication: a review of the literature. Social Science and Medicine, 40 (7), 903-18. 

Roter D. (1995). The Roter Method of Interaction Process Analysis, (3rd ed.) Baltimore, MD: Johns Hopkins University School of Hygiene and Public Health.  

Roter D, Rosenbaum J, de Negri B, Renaud D, DiPrete-Brown L & Hernandez O. (1998 Mar). The effects of a continuing medical education programme in interpersonal communication skills on doctor practice and patient satisfaction in Trinidad and Tobago.Med Educ, 32(2):181-9.

Nestel, D. & Betson, C. (1999). An evaluation of a communication skills workshop for dentists: Cultural and clinical relevance of the patient-centered interview. British Dental Journal, 187(7), 385-388.  

Sondell, K., Soderfeldt, B., Palmquist S. (1998). A method for communication analysis in prosthodontics. Acta Odontologica Scandinavica.56(1), 48-56.  

Van Ryn M. (2002 Jan). Research on the Provider Contribution to Race/Ethnicity Disparities in Medical Care. Med Care, 40(1 Supp):140-151.

Median Scores Consultation Records Male Female Sig. Male Female Sig. TIME 493 350.5 .010 522 510 WARMth 3 3 3 3 Talking to OTHERS 0 11 .084 17 12.5 PERSonal 4 9.5 11 6.5 .040 LAUGH 4 9.5 4 6.5 APPROV 2 9 21 29.5 AGREE 11 10 10 7.5 EMPATH 0 0 0 1 .059 CONCERN 1 4 .007 3 2 ENCOUR 5 4 3 2.5 PARTNER 3 1 0 0 SELFDISclose 0 0 0 0 DISAPProval 0 0 0 0 CRITICAL 0 0 0 0 ORIENT 27 32 126 108 ADMONInsh 0 0 0 0 CHECK for understanding 3 2 5 5.5 ASKS for opinion 7 8 6 8 MEDCLOSed ended questions 3 1 22 21 MEDOPEN ended questions 0 0 3 2 NONMEDical questions and answers 5 5.5 2 1.5 GIVEINFO 127 72.5 4 6 INSTRUCts 17 7.5 .010 0 0

Medians Non-White White TIME 492.5 476 WARMth 3 3.5 Talking to OTHERS 12 11.5 PERSonal 9 7 LAUGH 5 7 APPROV 16.5 15.5 AGREE p=.006 8 17 EMPATH 0 0 CONCERN 3 2.5 ENCOUR p=.081 3 5 PARTNER p=.013 0 2 SELFDISclosure 0 0 DISAPProval 0 0 CRITICAL 0 0 ORIENT 95 99 ADMONish 0 0 Asks for opinion p=.091 6.5 10 CHECK for understanding 5 4 MEDCLOSed ended questions 16 9.5 MEDOPEN ended questions 1 1 NONMEDical questions and answers p=.017 1.5 4.5 GIVEINFO 8 12.5 INSTRUCts 1.5 3.5