Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care (2003) / Chapter Skim
Currently Skimming:
The Culture of Medicine and Racial, Ethnic, and Class Disparities in Healthcare
The Culture of Medicine and Racial, Ethnic, and Class Disparities in Healthcare
Pages 594-625
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From page 594... ...
Good, Ph.D., Professor of Medical Anthropology Anne E Becker, M.D, Ph.D., Assistant Professor of Medical Anthropology Department of Social Medicine, Harvard Medical School INTRODUCTION Racial disparities in medical treatments and in health status have been documented in numerous studies over the past two decades.
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From page 595... ...
Group on Racial and Ethnic Disparities focused on the culture of medicine. How do the culture of medicine, the training of medical students and residents, and the organization and delivery of healthcare affect patient treatment in such a way as to produce obvious and documented disparities in therapeutic action?
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From page 596... ...
Professional careers are made in communityoriented medical service and in teaching "cultural competence" to one's medical students and residents. Nevertheless, both the charismatic hero physicians who are leaders in social medicine (see Farmer, 1999)
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Why do racial and ethnic disparities continue to exist despite the two decades of documented research, of educational efforts to teach medical and health professionals "cultural competence" and social medicine, of programmatic efforts to attend to health needs of underserved communities, and most recently of NIH/NCMHD and previous governmental efforts to redress the inequities in medical care and health status? Are educational and research programs ineffective in changing clinician behavior and institutional and professional culture?
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From page 598... ...
Where one receives healthcare, including how one enters a healthcare institution, via an Emergency Room or via a controlled appointment process, influences the type and scope of care provided. It may also influence how healthcare providers, from nurses and physicians to medical students and technologists, interpret who their patients are, what life experiences they carry with them, and what problems they may r )
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document similar experiences, suggesting historical depth and continuity in the culture of medical education. This continuity of medical educational culture persists despite a sea change in the gender, and to a lesser extent, the racial and ethnic profile of medical students.
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These narratives smooth the working of what one of our junior colleagues calls "the medical machine" (personal communication, Herskovits, 2001~. Disruptions in the Medical Machine Or Recent interviews with attending physicians, residents, and medical students in the Boston area suggest several ways the medical gaze may lead to disparities in healthcare.
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601 Patients derail physicians when they present with what an attending described as "socially complex problems." The notions of the medical machine, of derailment and befuddlement, are relevant to explaining why disparities exist. The comments of a cardiac specialist, who has practiced in community clinics as well as in a major teaching hospital, highlight similar issues.
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From page 602... ...
New immigrants versus academics. This very thoughtful student and I discussed how readily one distinguished different groups of Asians, some difficult to care for because of language barriers and social situations, others more similar in educational status and class to the medical community and easy to communicate with but that it was easy to slip into grouping African-American patients into one category.
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Does this lead to explicit racism or bias in what is offered to patients in terms of medical interventions? An African-American attending psychiatrist noted that in his consultations on psychotropic medications he often finds that primary care physicians prescribe less current drugs for their black patients.
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Medical students with whom we spoke note they never hear overtly negative racist comments in the hospital or among classmates. This sensitivity is new to the late twentieth century generation of medical students and faculty in our study area.
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In the metropolitan area where the authors work, the hospitals' staffs include many new immigrants, some of whom speak English as a second language and with limited fluency. The impression of our interviewees as well as of the authors is that the majority of the medical teams in the local teaching hospitals, including the nurses and doctors, are of European background and considered "white." However, the medical staff is a minority of the hospital labor force.
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The following section addresses ways that health professionals have been trained thus far and the limits of current approaches. Addressing Healthcare Disparities Through the Training of Healthcare Professionals The literature on health disparities among ethnic minority populations includes discussion of sources of inequality based on institutional, clinician-centered, and patient-centered factors.
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, but also underscores the shortage of evidence-based data in addressing and resolving healthcare disparities. The developing interest in cultural competence in clinician training is both a pragmatic response to the increasing proportion of ethnic minority individuals in the United States population and the failure of a strictly biomedical model in achieving uniform outcomes in this diverse population and a moral response to the inequities of healthcare among ethnically diverse populations.
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From page 608... ...
and another found that race-concordance in the physician-patient encounter was associated with higher participatory decision-making (CooperPatrick et al., 1999~. Another dilemma in training clinicians identified by two psychiatrists teaching psychiatry residents about cultural competence in a Boston teaching hospital is in negotiating the tension that occurs when clinicians are exposed to the diversity of cultural traditions while resisting the tendency to stereotype or racially profile patients.
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things," creating a safe environment in which to explore and discuss countertransferential feelings generated in racially and ethnically diverse clinical encounters remains "a training challenge." They report that "although we are not living in an era in which there is complete closure to this subject [of cultural sensitivity] ," they have noted an increasing sophistication among residents with respect to awareness of cultural diversity, in part due to greater exposure to experiences working in other countries.
