Does a physician's attitude towards a patient with mental illness affect the clinical management of diabetes?: Results from a mixed method study

We examined whether physician attitudes towards patients vary by mental health comorbidity and whether this affects clinical management of a chronic condition (type 2 diabetes). A factorial experiment included 256 primary care physicians who observed video vignettes of a patient with diagnosed but uncontrolled diabetes. Patients were varied by age, gender, race, and comorbidity (depression, schizophrenia with normal affect [SNA] or bizarre affect [SBA], eczema as control). Respondents participated in a structured interview, wrote a chart note, and engaged in a qualitative interview. Quantitative measures of attitudes towards the patient included four subscales: Ability to Manage Health, Personal Attributes, Willingness to be Socially Connected with the Patient, and Patient's Danger to Self/Others. Quantitative outcomes included number of clinical actions; glycemic control; and screenings for diabetes complications. ANOVA models tested differences in attitude subscales by comorbidity, adjusting for patient, physician, and organizational characteristics. Linear regression tested for relationships between attitude subscales and clinical actions. The qualitative interview addressed respondents' impressions of the vignette patient, additional information they would include in the chart, and what they would discuss with colleagues that was not in the chart note. Qualitative thematic analysis was conducted by comorbidity group. Findings: Physicians rated patients with SBA lowest on Personal Attributes (F=8.60, p<0.001) and highest on Danger (F=11.79, p<0.001). Differences in attitudes that were attributable to comorbid mental illness (particularly SBA) did not predict diabetes management as measured quantitatively, but qualitative data revealed differences in management of patients with SBA. Mental health co-morbidities generally increased engagement with patients about social history; however, physicians had less trust that patients with SBA would give reliable information, leading to less engagement of the patient. Additionally, physicians were more likely to tell colleagues about a schizophrenia diagnosis when the patient had a bizarre affect, thereby shaping expectations before interactions occurred. Conclusions: Results are consistent with common stereotypes about people with serious mental illness; importantly, vignettes did not include intentional indication of danger or unreliable reporting. Subtle differences in management of patients with comorbid SBA could lead to disparate care over time. Different management of patients with SNA vs. SBA suggests that affect contributes to variation in care. Despite medical training, physicians are not immune to common stereotypes that can shape behavior, thereby potentially perpetuating stereotypes. Reducing healthcare disparities requires attention to subtle aspects of managing patients--particularly those with atypical affect--as seemingly slight differences can engender disparate patient experiences over time.