Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care (2003) / Chapter Skim
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Pages 594-625
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The Culture of Medicine and Racial, Ethnic, and Class Disparities in Healthcare Mary-Jo DelVecchio Good, Ph.D., Professor of Social Medicine Cara James, B.A. Byron J
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595 CULTURE OF MEDICINE tions about how we might best understand the mechanisms -- attitudinal, structural, institutional, and ideological -- that produce disparities in medical care and in health status. Our initial study questions for the Institute of Medicine (IOM)
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596 UNEQUAL TREATMENT practicing at a community clinic as less prestigious than practicing at an academic medical center, where private as well as public patients receive care. The diversity of medical professional communities also allows for "the saint" or hero physician, who is devoted to the care of the underprivileged or the poor.
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597 CULTURE OF MEDICINE viding healthcare for the poor or marginally served ethnic groups. A third program, and among the most impressive, was begun when the University of New Mexico established its medical school in 1968.
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598 UNEQUAL TREATMENT tal, political and attitudinal. Individual behavior as well as institutional culture and practices are implicated.
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599 CULTURE OF MEDICINE our pilot interviews and seeks to raise what we believe are some reasons disparities persist. Our past research on medical education and the socialization of medical students was carried out at Harvard Medical School in 1986-1991, and addressed how medical students and physicians-in-training learn to see, present and write up patient cases (B.
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600 UNEQUAL TREATMENT clinicians who have learned appropriate professional behavior. How does this professional socialization affect physician behavior so as to have an impact on the treatments offered to patients of different social groups?
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601 CULTURE OF MEDICINE opposite of anthropology. You learn to do a better job by not listening to your patients.
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602 UNEQUAL TREATMENT When we discussed if he detected any bias in the curriculum or in modeled behavior by attendings or residents that might have an impact on how minority patients were treated he reflected: One modeled message currently about hospital care is rapid assessment, effi ciency, and treatment. One thing about minority, indigent, low-income patients, is that their social situations are complex in negative terms and not fixable by any intervention that can happen in the hospital.
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603 CULTURE OF MEDICINE mestic violence in their lives, if I think it makes sense; a sense of culture bound category. Everybody calls them crazy including Hispanic doctors." In this case, the resident's advanced degrees in medical anthropology have added to her ability to bridge cultural gaps between this population of patients and the medical world.
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604 UNEQUAL TREATMENT The attempt was successful. The resident commented on a second patient, with whom she was having less success.
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605 CULTURE OF MEDICINE The gap between the culture of medicine and the social and cultural resources, contexts and frames of reference of certain social groups clearly is related to how healthcare is delivered and how therapeutic options are offered and chosen by clinicians. The boundaries are fluid.
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606 UNEQUAL TREATMENT This change in resident color, gender and ethnicity is the future face of medicine in the United States. However, color, race, and gender do not make medical culture.
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607 CULTURE OF MEDICINE geoning ethnic minority population within the United States, and the welldocumented underrepresentation of ethnic minority practitioners in healthcare professions (Nickens, 1992; Stoddard et al., 2000; Gonzalez et al., 2000)
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608 UNEQUAL TREATMENT populations in the DSM-IV (American Psychiatric Association, 1994) , used by most practicing psychiatrists.
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609 CULTURE OF MEDICINE plexity of cultural, social, and personal variables that come to bear on the health problem at issue. These two psychiatrists agreed that case studies provide an excellent avenue for residents to explore "the multiple layers" and "complexity of clinical decision-making." Another paramount concern identified in the education of clinicians on cultural sensitivity and competence is in helping clinicians-in-training to move beyond a mastery of the catalogue of diverse healthcare-related practices to an examination of their own preconceived notions and feelings in clinical encounters with patients from ethnically diverse backgrounds.
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610 UNEQUAL TREATMENT them to seek "shortcuts" in managing complex clinical problems. In a recent review of biases in clinical judgment, Lopez (1989)
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611 CULTURE OF MEDICINE pants (Baker et al., 1997)
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612 UNEQUAL TREATMENT present day struggles with racism and discrimination, and that minorities are overrepresented among vulnerable, high-need subgroups such as persons who are homeless, incarcerated, or institutionalized. But its strongest conclusions focus on disparities in access to and use of services and the quality of care that members of minority groups may expect to receive.
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613 CULTURE OF MEDICINE put members of minority communities at special risk for poor medical care. In particular, research dating back to the 1960s provides strong evidence that African Americans in mental health settings are diagnosed with schizophrenia at much greater rates than white Americans and that whites are diagnosed with affective disorders at much higher rates than African Americans, with data suggesting a similar -- though less severe -- pattern among Hispanics.
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614 UNEQUAL TREATMENT Culture and the Expression of Mental Illness One leading hypothesis about the source of the high level of apparent misdiagnosis in minority and immigrant populations is that it may result from cultural differences in the experience and expression of symptoms between such patients and "typical" majority patients. Since the current diagnostic manual is based explicitly on symptom criteria, the experience of culturally distinctive symptoms, such as "nervios" and "ataques" among Mexican-American patients, hearing voices of the dead among bereaved Indians, and hallucinations not associated with psychosis among Puerto Ricans or African Americans, may lead clinicians to misunderstand patients whose culture is different from majority culture norms.
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615 CULTURE OF MEDICINE tent findings of bias, and that "bias is also consistently revealed in diagnostic judgments of Black and White patients" (1989:191)
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616 UNEQUAL TREATMENT subjects who hold negative stereotypes of black people. He argues that "whites who identify with a liberal political agenda (e.g., endorse public policies that promote racial equality and combat racism, view themselves as nonprejudiced and nondiscriminatory, and sympathize with blacks' history of victimization)
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617 CULTURE OF MEDICINE stitutions. However, perhaps even more troubling is a consistent finding that African Americans are over-represented among those who are committed involuntarily.
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618 UNEQUAL TREATMENT research are needed to understand how this explanation fits with other social and institutional factors, and to extend the analysis to other minority groups. Detailed ethnographic and clinical research will be required to identify how assessment and commitment processes function in particular settings and with particular populations -- for example, rural Indians jailed for drinking, African Americans apprehended by the police, or persons assessed in psychiatric emergency rooms of general hospitals or state institutions.
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619 CULTURE OF MEDICINE tal illness, who are disproportionately African American, unmarried, male, less educated, and low income, almost three-fifths received no specialty mental healthcare in a 12-month period, one in five were uninsured, and only 37 percent were insured by Medicare or Medicaid. Because "persons covered by these public programs are over six times more likely to have access to specialty care than the uninsured," any explanations that ignore formal mechanisms for access to care are likely to be extremely partial.
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620 UNEQUAL TREATMENT respond to the charge given to these authors by the IOM Committee. "Culture counts," as Satcher's report notes.
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621 CULTURE OF MEDICINE behavioral modeling and hierarchical relationships that may influence patterns of care and choice of treatments as well.
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622 UNEQUAL TREATMENT REFERENCES Adebimpe VR.
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623 CULTURE OF MEDICINE Good BJ.
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624 UNEQUAL TREATMENT Link BG, Andrews H, Cullen FT. 1992 The violent and illegal behavior of mental patients reconsidered.
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625 CULTURE OF MEDICINE Snowden LR, Cheung FK.
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