Introduction

Patient-physician relationships in healthcare can influence healthcare provision, patient engagement, and health outcomes [1,2,3]. Trust, knowledge, regard, and loyalty have previously been described as the 4 components that frame the patient-physician relationship and its impact on health outcomes [4]. Patient factors (e.g., prognosis, new patient, health literacy), provider factors (e.g., career stage, burnout), mismatch factors (e.g., language, culture), and systemic factors (e.g., time, space) can all interfere with this relationship [4]. Additionally, preconceived expectations and biases related to sociodemographic characteristics, like race or social class, can also influence patient-physician relationships and health outcomes among patients [5, 6]. Sociodemographic characteristics of patients including age, gender, race, sexual orientation, and education are also associated with disparities in the provision of healthcare and health outcomes [5, 7].

Patient-physician social concordance, or similarity of sociodemographic characteristics such as race/ethnicity, gender, sexual orientation, disability status, culture, or language, between patients and providers [5], has been suggested as an important factor in patient-physician relationships and the quality of healthcare delivery and patient outcomes [5, 6, 8]. Patients may experience improved adherence, more timely healthcare delivery, greater shared decision-making, better communication, and higher satisfaction when seen by racially concordant providers [5, 9,10,11,12,13,14,15,16,17]. Patient-physician concordance has additionally been linked to higher patient experience ratings among parents of minority youth [18]. However, these studies have only assessed adult perspectives of their own care or the care of their children and these results are mixed [19, 20]. Less is known regarding the role of patient-physician concordance, and its impact on health outcomes and healthcare interactions among adolescents and young adults [21].

Patient-physician relationships are particularly important among youth who may be entering the healthcare system alone for the first time and have unique concerns of confidentiality, embarrassment, or judgement related to health behaviors [22]. Youth often feel unprepared to independently navigate the healthcare system and young adults are less likely to access healthcare services compared to teens and older counterparts [22, 23]. Greater understanding of youth perspectives on patient-physician relationships can inform programs and policies that improve youth engagement in healthcare and health outcomes. Therefore, the aim of this study was to understand youth perspectives of their relationships with their healthcare providers and the importance of sociodemographic similarities and differences as reported by youth.

Methods

Data was collected via MyVoice, a nationwide text message poll of youth aged 14–24 years [24]. Targeted recruitment was performed through social media advertisements based on national benchmarks for age, gender, race, and census region from weighted samples of the American Community Survey. Demographic data, as well as contact information, were collected in an online survey upon consent for the study, including age, sex, race, ethnicity, level of education, qualification of free or reduced-price school lunch, and census region.

Five open-ended questions were sent via text message to all active MyVoice participants on April 10, 2020 and participants had a week to respond. The questions were created by a team of experts in youth-centered text message survey design, including youth. The 5 questions posed to youth were (1) This week we want to know what you would look for when choosing a doctor. What characteristics are important to you, if any? Why?; (2) Is it important that you have similar characteristics to your doctor (age, gender, race/ethnicity, disability, background, personality, etc.)? If so, what characteristics?; (3) When would being similar to your doctor be important? Specifically, for what type of healthcare visits?; (4) How would being similar to your doctor impact what you say or do during your visit?; (5) If you were in a situation where you felt uncomfortable with your doctor, what could they do to make you feel more comfortable?

Prior to analysis, survey responses are merged with respondent demographic characteristics and deidentified. Two researchers reviewed all open-ended qualitative responses to iteratively develop a codebook of major concepts reported by respondents using content analysis. These codes were then independently applied to the entire dataset by two investigators and organized into major themes. Any discrepancies in coding were discussed to reach a consensus to ensure validity in final categorizations of codes. Demographics and frequency of codes were summarized using descriptive statistics (SAS 9.4). Code frequencies of respondents’ perspectives on the importance of concordance were also compared using chi-square testing.

Investigators responsible for coding and describing major themes included two family medicine physicians, four undergraduate research assistants, one medical student, and a research project manager. All investigators have no relationship to participants and no reported personal attributes or experiences that may influence the research beyond their own experiences with healthcare.

