“They treat us like dogs when they see these callused hands. But they don't realize it's these callused hands that put food on their plates.”
This statement, from an itinerant farm worker in an urgent-care setting, may seem emblematic of health care delivery for an injured, migrant field worker. But quite possibly, no one at the health care facility this woman visited meant to behave in a way that caused her to make such a harsh, self-loathing pronouncement. Yet to a disenfranchised, impoverished person with a poor understanding of English, the treatment was another ugly reminder of her low status.
As recounted in the book Medical Anthropology in Ecological Perspective, this incident seems discriminatory, even defamatory, to the patient. But now emergency physicians are taking a long, hard look at this issue and finding the reasons behind such patient encounters may not have such a simple explanation. Like so many of the diseases they treat, the cause appears largely multifactorial.
For years, the health care system has suffered from racial disparities, but publications about the gap — up until fairly recently — put the blame rather squarely on socioeconomic factors in many cases. There also was the pervasive suggestion of subtle, even unconscious, race-based discrimination at play, at least part of the time. Why else would a Hispanic man with a head injury get less medical attention in the emergency department? Why would African American, Hispanic, or Asian children have higher odds of rupture during appendicitis than their white counterparts?
Misunderstanding and Candor
No one is disputing that occurs, but a body of growing research, much of it from emergency medicine, suggests that those twin devils — misunderstanding by health care providers and lack of candor by patients — may play a role, in addition to bias and poverty. And emergency medicine has come up with proposed solutions: Better cross-cultural training, more diversity in staffing, and stricter adherence to disease-specific guidelines (Acad Emerg Med 2003;10:1155).
This winter, a coalition of senators launched an effort, too, by introducing legislation designed to address health disparities for racial and ethnic minorities. This comprehensive national bill entitled “Closing the Health Care Gap Act,” addresses both access to care and the quality of care for underserved populations. It comes after several recent, large studies documenting that African Americans and Native Americans have higher death rates, poorer general health, and higher infant mortality rates than other Americans. The same kinds of findings have been reported for Hispanic populations, particularly recent immigrants.
The bill is aimed at rectifying disparity by improving treatment opportunities, but also by promoting programs that strengthen local and national leadership and increase the diversity of the nation's health care workforce. It arrives less than a year after a report by the Institute of Medicine (IOM) conducted at the behest of Congress showed wide differences in the quality of heath care related to race and ethnicity. The IOM report, “Unequal Treatment,” attempted to rule out access issues, such as the inability to pay for care or lack of insurance.
Much of the other research that supports the proposed new law comes straight from emergency medicine. In one recent study of the care for mildly brain-injured patients, for example, Hispanic patients were found to be more likely to receive nasogastric tubes than non-Hispanics. And non-whites with mild traumatic brain injury were more likely to receive emergency care by a resident and less likely to be sent back to the referring physician after discharge from the emergency department (Acad Emerg Med 2003;10:1209).The reasons behind these disparities need to be examined, said Jeffrey Bazarian, MD, the senior author of the study.
“Our paper takes the first step out but not the second one,” cautioned Dr. Bazarian, an associate professor of emergency medicine and neurology at the University of Rochester School of Medicine and Dentistry in Rochester, NY. Attributing this finding to one broad explanation is enticing but probably dead wrong, he said.
“These are people we are taking care of, and we need to know these things.” - Dr. Jeffrey Bazarian
That view was echoed by Brent King, MD, who surveyed the pediatric literature and found similar results and problems interpreting the findings. Higher rates of suspected child abuse, for example, are seen in certain minority populations although “the overall suspicion may be lower” for Caucasian, middle-class families. “We don't necessarily think about them as much,” said Dr. King, the chairman of emergency medicine at the University of Texas-Houston Medical School.
In one case with which he is familiar, bloody spinal fluid in a Caucasian baby at an ED initially didn't raise a red flag for further investigation, noted Dr. King, who also is the chief of emergency medicine at Hermann Hospital. Abuse, however, not underlying disease, proved to be the culprit.
The situation was highlighted by Atul Gawande, MD, in his fearlessly honest account of the profession of medicine (Complications — A Surgeon's Notes on an Imperfect Science, Picador, New York, 2002). “A few years ago, my one-year-old daughter Hattie was playing in our playroom when suddenly she let out a blood-curdling scream. My wife ran in and found her lying on the ground, her right arm bent midway between the elbow and the wrist like an extra joint,” he wrote. “When I arrived with her at the hospital, I was grilled by three different people asking me over and over again, ‘Now, exactly how did this happen?’
“It was, I knew all too well, a suspicious story — an unwitnessed fall resulting in a bad long-bone fracture.” But his presentation and his title overcame those suspicions.
