Minorities get poorer care, says IOM report

Stereotyping can even lead to higher death rates

It’s something few health care professionals like to admit or even accept, but racial stereotyping continues to cause differences in treating heart disease, cancer, HIV infection, and other conditions, partly contributing to higher death rates among minorities.

This alarming reality was brought into clear focus with a recent study by the Institute of Medicine, titled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. (The entire study is available free at the National Academy Press web site: www4.nationalacademies.org.)

"The study showed a difference in the quality of care received by minorities, even when adjusted for insurance, income, age, and severity of condition," notes Sandra Adamson Fryhofer, MD, MACP, general internist and clinical associate professor of medicine at the Emory University School of Med-icine in Atlanta, and a member of the committee that produced the study. "These racial and ethnic disparities are real and are associated with worse outcomes and can contribute to a higher death rate," Fryhofer explains.

Here are just a few of the disparities the study uncovered:

• Lung cancer: Of 11,000 patients who had lung cancer surgery, the five-year survival rate for whites was 34%; while for minorities, it was 26%.

• Heart disease: For every 100 whites who received a procedure to clear blocked arteries, only 74 minorities received the same procedure.

• Emergency department treatment: Blacks were 1.5 times more likely than whites to be denied authorization for treatment by managed care providers.

"Many sources may contribute to these disparities — patients’ preferences; some clinical uncertainty among health providers; financial and organizational arrangement of the health care system," Fryhofer posits. "But when you look deeper, there might be a role of stereotyping, prejudice, and bias. Even well-meaning people who are not overtly prejudiced may demonstrate some unconscious negative stereotype," she says. "And the likelihood of that happening is increased when you consider our current time constraints."

Facing a hard truth

For quality managers and other health care professionals, the first challenge is to admit this problem exists, Fryhofer says. "It’s tough to think about," she concedes. "When you think that this kind of thing might exist in your facility, it’s kind of upsetting. But when you’ve been involved in this study and seen the end result, you know that it’s a wake-up call and that we have to change this situation."

The problem is multifaceted, Fryhofer emphasizes. "For example, there might be language barriers," she says. "As a practicing physician, you need to communicate. If you can’t, you need someone there who can." Thus, one of the committee’s recommendations is to have interpreters present to aid the communication process. Because the health care maze is so complicated, "You might consider using community health workers to help patients navigate through the system," Fryhofer suggests. "This can also strengthen doctor/patient relationships, and helps patients get over their fears."

Patient education is another critical area. "You need to make sure patients have access to medical information they understand, whether that means having it in a language they understand or having it on their grade and intellect level," she says.

As for specific vehicles, the committee points to evidence that education through books and pamphlets, in-person instruction, CD-ROMs, or the Internet can increase the level of patient participation. Education efforts must extend to staff as well, to help them better understand different cultures.

"There are many different vehicles," Fryhofer says. "You have to figure out the best way for your facility. It could be continuing medical education for docs, inservices, weekly medical conferences. We have to take a multifaceted approach for a multifaceted problem; there’s not just one way to reach the numbers of people who need to be reached."

Through cross-cultural educational strategies, "We hope to make everyone aware of the role of stereotyping and bias — even if it is unconscious," she explains. "We must enhance awareness of the key issue: that all patients should receive health care matched to their needs and be treated with dignity and respect."

For more information, contact: Sandra Adamson Fryhofer, MD, MACP, Emory University School of Medicine, 1938 Peachtree Road, Suite 502, Atlanta, GA 30309. Telephone: (404) 355-4388.