Eliminating Racial and Ethnic Disparities in Health Care: What Is the Role of Academic Medicine?
Betancourt, Joseph R. MD, MPH
Dr. Betancourt is director, Disparities Solutions Center; senior scientist, Institute for Health Policy; director of multicultural education, Massachusetts General Hospital; and assistant professor of medicine, Harvard Medical School, Boston, Massachusetts.
Correspondence should be addressed to Dr. Betancourt, Harvard Medical School, 50 Staniford St., Ste. 942, Boston, MA 02114; telephone: (617) 724–9713; fax: (617) 724–4738; e-mail: (firstname.lastname@example.org).
Research has shown that minority Americans have poorer health outcomes (compared to whites) from preventable and treatable conditions such as cardiovascular disease, diabetes, asthma, and cancer. In addition to racial and ethnic disparities in health, there is also evidence of racial and ethnic disparities in health care. The Institute of Medicine Report Unequal Treatment remains the preeminent study of the issue of racial and ethnic disparities in health care in the United States. Unequal Treatment provided a series of general and specific recommendations to address such disparities in health care, focusing on a broad set of stakeholders including academic medicine. Academic medicine has several important roles in society, including providing primary and specialty medical services, caring for the poor and uninsured, engaging in research, and educating health professionals. Academic medicine should also provide national leadership by identifying innovations and creating solutions to the challenges our health care system faces in its attempt to deliver high-quality care to all patients.
Several of the recommendations of Unequal Treatment speak directly to the mission and roles of academic medicine. For instance, patient care can be improved by collecting and reporting data on patients’ race/ethnicity; education can minimize disparities by integrating cross-cultural education into health professions training; and research can help improve health outcomes by better identifying sources of disparities and promising interventions. These recommendations have clear and direct implications for academic medicine. Academic medicine must make the elimination of health care disparities a critical part of its mission, and provide national leadership by identifying quality improvement innovations and creating disparities solutions.
Research has shown that minority Americans (African-Americans, Hispanic/Latinos, Native Americans, Asian-Americans, and Pacific Islanders) have poorer health outcomes (compared to whites) from preventable and treatable conditions such as cardiovascular disease, diabetes, asthma, cancer, and HIV/AIDS, among others.1 Multiple factors contribute to these “racial and ethnic disparities in health.” First and foremost, social determinants—for example, lower levels of education, overall lower socioeconomic status, inadequate and unsafe housing, and living in close proximity to environmental hazards—disproportionately affect minority populations and thus contribute to their poorer health outcomes.2–6 Second, lack of access to care takes a significant toll, as minorities are more likely to be uninsured than their white counterparts, making them less likely to have a regular source of care, more likely to report delaying seeking care, and more likely to report that they have not received needed care.7–9
In addition to the existence of racial and ethnic disparities in health, there is also evidence of racial and ethnic disparities in health care. For instance, disparities have been shown to exist in physicians’ utilization of cardiac diagnostic and therapeutic procedures (African-Americans being referred less than whites for cardiac catheterization and bypass grafting),10–14 prescription of analgesia for pain control (African-Americans and Latinos receiving less pain medication than whites for long-bone fractures and cancer),15–17 and surgical treatment of lung cancer (African-Americans receiving less curative surgery than whites for nonsmall-cell lung cancer).18 Disparities have also been seen in the pattern of physician referrals for renal transplantation (African-Americans with end-stage renal disease being referred less to transplant lists than whites),19 treatment of pneumonia and congestive heart failure (African-Americans receiving less optimal care than whites when hospitalized for these conditions),20 and the utilization of general services covered by Medicare (i.e., immunizations and mammograms).21 Two more recent studies highlight that these disparities have persisted over the last decade—especially in physicians’ use of major procedures among the elderly in the management of myocardial infarction—despite a gradual increase in awareness of this issue during this time.22,23 Again, many of these disparities occurred even when variations in factors such as insurance status, income, age, comorbid conditions, and symptom expression were taken into account.
Key Issues and a Blueprint for Action
The Institute of Medicine (IOM) Report Unequal Treatment, released in March 2002, remains the preeminent study of the issue of racial and ethnic disparities in health care in the United States.24 The IOM studied health system, provider, and patient factors in order to assess the extent of racial/ethnic differences in health care that are not otherwise attributable to known factors such as access to care, to evaluate potential sources of racial and ethnic disparities in health care, and to provide recommendations regarding interventions to eliminate health care disparities. The major findings of this report stated that:
* Racial and ethnic disparities in health care exist and, because they are associated with worse health outcomes, are unacceptable.
