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Doctor, heal thy patient: How cultural sensitivity may cut disparities in health care

This article first appeared in the St. Louis Beacon, Nov. 6, 2009 - Dr. Will Ross has many titles behind his name at the Washington University Medical School -- associate dean, director of the office of diversity, mentor to medical students, kidney disease specialist and the proud owner of a master's degree in public health. But if Ross could award one unofficial title to doctors who treat minorities, it would be "culturally competent" -- attesting to a doctor's ability to deliver good care to patients from diverse cultures.

Though gaining currency, the concept of cultural competence isn't emphasized nearly enough in medical schools, says Ross. The issue has taken on added importance as Latinos become the nation's largest minority group and as questions are raised about whether cultural competence -- or its lack -- may account at least in part for racial and ethnic disparities in health care.

When a poor patient consistently misses office appointments, for example, or fails to take medications, Ross says a culturally competent physician would look at the broader picture. The doctor might discover that the patient "might have three or four children at home or didn't have money for transportation or shared their medications with another family member."

Addressing disparities, Ross says, "goes beyond diagnosing and giving a patient a prescription."

People who are turned off by the way they are treated by health-care institutions and professionals may decide not to seek care and possibly worsen an already serious illness. That's one reason the National Conference for Community and Justice of St. Louis will begin sponsoring three-day workshops next year to address issues like those mentioned by Ross.

"The program will be for everyone in health care, from people on the front line who admit patients to those who treat them," says Denise DeCou, NCCJ's executive director. "We will provide training to create more cultural senstivity and cultural competence as a way of helping eliminate disparities.

"The idea is to create a climate in which clients feel comfortable, feel that providers understand and really care about them and are receiving information in a way, in plain English, that's free of jargon and that (patients) can understand."

Health-care access on north side

The disparity issue is also important to Ross because he, along with Alderman Terry Kennedy, D-18th Ward, co-chairs a task force that looked at health-care access in north St. Louis. It called attention to the relationship between race and place, the high rates of disease and death among these residents.

While acknowledging that many middle-class blacks still live on the north side, the task force depicted the area as devoid of health-care facilities and providers. An area that's home to more than 160,000 people has no hospital, no emergency room and few doctors.

Many health-care professionals want to improve the quality of life in the this area. Some were part of a conference organized recently by Dr. Consuelo H. Wilkins, an associate professor of medicine and psychiatry at Washington University Medical School; and Darcell P. Scharff, an associate dean at St. Louis University's School of Public Health.

The conference's goal was to begin a conversation about helping medical researchers and community residents reach common ground on addressing health disparities. The "Our Community, Our Health" conference at Harris Stowe University was sponsored jointly by Washington University and St. Louis University medical schools.

Wilkins couldn't help noting the irony: St. Louis is the site of two major medical research universities whose hospitals offer world-class care for many -- and yet St. Louis is a place where many residents don't get prompt and appropriate treatment for illnesses such as cancer and diabetes.

One big challenge, Wilkins says, is that the community does not rank health conditions in the area the same way that researchers do. Reaching consensus on what conditions need to be addressed and what research needs to be done will be an important first step to be tackled in future conferences, Wilkins says. 

SLU's Scharff says issues involving doctors are only one part of the problem. Studies show, she says, "some bias on the part of providers. But it may not be intentional."

She adds that disparities also are influenced by socioeconomic issues in certain poor neighborhoods "where people see billboards advertising tobacco use and alcohol use," and unhealthy foods. "For a long time, we thought people had choices. But people in underserved areas don't have access to some services. And we now think that the disparities are beyond individual choices," Scharff adds.

In addition, Elizabeth Baker, a professor in SLU's School of Public Health, says researchers have to show more empathy to build inroads to people in north St. Louis.

"We really have a lot to learn," she says. "We recognize there is a history of distrust in the community." She adds that "there is an arrogance, a lack of humility. There is also a lack of programs to train people that (their) skills are only useful to the extent that you can work with others."

