>>KOPELOW: So, Dr Boone we’ve come together
to talk about disparities in health care.
>>BOONE: Yes.>>KOPELOW: And I read in the commission to
end health care disparities it had four objectives for the period ending in 2011.
And the first one was to promote leadership development, to educate current physicians
and physicians in training on issues of diversity and solutions identified thus far
to eliminate disparities. And we’re here to talk
about how continuing medical education could support that objective. We’re here to talk
about examples and ways that that education community inside accredited continuing
medical education can support this goal and its objective. So, before we start I thought
we should do some definitions. There’s diversity
in health care, there’s disparities in health care, health care literacy, cultural competency,
equities in health care>>BOONE: Right.
>>KOPELOW: How about, you help us go through these things and define for us what
we mean. So, as we have our conversation about this people will understand what our
common language. So, diversity in health care?>>BOONE: Yeah, I appreciate you wanting to
clarify some of these terms, because sometimes they’re used interchangeably and
shouldn’t be. For diversity in health care really focuses on, how in a community a health
care community, whether that’s a hospital, a clinic, or a group practice setting,
for example, how does that practice reflect the communities that they serve? In other
words, within a Latino community, for example, are there Latino and Spanish speaking
staff that are there? Are there Latino and Spanish speaking physicians on staff? So,
that’s really what is reflected within diversity. And also, embraces inclusion. So, how is it
that an organization if they are diverse and reflecting the communities that they serve,
how are they really paying attention to the workforce diversity issues that can come up?
In other words, people that are diverse in their organization are their needs being met
as an employee within that organization?>>KOPELOW: So, disparities in health care?
How about disparities in health care?>>BOONE: Disparities in health care really
talks about the differences in outcomes that have, can occur within the health care setting.
The differences in outcome particularly as it relates to racial and ethnic minorities.
For example, over many years we know that the
health care system was segregated. Even when desegregation occurred the treatment of
minorities was not necessarily separate and equal or integrated and equal. It was unequal.
And that point was really illuminated one of the first times in 2002 when the Institute
of Medicine released the Unequal Treatment report.
And we became aware, in no uncertain terms, but for sure, backed up by the data
that unequal treatment over years and years in
the health care system has resulted in disparities in outcomes.
>>KOPELOW: So, the other term, equity in health care is that the opposite of disparity
in health care? Equity in health care?>>BOONE: Equity in health care really is
our goal. You know, really wanting to get to a
point where all patients, all people are treated with the highest quality of care. So, also
back in the two thousands, early two thousands, we saw a need to have quality measures
really focused on in a hospital setting, within a clinic care setting. And along with that
or parallel with that understanding the IOM’s
Unequal Treatment report and disparities we’ve come to learn that highest quality of
care can be delivered to all patients. So,>>KOPELOW: So, one of the definitions, the
last one, that’s talked about a lot is cultural competency. This sounds like it’s
a>>BOONE: Yes.
>>KOPELOW: it’s a tool to achieve some of this other, cultural competency, what’s
that?>>BOONE: Absolutely. Cultural competency
has to do with how we deliver care in a way that is both respectful of and sensitive
to a patient’s background their health beliefs. And so, basically this is one of the ways
that we can ask physicians and train our physicians in training how to approach patients,
who may be different from themselves. And cultural competency really speaks to communicating
with patients, understanding their culture, understanding their language
or having an interpreter if you do not understand their language. But, cultural competency
really embraces the idea that we are never going to know every idea about every
culture within, on our planet, but how do we
talk to a patient in a respectful way and ask questions that help illuminate what are
their health beliefs? How can we have a partnering
relationship? So that patients trust us as physicians and trust the health care system
and are therefore, over time, have better outcomes.
>>KOPELOW: Alright, so, let’s talk about some of the things that are really the issue.
Some of the things in this system that we’re trying to change, we’re trying to improve
that that aren’t equitable. And I read in a report from the Joint Center for Political
and Economic Studies, it was a report on the Affordable
Care Act, in the section on education that can support the Affordable Care Act,
it said, Persons of color are more likely to
report experiencing poorer quality and patient provider interactions than whites; a
disparity which is particularly pronounced among individuals, whose primary language
is other than English. So, this talks about color,
and this talks about language, but it’s more than that, right? It’s more than just color
and language?>>BOONE: It’s absolutely more than that.
