Improving Patient Counseling, Reducing Medical Error, and Advancing Health Equity in Primary Care: Strategies and Policy Proposals

Research shows that one in 20 patients are vulnerable to avoidable medical harm1; a portion of these medical failures stems from inadequate patient counseling. In 2016, the Global Burden of Diseases, Injuries, and Risk Factors Study revealed that nearly 50% of the global health burden was a product of modifiable risk factors.2 Both of these concerns have serious implications for health outcomes, including disease, injury, suffering, and death1, but differ in their respective emphases on a preventive and outcome basis. Inadequate patient counseling reflects a failure to inform patients of care options and intervene in modifiable behaviors; improper patient counseling undermines quality of care by fostering the onset or worsening of health condition(s). Conversely, medical errors emerge from negligence, where the physician undermines quality of care by inducing or perpetuating patient suffering via misdiagnosis and failure to refer to specialized care.

Role of Racial Disparities in Perpetuating Quality of Care Concerns

Among these two concerns, patient counseling plays a more prominent role in perpetuating health disparities; this is realized in the context of physician bias. Unconscious bias and racism harm patient health, increase health care costs, and reduce quality of care. Consistent across facilities, age groups, and treatment methods, racial disparities persist in care; racial and ethnic minorities are more likely to receive inadequate care for conditions such as cardiovascular disease, asthma, and diabetes.3 These disparities manifest in interactions within the health system, where minority patients experience care disparities (i.e., access, quality) as a product of their primary care provider’s biases. 

Policy Implications and Recommendations (see Figure I):

Policymakers should give serious consideration to the codification of universal health coverage and quality of care standards for primary care providers.

Health care accessibility disparities emerge from the absence of a right to health care in the Constitution.4,5 Given the persistence of health care inequalities in the U.S., universal access to care is a pivotal step towards minimizing and eliminating health disparities. Care must also be of high quality and incorporate provider accountability standards for inducing patient harm. Incentivizing evidence-based treatment and comprehensive physician training are few strategies to improve primary care quality.5

Primary care providers should make standardized performance information publicly available.

Patient education, choice, and empowerment must be prioritized in medical consumerism. Identifying patients as “consumers” raises concerns about care commercialization and profit motive.7 The compilation of standardized information on primary care provider performance and making it publicly accessible is an example of such an initiative. This would ensure provider accountability and public accessibility to practice-specific information. In turn, individual care choices are better informed and medical errors reduced by accessibility of practice quality standards and performance information.8

Professional medical associations should redefine “medical professionalism” and incorporate the Biased Care Model into association guidelines.

Clinician associations’ revision of norms is integral to improving primary care quality.9 Such revisions require a two-pronged approach: redefining “medical professionalism” and adopting the Biased Care Model. Understanding medical professionalism as a range of actions that are taught over time as opposed to an innate, fixed trait is essential.10 Integrating the Biased Care Model would enhance this reevaluation by critically examining physician and patient interactions at all stages of clinical care encounters. Utilizing this lens provides insight into how racial discrimination perpetuates health disparities and informs an equitable approach to primary care provision.11 

Primary care providers should employ patient navigators and offer controlled community forums/patient counsels to collect feedback from patients and the broader community.

Social capitalist concepts of trust, commitment, and shared purpose are critical to addressing primary care shortfalls.12 At the core of social capital perspectives is the prioritization of community voices, which is grounded in health system accountability and governance. Strategies to strengthen social interactions and networks include employing patient navigators to guide patients throughout the care process and connect them to larger social supports. Another strategy is to require primary care providers to hold community forums and/or patient counsels to ensure patient voices are included in decision-making processes.

The Role of Social Institutions in Addressing Racial Health Disparities

The most promising way to reduce racial disparities in patient counseling and adverse medical events exists within the collective action of markets and professions.  The role of social institutions in addressing health disparities are best understood within the context of a policy proposal; namely, the implementation of evidence-based health care quality performance measures in primary care settings. Analysis of comprehensive primary care in the U.S. revealed that despite evidence that primary care investment can lower costs, improve health outcomes, and reduce health disparities, the nation largely underinvests in primary care.14 Incorporation of safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity measures in the analysis of primary care entities would ensure provider evaluation, accountability, and identify areas for growth and improvement.15

In this proposal, the federal government would inform and incentivize markets to conduct quality performance measures in primary care settings. Professions supplement this by reforming clinical care norms to center inclusive and anti-racist praxis in care provision processes. Rights and communities provide the foundation for policy innovation; patients must have the right to be fully informed and complain about inadequate and inaccessible primary care and communities provide social and financial context that influences care accessibility and choice. However, several limitations and potential unintended consequences exist; one of which includes consistent operationalization of primary care quality measurement strategies across major primary care providers. An unintended consequence is that in the process of ticking all of the boxes in the quality assessment process, the ability to thoughtfully form strong, trusting bonds with patients is compromised.

Next Steps

Addressing pitfalls in patient counseling and adverse medical events in primary care requires multi-level, equity-based interventions. Existing research on racial disparities in the U.S. necessitates interventions to prioritize patient-centeredness and access to quality, affordable care.