* Racial and ethnic disparities in health care occur in the context of broader historic and contemporary social and economic inequality, and are evidence of persistent racial and ethnic discrimination in many sectors of American life.
* Many sources—including health systems, health care providers, patients, and utilization managers—may contribute to racial and ethnic disparities in health care.
* Bias, stereotyping, prejudice, and clinical uncertainty on the part of health care providers may contribute to racial and ethnic disparities in health care.
* A small number of studies suggest that certain patients may be more likely to refuse treatments, yet these refusal rates are generally small and do not fully explain health care disparities.
Unequal Treatment went on to provide a series of general and specific recommendations to address racial and ethnic disparities in health care, focusing on a broad set of stakeholders, including academic medicine. These recommendations pertain to legal, regulatory, and policy interventions (such as avoiding fragmentation of health plans along socioeconomic lines and increasing diversity in the health care workforce); health systems interventions (such as race/ethnicity data collection, broader use of evidence-based guidelines and multidisciplinary teams, and supporting interpretation services); patient interventions (such as improving patient education, activation, and health system navigation); and provider interventions (such as cross-cultural education).
The Role of Academic Medicine
Academic medicine has several important roles in society, including providing primary and specialty medical services, caring for the poor and uninsured, engaging in research, and educating health professionals.25 In addition, many key health care stakeholders and the public expect that academic medicine will provide national leadership by identifying innovations and creating solutions to the challenges our health care system faces in its attempt to deliver high-quality care to all patients. Several of the recommendations of Unequal Treatment speak directly to the mission and roles of academic medicine, and have clear and direct implications for patient care, education, and research.
Recommendations for patient care: Improving systems to address disparities
Collect and report data by patients’ race/ethnicity.
Unequal Treatment found that not only do we lack the appropriate systems to track and monitor racial and ethnic disparities in health care, but we also know little about the disparities that minority groups other than African-Americans (e.g., Latinos, Asian-Americans, Pacific Islanders, Native Americans, and Alaska Natives) may be experiencing. For instance, the Medicare database has only recently begun to collect data on patient groups outside the standard categories of “white,” “black,” and “other.”26 Federal, private, and state-supported data collection efforts are scattered and unsystematic, and many health care systems, hospitals, and health plans, with a few notable exceptions, do not collect data on patients’ or enrollees’ race, ethnicity, or primary language.24,27 Within academic medicine, it is clear that our ability to track and eliminate racial and ethnic disparities centers on our ability to collect race and ethnicity data as it relates to patients’ health care access and utilization in a systematic and standardized fashion. A major citywide effort is underway among the academic health centers in Boston to accomplish this goal, as set forth by the mayor and the Boston Public Health Commission in partnership with the Conference of Boston Teaching Hospitals.28
Encourage evidence-based guidelines and quality improvement.
Unequal Treatment highlights the subjectivity of clinical decision making as a potential cause of racial and ethnic disparities in health care by describing how clinicians may offer different diagnostic and treatment options to different patients (consciously and unconsciously) based on the patients’ race or ethnicity, even in the presence of well-delineated practice guidelines. Accordingly, the adoption and implementation of evidence-based guidelines broadly is a major recommendation to eliminate disparities. For instance, there now exist evidence-based guidelines for the management of diabetes, HIV/AIDS, cancer screening and management, and asthma—all areas where significant disparities exist. As part of ongoing quality improvement efforts, particular attention should be paid to the implementation of evidence-based guidelines for all patients, regardless of their race and ethnicity. Academic medicine can play a major role in advancing this agenda by researching and implementing strategies that facilitate the use of evidence-based guidelines in the clinical setting—especially in light of the attention being given to the use of health information technology as a means of improving quality. The development and evolution of the electronic medical record provides the perfect opportunity to assure that health care providers are prompted to follow evidence-based guidelines for all patients, which in turn would help eliminate disparities.
Support language interpretation services in the clinical setting.