One of the things I think we do have to solve, though, is that is a large piece of it. The
fact that we have racial and ethnic disparities that
are so pronounced in the United States. I think we have to solve that issue and then,
also, in parallel or, for sure, have focus on some
of the other issues around disparities, for example, disparities and outcomes in rural
health care, disparities and outcomes that is
experienced by the Gay, Lesbian, Transgender communities in the United States. Even
within our elderly population there are disparities that are experienced. But, even in
solving some of those problems and some of those challenges that we have the disparities
that are experienced around racial and ethnic patients. So, given the challenges with
various areas with disparities that we are really wanting to educate our physicians in
practices about and our trainees the issues around the outcomes in disparities for racial
and ethnic minorities are so pronounced that they are an imperative that we need to
address immediately.>>KOPELOW: We had a physician here several
years ago talking about disparities in breast cancer outcomes between African-American
>>BOONE: Right.>>KOPELOW: and White women in the Chicago
area.>>BOONE: Yes.
>>KOPELOW: It was David Ansell the author>>BOONE: Dr Ansell.
>>KOPELOW: Dr Ansell, he just published a book called County, about health care
disparities in Chicago sort of through the eyes of trainee at Cook County Hospital.
>>BOONE: Yes.>>KOPELOW: It was an interesting, it’s an
interesting book and story and in that, one of the things he talks about is the life expectancy
difference between people born in downtown Chicago and on the Southside of Chicago.
There’s a variation inside our community of ten years in a ten mile difference.
So,>>BOONE: Yeah.
>>KOPELOW: it’s not just national. These are local issues, these are issues of color,
but of sexual orientation,
>>BOONE: Yes.>>KOPELOW: of language, of immigrants versus
non-immigrants. What other examples are there that are concrete at risk
populations or situations in clinical, in practice where these things are manifest,
we could be focusing education on?>>BOONE: Right, absolutely, when you talk
about the local issues, I am sure that every city especially large metropolitan cities
in the United States could focus or point to some
changes or issues in disparities in outcomes within their community. Some other
examples, even within Chicago, relate to neighborhoods, so, by zip codes you can
identify disparities happen in health care, whether it’s treatment of cancer, cancer care
or identification and treatment of high blood
pressure, for example. Diabetes, we have several or I know of several collaborations
between communities on the Southside, on the West side of Chicago and major medical academic
centers looking at diabetes and how to eliminate diabetes disparities in care. So,
I definitely agree with you there are some issues
that are national issues where we can find those solutions to eliminate those disparities,
but there are also local issues that organizations such as, local medical societies ,
physician, other physician organizations can get involved with to come up with solutions
tailored to their communities to eliminate disparities.
>>KOPELOW: And that’s interesting. That point you just introduced the kinds of
organizations and what they can do cross referenced with the kind disparity issues and
inequities issues that there are and that’s important for this community that we’re talking
to because when you try to think of, well I’m going to go out and change the breast
cancer survival of African-American women in Chicago, there’s a lot of intervening
variables between a single educational intervention and a single physician or professional
in changing those disparities. There’s a lot of things.
>>BOONE: Absolutely.>>KOPELOW: So, let’s put that over here for
a second and come back to the educational interventions for the individual
people and speak to the point that that if there
is this issue at a national level very complex, it is appropriate for organizations to
collaborate, to come together, to create strategies for each of them to do a piece of the
puzzle.>>BOONE: Right.
>>KOPELOW: for each of them to do educational intervention for their members, for
the public, for others, to develop strategies, you must have seen this in your work?
>>BOONE: Yes, definitely.>>KOPELOW: Can you give us some examples
of perhaps with local coalitions or others that might be working on overcoming
disparities with groups of partners and other organizations?
>>BOONE: Yes, sure. For example, through the Office of Minority Health, years ago,
several centers for excellence in eliminating disparities were set up in different cities
around the country. We happen to have one here in Chicago through the UIC extension.
>>KOPELOW: University of Illinois in Chicago.>>BOONE: University of Illinois in Chicago.