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From page 610... ...
Their study demonstrated differences in cultural sensitivity based on the ethnic background of the student; based on their results, the authors advocate curricular intervention, but did not use their intervention to test outcome in acquisition of cultural competence skills. One study was able to document an increase in language skills and cultural knowledge among medical student participants in a didactic and experientially based program (including an educational trip to learn firsthand about health practices in Mexico)
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Examples of research, such as the work on mental health services, may suggest ways to pursue analyses of reasons for disparities in medical treatment in the non-psychiatric domains of medicine. A Case Analysis of Disparities in Mental Health Services: Evidence for the Role of Clinician "Bias" and the Culture of Mental Health Institutions lust as we were completing this review of the role of health professionals and the culture of institutions in reproducing health disparities, Surgeon General David Satcher announced the release of his office's report on disparities in mental healthcare in America.
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What is meant by suggesting that racism and discrimination are a part of the culture of the mental health profession and the healthcare system, given that community mental health professionals are often among the leading advocates for the poor and for minority persons suffering mental illnesses? We focus here on two very specific debates the overdiagnosis of schizophrenia among African Americans, and the elevated rates of involuntary commitment of African Americans.
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From page 613... ...
found that African-American patients seen in an emergency room received 50 percent higher doses of antipsychotic medications than patients of other ethnic groups, while their doctors devoted less time to assessing them and scored significantly lower on an Art of Care Scale. Although these studies do not prove that black patients are misdiagnosed, they are consistent with a conviction among many researchers that African Americans are at serious risk for receiving a misdiagnosis of schizophrenia, for being provided inappropriate and inappropriately high levels of antipsychotic medications, and for receiving poorer care than white patients in the same settings.
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A1though there is now a large literature on cultural shaping of psychiatric symptoms, few studies have systematically examined explicitly whether these differences lead to increased levels of misdiagnosis for cultural or ethnic minority patients, such as difficulties in assessing and diagnosing African-American patients who suffer psychoses, depression or anxiety disorders. "Clinician Bias," "Aversive Racism," and Misdiagnosis A second set of hypotheses suggests that systematic patterns of misdiagnosis may result from clinician bias, and that the social and cultural context of diagnosis and diagnostic judgments should be submitted to sustained research.
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However, black patients were given significantly more severe diagnoses, and black psychiatrists shared in this pattern of rating. However, one clear pattern emerged.
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Whaley focuses particular attention on research that identifies "bias in mental health professionals' judgments associated with the racial stereotype of blacks as violent" (1998:51~. He reviews evidence that African Americans are likely to be sent to local correctional facilities, while white patients with similar levels of psychopathology and violent behavior are more likely to be referred to a mental health hospital.
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From page 617... ...
However, research also indicates that "excess risk for violence among mental patients is modest compared to the effects of other factors," in particular when compared with the effects of alcohol and drug abuse, and "only patients with current psychotic symptoms have elevated rates of violent behavior and it may be that inappropriate reactions by others to psychotic symptoms are involved in producing the violent/illegal behavior" (Link, Andrews, and Cullen, 1992:290~. The sources and types of risk of violence among persons suffering mental illness and those who engage in substance abuse, as well as the implications for mental health services and involuntary commitment, are significant issues in ongoing research (Link and Stueve, 1995; Junginger, 1996~.
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From page 618... ...
The linkages in this case are highly specific, rather than a result of generalized attitudes or tendencies to discriminate. Indeed, because good care requires assessment of levels of dangerousness to self and others, the role of stereotyping those who are to be considered "violent" may well "slip under the radar" of efforts to provide training to support "cultural sensitivity" or culturally competent care.
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Misdiagnosis in this study was shown to be as high for whites as blacks, and even the most carefully designed study continued to find higher rates of schizophrenia among hospitalized African Americans than among hospitalized white Americans. Thus, although mental healthcare provides an important model for how to approach the issues to be addressed in this review, it remains a particularly difficult domain to make claims with great certainty.
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Until recently, when cultural analyses were proposed, the focus was largely on patient culture. Burdens of difference were on patient communities, and medicine and health professionals were expected to learn to be culturally competent in attending to the diverse populations that make up American society.
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4. Explore how the sea change in the ethnicity and race of medical students, physicians, nurses, and healthcare staff affects provision of care to ethnic and racial minorities, new immigrants, and the poor.
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1996. Comparison of cultural competence and cultural confidence of senior nursing students in a private southern university.
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1991. Into the Valley: Death and the Socialization of Medical Students.
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2001. Assessing medical students' awareness of and sensitivity to diverse health beliefs using a standardized patient situation.
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1990. Use of inpatient mental health services by members of ethnic minority groups.
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