1. Health Disparities and Multicultural Practice Clarence H. Braddock III, MD, MPH, FACP Associate Professor of Medicine Associate Dean, Medical Education

2. Goals for this afternoon Why are we talking about this? To recognize the challenge of health disparities to medical practice As a lens through which to view your training To contemplate your future role in addressing

3. Overview Discuss extent of disparities View examples of disparities and of multi- cultural practice Gain insight into our own biases

4. How extensive are healthcare disparities?

5. 5 Unequal Treatment Generally speaking, how often do you think our health system treats people unfairly based on their race or ethnic background? Generally speaking, how often do you think our health system treats people unfairly based on their race or ethnic background? 1=Very often 1=Very often 2=Somewhat often 2=Somewhat often 3=Rarely 3=Rarely 4=Never 4=Never

6. 6 Responses % saying “very/somewhat often” Physicians 29% Physicians 29% White physicians 26% White physicians 26% Asian physicians 33% Asian physicians 33% Latino physicians 52% Latino physicians 52% Black physicians 77% Black physicians 77% Public 47% Public 47% Kaiser Family Foundation National Survey of Physicians, 2002, Survey of Race, Ethnicity and Medical Care: Public Perceptions and Experiences, 1999

7. 7 Cardiovascular care Rate your agreement with this statement: Rate your agreement with this statement: “African Americans with heart disease are just as likely as whites who have heart disease to get specialized medical procedures and surgery.” 1=Agree 1=Agree 2=Disagree 2=Disagree 3=Not sure 3=Not sure

8. 8 Responses %saying “Disagree” Physicians 65% Physicians 65% White physicians 67% White physicians 67% Asian physicians 54% Asian physicians 54% Latino physicians 68% Latino physicians 68% Black physicians 89% Black physicians 89% Public 37% Public 37% Kaiser Family Foundation National Survey of Physicians, 2002, Survey of Race, Ethnicity and Medical Care: Public Perceptions and Experiences, 1999

9. 9 Summary of disparities literature White patients receive more healthcare services and achieve better outcomes than African- American, Latino, Native American, Asian- American patients Cardiovascular disease: MI, stroke Cardiovascular disease: MI, stroke Asthma Asthma Cancer: breast, lung, colorectal Cancer: breast, lung, colorectal Screening and preventive services Screening and preventive services HIV/AIDS HIV/AIDS Psychiatric care Psychiatric care

10. 10 Reasons for healthcare disparities Would you say the following statement is a major reason, minor reason, or not a reason why the health care system treats people unfairly based on race or ethnic background? Would you say the following statement is a major reason, minor reason, or not a reason why the health care system treats people unfairly based on race or ethnic background? “Many people from minority groups live in areas where there are fewer doctors or have trouble with access” 1=Major reason 1=Major reason 2=Minor reason 2=Minor reason 3=Not a reason 3=Not a reason

11. 11 Responses % saying “major reason” Physicians 58% Physicians 58% White physicians 61% White physicians 61% Asian physicians 58% Asian physicians 58% Latino physicians 59% Latino physicians 59% Black physicians 50% Black physicians 50% Public 40% Public 40% Kaiser Family Foundation National Survey of Physicians, 2002, Survey of Race, Ethnicity and Medical Care: Public Perceptions and Experiences, 1999

12. 12 “The preponderance of studies…find that even after adjustment for potential confounding factors…racial and ethnic disparities in cardiovascular care remain.” Access Access Disease severity Disease severity Site of care (e.g. geographic variation or hospital type) Site of care (e.g. geographic variation or hospital type) Disease prevalence Disease prevalence Co-morbidities or clinical characteristics Co-morbidities or clinical characteristics Refusal rates Refusal rates Overuse of services Overuse of services IOM, Unequal Treatment, 2003

13. 13 Evidence of provider bias Actors portrayed patients with same clinical characteristics but different gender and race Actors portrayed patients with same clinical characteristics but different gender and race Physicians viewed videotapes; made recommendations for managing chest pain Physicians viewed videotapes; made recommendations for managing chest pain Schulman, NEJM 1999

14. 14 Evidence of provider bias Schulman, 1999 The study examined: physician recommendations for referrals physician recommendations for referrals assessment of personality traits assessment of personality traits predictions of behavior predictions of behavior Multivariate analysis of predictors adjusted for physician assessment of probability and severity of symptoms adjusted for physician assessment of probability and severity of symptoms

15. 15 Schulman, K. A. et al. N Engl J Med 1999;340:618-626 Patients as Portrayed by Actors in the Video Component of the Survey

16. 16 Evidence of provider bias Schulman, 1999 Catheterization referrals differ significantly: Catheterization referrals differ significantly: Black patients less likely to be referred than white patients Black patients less likely to be referred than white patients Odds ratio 0.6, p = 0.02 Women less likely to be referred than men Women less likely to be referred than men OR 0.6, p = 0.02 In a combined analysis, black women fared the worst as compared to white males In a combined analysis, black women fared the worst as compared to white males OR 0.4, p = 0.004

17. 17 Evidence of provider bias Schulman, 1999 Physicians more likely to attribute negative personality traits to black patients and women. Categories included: Physicians more likely to attribute negative personality traits to black patients and women. Categories included: White women perceived sadder, more worried White women perceived sadder, more worried Black women more likely to over-report symptoms Black women more likely to over-report symptoms White men more likely to sue White men more likely to sue

18. Health Disparities Robert Phillips story