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June 2002 Reporter
AAMC Strives for Improved AMCAS
Residents' Lawsuit Takes Aim at the NRMP
Confronting
"Unequal Treatment"
Doctor
Musicians
Viewpoint
Word from the President
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Confronting "Unequal Treatment":
The Institute of Medicine Weighs in on Health Care Disparities
By Barbara A. Gabriel
The 14th amendment to the Constitution of the United States guarantees
to all citizens "equal treatment under the law." In titling
a paper detailing the results of a comprehensive study of racial
and ethnic health disparities in the United States, the committee
responsible for the paper chose to emphasize their findings by creating
a play on words that belie the 14th amendment's guarantee. "Unequal
Treatment: Confronting Racial and Ethnic Disparities in Health Care"
fulfills a 1999 congressional directive to the Institute of Medicine
(IOM) to evaluate potential sources of racial and ethnic disparities
increasingly evident in health care and medical outcomes in this
country.
In a report spanning nearly 600 pages and representing 18 months
of independent research and comprehensive literature review, the
15-member IOM Committee on Understanding and Eliminating Racial
and Ethnic Disparities in Health Care builds a strong case for the
findings and recommendations it makes to fulfill its congressional
mandate. Beginning with the documentation of "overwhelming
evidence," in the words of committee chair Alan R. Nelson,
M.D., of the existence of racial and ethnic disparities in the U.S.
health care system, the report states that these disparities are
associated with higher morbidity and mortality rates among minority
patients; they are, in a word, "unacceptable."
News organizations across the country have emphasized the report's
findings that even when insurance status, income, age, and severity
of diagnosis are comparable among minority and non-minority patients,
racial and ethnic minorities continue to receive lower-quality health
care than their white counterparts. The report attributes these
disparities to a number of causes, including a lack of awareness
of the existence of disparities among both the general public and
health care providers, the fragmentation of health plans along socioeconomic
lines, the lack of interpretation services where needed, and the
need for more resources to enforce civil rights laws.
"What is needed is a comprehensive, multi-level intervention
strategy to address disparities," says Brian D. Smedley, senior
program officer at the IOM, study director for the committee, and
editor of "Unequal Treatment." "The report attempts
to make very clear that the health care playing field is not level.
We know that these disparities are consistent and persistent across
a wide range of settings, even after controlling for access-related
factors, such as insurance status or ability to pay. But it remains
a complex problem and we need complex solutions to address it."
A Wake-Up Call for the Medical Profession
The report makes numerous claims regarding the role that health
care providers - and the medical education system - play in perpetuating
health care disparities along racial and ethnic lines. Thomas S.
Inui, Sc.M., M.D., an IOM committee member who is also a senior
scholar at the Fetzer Institute in Kalamazoo, Michigan, and Petersdorf
scholar-in-residence at the AAMC, says that members of the committee
were "stunned" by a "strong body of evidence"
supporting the role that bias, stereotyping, prejudice, and clinical
uncertainty on the part of health care providers play in perpetuating
health care disparities. "The problem we uncovered is one in
which physicians and other health professionals create a pattern
of care which, on the face of it, is discriminatory," says
Dr. Inui. "I think what the report amounts to is a wake-up
call for the profession."
Dr. Inui notes that the report's conclusions were made on the basis
of indirect evidence drawn from a pool of social psychology literature
that examines how attitudes operating at an unconscious level shape
the clinical encounter. "The committee did not uncover racism
of an explicit type," Dr. Inui explains. "However, within
the social psychology literature we examined, we gathered a strong
body of evidence that looked at how attitudes operating at an unconscious
level might be present in everybody. Under considerable time constraints
and when serious consequences may result from their decisions, physicians
might draw upon stereotypical information, which may in turn affect
clinical decision-making."
Dr. Inui says that evidence of stereotypical assumptions affecting
physicians' decisions are apparent in post-evaluation interviews
in which physicians are questioned about the reasons they made specific
decisions concerning different patients. "They don't express
universal beliefs about specific minority populations, but physician
comments about patients' intelligence, ambition to return to work,
and the security of their social situations pop up more often when
they explain their decisions regarding minority patients than they
do when they explain what they decided to do with white patients,"
says Dr. Inui.
He adds that while explicit prejudices or biases may contribute,
the unconscious mechanisms involved in stereotyping are the best
explanation the committee could uncover to account for its findings.
"The difficulty in dealing with this phenomenon is that it
literally operates without our knowing it," affirms Dr. Inui.
Antonio M. Gotto, Jr., M.D., D.Phil., dean of Cornell University
Joan and Sanford I. Weill Medical College and Graduate School of
Medical Sciences, agrees. "The doctors I see, the doctors we
train, I don't believe are aware of a racial bias," he says.