Health care systems that lack interpreter services can lead to patient dissatisfaction, poor comprehension and compliance, and ineffective or lower quality care for patients with limited English-language proficiency.29–37 Doctor–patient communication without an interpreter, in the setting of even a minimal language barrier, is recognized as a major challenge to effective health care delivery, resulting in definite adverse outcomes.29–37 Unequal Treatment’s recommendation to support the use of interpretation services has clear implications for delivery of quality health care, and academic medicine can take the lead in identifying, implementing, and supporting strategies that help bridge language gaps. Progress has been made in this area, including new technologies identified to address language barriers in the clinical encounter, through a national initiative funded by the Robert Wood Johnson Foundation entitled “Hablamos Juntos.” This project worked with several hospitals—including academic health centers—to being to identify and disseminate strategies to bridge the language gap in health care.38
Recommendations for education: Addressing disparities through training
Increase awareness of racial/ethnic disparities in health care.
Recent surveys have shown that physicians aren’t aware of either the extent or the severity of racial and ethnic disparities in health care in the United States. For example, a national mail survey of 2,608 physicians whose primary activity was patient care conducted by the Kaiser Family Foundation in 2001 found that the majority of those surveyed (mainly white) said that the health care system “never” (14%) or “rarely” (55%) treats patients unfairly based on their race/ethnicity.39 Increasing awareness of racial and ethnic disparities among health care professionals is an important first step in addressing disparities in health care. Academic medicine can increase awareness and education regarding health disparities through several venues—for instance, grand rounds, public relations campaigns, newsletters as part of ongoing curricula, and the like.
Increase the proportion of underrepresented minorities in the health care workforce.
Recent data available from the American Medical Association indicate that of the 60% of U.S. physicians whose race and ethnicity is known, Latinos make up 3.2%, African-Americans 2.3%, and American Indian and Alaska Natives less than 0.6% percent.40 Data regarding the racial/ethnic composition of medical school faculty is no different, with minorities composing only 4.2% nationally. It should further be noted that approximately 20% of this group are located at three historically black medical schools, and three Puerto Rican medical schools accredited by the Liaison Committee on Medical Education.41 In terms of the future health care workforce, despite composing 30% of the overall U.S. population, minority students accounted for only approximately 11.4% of medical school graduates in 2005.42 In sum, given the important role academic medicine plays in training our future health care workforce, it is increasingly important that recruitment, retention, and promotion of minorities at all levels of the academic ladder become a mainstream admission and promotion policy. The goal of this recommendation is to develop a diverse health care workforce that can meet the needs of an increasingly diverse population, not only from the standpoint of direct clinical care, but also from the standpoint of leadership, health system design, and research. A recent IOM report entitled “In the Nation’s Compelling Interest: Achieving Diversity in the Health Care Workforce” provides a blueprint for how this can be accomplished, and highlights several best practices nationally.43
Integrate cross-cultural education into the training of all health care professionals.
There is a growing literature that delineates the impact of sociocultural factors, race, and ethnicity on health and clinical care.44 These sociocultural differences between patient and provider influence communication and clinical decision making, and are especially pertinent given the evidence that links provider–patient communication to patient satisfaction, adherence, and, subsequently, health outcomes.45,46 Thus, when sociocultural differences between patient and provider aren’t appreciated, explored, understood, or communicated effectively in the medical encounter, patient dissatisfaction, poor adherence, poorer health outcomes, and racial/ethnic disparities in care may result.47 Cross-cultural education is a strategy to directly address these issues. The two foremost goals of cross-cultural education are to improve providers’ ability to understand, communicate with, and care for patients from diverse backgrounds different than their own, and focuses on enhancing providers’ awareness of sociocultural influences on patients’ health beliefs and behaviors, and to provide physicians with the skills to understand and manage these factors in the medical encounter. Despite the importance of this area of education, as well as the attention it has attracted from medical education accreditation bodies, a recent national survey of resident physicians found that more than one in five felt unprepared to deal with cross-cultural issues, including caring for patients that have religious beliefs that may affect treatment, patients who use complimentary medicine, patients with health beliefs at odds with Western medicine, patients with mistrust of the health care system, and new immigrants.48 Academic medicine can clearly lead the way in identifying, developing, and implementing effective curricula in cross-cultural education. The Association of American Medical Colleges has developed the “Tool for the Assessment of Cultural Competence Training,” which can facilitate this process and is working effectively at medical schools across the country.49,50
Incorporate teaching on the impact of race, ethnicity, and culture on clinical decision making.
