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AAMC Reporter: June 2005
A Word from the President:
"What Can We Do About Disparities?"
I'm a highly educated, well-insured, affluent, white American who lives within easy access of excellent health care providers of all kinds. Even if I weren't a doctor with intimate knowledge of the health care system, given those demographic characteristics I would have an excellent chance of receiving the care I needed were I to get sick. Statistically speaking, I'm as well positioned as possible to receive all the benefits modern medicine has to offer. For all its flaws, the American health care system is well designed to take care of people like me.
Now, suppose I happened to be in a lower socioeconomic strata (that is, I have less income and less education). That fact alone would predict that my chances of receiving the best care available would be diminished. And the lower my socioeconomic status, the more diminished those chances would be. What's more, whatever my socioeconomic circumstances might be, if I didn't have health insurance the likelihood would be far less still of my even getting access to needed care, let alone of enjoying a good outcome. Indeed, not having health insurance in this country, especially if one is poor, is downright dangerous to one's health.
Surely it can't get worse than that, can it? Well, as we all know, it can and does get worse. Throw minority status into the mix and the cards get stacked even higher against getting proper health care. The facts are in, and they should give all of us cause for deep concern. Irrespective of income, and no matter how well educated, and regardless of health insurance status, if you are a member of a racial or ethnic minority in America you have demonstrably less chance than if you are white of receiving optimal care for a host of medical conditions.
The Institute of Medicine's 2003 report entitled Unequal Treatment detailed the evidence, which shows conclusively that substantial differences in the quality of health care exist among racial and ethnic groups over a wide range of illnesses and services. The report took great pains to distinguish between the large array of measurable differences in healthcare quality and the pernicious subset of differences deserving the label disparities.
As defined in this monumental work, healthcare disparities are racial and ethnic differences in the quality of healthcare that are not due to access-related factors (e.g., patient income, education, insurance status), clinical needs (e.g., genetic predisposition, stage of disease), or patient preferences (e.g., choices based on cultural norms). After excluding those factors, all of which are associated with detectable and sometimes large differences in the quality of health care among subgroups of patients, study after study has documented significant residual differences (i.e., disparities) that must reflect "undue differential treatment on the basis of race or ethnicity."
The factors potentially responsible for such undue differential treatment are numerous and can interact in complex ways. Some can involve patients themselves, who may refuse or fail to comply with recommended treatment. Some certainly involve the healthcare system, which often disadvantages racial and ethnic minority populations because of disparate financing arrangements and disparate availability of services. Arguably the most troubling factors involve healthcare providers, whose interactions with minority patients may be influenced adversely by stereotypic attitudes or frank bias.
What has all this to do with medical schools and teaching hospitals? Obviously, quite a lot.
- As stewards of medicine's ethical standards, those of us in academic medicine must acknowledge and bewail the inequities and injustices evident in the very existence of racial and ethnic disparities in healthcare. And we must take forceful action to eradicate them.
- As creators of new medical knowledge, we must spearhead the research efforts needed to better understand the causes of healthcare disparities so that effective countermeasures can be developed and deployed.
- As providers of healthcare services, we must purge our own practices of racial and ethnic biases and we must ensure that our own management systems do not inadvertently disadvantage our minority patients.
- As educators of tomorrow's doctors, we must raise awareness among all future physicians about the nature and adverse consequences of racial and ethnic disparities in healthcare. And we must arm them with the knowledge and skills to take assertive actions to reduce those disparities.
- As advocates for opportunity, we must encourage all qualified minority students to consider a career in medicine, so that they may participate directly in the noble cause of eliminating disparities and thereby improving the quality of healthcare for their communities.
- As gatekeepers to the medical profession, we must ensure that our admissions committees continue to value personal attributes as well as academic achievement and use every legal means available to increase the racial and ethnic diversity of our classes.
We know that medical students from underrepresented minority backgrounds choose disproportionately to practice in underserved communities and to care for uninsured patients. We also know that racial concordance between patients and their physicians improves communication and compliance with medical advice. Moreover, we can reasonably surmise that minority physicians and scientists tend to select research topics of relevance to minority health concerns. It is clear from these and other considerations that increasing the racial and ethnic diversity of the physician workforce is one clear and powerful antidote to the racial and ethnic disparities that currently plague our vaunted healthcare system.
Last year, the Supreme Court re-affirmed the legality of affirmative action as a tool in higher education admissions. The court's governing rationale emphasized that all students benefit from racially and ethnically diverse learning environments. By precisely the same reasoning, we can confidently argue that all patients, minority and non-minority alike, stand to benefit from a racially and ethnically diverse physician workforce. To the extent that diversity among physicians serves to reduce healthcare disparities, it serves also to improve the quality of care for everyone.
As we continue to strive toward a more equitable and effective healthcare system for America, our efforts to eliminate racial and ethnic disparities must occupy center stage.
Jordan J. Cohen, M.D.
AAMC President
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