"But there may be some attitudes present at the subconscious
level that affect ways in which physicians view their patients."
Learning to Stereotype
The IOM committee also found that the medical education process
might have a hand in generating the racial and ethnic stereotypes
that result in the disparate treatment among patients of different
colors and cultures cited in the report. Dr. Nelson, who in addition
to serving as the IOM committee's chair is a special advisor to
the CEO of the American College of Physicians-American Society of
Internal Medicine, says that medical students learn stereotyping
as part of the medical education process. "Stereotyping is
a mental shortcut we all take that keys our responses to specific
experiences," Dr. Nelson explains. "In the medical education
process, we learn these mental shortcuts that may be accurate in
the aggregate but can result in bias that results in disparate treatment
on a case-by-case basis."
According to Dr. Inui, attempts by medical schools and residency
programs to institute cross-cultural training may in fact backfire
and result in additional patient stereotyping if applied as a form
of simple "ethno-medicine" that encourages generalizations
about different groups' experiences of pain and illness. "If
done in a simple-minded way, ethno-medicine is another set of simple
facts to memorize about racial and ethnic sub-populations,"
he explains. "It can add up to simple-minded stereotypes and
a formulaic approach, such as, 'If this patient is Hispanic, I must
be careful about over-estimating the amount of pain he is in because
they are demonstrative about pain.' Such simple recipes do not promote
deeper thinking or decision-making about what's happening in a doctor-patient
interaction."
Another part of the problem, says Dr. Inui, is the environment
in which many medical students serve their residencies. Such settings
are often hospitals in which poor populations of minority patients
are cared for. Often the only aspects that students see of the communities
in which they work are what produces the circumstances that bring
individuals to the hospital: violence and drug abuse. Over time,
Dr. Inui says, students and residents acquire the impression that
these are common occurrences in all racial minority communities.
Jeanette E. South-Paul, M.D., professor and chair of the Department
of Family Medicine at the University of Pittsburgh School of Medicine,
concurs that students and residents are exposed in their training
years to a skewed patient population. "The bulk of patients
cared for by our medical students are suffering from poor lifestyle
choices, a lack of insurance and therefore a lack of access, and
conditions that patients allow to get worse before they seek treatment,"
she says. "I don't think there is any way you can discount
the resulting contribution of bias on continuing disparities in
health care."
Professional Diversity as a Remedy for Disparity
The obstacles that the above factors pose to effective doctor-patient
communication, says Dr. Nelson, were repeatedly highlighted by much
of the social psychology literature, experts, and focus groups assembled
and reviewed by the IOM committee. This finding led committee members
to point to communication difficulty as a primary barrier to effective
care that in turn indirectly results in worse outcomes. "Data
show that minority patients indicate a higher level of satisfaction
with their care if that care is provided by members of their own
race," says Dr. Nelson. "So I'm confident that to the
degree that physician communication skills are improved and cultural
awareness and attitudes are bettered, patient compliance and confidence
in the clinical encounter will improve as well."
However, Dr. Inui cautions that the observation that minority patients
are more satisfied with health care delivered at the hands of members
of their own racial or ethnic group not be used to argue that "race
matches" are the most desirable solution to health disparities.
"That could possibly create 'race ghettos' for medical care
in our society," he warns. "And I don't think any of us
want to repeat our history of segregated public services."
Dr. South-Paul echoes his sentiments. "We need to be training
all physicians to care for patients who do not look like them,"
she affirms. "That's a responsibility of everyone who is a
member of the medical profession, not just those who are minorities."
However, the committee concurred on the importance of giving patients
who want race-matched interactions with their clinicians the choice
to have them. "Since we don't have enough minority physicians
to always make that choice possible," says Dr. Inui, "committee
members agreed that we must increase racial diversity in the health
care professions, both for the benefit of patients and the educational
experience of students and residents." Dr. Gotto, for one,
is striving to achieve racial parity at Cornell University Weill
Medical College, where 25 percent of the incoming class of 2005
are underrepresented minorities. "I don't think there's any
doubt that increasing the number of minority physicians will help
address the disparities we now see," says the dean.
Echoing the language of the IOM report, Dr. Inui affirms that medical
schools that explicitly attempt to develop racially and ethnically
diverse student bodies and faculty and structure their education
methods around diverse small-group learning give their students
opportunities to constructively learn how race and culture impact
medical care. "There's a close relationship between what we
model in the teaching and learning environment and what our students
decide medicine is about," Dr. Inui explains. "So bringing
to light racial and ethnic differences and learning about them in
small groups with a heterogeneous faculty and student body is an
important element in ultimately reducing health care disparities."
Dr. Nelson agrees that it is only by illuminating physicians' racial
biases that they can be remedied. "As the title of the report
attests," he affirms, "we must not simply recognize health
care disparities, but we must confront them as well."
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