By Ibby Caputo
March 27, 2012
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BOSTON — Today, the U.S. Supreme Court turns its attention to the cornerstone of President Barack Obama's health care plan: the individual mandate. Lost in all the legal talk is a unique effort by local doctors to improve the level of health care, especially in populations of color.
Who gets good care?
An exercise: Raise your hand if you or someone you care about is black, Asian, Latino, disabled, obese, gay, old, an immigrant or a woman. Is your hand raised? These are nine of the 13 groups of people who are at risk of receiving disparate medical treatment. The four others are Native Americans, prisoners, the Appalachian poor and members of certain religious groups.
Dr. Augustus White III is a professor of medical education and orthopedic surgery at Harvard Medical School. He uses this exercise when he lectures on health care disparities.
"When I think about health disparities, what I’m thinking about is the interaction between the doctor and the patient resulting in the patient getting slightly or significantly inferior care, and that’s a health disparity," White said.
His book, “Seeing Patients: Unconscious Bias in Health Care,” says that the show of hands demonstrates how pervasive the problem is, and how providing good health care would be difficult enough without superimposing conscious and unconscious biases on such a huge portion of the population.
... And who wears the lab coat?
Now, another exercise — this time for the imagination. Consider if all the doctors in the nation were to gather in one large room. A moderator stands on a very high podium and asks, “Would all minority doctors please raise their hand?”
Although minorities make up nearly one-third of the U.S. population, only six percent of the doctors in the room would raise their hand. That’s because there’s a lack of diversity among medical professionals, specifically doctors, nurses and dentists. That statistic affects health care outcomes, especially for minority patients.
Dr. Alden Landry is an attending physician of emergency medicine at Beth Israel Deaconess Medical Center in Boston. African Americans account for 13 percent of the total population in the U.S., but they only make up three percent of the physician workforce. As an African American doctor, Landry is part of that underrepresented minority. He regularly witnesses the effect his presence has on some of his patients.
"I’ve walked into rooms and there’s an elderly black woman laying on the stretcher. I walk up to her and I introduce myself to her as her doctor, who will be taking care of her while she’s in the emergency department. This has happened more than once," Landry warns. "The patient will grab my hand, look me in the eye and say thank you for being my doctor, I am so proud of you, you remind me of my grandson, and it will be so good that you will be my doctor taking care of me."
Studies show that racial and ethnic minority patients receive lower-quality interpersonal care than white patients. When minority patients and doctors have the same background, however, patients report physicians as being significantly more participatory, asking more questions and getting the answers.
Landry added, "In the society that we live in there is a certain level of comfort knowing that someone may be from the same background as you and the patients may be able to divulge what’s going on in your personal life, and what’s going on in your personal life has a huge impact on what’s going on in your overall health."
Cross-cultural communication on the gurney
What’s going on in your personal life also impacts your ability to comply with a medical regimen and follow-up tests or appointments. For example, let’s say a doctor advises you to stay off your feet because you are agitating a wound, but your job requires you to stand; or you need a blood test, but you’re afraid to take time off work. Communication with your doctor in these types of circumstances is crucial.
"Culturally competent care is care that is given to someone which is the same when both the caregiver and patient are in the same group, culturally, ethnically, etc.," says White.
He adds that culturally competent care means that, for example, a white, straight, fit, middle-class male doctor should be able to give a patient with different circumstances — let’s say an obese, gay, Hispanic female patient — the same care he would his white male counterpart.
White admits, "That’s setting the bar pretty high, that’s a high ideal, but is there any reason it shouldn’t be that way?"
Attracting future doctors to the field
In an effort to increase diversity, Dr. Landry and colleagues came up with an innovative approach: the Tour for Diversity in Medicine. He explains, "The whole purpose is to cultivate, educate and inspire future physicians."
Five physicians, four medical students, a dentist and a pre-health advisor toured five historically black colleges and universities to promote careers in the health professions to underrepresented minorities. The group is comprised of 10 African Americans and one Hispanic American.
"We wanted to make sure all the mentors who were there were fairly young, so these kids can relate and say, wow this person’s only 5 years older than me, but they’re in medical school. Wow, this person's only 10 years older than me but they’re a physician," Landry says, mentioning that he’s a doctor because he had a lot of great mentors who helped him get from point A to point B.
"I wanted to make sure that other individuals had those same people in their lives to help them get from point A to point B," Landry says.
Insight into patients' lives
Love Anani is a fourth-year medical student at Howard University in Washington, D.C. He was one of the medical students on the tour. Anani says he’s grateful for Landry’s mentorship.
"Every day I kind of felt like I couldn’t do it. I’d never seen a black ER doctor — they don’t exist. All I have to do is think of Dr. Landry. He’s only a text message or phone call away," Anani says.
Anani graduates this May and will be a resident at Saginaw in Michigan. He’ll be one of two African American residents in his program. He says he has an important role and insight that might be lost on other doctors, especially when treating African Americans.
"If someone told a Caucasian doctor 'Oh, I was eating greens yesterday for dinner,' they’ll probably think 'Why is your hypertension high — you're eating greens?'" Anani says. "You tell me you're eating greens for dinner and I think, 'How long did you soak it for? What did you wash them in? Did you have ham hocks? Did you cook them? Did you boil them? What else did you eat with them?' I know greens do not come alone on a plate for a typical African American. Those are conversations I can have with them, because there is a reason hypertension, diabetes and cardiac disease are killing African Americans. These are the trends."
What it's like in practice
Back at the Emergency Department at Beth Israel Deaconess Medical Center, Landry gives some good news to Orville Wright, a professor of music at UMass Boston.
"All right, so we got the results of the CT scan," Landry begins. "Nothing’s going on that we can see, and your blood work shows that your creatine is okay, so we should be able to start you on the Lovenox. So we are going to have the nurses come in to teach you about the injections. Any questions?
"No, I don’t have any questions," says Wright.
"We’ll be able to get you home," Landry replies.
"Beautiful! That is what I’m looking forward to," Wright exclaims.
"I figured you wanted to hear that answer," Landry says, laughing.
Wright says this is the first time he has ever had an African American attending physician. He wishes there were more African American faces for patients of color to interact with.
"For me, it's just nice being able to see another black face. You know, something inside of me says yeah. You know, that’s a good feeling," Wright says.
The Supreme Court's decision this week could have far-reaching impacts across Massachusetts. WGBH News brings you FOCUS coverage all week, from local stories to broadcast of the Supreme Court hearing in its entirety.
FOLLOW THE TOUR FOR DIVERSITY IN MEDICINE