Unequal Treatment found that stereotyping by health care providers might lead to disparate treatment based on a patient’s race or ethnicity. As such, it is now felt that medical education should teach how preconceptions of patients’ race, ethnicity, and culture may affect providers’ clinical decision making. Doctors are taught that their own personal background, and the characteristics of the patient and the clinical setting, should be excluded from consideration in the formulation of clinical decisions.51 Social cognitive theory, however, has brought to our attention the ways in which natural tendencies to stereotype might influence clinical decision making. Everyday we are faced with enormous amounts of information that we must sift through in order to make decisions. As a result, we all share the subconscious strategy of attempting to simplify our decision making process and lessen our cognitive effort by using “categories” or “stereotypes” in which we apply beliefs and expectations about groups of people to individuals from that group.52–54 This is a normal, functional, adaptive, cognitive process that is automatic, and usually centers on characteristics that manifest visually, such as race, gender, and age.54 Interestingly, we tend to activate stereotypes most when we are stressed, multitasking, and under the time pressure—the hallmarks of the clinical encounter.
For example, many medical students and residents are often trained—and minorities cared for—in academic health centers or public hospitals located in socioeconomically disadvantaged areas. As a result, doctors may begin to equate certain races and ethnicities with specific health beliefs and behaviors (i.e., “these patients” engage in risky behaviors, or “those patients” tend to be noncompliant) that are more associated with the social environment (e.g., poverty) than patient’s racial/ethnic background or cultural traditions. This stereotyping is a natural and expected—but no less dangerous—phenomenon that may affect the way doctors make decisions and offer specific interventions to different patients based on their race or ethnicity. It is incumbent upon academic medicine to incorporate teaching about stereotypes and clinical decision making as part of its mission of health professions education.
Recommendations for research: Identifying strategies to eliminate disparities
Identify sources of disparities.
Although the literature that formed the basis of the findings and recommendations of Unequal Treatment provided significant evidence for racial and ethnic disparities in health care, additional research is needed in several areas. Most of the disparities literature focuses on differences between how African-Americans and whites are treated; much less is known about the experiences of other minority groups. Improving our ability to collect racial and ethnic patient data should facilitate this process, but in instances where those systems are not yet in place, such data may be collected prospectively in the setting of clinical or health services research to better understand disparities for other populations.
Develop and evaluate interventions.
Much of the literature on disparities to date has focused on defining areas where they exist, but much less has been done to identify the multiple factors that contribute to those disparities, and very little has been done to develop and evaluate interventions to address them. There is clearly a need for a research agenda that identifies promising practices and disparities solutions.55 Academic medicine can be at the cutting edge of this agenda.
Conclusion: Achieving Equitable Health Care
The issue of racial and ethnic disparities in health care has gained national prominence, both with the release of the IOM Report Unequal Treatment and with the many recent articles that have confirmed their persistence. Furthermore, another influential IOM report, Crossing the Quality Chasm, highlights the importance of equity—that there be no variations in the quality of care according to patients’ personal characteristics, including race and ethnicity—as a central principle of quality of care.56 Given academic medicine’s role in providing primary and specialty medical services, engaging in research, and educating health professionals, there are many obvious opportunities for intervention and leadership in the critical area of eliminating racial and ethnic disparities in health care. Accomplishing this will require that academic medicine address several key barriers to change in this field. First, the issue of racial and ethnic disparities in health care must be viewed and treated as a quality of care problem. This includes making the collection of race and ethnicity data a central part of quality improvement, among other key systemic interventions described here. Second, in an already crowded undergraduate and graduate medical education curricula, some space must be made to teach key tools and skills that will help health care providers be attentive to—and address—racial and ethnic disparities in health care. This includes curricula in the impact of race, ethnicity, and culture on clinical decision making as well as cultural competence. Third, although there are the many competing topics for research, the issue of identifying root causes and strategies to eliminate racial and ethnic disparities should be part of the agenda. Finally, and perhaps most important, leaders in academic medicine must pave the way for these changes to occur. Without the support of academic health center presidents, chiefs, deans, and division leaders, there is little chance that these improvements and innovations will take root.
With a blueprint for action in place, academic medicine must provide national leadership by identifying quality improvement innovations and creating disparities solutions in clinical practice, health professions education, and research. Ultimately, these sets of activities will improve the care of all patients, not just those who are racial and ethnic minorities. No longer should eliminating disparities be considered a marginal or “add-on” issue, but instead must be a critical part of the mission of academic medicine. It is only then that we will truly achieve equity and bridge the quality chasm.
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