THURSDAY NIGHT IS HEALTH CARE CHANGE NIGHT, a weekly Daily Kos Health Care Series.
This is my first post in the series, so I thought a little introduction might be in order. I am an academic pediatrician, which is really just a fancy way of saying that I do research in addition to seeing patients. It just so happens that my interest lies in improving health care for underserved minority patients.
My interest in disparities has roots in my earliest years in California.
After medical school, I moved to Seattle to complete my residency. It was here that I realized my homeland of California is a uniquely multicultural place. In Washington, I saw residents and attendings alike floundering when dealing with patients whose backgrounds were different than their own. I cringed as doctors would raise their voices to be better understood by non-English speaking patients, and I witnessed time and time again Latino families ignored and passed over during rounds because no interpreter was available. I suppose this is not unique to Washington based on the national statistics on health disparities, but I was motivated to act.
The Institute of Medicine released a report in 2002 called "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care". The IOM concluded,
"The preponderance of studies ... find that even after adjustment for many potentially confounding factors—including racial differences in access to care, disease severity, site of care (e.g., geographic variation or type of hospital or clinic), disease prevalence, co-morbidity or clinical characteristics, refusal rates, and overuse of services by whites—racial and ethnic disparities remain."
(1) (IOM 2002)
The Commonwealth Fund did a health care quality survey in 2001 and found that African Americans, Asian Americans and Hispanics are more likely than whites to experience difficulty in communicating with their physician. They also report disrespect when recieving care and more barriers to care (including lack of insurance or a regular doctor). Minority patients say that they feel they would have gotten better care if they were white. These types of interpersonal barriers are disturbing.
But perhaps even more disturbing are the actual disparities in health outcomes that minorities experience. Let me outline a few of these disparities for you here.
-Of adults over 50, only 1 in 4 (25%) report having received colon cancer screening. This is dismal in its own right, and I believe speaks to larger problems in our system. However, when you break it out by race/ethnicity, only 18% of Hispanics and 16% of Asians reported receiving screening. (2)(Commonweatlh Community Concerns, 2002)
-African Americans are less likely to undergo coronary artery bypass grafting, angiography than whites with similar disease.
-Hispanics who undergo angiography are 40% less likely than whites to undergo coronary artery bypass grafting. (3)
-In patients with kidney failure, 52% of white patients are evaluated for transplant, while only 17%(!) of blacks are evaluated. (3)
-Hispanics and blacks are less likely than whites to have appropriate pain management for fractures.
I could go on all day just about these disparities, but that would only serve to make us all mad and doesn't really address the problem.
A 2001 survey found that 2/3's of physicians don't believe that disparities are a serious problem. (4) They instead believe that socio-economic differences account for the majority of differences in care. I suppose this is the easier thing to believe, and allows a degree of impunity when taking care of patients. However, if we can't even get people to acknowledge a problem, how in the world are we going to provide solutions?
I suppose that first we have to understand the roots of these disparities. Much has been discussed about socio-economic differences, and it is well documented that those who do not have access to health care have less good outcomes, less doctor visits, less preventive care... but these disparities persist despite socio-economic differences. Why?
The harshest critics would say that providers and systems have a conscious bias against minorities. Those involved in the system have a tendency to either "blame the victim" or to say that they do the best they can with the resources available to provide for their patients. In the end, both of these perspectives are defeatist because they chalk up the problem to willful personality flaws rather than addressable issues.
I recently read the book Blink by Malcolm Gladwell. If you haven't read it, I highly recommend it. In it, Gladwell explains how we think without conscious cognition. He also explains that we are not helpless in the face of our unconscious biases. In order to override unconscious associations, we need to change those associations to positive ones.
If you've ever taken the Implicit Association Test https://implicit.harvard.edu/..., then you know that we all possess certain biases and that these biases are created through what we are taught, and our own personal experiences (this includes media). I highly recommend that everyone take this test as an eye opening experience.
So the key to changing these associations is to expose yourself to minority cultures, especially the best aspects of these cultures. The more positive associations are formed, the more likely the medical decisions we make about minorities will be adequate. Also, the more exposure an individual has to different cultures, the more comfortable they are in communicating with individuals from these cultures.
There are many more things that we should emphasize as well, especially including the support and training of more minority health professionals that reflect the racial/ethnic makeup of the communities they serve... but I'll save that aspect for another time.
Let me close today with a couple of recent stories that emphasize my point. The first is about a young man that I met in my clinic. He's a 20 year old African American who has been known to get himself into a bit of trouble here and there in the past. He's a really good kid who's had less than adequate role models. He struggled through high school, and then when he finished he got a part time job and mostly just "hung out".
He came into clinic for a routine physical after not having seen us for a while. He was nicely dressed, made good eye contact and seemed eager to talk. I asked what he was doing with himself these days, and he replied, "Well, I'm going to college. I'm playing basketball on a team. I'm going to run for student government."
I wondered, and actually asked, "Hmm, this is a change... What has brought you to this?"
He said, "Well, I figure if Barack Obama can become president, then I can be anything I want to be... and I think I want to study political science and then law... and I think I could really do some good."
And you know what? He is going to be really, really good.
But this wasn't an isolated incident. I had a 10 year old African American boy in the hospital. He was really sick... but it struck me that he was so polite despite his illness. He always said, "Yes doctor. No doctor. Please. Thank you." This was a kid that was one step away from the ICU, so his formality seemed out of place. I asked his mom, "Why is Q so polite?"
She said, "Aww, I don't know. Ever since all this Barack Obama stuff, Q's been talking like he's going to be the president." I asked if she thought it has had a big or a little impact on him.
She said, "Well, he went from average grades to straight A's and now he has plans for college already. I don't think he ever even knew about college until Barack Obama came up."
So, if this one distant role model can change the entire course of life for at least 2 of my patients, then think of the impact that positive associations can have on providers... We need to make sure that more positive associations are being disseminated, both through the hospitals and through the media. If the lede is always about minority violence, we will have negative associations with that minority group, whether we want to or not... but if positive stories are emphasized, we stand a much better chance of changing those associations to positive ones.
This burden falls to all of us!
In the end, the personal is political and the political is personal.
- Institute of Medicine, Unequal Treatment Confronting racial and ethnic disparities in health care, National Academy Press, Washington, DC (2002).
- DIVERSE COMMUNITIES, COMMON CONCERNS: ASSESSING HEALTH CARE QUALITY FOR MINORITY AMERICANS FINDINGS FROM THE COMMONWEALTH FUND 2001 HEALTHCARE QUALITY SURVEY Karen Scott Collins, Dora L. Hughes, Michelle M. Doty,Brett L. Ives, Jennifer N. Edwards, and Katie Tenney. March 2002.
- BMJ
4.Kaiser Family Foundation. National survey of physicians, part 1: doctors on disparities in medical care. Menlo Park, Calif: Henry J Kaiser Family Foundation, 2002.