This study was approved by the University of Michigan Institutional Review Board (HUM00119982) including a waiver of parental consent for minor participants. Online consent, or assent for minors, was obtained from all participants. American Association for Public Opinion Research (AAPOR) and the Standards for Reporting Qualitative Research (SRQR) guidelines for survey research are followed in reporting [25,26,27].

Results

A total of 944 participants responded to at least one question (response rate: 81%, 944/1,163). Respondents (Table 1) had a mean age of 19 years (SD: 2.8), were a majority female (54%), white (56%), and had less than or equal to a high school education (50%).

Table 1 Demographic characteristics of survey respondents
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After thematic review of the coded data, three key themes arose: (1) youth value personality, professionalism, accessibility, and the clinical training of healthcare providers; (2) youth most commonly cited gender concordance to be important, noting more comfort and open communication with similar providers; (3) respect and open communication make youth feel more comfortable and youth may switch doctors if they become uncomfortable (Table 2). Each of these key themes are discussed in greater detail below.

Table 2 Questions, themes, frequencies and example participant quotes
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Youth value personality, professionalism, and accessibility in addition to clinical training of healthcare providers

While 30% (279/930) of youth respondents noted education or intelligence as an important factor in choosing their doctor, a variety of other factors also emerged. Youth most commonly reported that “kindness, easygoing, friendly, and non judgemental” or other personality traits (31%; 291/930) were important in choosing their doctor. Others noted factors like “Cordiality, timeliness, and professionalism” (22%; 201/930), accessibility related to being “covered by my insurance…located near me, has availability to schedule appointments” (19%; 181/930), and “easy to talk to and explains information in a way that’s easy for me to understand” (19% (178/930). Some youth even noted they would rely on word of mouth or “good ratings” and reviews to help them choose a doctor (19%; 173/930).

Youth most commonly cited gender concordance to be important, noting more comfort and open communication with similar providers

When prompted about the importance of patient-physician similarity, almost half of youth respondents (44%; 401/903) noted that similarity with their physician was not important to them or that personality and relationship were more important.

No, I don’t care about my physician’s physical/social traits aside from personality. They need to be kind and considerate, but aside from that, I don’t care if they’re male, female, old, young, disabled, normally abled, poor, rich, white, black, brown, or even green! As long as they are a good person who cares, understands, and offers scientific treatment, I am happy with them.

About one third of respondents (37% 337/903) noted similarities were important while others said it depended on the situation or that it mattered for some characteristics but not others (18%; 159/903). Among this group that reported a preference for patient-physician concordance (55%; 496/903), most (68%; 339/496) noted that “It’s helpful to have the same gender for me.” Other factors noted by youth included age (“I prefer younger doctors just because it makes me more comfortable.”; 15%), race or ethnicity (“yes, my pediatrician is a black woman which is important for my because i am those things as well”; 15%), and personality (“A similar personality would be nice as well as similar beliefs”; 7%). Less commonly noted characteristics included values or religious beliefs, background (socioeconomic, life experiences, etc.), LGBTQ + status, and disability status.

Respondents identifying as female were more likely to report concordance as important overall compared to non-female respondents (female: 46% vs. male: 26% and other identity: 38%; p < 0.0001) and more likely to note a desire for gender concordance specifically (female: 81% vs. male: 43% and other identity: 55%; p < 0.0001). Among respondents noting any preference for concordance, non-white and low-income participants were more likely to note a preference for racial concordance (29% vs. 4%; p < 0.0001 and 21% vs. 12%; p = 0.0089 respectively) and less likely to note a preference for gender concordance (62% vs. 73%%; p = 0.0103 and 52% vs. 75%; p < 0.0001 respectively) compared to their counterparts. Within the full cohort 8.1% of respondents noted a preference for racial concordance (15.9% of non-white and 2.2% of white individuals, p < 0.0001). Black respondents were most likely to report preference for racial concordance (25%) compared to individuals with Asian (15%), Hispanic (14%), white (2%), and other (8%) racial identities (p < 0.0001).

