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Position Papers |

Recommendations for Teaching about Racial and Ethnic Disparities in Health and Health Care

Wally R. Smith, MD; Joseph R. Betancourt, MD, MPH; Matthew K. Wynia, MD, MPH; Jada Bussey-Jones, MD; Valerie E. Stone, MD, MPH; Christopher O. Phillips, MD, MPH; Alicia Fernandez, MD; Elizabeth Jacobs, MD, MPP; and Jacqueline Bowles, MD, MSCE
[+] Article and Author Information

From Virginia Commonwealth University, Richmond, Virginia; Massachusetts General Hospital, Boston, Massachusetts; The Institute for Ethics at the American Medical Association and Stroger Hospital of Cook County & Rush University Medical Center, Chicago, Illinois; Emory University School of Medicine, Atlanta, Georgia; The Cleveland Clinic Foundation, Cleveland, Ohio; San Francisco General Hospital, San Francisco, California; and Sepulveda Ambulatory Care Center, North Hills, California.


Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Wally R. Smith, MD, Division of Quality Health Care, Medical Director, Center on Health Disparities, Virginia Commonwealth University, Box 980306, 1200 East Broad Street, Room W10W-402, Richmond, VA 23298-0306.

Current Author Addresses: Dr. Smith: Division of Quality Health Care, Center on Health Disparities, Virginia Commonwealth University, Box 980306, 1200 East Broad Street, Room W10W-402, Richmond, VA 23298.

Dr. Betancourt: Massachusetts General Hospital, 50 Staniford Street, Suite 942, Boston, MA 02114.

Dr. Wynia: The Institute for Ethics at the American Medical Association, 515 North State Street, Chicago, IL 60610.

Dr. Bussey-Jones: Emory University School of Medicine, 69 Jesse Hill Jr. Drive SE, Atlanta, GA 30303.

Dr. Stone: General Medicine Unit, Massachusetts General Hospital, Bulfinch 130, 55 Fruit Street, Boston, MA 02114.

Dr. Phillips: Health Services Research Section of Hospital Medicine, E13, Department of General Internal Medicine, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195.

Dr. Fernandez: San Francisco General Hospital, Primary Care Research Center, Ward 95, 995 Potrero Avenue, San Francisco, California 94110.

Dr. Jacobs: Collaborative Research Unit, Stroger Hospital of Cook County & Rush University Medical Center, 1900 West Polk Street, 16th Floor, Chicago, IL 60612.

Dr. Bowles: Sepulveda Ambulatory Care Center, 16111 Plummer Street (00PG), North Hills, CA 91343.


Ann Intern Med. 2007;147(9):654-665. doi:10.7326/0003-4819-147-9-200711060-00010
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Racial and ethnic minorities often receive lower-quality health care than white patients, even when socioeconomic status, education, access, and other factors are used as controls. To address these pervasive disparities, health care professionals should learn more about them and the roles they can play in eliminating them, but few curricula are focused on understanding and addressing racial and ethnic health disparities, and well-accepted guidelines on what and how to teach in this complex area are lacking.

The Society of General Internal Medicine Health Disparities Task Force used a review and consensus process to develop specific recommendations and guidelines for curricula focusing on health disparities. Learning objectives, content, methods for teaching, and useful resources are provided. Although the guidelines were developed primarily for teaching medical students, residents, and practitioners in primary care, the Task Force's general recommendations can apply to learners in any specialty.The Task Force recommends that a curricula address 3 areas of racial and ethnic health disparities and focus on the following specific learning objectives:1) examining and understanding attitudes, such as mistrust, subconscious bias, and stereotyping, which practitioners and patients may bring to clinical encounters; 2) gaining knowledge of the existence and magnitude of health disparities, including the multifactorial causes of health disparities and the many solutions required to diminish or eliminate them; and 3) acquiring the skills to effectively communicate and negotiate across cultures, languages, and literacy levels, including the use of key tools to improve communication. The broad goal of a curriculum on disparities should be for learners to develop a commitment to eliminating inequities in health care quality by understanding and assuming their professional role in addressing this pressing health care crisis.

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Adapting the "Rooney Rule" to Healthcare
Posted on November 3, 2007
Mahesh Krishnamurthy
Easton Hospital
Conflict of Interest: None Declared

It is laudable that the Society of General Internal Medicine Health Disparities Task Force has addressed the importance of racial and ethnic disparities in health and health care and formulated recommendations. (1) The practice of medicine is indeed extremely complex and the fact that healthcare practitioners deal with a variety of people from different backgrounds makes this really challenging. It is a matter of immense shame that in the great democratic American society, we have such glaring disparities in healthcare delivery, purely because of the racial and ethnic differences in background. Modern day medical education does not adequately address cultural issues in healthcare at both medical student and medical resident levels. Cultural sensitivity education should definitely be made mandatory for all healthcare providers and it should be required for them to attend cultural sensitivity seminars periodically. It has been suggested by prior research that these may result in more effective healthcare delivery to patients from diverse backgrounds. (2)