“My daughter got a pink cast, and I took her home without incident. I couldn't help but think, however, that my social status played a role in all this. As much as doctors may try to avoid it, when we decide whether to call officials in a case, social factors inevitably play a role.”
Dr. Bazarian said it is tough to tell whether some of this results simply from identifying too strongly with “people like us,” meaning patients with higher education and income and the relative inability to communicate well with people of different backgrounds. “It is not easy,” he said.
It has been fairly well established that some ethnic and racial groups simply respond differently to the kind of intrusive treatment that emergency care provides. As a group, for example, Asian and Hispanic women are far less likely to be forthcoming about urogenital complaints, and both genders in immigrant populations have been reported to portray themselves as having a better understanding of English than they often do, so an emergency physician who asks, “Do you understand?” may get an affirmative nod from an utterly confused patient.
“Things move at a glacial pace.” - Dr. Andra Blomkalns
“These are people we are taking care of, and we need to know these things,” said Dr. Bazarian. In his area of New York, which is considered representative of the diversity seen across the country, medical personnel are taking some steps to help change the situation. For example, they had been depending on an ED receptionist to determine the race or ethnicity with a careful glance when patients walked in the door. But as national surveys have shown, someone who looks Anglo-Saxon may be Hispanic; someone who speaks Spanish may be from Portugal, not Mexico. “First, we need to make sure we know who is what,” he said.
Carlos A. Camargo, MD, who, along with colleagues at Massachusetts General Hospital in Boston, conducted studies into racial and ethnic identification, said there isn't a lot of evidence that it makes a big difference when patients are required to answer the kinds of questions that are taken on a national census. “The difference actually was very small,” said Dr. Camargo, the director of the EMNet Coordinating Center at the hospital.
“The overall suspicion may be lower” for Caucasian, middle-class families. - Dr. Brent King
“I think it would help to focus more attention on language barriers,” he said. “In medical school and residency, we all are taught the importance of a good history. However, when someone cannot speak English and interpreter services are not available, there can be acceptable ‘tolerance’ for a vague or even inaccurate history.”
Sexism in Medical Care
It may be that the time has come to take a cue from the advocates for women's health, who have put conditions from breast cancer to spouse battering in front of the public not to mention at the bench of clinical research. One of those who has done so in cardiology is Andra Blomkalns, MD, the residency director at the University of Cincinnati. “Things move at a glacial pace,” she said.
Along with several other investigators, Dr. Blomkalns has documented that women with acute coronary syndromes receive out-of-hospital electrocardiograms less often than men do. But she doesn't attribute the findings solely to sexism. “Tell a woman she's had a heart attack, and she's like, ‘What? Me?’
“I think maybe it could be that we are hard-wired differently for pain. The idea that chest pain is a symptom is more true for men. Women complain of nausea, of upper-abdominal pain,” she said. “It's like everything has been designed about the 50-year-old [white man].”
And indeed, say some researchers, that may be the crux of the problem when it comes to minorities. In fact, there may be a need to tailor care to certain racial and ethnic populations, at least to some extent. The concept of these differences, which now are being genetically documented in some cases, constitute “a phase of discovery,” according to an editorial in the New England Journal of Medicine (2003;348:1081).
“It is clear that gene variants that cause monogenetic disease — in which a single gene is necessary and sufficient to cause disease — are enriched in some populations and not others,” stated Elizabeth Phimister, PhD, who wrote the editorial. “Geneticists often go ‘gene hunting’ in such populations, and meet with success.” She warned that “the subject is fraught with sensitivities fueled by past abuses and the potential for future abuses.”
Dr. Camargo expressed optimism that abuses are rare in emergency medicine. “Many ED staff think about these issues,” he said. “Fortunately, by and large, research data suggest that the ED staff do not treat people differently by race and ethnicity, at least not to the extent seen in other fields.”
In fact, those in academic medicine have published a compendium on the problem, “Disparities in Emergency Health Care” (Acad Emerg Med 2003;10:1). In the special-issue publication, some authors call for sorting out in a more deliberate way what factors influence higher prevalence rates of conditions ranging from diabetes to hypertension. Is it substandard housing? Prejudicial allocation of resources? Genetic predisposition in some groups?
“Low socioeconomic status has potentially deadly consequences,” according to Robert O'Connor, MD, and Leon Haley, MD, in one of the reports. But the authors assert that neither poverty nor lack of patient compliance fully explain the disparity. “Most health care professionals are inadequately trained in the area of cultural sensitivity,” they noted. “The struggle against the prevalence of diseases in disadvantaged populations must incorporate cultural sensitivity.”
Most emergency physicians would agree. But Dr. Camargo said he isn't certain that much cultural insensitivity truly exists in his chosen field. “I think the emergency aspect of our job provides fewer opportunities for low-level racism to creep in,” he said. “When people are very sick, they need help. Now. Period. Regardless of the color of their skin.”