American College of Physicians*
*This paper is an abridged version of a full-text position paper (available at www.acponline.org/hpp/healthcare_disp.pdf) written by Shannon R. Lightner, MSW, MPA, and adapted for publication in Annals of Internal Medicine by Rachel Groman, MPH, and Jack Ginsburg, MPE. The original position paper was developed for and approved by the consensus of the Health and Public Policy Committee of the American College of Physicians: Charles K. Francis, MD (Chair); Frederick E. Turton, MD (Vice Chair); Louis H. Diamond, MD; Joe E. Files, MD; Gregory A. Hood, MD; Lynne M. Kirk, MD; Joel S. Levine, MD; Mark E. Mayer, MD; Thomas McGinn, MD; Carla Nester, MD; and Laurence D. Wellikson, MD. Approved by the Board of Regents on 31 March 2003.
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Disparities clearly exist in the health care of racial and ethnic minorities. This position paper of the American College of Physicians (ACP) provides ample evidence illustrating that minorities do not always receive the same quality of health care, do not have the same access to health care, are less represented in the health professions, and have poorer overall health status than nonminorities. The ACP finds this to be a major problem in our nation's health system that must be addressed. The ACP is dedicated to working toward eliminating all disparities in health care. This position paper sets forth specific positions for reducing these disparities and will be the foundation for public policy advocacy by ACP for eliminating racial and ethnic disparities in health care.
Table. Racial Breakdown of the U.S. Population and Uninsured Population
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M. E. Nassar
August 7, 2004
Causes and suggested solution for" Racial and Ethnic Disparities in Health Care"
There is no doubt that the position paper of the American College of Physicians, advocated by the Health and Public Policy Committee(1) is of prime importance and a step in the right diection to amend perceived racial and ehtnic disparities in the management and practices of health care institutionsin the U.S.A. My concern is that the root causes of where we are now have not been adequately explored to reverse the disparities. Since thirty years, the overall riding momentum mainly, the "business of medicine", invaded and infiltrated the sacro sanct relationship of the physician-patient relationship so that the role of the sole family physician has disappeard, especially in rural areas. Instead HMOs and organized group physician practices have taken the place of the family physician and those became concentrated in cities around large university medical centers. Unless minority physicians were able to pass the strict exams and regulations of the various Medical Boards, they were left behind.Similarly not all immigrant minorities could afford city life and some remained living at the periphery of where the "business" is. Second, the powerfull pharmaceutical companies are nowadays dictating to physicians what to prescribe in return for many perks, raising many ethical issues. Third, the academic centers are more geared to cutting edge research, with clinical medicine teaching of lesser importance. In my opinion, the main problem, or common denominator is the uninsured population including migrant workers, irrespective of who they are racially and ethnically. My solution: The academic institutions, and hospitals and emergency departments across the nation have to establish philanthropic trust funds for the care of the poor and the uninsured. The curricula in medical schools have to change with emphasis on graduating primary care physicians with subspecialties in the various disciplines of medicine, surgery etc., hence the primary care clinics become in reality subspecialty clinics, under the direction of professors, to teach to interns and residents subspecialty primary care medicine. For example a poor uninsured patient in primary care medicine clinic is found to have a cardiac problem he maybe referred to the cardiac clinic next door. The same applies if the patient requires admission. he or she are admitted to a " teaching ward", or an "ICU/CCU" under the care of chief resident under the supervision and rounding professor. The presence of "Wards" will raise the question of unequal treatment as compared to paying insured patients. Not true. Medical standars are the same for both, only the location is different. Academic centers should direct the primary care subspecialty clinics in rural areas with obligatory resident rotation to those rural areas. I am a minority physician and have experienced all of the above. Refernce:(1) Racial and Ethnic Disparities in Health Care ACP Position Paper, 3/08/2004, Vol 141(3), 226-232.
Fellow in General Internal Medicine, NYU School of Medicine, NY, NY 10010.
August 10, 2004
Addressing Racial And Ethnic Disparities In Health Care Through Trained Medical Interpretation
To the Editor:The need for improved interpreting services in health care is being driven by the rapid increase in limited English proficiency (LEP) patients, and a federal mandate in 2000 to enforce the Civil Rights Act of 1964, granting LEP patients equal rights to health care as English speaking patients. The Position paper(1)has identified cost and staffing for certain ethnic and minority patients' language needs as two barriers for providing trained interpreter services.
There is evidence that trained interpreter services for LEP patients increases their use of preventive services(2), thereby providing potential cost benefits. Trained interpreters for LEP patients in the Emergency department (ED)is associated with reduced ED return rates and lower 30 day charges without any simultaneous increase in the length of stay or cost of visit(3). Some hospitals have developed interpreter programs after legal complaints were lodged on behalf of patients, whose linguistic needs in health care were not met.
Language lines provide a 24- hour telephone interpreter service and though expensive, is indispensable for certain rare languages, and is an effective solution for health care facilities serving multiple ethnic and minority populations. Remote Simultaneous Medical Interpretation (RSMI) has been recently introduced in health care. RSMI uses wireless headsets for patients and providers who hear each other's words as they are spoken, not delayed or paraphrased, mimicking a language concordant interview and maintaining patient confidentiality. The interpreters are extensively trained in the art of simultaneous medical interpretation and they are at a distant site. Wireless headsets are connected in the clinical areas using Voice Over Internet Protocol, to remote interpreter computer workstations. The first randomized controlled trial comparing RSMI with a trained medical interpreter in the room(4), demonstrated its superiority by greater transfer of information between patient and provider, fewer inaccuracies and greater preference for this modality by both patient and provider. RSMI is a cheaper alternative to the language line for commonly interpreted languages. At New York University (NYU) School of Medicine, RSMI is employed for Spanish, Bengali, and Chinese languages. Studies are ongoing to ascertain if the RSMI compared to other traditional modalities of medical interpretation, is more efficient, causes fewer interpretation errors, and can improve patient follow up for chronic medical conditions and cancer screening. If RSMI can be shown to be a superior modality of interpretation, interpreters may be trained in rare languages as well, and services rendered nation wide, providing a potential solution for staffing needs.
