About Disparities in Health Care By H. Jack Geiger, MD |
I will not spend hardly any time on the evidence of racial and ethnic disparities in medical care because, as far as I'm concerned, the case has been proven over and over and over again. Over the last four years, my colleagues and I have abstracted and annotated close to a thousand peer-reviewed articles on racial and ethnic disparities in care that met adequate criteria for sample size, control of confounding variables, and all the other things that health care research studies and epidemiologic studies properly worry about. This report, The Right to Equal Treatment, and a complete annotated bibliography, organized by disease, are available online.
| “I will not spend hardly any time on the evidence of racial and ethnic disparities in medical care because, as far as I'm concerned, the case has been proven over and over and over again.” |
We also know that the causes are multi-factorial and complex. There is no single smoking gun. Negative racial and ethnic stereotyping on the part of physicians and other health care providers is just one of multiple contributing causes, some of which we know about, most of which we need to know more about.
Patient-Level Factors. These include patients' knowledge and beliefs about health and illness, as well as the issue of patients' trust in the physician and in the health care system. I started out in looking at this literature on the issue of trust thinking, "Well, here is another victim-blaming attempt to say that all minorities are paranoid and it's their own damn fault." In fact, the evidence is compelling. A recent survey of African-American respondents — we need similar studies of Hispanics and other groups — found a significant plurality of African-American respondents said that their own physician was capable of experimenting on them without their consent, giving them potentially dangerous experimental drugs without telling them, even in the face of evidence that continuity of relationship does mitigate this kind of mistrust. The message of the data on mistrust is that this is yet another element that physicians, other health providers, and institutions and organizations of health care need to be aware of and address.
Patient-level factors also include the out-of-pocket cost of health care independent of the adequacy of health insurance (affordability), fluency in English, health care literacy (knowing something about your disease, disease in general and your recommended regimen), and what are called "preferences," which is a code word for "I refuse to do what the doctor is recommending." There is good evidence for the existence of these preferences. However, in the studies that have looked at it prospectively and elicited evidence of patient preference as a contributor to differential treatment, in no case has that factor been anywhere near sufficient to account for the magnitude of the existing disparities. It is a contributing factor, but not the main element.
Provider Factors. The classic study of negative racial and ethnic stereotyping by physicians is by Michelle Van Ryn and Jane Burke (Social Science & Medicine, March 2000, pp. 813), in which they talked to the patients and the decision-making cardio-thoracic surgeons after angiograms had been performed. They found a profound differential by race in the decision of whether to perform angioplasty or bypass grafting, all other things being the same (how many lesions, where the lesions were, income, health insurance status, co-morbidity, all the rest). They were able to determine, first of all, whether patient preference was a factor. They were also able, subtly and cleverly, without the decision-making physicians knowing that race was the area of inquiry, to determine some of the attitudes that dictated those decisions. It turned out that the decision-making clinicians, usually on the basis of an average 12-minute interview, had decided that the African-American patient did not have the energy to do cardiac rehab; was not smart enough to stay with rehab and really understand all the things that he or she needs to do to manage the disease; did not have a good social support system; did not have a stressful job. Recognize the relationship of these decision-driving views to classic stereotypes provided by our culture. They have their analogues for other minority groups.
This is a double violation. It is a violation of what society professes to be about, and of medical ethics and the commitment of medicine to treat everybody equally.
I also refer you to one other study, from the Cleveland Veterans Administration Hospital. In this study the cardiology fellow worked up the patient and presented all of the clinical and cath lab and history and echocardiograms and other findings to a panel of cardiologists and surgeons. They then discussed each case — some 900 in all — and reached a consensus as to what should be done — medical treatment, angioplasty, bypass grafting. In those 900 cases, there was complete presentation of all of the data, but no mention of race and there was no difference between blacks and whites in who got angioplasty or bypass grafting. Removing the one variable removed any signs of disparity, which is pretty powerful evidence for what is going on.
Other provider factors include clinical uncertainty, stemming from lack of cultural competence or linguistic competence, competing demands and cognitive overload (leading to shorthand thinking and stereotyping), and whether the physician has a patient-friendly style or an authoritarian approach when interacting with patients. In all of these, there is evidence of differentials in care.
Institutional and Community Factors. Finally, there are institutional or organizational factors that contribute to racial and ethnic disparities in the quality of care. We all know about the location of physicians' offices, the neighborhoods where resources are and are not. These factors also include interactions with office staff, the experiences that minority patients report. It is not just the physician. It is the triage nurse, the clerk, all kinds of other people in the health care apparatus who may be contributing in significant ways. What might be called the organizational culture of the health care-providing institution is important including, for instance, the reading level and cultural appropriateness of written or other materials that are provided. I taught for a long time on the faculty of Tufts' Medical School, which sits right on the edge of Boston's Chinatown, and I was there six years before it occurred to Tufts that it might be a sensible thing to put up some signs in Chinese. There is the matter of how co-pays and deductibles are handled. And there is the question of whether a quality oversight and improvement program is in effect at the health care institution. And I would add community-level factors. Are there safety net providers in the community? What are the levels of insurance coverage in that community? What is the level of what might be called "community trust" in the health care system?
Further Study. We need to know much more about the variations in disparities. If we want to find effective interventions, we need to know the relative contribution of each of the multiple factors I have mentioned. If we do not know what is really going on in a given set of circumstances, our intervention — however well-meaning — may totally miss the mark. We do not know what works for cultural competence training, which is all the rage at this point. Many of the early cultural competence curricula are simply lists of the strange behaviors of other people, stereotype-reinforcing items one after the other, never addressing the idea that medical and other health profession students bring two cultures to their work: their own culture — including biases conscious and unconscious — and the culture of medicine. Cultural competence begins with self-examination, rather than the idea that culture is something that is just an attribute of other people.
We do not know very much about how to intervene in physician-patient communication styles. We do know that it is better when there is physician-patient racial or ethnic concordance. We do know that African-Americans and Hispanics will almost always choose preferentially for physicians and providers of their own racial or ethnic or language group.
And we do not know very much about community variations. Why is it, for example, that African-Americans do as well or better than whites at getting pap smears but much worse than the white elderly at getting flu vaccines or pneumococcal immunizations?
What can we do now? First of all, we have to see to it that all clinical data in every
organized setting of care is recorded by race and ethnicity. Minority group respondents are understandably skeptical of doing that. However, there is no way we can monitor what is happening by race and ethnicity, in terms of the quality of care, unless we are collecting data in this way, and it is legal and even federally-mandated to do so.
Secondly, we need to push every organized provider of care to have a quality improvement program and to use practice guidelines for all their patients. One of the reasons quality improvement is useful is that it is something that every physician almost has to subscribe to, and it is less challenging than going head-on with many physician groups about the issues of negative racial and ethnic stereotypes. And there is evidence that it works. There are now about a hundred community health centers, to give one example, that are part of the Health Disparities Collaborative, in which quality improvement guidelines and a set of related mechanisms have reduced disparities in treatment and outcomes.
We should also be training patients from minority groups to be more assertive and demanding. There is evidence that it makes a difference. By changing the nature of physician-patient communication it has an effect on what happens, what is prescribed, and on the quality of the follow-up.
And that leads me to my final point: I do not think change in all of this is going to happen if it is all top-down. This effort has to also involve community-based advocacy groups and community organizations. We have been at this for a decade (we, collectively people researching in this area). We have obviously a lot of work yet to do, but this is a problem that we can and will solve.
— Excerpted with permission from a talk given by Dr. Geiger at a forum sponsored by the NY Metro Chapter of Physicians for a National Health Program.
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