Documenting disparities

An important development in health-care policy over the years has been to collect, compare and interpret data in ways that increase awareness of health-care disparities and bias, consciously or unconsciously in the delivery of health services. (The Institute of Medicine has defined disparities as "the differences in quality of care among groups, which cannot be accounted for by patient preferences or clinical characteristics.")

Without the data, for example, Missourians would be clueless about how black patients have been shortchanged in medical care even when they had the means to pay for service. Missourians would not know, for example, that black women on Medicare, aged 65 to 69, were less likely to get mammograms than whites, according to a Dartmouth University study. Nor would they know that black Missourians with diabetes were four times as likely to have a limb amputated than whites. Black patients also were less likely than whites to receive annual hemoglobin A1c testing for diabetes.

These examples might also help explain the American Medical Association's move to make doctors more culturally sensitive. The AMA's embrace of the principle represents a significant shift for an organization once slow to change. Last year, the AMA apologized for once excluding black doctors. The year before that, it joined the National Medical Association, the voice of African-American physicians, in setting up a commission to end health-care disparities.

Now, the organization has added an online course on health disparities to its continuing medical education program.

The course shows instances in which African Americans and Hispanics received less treatment -- such as catheterization, angioplasty and bypass surgery -- than whites for heart disease. Doctors also learn that only 49 percent of Asian women get pap tests, compared to the national average of 64 percent.

A Kaiser Family Foundation survey in 2002 found that 55 percent of doctors felt patients were rarely treated unfairly based on race or ethnic background. It's unclear how much attitudes have changed in seven years since the Kaiser study, but many black doctors in particular are impressed that the AMA is finally acknowledging health disparities and embracing the need for culturally competent doctors.

Training more minority doctors

Still some are more guarded. Dr. Nathaniel H. Murdock, who retired this year as an obstetrician-gynecologist, served as president of both the National Medical Association and the predominantly white St. Louis Metropolitan Medical Society.

"An apology is fine," he says, "but I think you have to go further than that. You must establish certain things to address disparities, such as scholarships to help more African Americans go to college and get specialized training and help African-American physicians raise the health standards of all Americans. To me, that's more important than an apology."

Other doctors, such as Ross and Wilkins, agree on the need for more black physicians. Wilkins says the list of African-American doctors here is growing. The Mound City Medical Society, a St. Louis group of African-American doctors, now has about 180 members, she adds.

One way to address the cultural competence issue is training more African-American and Latino physicians, says Ross. Together, they make up 25 percent of the country, but only about 8 percent of the nation's physicians. In addition, Ross says, no more than 4 percent of medical school students are minorities.

"We need more physicians of color," he said. "But we can't just focus solely on increasing the number of African-American, Native American and Latino doctors. It takes too long to do that when people are suffering.

"We also need to increase the awareness of majority physicians about how to care for the disaffected population -- increase their culture competence and (their ability to) relate to that population effectively."

The north side access study showed health disparities for city residents living in several ZIP codes -- 63106, 63107, 63112, 63113, 63115, 63120, 63147. These locations had higher mortality rates from diabetes, cancer and heart disease than any other ZIP codes in the city. The data also showed that residents of two of those ZIP codes -- 63106 and 63113 -- had lower life expectancy than people in other parts of St. Louis.

"The information was staggering," Kennedy said. "Still further, it showed us that health care was not an essential part of their (residents') budget. It was a luxury, behind rent, food, clothing, heat, gas and electricity."

The upshot, he says, is a population of vulnerable residents who avoided checkups and refused to seek medical help until an illness "got so severe that they no longer could ignore it."

Robert Joiner has carved a niche in providing informed reporting about a range of medical issues. He won a Dennis A. Hunt Journalism Award for the Beacon’s "Worlds Apart" series on health-care disparities. His journalism experience includes working at the St. Louis American and the St. Louis Post-Dispatch, where he was a beat reporter, wire editor, editorial writer, columnist, and member of the Washington bureau.

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