Map of life expectancy at birth from Global Education Project.

Wednesday, November 19, 2014

What I'm about to say

I'm appearing on a panel tonight at our great university, entitled "Doctors reading race: how conceptions of race shape medical care." Since you probably can't attend, here's the sneak preview.

When I first began to study this issue, 15 or 20 years ago, there were quite a few influential studies that identified disparities in physicians' treatment decisions based on patients' race or ethnicity. For example, Latino patients with long bone fractures were less likely to be prescribed opioids in emergency departments. Doctors were less likely to take a sexual history from adolescent white adolescent girls presenting with abdominal pain than from Black and Latino girls. Black veterans in VA hospitals who'd had myocardial infarctions were less likely to undergo revascularization. (Interestingly, they were also less likely to die. This led the authors to propose that "process of care is a more specific indicator of quality than is outcome. Ha ha.) There were others.

Back then we had all sorts of calls for "cultural competence" in health care, and people sprang up who offered cultural competency training, generally for a fee. In its earliest incarnation this mostly consisted of people who would proffer interesting tidbits from medical anthropology about exotic health beliefs. They'd tell you that Puerto Ricans believe in the Evil Eye and rural African Americans are into rootwork and mojo, that sort of thing. Absolutely ridiculous. It's like teaching doctors that patients from California believe in the healing power of crystals. Maybe a few of them do but that's not what you need to be culturally competent.

So then we got a better class of cultural competency trainers who claimed, more plausibly, that the first step toward becoming culturally competent is to have insight into your own culture. What are your preconceptions and how do you understand the nature and meaning of health and illness, and medical care? The next step is to learn how to not make assumptions about the people you encounter, but rather to learn from them. Ask them! What do you want to know? What are you comfortable and not comfortable telling me about yourself? How do you understand your condition and treatment? How do you want us to relate to each other? Everybody is unique, your job is to understand each person.

This all sounds great but I haven't seen any evidence that this sort of intervention produces better results or more satisfied patients, though I don't suppose it can hurt. So what have I found in my own research?

First of all, using my structured methods for analyzing clinical encounters, we've noticed a couple of things. Black patients, on average, talk less than Latino or white non-Hispanic patients, but there doctors talk just as much. This has been observed by others, in a couple of different settings. The result is that the so-called verbal dominance ratio -- the proportion of doctor to patient talk -- is higher for Black patients. Of course I have no idea why. There are also some other indications of less rapport or patient engagement, including fewer so-called expressive utterances by Black patients -- those are expressions of desires, goals, feelings, intentions -- and less joking with Latino patients. But again, I don't know why this happens or what significance it has.

What I have observed is that where things tend to go wrong is doctors not understanding patients' lifeworlds. The fact is that most medical encounters are essentially cross-cultural. Physicians tend to start off as higher socio-economic status than most patients before they get to medical school. Being a physician is, in fact, often a hereditary condition in itself. Then they go through a socialization process in which they internalize a particular way of understanding human beings and the nature of health and disease. Then they ultimately go on to live in pleasant neighborhoods and have nice things.

This makes it hard enough to understand the experience, perceptions and needs of the typical patient who comes before them; But more social distance, be it of class, ethnicity, language and culture, just compounds the problem. The physician may make stereotypical assumptions about people, and may make other assumptions based on assuming that the patient or the patient's situation is more similar to the physicians than the reality. I have many fascinating examples but I'm only supposed to talk for 10 minutes so maybe I'll get to some of them in the Q&A.

So I'll just leave off with this. When I worked for the New England Coalition for Health Equity, I'd go around to various meetings and conferences where one way or another the idea of cultural competency was promoted. I can't tell you how many times I heard doctors say, "I don't need any training, I don't have any issue with cultural competency. I treat everybody the same." I'll leave it to you to ponder if that's a good answer.

1 comment:

Hasib Rahman said...

Wonderful!! If I had to add to your already great list, it would be just to say "Make a plan". I will need to do for them. To work more efficiently, you definitely need to plan ahead.
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