American College of Physicians: Internal Medicine — Doctors for Adults ®

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Working to close the racial and ethnic 'health gap'

From the October ACP Observer, copyright © 2003 by the American College of Physicians.

If you reviewed your office, clinic or hospital setting, would you find that all your patients are treated with respect regardless of their race, ethnicity or socioeconomic status? Would you find that they all receive the same level of medical attention, the same preventive health measures, judicious referrals and well-explained treatment plans?

You would probably find that some patients—say, an elderly African-American woman or a young Hispanic man—come to you later in the course of their disease than other patients. As a result, their conditions are often more advanced on first presentation and more difficult to treat.

You might also realize that before this illness, these patients had fewer office visits, more emergency room encounters, less screening and more risk factors than their white, middle-class counterparts. These hallmarks of disparate health care are often the result of poor access, low income, limited English literacy or no health insurance.

Deep—and real—disparities

Equality in our society, while a precious and lofty goal, still eludes us. This is just as true in health care, where racial and ethnic minorities often do not enjoy the same access to care as the majority population, nor receive the same services within the same, relatively prompt timeframe. Sadly, this is true whether we're speaking of preventive health services, curative treatments or palliative care.

Recent reports from several health care organizations, including the Institute of Medicine's "Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care" (2002), have brought the issue of disparities into the public spotlight. Such efforts have helped society and the medical profession "discover," document and explore a complex, deep-seated national problem.

At the same time, we shouldn't fool ourselves that the problem is rooted only in socioeconomic issues—such as low income and lack of health insurance—and has nothing to do with the behavior of U.S. physicians and health care institutions. Researchers investigating medical practice itself are documenting blatantly differential treatment of minority patients with common conditions. Such disparities mean that African Americans, Hispanic Americans and other minority groups suffer and die disproportionately from, among other things, cardiovascular disease, diabetes and several types of cancer.

Organized medicine responds

Last April, the College's Board of Regents adopted as ACP policy the position paper, "Racial and Ethnic Disparities in Health Care." This report is commendable because it provides striking evidence of unequal care.

The report commits the College to taking immediate action on several fronts to remedy disparities in health and health care for minorities. The paper states, for example, that ACP endorses Healthy People 2010. This HHS initiative aims to increase the quality and years of healthy life, and to "close the health gap" that is growing as our nation becomes more of a mosaic of racial and ethnic populations.

The ACP Foundation is seeking to enhance communication, including that between doctor and patient, to improve health care for minority Americans and eliminate racial and ethnic disparities. Together with the Institute of Medicine, the Foundation held a conference in October of last year to explore how improved communication might advance all aspects of medical practice. A second, follow-up conference is planned for next month.

ACP is also co-sponsoring an initiative to engage physicians in dialogue about racial/ethnic disparities in care. This national initiative will help alert physicians about the reality of the "health gap" and enlist their help in closing it. Our partners in this effort are the Henry J. Kaiser Family Foundation, the Robert Wood Johnson Foundation, the Association of American Medical Colleges and eight other health care associations.

I attended the project's kick-off conference, which focused among other issues on disparities in cardiac care. Before hearing the evidence presented in that forum, I believed that patients' low socioeconomic status and lack of coverage were the basis for most health care disparities.

It became clear, however, that this simply is not the case. We were shown data indicating that cardiac care was unequal—that is, less satisfactory—for African Americans and other minorities, even when studies were controlled for clinical and socioeconomic factors. The research assessed a variety of common clinical measures including angioplasty, bypass procedures, thrombolytic therapy and drug treatment of congestive heart failure, with disparities persisting in every category. My eyes were opened.

Individual scrutiny

As physicians devoted to caring for all patients, we may well ask, "How can this be?" An easy or clear-cut explanation seems unlikely. Nevertheless, as we confront the problem and seek solutions to this grave shortcoming in American health care, we must examine ourselves both as individuals and as leaders of our health care teams and institutions.

Bias and stereotyping are common in our society, often the result of naive presumptions about other Americans we do not know well. As we try to practice our craft free from these insidious forces, are our care decisions being influenced, perhaps subtly, by bias and stereotypes?

Similarly, our civic and health care organizations reflect the values, expectations and traditions of this country's powerful majority population. Might mainstream American medical practices themselves be somehow inherently discriminatory by not taking into account the cultural practices, familial and communal structures, and belief systems of racial and ethnic minority groups? Can the culture of medicine be more accommodating to the needs of diverse patients?

And what might members of minority populations tell American medicine about health disparities? Alan R. Nelson, MACP, Special Adviser to the College's Executive Vice President, chaired the Institute of Medicine's committee on understanding and eliminating racial and ethnic disparities in health care. As part of its work, this body convened focus groups of patients with various disorders.

Referring to those discussions, Dr. Nelson was quoted in a newspaper as saying, "There was no evidence of frank racism as a systemic problem in our health care system." However, he continued, "Some of the quotations were really quite striking in identifying a clear perception on the part of minority patients that they are receiving a lower level of quality health care."

Moving forward

So how do we alleviate this vexing problem? We would do well to consider the words of Richard L. Neubauer, FACP, Governor for the College's Alaska Chapter, who discussed the issue recently on one of the College's online newsgroups:

I think the solution lies with physicians, who need to constantly strive to perfect ways to be unbiased in their judgments while at the same time applying their knowledge of how genetic, ethnic and socioeconomic factors can be tools to improve their care to individual patients. To the extent that words and deeds reflect inner processes, they need to be very carefully used in ways that guide and direct the system away from biases that can tear a society apart from within.

Dr. Neubauer's challenge is to each and every one of us. Even though large organizations—including ACP, the AMA, the Institute of Medicine, the Robert Wood Johnson Foundation and the Kaiser Family Foundation—are all engaged in trying to end disparities, they cannot close the health gap alone. Racial and ethnic inequalities will not disappear without a commitment from the individuals who make treatment decisions and provide care. The key to eliminating disparities belongs to each of us.

First, alone and together, we must review and evaluate our own feelings and actions, especially the routine ways we deal with patients. Self-examination and self-reflection are important steps toward dispelling bias as a basis for differential treatment.

Are we really giving all patients equal attention and treatment—and how can we do better? Do cultural, economic or linguistic barriers compromise the care we give certain patients—and how can we remove those barriers?

Second, we must acquire the cultural competency to be able to care for all our patients in this increasingly diverse nation. As practitioners, we also serve as cultural brokers, bridging (successfully or not) the patient's world and the culture of American biomedicine. That can be a formidable challenge, as those familiar with Anne Fadiman's landmark book, "The Spirit Catches You and You Fall Down," well know.

Cultural competency is a term now much in vogue in medical education, and it has complex working definitions. But practically speaking, cultural competency is part factual knowledge of our patients' backgrounds, values and characteristic behaviors, and part imaginative leap to stand in their shoes. Putting cultural competency to work means changing some of how we practice medicine, as well as engaging each patient with respectful, open curiosity about his or her particular cultural milieu.

Finally, the precepts of professionalism must guide us to be examples and set the tone in our practice, whatever the setting. Our commitment to professionalism challenges us to eliminate discrimination in health care whether based on race, gender, socioeconomic status, ethnicity, religion, sexual preference or any other social category. It also obligates us to respect and advocate for each and every patient. To the extent that we can influence our colleagues and the institutions where we work, we must strive to ensure that each patient is afforded respect, compassion and fairness.

I'm confident that by combining our individual actions, we will go far to eliminate disparities in both health and health care. Thus will each of us help remove a shameful blot from the conscience of American health care and accomplish a national healing.

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