Institute of Medicine panel wrestles with racial, ethnic disparities in care

Medical and legal experts are assessing differences in care, exploring what causes these differences and offering policy, practice recommendations to address them.

By Stephanie Stapleton, amednews staff. Sept. 24, 2001.

Washington -- Surgeon General David Satcher, MD, PhD, often recounts the story of a serious illness he suffered as a very young child in Anniston, Ala. His father had to summon the only African-American physician in the area to come to the family home.

It was a defining experience, he says. It was this event that led him to develop an interest in pursuing a career in medicine. It was also his first exposure to racial and ethnic disparities in health care -- a topic, he says, "in which I've had some interest for a few years now."

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Dr. Satcher was speaking at a workshop held Sept. 6 by the Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care.

The meeting was one in a series of five public sessions held by a 15-member expert panel in response to a 1999 congressional request to assess the extent of differences in the types and quality of health care services received by racial and ethnic minorities and nonminorities in the United States. Congress also asked the IOM to explore factors that may contribute to any inequities in care. The panel was also charged with developing policy and practice recommendations that could help lead to the elimination of any such inequities.

A large and consistent body of research demonstrates that racial and ethnic minorities receive a lower quality and intensity of health care, even when factors such as insurance status, education, income, comorbid conditions and the severity of presenting symptoms are taken into account, according to IOM materials.

Still, there appear to be many questions and no clear-cut answers explaining why this is the case.

"This is a very important topic -- and not an easy one," Dr. Satcher said.

During the panel discussion, there was much consideration of the forces that may be at work. While some panelists were focused on the question of how good the evidence of the differences in health outcomes actually is, others emphasized the need to delineate root causes and contributing factors. Some focused on how barriers that exist in, and are perpetuated by, both public and private health care systems lead to poorer health status among certain vulnerable populations. Others focused on bottom-line issues of race.

Not an easy topic

"It is hard to talk about race in general and discrimination in particular," said Thomas Perez, a former director of the Dept. of Health and Human Services Office of Civil Rights. "Discrimination, as much as we don't want to admit it, is very real. Race does matter," he said. And sometimes it finds its way into the examination room, he added.

But others cautioned against moving too fast in any one direction.

"There is immense cost in assuming discrimination [is the culprit] if it is not the root cause," said Richard Epstein, a University of Chicago Law School James Parker Hall Distinguished Service Professor. Spending time and resources attempting to correct this problem will not change health outcomes if disparities are actually being caused by other elements, such as a lack of patient involvement and education, he added.

Perez, too, agreed that patient education and empowerment is critical. "It's not just a matter of raising awareness among physicians," he said. "Part of the challenge is educating vulnerable populations about asking for second opinions, about finding out alternatives and other options."

Meanwhile, Dr. Satcher said that the physician-patient relationship is critical to future progress.

Race sometimes can affect other interactions, and "that is certainly true in medicine," he said. "How do we make sure that doesn't impact quality of care?"

The IOM panel will likely complete drafting the report later this year and publish it next year, according to David Nelson, MD, committee chair.

ADDITIONAL INFORMATION:

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IOM ongoing study "Understanding and Eliminating Racial and Ethnic Disparities in Health Care" (http://www.iom.edu/IOM/IOMHome.nsf/Pages/Ethnic+disparities)