When asked when being similar to their doctor would be important, most respondents (74%; 628/852) again noted that similarity would matter only in specific instances and a few (9%; 74/852) noted it would always be important. Sexual health related care was the most commonly noted scenario in which similarity would be important (58%; 405/702). Within this group, most (76%; 308) specified the importance of similarity for female health issues, “Gynecologist, anything that is gender specific,” with fewer individuals (10%; 40) reporting on male specific issues like, “Male doctor for male things.”

Participants identifying as male were least likely to report that being similar was always or sometimes important (male: 70% vs. female: 90% and other identity: 86%; p < 0.0001) with females most likely to report importance for sexual health visits (female: 68% vs. male: 38% and other identity: 59%; p < 0.0001) compared to other genders. Non-white and low-income individuals were more likely to report similarity would be important for cultural or language related concerns (12% vs. 4%; p < 0.0001 and 13% vs. 4%; p < 0.0001 respectively) compared to their peers and less likely for sexual health visits (51% vs. 63%; p = 0.0024 and 51% vs. 61%; p = 0.0124 respectively).

In regard to the impact similarity would have on youth during a visit, respondents most commonly noted it would “Make me feel more comfortable disclosing personal information” (41%; 342/838) or “It would let me be more open and honest” (37%; 307/838). They also noted they “might be more honest with someone who understands my culture and is not judging” (14%; 116/838). Many youths however noted it would have no impact (20%; 168/838) or they were unsure how it would impact what they said or did during a visit (5%; 41/838).

Non-cisgendered respondents were most likely to report that similarities would help youth feel more understood (other identity: 26% vs. female: 14% and male: 10%; p = 0.0015) and create more open communication (other identity: 55% vs. female: 37% and male: 30%; p = 0.0003) while females were most likely to report being similar would help them to feel comfortable (female: 50% vs. male: 27% and other identity: 28%; p < 0.0001). Non-white participants were more likely to report similarities would help them feel more understood (17% vs. 11%; p = 0.0035) compared to white participants.

Respect and open communication make youth feel more comfortable and youth may switch doctors if they become uncomfortable

When youth were asked about what would make them feel more comfortable if they felt uncomfortable with their doctor, youth noted both situational and provider specific ideas. Youth most commonly (20%; 167/821) noted that their doctor should just “treat me with respect” or “just have more open conversation overall” (14%; 114/821) in these instances. Respondents also suggested they “address the discomfort and talk through it” (13%; 108/821), “be reassuring” (13%; 103/821), and “Be empathetic and truly listen” to their concerns (10%; 84/821).

From a situational perspective, a number of respondents (7%; 59/821) noted that their doctor could bring a chaperone into the room to help them feel more comfortable: “have another person in the room to help mediate” or “Possibly have another female present.” Another group of respondents (13%; 108/821) however noted that if they were made uncomfortable by a doctor there was nothing to be done and they would simply switch providers or want their provider to provide a referral to another provider - “I would switch right away.”

Discussion

Youth respondents in our study valued providers’ personality and empathy when choosing their provider. Demographic characteristics such as age, gender, and race/ethnicity were less commonly noted to be important. When reported, gender concordance was most often noted by self-reported female respondents and in the context of sexual health visits. Non-white and low-income respondents were more likely to prefer racial concordance than their peers, though desire for racial concordance was low for both groups. Participants also noted that uncomfortable situations could in part be mitigated by respect and open communication, though some youth preferred to simply switch providers.