As a physician (of minority background) taking care of patients (a significant proportion of whom hail from racial and ethnic minorities), I believe communication gaps in patient-physician relationships are the most significant reason for poorer healthcare outcomes in these groups. Having multi-ethnic staff at healthcare facilities is the best way to make these patients comfortable and communicate better. It is also the best way to make physicians and other healthcare personnel sensitive to cultural, linguistic and literary issues. This is akin to the "Rooney Rule" in the National Football League (NFL) that requires teams to interview minority candidates for head coaching opportunities. Since the "Rooney Rule" was established, several NFL franchises have hired minority head coaches. This rule has not eliminated discrimination in NFL hiring, but it has established procedures that will reduce discrimination's impact over time. The key to eliminating racial and ethnic disparities lies in eliminating the implicit biases that are produced and perpetuated by everyday life experiences and that manifest themselves in unconscious decisions and perceptions. (3) The importance of recruiting healthcare personnel (physicians, nurses, medical technicians etc.) from diverse cultures is that it would reduce these biases and also positively influence the environment perceived by all the patients. It might then improve outcome measures like patient satisfaction and treatment adherence and reduce disparities. We should therefore consider seriously the NFL's experience and adapt this to the healthcare work environment.

References

1. Smith WR, Betancourt JR, Wynia MK etal Recommendations for Teaching about Racial and Ethnic Disparities in Health and Health Care Ann Intern Med. 2007 Nov 6; 147(9): 654-665

2. Tucker CM, Herman KC, Pedersen TR, Higley B, Montrichard M, Ivery P. Cultural sensitivity in physician-patient relationships: perspectives of an ethnically diverse sample of low-income primary care patients.Med Care. 2003 Jul; 41(7): 859-70.

3. Blumenkrantz AP, Rajendra R. NFL rule combats discrimination in hiring http://www.northjersey.com Friday, February 9, 2007 (Accessed November 2nd 2007)

Conflict of Interest:

None declared

Health disparities curricula must address measurement issues
Posted on May 9, 2008
James P Scanlan
James P. Scanlan, Attorney at Law
Conflict of Interest: None Declared

The Position Paper of the Society of General Internal Medicine Health Disparities Task Force [1] encourages the development of curricula to give serious attention to health and healthcare disparities, including the teaching of how to gain knowledge of the existence and magnitude of health disparities. But, while citing the Agency for Healthcare Research and Quality's (AHRQ's) National Healthcare Disparities Report as a useful source of information, and providing numerous other references where researchers have attempted to quantify health or healthcare disparities, the paper fails to recognize that there exist serious methodological issues concerning the measurement of these disparities. As with the references it cites, the paper fail to recognize that each standard measure of health disparities tends to change systematically as the overall prevalence of an outcome changes "“ with various measures tending to change systematically in the opposite direction of other measures "“ and that it is impossible to analyze the magnitude of health disparities without consideration of these tendencies.[2,3]

In the healthcare area, a useful illustration may be found in a recent study by Morita et al.,[4] where the authors found that, in addition to increasing overall hepatitis B vaccination rates, a school- entry vaccination requirement led to dramatic decreases in racial and ethnic disparities in vaccination rates. In measuring disparities, the authors relied on relative differences in vaccination rates (a fairly common approach). As discussed in a comment to that study,[5] because the National Center Health for Health Statistics (NCHS) would measure disparities in terms of relative differences in failing to be vaccinated, that agency would have found the disparities to have dramatically increased. AHRQ, which would have used relative differences in vaccination rates for part of the period examined and relative differences in failure to receive vaccination for another part of the period, would have agreed with Morita et al. as to part of the period and would have agreed with NCHS as to part of the period. Researchers who rely on absolute differences between rates would have agreed with Morita et al. as to part of the period examined and disagreed with them as to part of the period. But, so far as mainstream research to date reveals, no researchers would have considered the extent to which the observed changes in whatever measure they used were to be expected simply because overall vaccination rates were increasing.

Theoretically, there may be some value in attempting to teach about things like subconscious bias and effective communication to different cultures without regard to whether the magnitude of health disparities can be reliably measured. But it is a mistake to develop ambitious health disparities curricula without recognizing the measurement issues and attempting to address them.

References:

1. Smith WR, Betancourt JR, Wynia MK. Recommendations for teaching about racial and ethnic differences in health and health care. Ann Intern Med 2007;147:654-665.

2. Scanlan JP. Can we actually measure health disparities? Chance 2006:19(2):47-51: http://www.jpscanlan.com/images/Can_We_Actually_Measure_Health_Disparities.pdf

3. Scanlan JP. Measurement Problems in the National Healthcare Disparities Report, presented at American Public Health Association 135th Annual Meeting & Exposition, Washington, DC, Nov. 3-7, 2007: PowerPoint Presentation: http://www.jpscanlan.com/images/APHA_2007_Presentation.ppt;Oral Presentation: http://www.jpscanlan.com/images/ORAL_ANNOTATED.pdf; Addendum (March 11, 2008): http://www.jpscanlan.com/images/Addendum.pdf

4. Morita JY, Ramirez E, Trick WE. Effect of school-entry vaccination requirements on racial and ethnic disparities in Hepatitis B immunization coverage among public high school students. Pediatrics 2008;121:e547-e552: http://pediatrics.aappublications.org/cgi/reprint/121/3/e547?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=morita&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&resourcetype=HWCIT

5. Scanlan JP. Study illustrates ways in which the direction of a change in disparity turns on the measure chosen. Pediatrics Mar. 27, 2008: http://pediatrics.aappublications.org/cgi/eletters/121/3/e547

Conflict of Interest:

None declared

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