And, within that CEED program, Center for Excellence for Eliminating Disparities.
They’re focusing on, for example, the AMA, myself, representing the AMA is involved with
a committee, a sub-committee of CEED working on how community health workers are
a major part of connecting patients from the community with the health care system
and navigating the health care system. And that’s also mentioned within the Accountable
Care Act at how community health care workers, Promotoras, for example, can help
eliminate disparities. So, that’s one way doctors can get involved. The other part I’d
really like to emphasis is that on a one on one
basis you know, for those physicians, who are in charge of developing continuing
medical education programs for physicians, who may not be involved in that
development, but arte receiving that information for their CME credits, what can they do?
And one of the issues or one of the ways they can help eliminate disparities is to look
at the systems within their hospitals setting,
within their immediate practice setting. And try
to understand either some disparities that are happening, unintended, that they might
be able to eliminate right there in their practice.
For example, are there patients that they see
that need language services? Having an interpreter or an interpreter system on hand to
handle that whether it’s the language line or it’s live interpreters, which is usually
best, having them available for their patients.
So, system-wise identifying those needs ahead of
time, so that it’s convenient for the patient, it’s convenient for the physician as well.
>>KOPELOW: Now, from an educational perspective, to reframe that, which was very
much appropriate approach from what an individual physician can do. What can an
individual educator do and there is a interesting article that you shared with me from
some years ago that was in the Journal for Health Care for the Poor and Underserved in
1998, an article called Cultural Humility Versus Cultural Competence by Tervalon and
Murray-Garcia. The authors say, at the heart of this education process should be the
provision of intellectual and practical leadership that engages physician trainees in
ongoing courageous and honest process of self-critique and self-awareness. Guiding
trainees to identify and examine their own patterns of unintentional and intentional
racism, classism, and homophobia is essential. That brings in what you said earlier in this
conversation that this is more than just color and language, but classism, homophobia,
those are important parts about this. But, this idea of reflective self-assessment, self-
critique, and self-awareness, those that’s almost the same language of the current
proposals for the maintenance of licensure systems in this country that talks about
reflective self-assessment. These authors talk about what you were saying from a
>>BOONE: Yes.>>KOPELOW: As educators they could take their
groups of learners and engage them in a reflective self-assessment process comparing
what they’re doing to what they could be doing.
>>BOONE: Yes. OK.>>KOPELOW: Right?
>>BOONE: Compare it, yes.>>KOPELOW: Where is the information available,
is there information easily available on the AMA Web site, what are the resources
that you know where educators could say, Let’s find out how sensitive we are. Let’s
find out how aware we are.>>BOONE: Yes.
>>KOPELOW: Is there?>>BOONE: Absolutely. There are some tools.
>>KOPELOW: yes.>>BOONE: To help identify that, and just
to mention, this is essential to understanding how we deliver health care as physicians,
understanding our own biases. And understanding that, even if we feel like we
don’t have any biases, that there is a medical cultural divide between how we interact with
the patient and how the patient perceives the medical culture or the physicians that
they encounter.>>KOPELOW: You mean how we intend to do things
and how it’s actually received.>>BOONE: how it’s received. And there re
many studies looking at how patients will have the bias of they may not understand the
doctor, because they’re going to speak in jargon. And then we as physicians, you know,
try to speak in lay terms. And that becomes a divide, in and of itself. But, to
your point, yes, to your point about how we can
have tools to really overcome this issue understand our own biases, introspection etcetera,
There are tools located through the Disparities Solution Center, Dr Joe Betancourt and his
team have identified some ways that people can go through a self-assessment in the
Disparities Solution Center. And be able to understand immediately, Yeah, well maybe I
do have some biases And understanding those particular biases or preconceived notions
about patient populations or just patients in general. That helps us to then understand
how to recognize when those biases are coming
forward and be able to put them aside when it
comes to that point of a patient encounter that we’re going to deliver a diagnosis or
deliver a treatment plan. And make sure that that treatment plan is the highest quality
treatment plan for all the patients that we see.
>>KOPELOW: That concept is critical ion medical education, we talk about knowing,
>>BOONE: Yes.>>KOPELOW: and putting knowledge in action.