Across all respondents, concordance was most important in relation to gender and, relatedly, in the provision of sexual health related care. These results are similar to prior research in adults that has suggested gender concordance to be particularly important to patients and tied to perceived quality of care [28, 29]. Preference for racial concordance in our sample was primarily reported by non-white participants. This may be expected since the majority of physicians in the United States identify as white, making racial concordance inherently more likely for white youth [30, 31]. Additionally, non-white participants were more likely than white respondents to prefer providers that had similar cultural backgrounds or language fluency, which is similar to past studies that demonstrate that minority or non-English speaking patients prefer racial and language concordance [28, 32]. However, overall, the percentages of non-white youth and youth overall reporting that racial concordance was important was relatively low (16% and 8% respectively), with some youth reporting explicitly that it was not important. Evidence from past studies is mixed on the impact of concordance on healthcare [20, 33, 34], with the exception of language concordance [35, 36]. Healthcare providers may better engage and support youth as they develop more independence in their own healthcare if youth are provided options and are guided in selecting a provider that would be a good fit. Online reviews or ratings, which are critical to many consumers [37], may be of particular interest to youth in selecting a provider and these avenues were already noted by respondents in our study. Similarly, education regarding how to change their provider may empower youth to “shop” for a provider that best fits their needs by researching online or via their social network, rather than avoiding care if/when they have uncomfortable experiences with a provider.

Many youths also mentioned the importance of respect, compassion, and communication within patient-provider relationships. These perspectives are similar to previous research that highlighted the importance of providers being “youth-friendly” [38]. This research, as well as guidelines for youth care, note the importance of ensuring good communication so youth feel heard and understand their care plan. Youth-friendly care also includes creating an environment that is friendly, respectful, non-patronizing, non-judgmental, honest, and unbiased among others [38,39,40,41,42,43]. These insights emphasize educating and preparing providers and healthcare administrators to implement these tangible and intangible factors. Programs such as the Adolescent-Centered Environment Assessment Process (ACE-AP) are designed to assess and improve the adolescent-friendliness of clinics and have been found to improve the quality and satisfaction of care provided to youth [44]. Inclusion of training on concepts such as cultural humility [45] and structural competency [46] may additionally enable providers to care for youth in a respectful and supportive way. The Association of American Medical Colleges has also developed a professional readiness exam (PREview) for pre-medical students that assesses cultural competence, social skills, and listening skills. These new assessments demonstrate the value that medical schools are beginning to place on these skills [47, 48].

Similarly, if concerns were to arise where youth felt uncomfortable with a provider, respondents in our sample favored providers being “nice,” “respectful,” and addressing the issue directly to ease their discomfort. Though directly addressing uncomfortable situations may be difficult for providers, youth have previously reported higher satisfaction when sensitive topics were addressed at their visit [49] as well as appreciation of direct communication [38]. However, as mentioned by participants in this study, some youth may simply need to change providers to improve their care experience [38]. In these situations, it may be important for providers and clinic staff to offer alternative options so youth understand that they can ask for a new provider who they may feel more comfortable with or connected to. Opportunities to connect with adolescent and young adult specialists, who are specifically trained to support this population, during this period of transition may also be an important option [50]. Efforts to accommodate patients’ preferences for patient-physician concordance should be undertaken with care, so as to not exacerbate the minority tax [51] on physicians from historically marginalized backgrounds in medicine. This can potentially be accomplished by diversifying the physician workforce and by training all healthcare providers to better deliver care across differences.

Limitations

There are several limitations of this study. The MyVoice sample is not nationally representative and therefore responses may not be generalizable. The questions asked were also hypothetical and may not match their behaviors as we did not ask youth about their actual interactions in healthcare to protect their confidentiality. Some respondents were also under age 18 and may have limited experiences with managing their healthcare independently. As in all surveys, it is also possible that youth’s responses are subject to desirability bias, though our findings included many responses that are critical and counter to current norms.

Conclusions

In conclusion, our findings suggest that personality and empathy are important provider characteristics valued by youth. Youth in our sample that identified as female were more likely to prefer gender concordant providers, particularly for sexual health related issues, and non-white respondents were more likely to prefer racial concordance compared to peers. Programs that assess and strengthen professional and interpersonal skills such as listening and cultural humility may improve engagement and satisfaction among adolescent and young adult patients, particularly non-white and female patients. Addressing uncomfortable interactions directly or switching providers are approaches youth in our sample endorsed.