(1) ACP (2004). "Racial and Ethnic Disparities in Health Care." Annals of Internal Medicine 141(3): 226-232.
(2) Jacobs, E. A., D. S. Lauderdale, et al. (2001). "Impact of interpreter services on delivery of health care to limited-English- proficient patients." J Gen Intern Med 16(7): 468-74.
(3) Bernstein, J., Bernstein, E., et al. (2002). "Trained Medical Interpreters in the Emergency Department: Effects on Services, Subsequent Charges, and Follow-up." Journal of Immigrant Health 4(4): 171-176.
(4) Hornberger, J. C., C. D. Gibson, Jr., et al. (1996). "Eliminating language barriers for non-English-speaking patients." Med Care 34(8): 845- 56.
co-principal investigator of a grant received from the "National Cancer Institute" to investigate the impact of Remote Simultaneous Medical Interpretation on cancer screening for limited english proficient patients.
Rachel F. Groman
Health Policy Associate, American College of Physicians
October 18, 2004
Response to Letters to the Editor
To the Editor,
In response to Dr. M.E. Nasser's comments on the American College of Physician's (ACP) position paper, ACP views the elimination of disparities in health care as one of many important steps needed to decrease the number of the uninsured and increase access to quality health care. ACP has developed a framework to provide health coverage for all lower-income Americans as a first step toward providing coverage for all.(1) To control rising out-of-pocket expenses, ACP advocates for reforms that will offer physicians the support needed to adopt health information technology, increase physician-patient time, and improve patient care.(2) Finally, ACP has developed policies to revitalize the profession of internal medicine and ensure an adequate supply of physicians in the specialties of internal medicine.(3)
ACP realizes that uninsurance is a problem that affects all individuals"”not just racial and ethnic minorities. But the striking evidence illustrating that minorities are worse off both in terms of access and care cannot be ignored. Eliminating racial and ethnic disparities in health care is just one more way to improve the overall quality of our health care system.
In response to Dr. Kenneth Cohen, ACP continues to support the consideration of race and ethnicity in determining admissions to institutions of higher education. Minorities are poorly represented in health professions. Affirmative action effectively increases the enrollment of qualified, underrepresented individuals who would not otherwise be afforded such an opportunity. Eighty percent fewer minorities would have been accepted into U.S. medical schools without affirmative action, a rate similar to that of the 1960s.(4) Following rulings throughout the 1990s that ultimately prohibited race-conscious decisions at public schools in four states, there was a decrease in underrepresented minority student enrollment at all U.S. medical schools. The four states where race-conscious admission policies were challenged accounted for 44% of the national decline in underrepresented matriculation during that period.(5)
Affirmative action enhances diversity in the profession, which causes people to challenge stereotypes, shapes the quality of medical education, research and care, and increases access to care. Affirmative action, alone, will not eliminate disparities in health care. ACP supports interventions throughout the educational pipeline, including strengthened math and science curricula, tutoring and mentoring programs, loan forgiveness programs, and efforts to increase the diversity of faculty. Overall, a health care system that mirrors the racial and ethnic makeup of the general population will be more capable of meeting the needs of individuals from diverse backgrounds.
Rachel Groman, MPH Health Policy Associate American College of Physicians
Jack Ginsburg, MPE Director of Policy Analysis and Research American College of Physicians
1. American College of Physicians-American Society of Internal Medicine: Achieving Affordable Health Insurance Coverage for All within Seven Years: A Proposal from America's Internists. Philadelphia: American College of Physicians-American Society of Internal Medicine; April 2002. Accessed at http://www.acponline.org/hpp/afford_7years.pdf on October 11, 2004.
2. American College of Physicians: Enhancing the Quality of Patient Care Through Interoperable Exchange of Electronic Healthcare Information. Philadelphia: American College of Physicians; April 200. Accessed at http://www.acponline.org/hpp/quality_care.pdf on October 11, 2004 and American College of Physicians: The Paperless Medical Office: Digital Technology's Potential for the Internist. Philadelphia, American College of Physicians; March 2004. Accessed at http://www.acponline.org/hpp/paperless.pdf on October 11, 2004.
3. Doherty, R. Focusing the College's Policy Agenda on Revitalization. Philadelphia: ACP Observer; September 2004. Accessed at http://www.acponline.org/journals/news/sep04/washington.htm on October 11, 2004.
4. AAMC Press Release. 3 April 1998. Accessed at www.aamc.org/newsroom/pressrel/1998/ 980403.htm on 4 November 2002.
5. Carlisle D, Gardner J, Lin H. The entry of underrepresented minority students into U.S. medical schools: an evaluation of recent trends. American Journal of Public Health. 1998;88:1314-8.
American College of Physicians*. Racial and Ethnic Disparities in Health Care: A Position Paper of the American College of Physicians. Ann Intern Med. ;141:226–232. doi: 10.7326/0003-4819-141-3-200408030-00015
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Published: Ann Intern Med. 2004;141(3):226-232.
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