And that’s what you suggested was that that people will know that there are
issues of disparity, but put that competency and
those skills into action by ensuring that they don’t have that outcome they don’t in
practice that’s what you were referring to.>>BOONE: Exactly. The other part of what
I think is really exciting is that if this is
aligned with the competency for ACCME it comes at a really tremendous time when
physicians in general can make a difference at every point of their encounter. And really
consider every encounter as my friend Dr. Bob Like says, every encounter is a cross-
cultural encounter between a physician and a patient. And that’s where I think we can
really help make a difference as providers, as educators, setting an example, being a
role model, and being able to change some of our
behaviors and how we treat patients.>>KOPELOW: You know, one of the things about
practicing medicine is you don’t always know you’re in a high risk situation.
>>BOONE: This is true.>>KOPELOW: You don’t always know. And, and
and sometimes it’s way down the line in the, but in this circumstance when you
sit down with someone who isn’t white and who doesn’t speak English very well you know
already that that you’re in a high risk situation not delivering care according to
measure. And you’re in a high risk situation for
not delivering care the same as the last patient that you just saw.
>>BOONE: Yeah.>>KOPELOW: And if the physicians have the
tools in order to address this, this would be welcome from the CME providers’ perspective.
Now,>>BOONE: Yes.
>>KOPELOW: a tool an approach is this concept that Tervalon and Murray-Garcia
talked about cultural humility.>>BOONE: Yes, absolutely.
>>KOPELOW: What does that mean to you, share that with us. With the people who are
listening. How that could be something, our goal perhaps. A professional practice a
competency try to imbue in people.>>BOONE: I think, and thank you for asking,
how do I perceive that cultural humility applies to me because I think it’s going to
apply differently to every person.>>KOPELOW: Of course.
>>BOONE: every physician and every trainee. But I definitely think cultural humility
has to do with how we stand in our shoes and look at the world and look at other people
whether it’s our colleagues the patients that we treat, the system that we’re working
within, it means that we embrace that we don’t know everything. And for physicians that
sometimes can be difficult. But, we don’t know everything. We will, as I said earlier,
we will never know all of the nuances of cultures
all around the world. In fact, even if we did, we can’t apply that initially to anyone
patient that we encounter. That’s reinforcing stereotypes and we don’t want to do that.
But, cultural humility has to do with understanding that each and every patient
in front of us, who comes to us for care and educating our trainees about this is a unique
individual, a unique person, and we may not know everything about them, but we can elicit
that information in a way that’s sensitive to and respectful of their background and
their health beliefs, which obviously may be
very different from ours. Or actually may be very similar. A quick story I’ll tell you
in terms of cultural competency that, you know,
I teach cultural competency I’ll talk a little bit about some other references or tools that
are available for cultural competency, but I
was seeing a patient and the patient, I’m African-American the patient sitting across
from me is African-American, and in the encounter
there was something else going on with him. He came in with a headache, he mentioned
that he was feeling uneasy and I said, Is there anything else? And that actually, asking
that question came from, you know, an article on asking the question, you know,
is there anything else, back in 1998 I believe and it wasn’t in cultural competency literature,
but I mention that because eliciting one more thing from this patient, he said then,
my son was in a car accident, I’m very worried about him had to take off work, I’m worried
about taking off work today as well, you know, to come and see about myself. And in
checking this gentleman immediate EKG. vital signs, etcetera, he had an evolving
MI. And as the ambulance came to take him out
of the clinic to the emergency department, I asked him one more time, Mr G. why didn’t
you tell me about this? You know, this impacted your blood pressure, and impacted
everything, but tell my why you didn’t tell me about this. He said, Doc I didn’t think
you’d care to know. You know, so, to your point about every situation can be high risk
and we may not even know it, that’s a point of cultural humility. You know, we all
should have a certain amount of cultural humility that really takes us to every encounter
with our colleagues, with our patients in a sense that, we don’t know everything. And
let’s explore this in a way that we can embrace that we don’t know everything. Cultural
humility embraces that.>>KOPELOW: Sonja Boone, thank you very much.
>>BOONE: You’re welcome.