Extinguishing inequities in health care

AMA Leader Commentary. By Ronald M. Davis, MD, Jan. 21, 2008.

AMA LEADER COMMENTARY

A few words about current events in medical practice

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A message to all physicians from AMA President Ronald M. Davis, MD.

Outside of medicine, Colin Powell's promise was noticed early by the U.S. Army, and Oprah Winfrey's talent was recognized by the television industry. César Chávez's leadership abilities were nurtured by labor leaders, and Amy Tan's writing skills were lauded by English and linguistics professors. The entire world is now a better place because they overcame disparities in their professions with some encouragement by mentors.

Our AMA has long been concerned about disparities in health care based on race or ethnicity. Our own record is far from perfect, but the House of Medicine is arguably the one venue -- more than any other -- that asks itself the tough questions daily. P erhaps this is because in medical care, unlike with most jobs, lives are literally at stake. And while that also may be true for firefighters and those in law enforcement and the armed forces, the people to whom physicians are providing care are usually a t their weakest, sickest and most vulnerable. That gives us a special incentive to correct and improve our skills.

When patients fail to receive high-quality care because of their race or ethnicity, the entire nation suffers. Fortunately, we in medicine are working hard to heal part of this disease of social injustice.

Selected racial and ethnic disparities in health care
Topic: The uninsured

The Institute of Medicine, in a 2002 report entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, summarized the evidence on racial and ethnic disparities in health care (see box) and examined how disparities in t reatment may occur in health care systems and clinical encounters. New research continues to document disparities. A study published in the Jan. 2 Journal of the American Medical Association, for example, showed that during 1993-2005, white patient s making pain-related visits to emergency departments were more likely to receive an opioid than black, Hispanic or Asian/other patients; differences did not diminish over time and persisted after adjusting for patient, visit and hospital characteristics.

I've been privileged to co-chair, along with Sandra Gadson, MD (past president of the National Medical Assn.), the Commission to End Health Care Disparities. The commission is a coalition of more than 50 state and specialty medical societies and other health professional organizations working collaboratively to eliminate disparities in health care and strengthen the health care system. For 2007, we had five strategic objectives, and I'd like to tell you how they turned out -- a progress report of sorts .

1. Our first objective was to initiate and influence federal, state and local government actions that curtail racial and ethnic disparities in health care. We published a framework for this advocacy, "Addressing Health Care D isparities: Recommended Goal, Guiding Principles, and Key Strategies for Comprehensive Policies." We believe it will assist anyone seeking to make a difference in this area. This effort included letters to members of the executive and legislative branches advocating for a reduction of sodium in packaged foods and food sold in restaurants. In addition, we prepared an issue brief on the role of sodium in causing cardiovascular disease and stroke in African-Americans.

2. Our second objective was to help physicians, medical students and other health professionals become more directly engaged in addressing racial and ethnic health care disparities. We tried to take existing information and t ranslate it into effective action. One of several practical tools we devised was a three-hour workshop that educates physicians about the issues and provides strategies for how doctors can reduce disparities by improving patient-physician communication. S o far, the workshop has been presented at meetings sponsored by six state and local medical organizations, and the feedback has been terrific.

3. Our third objective for 2007 was to study the practice environment and provide recommendations on strategies to eliminate disparities. We produced papers on how pay-for-performance and emerging technologies impact racial a nd ethnic health care disparities. The commission also is developing recommendations for promoting the collection of data in health care settings on patients' race, ethnicity and language.

4. Our fourth objective was to take steps to increase the diversity of the health professional work force. To do this, we used the Doctors Back to School program developed by the AMA's Minority Affairs Consortium. In cities a round the country, we found physician volunteers willing to reach out to students in underrepresented groups, from elementary schools to undergraduate colleges, and to encourage them to consider careers in health care. Our DBTS program already has been ad opted by three medical schools, and we had physician participation through a dozen different programs last year. This year, we plan to expand it further. I expect that, eventually, it will significantly improve the diversity of the physician work force -- one young future physician at a time.

5. Our final objective for last year was to promote the collaboration between medicine and private industry on strategies to eliminate disparities. Our commission created a vehicle for corporate membership and welcomed the fi rst six members: Eli Lilly & Co., AstraZeneca International, Purdue Pharma LP, BlueCross BlueShield of Florida, Pfizer Inc. and PhRMA. There is common ground here, and we're finding it.

In summary, we're proud of last year's results in our efforts to end the curse of health care disparities related to race and ethnicity. But in 2008, we look forward to doing even more.

We're also proud that leaders in the House of Medicine are serious about improving conditions for patients and doctors alike -- and that means every patient and every doctor.

All of us have heard that famous advice from the Gospel: "Physician, heal thyself." Collectively, we need to heal medicine to eliminate disparities in care wherever they exist -- in hospitals, clinics and doctors' offices throughout the country.

Please join us in making even greater strides next year. Get involved. You can see various ways how to do so on our Web site (www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/minority-affairs-consortium/news-resources/racialethnic-health-care-disparities.shtml).

Do it for a healthier and better America for everyone, and for a healthier and better world.

Dr. Davis, a preventive medicine physician living in East Lansing, Mich., served as AMA president during 2007-08. Dr. Davis died on Nov. 6, 2008.

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ADDITIONAL INFORMATION:

Selected racial and ethnic disparities in health care

The preponderance of studies find that even after adjustment for many potential confounding factors, racial and ethnic disparities in cardiovascular care remain.

Several studies demonstrate significant racial differences in the receipt of appropriate cancer treatments and analgesics.

Several studies are consistent in finding that African-American patients (and in some instances, other ethnic minority patients) are less likely to be judged as appropriate for transplantation, are less likely to appear on transplantation waiting lis ts, and are less likely to undergo transplantation procedures, even after patients' insurance status and other factors are considered.

African-Americans with HIV infection are less likely to receive antiretroviral therapy, less likely to receive prophylaxis for pneumocystic pneumonia, and less likely to receive protease inhibitors than are non-minorities with HIV. These disparities remain even after adjusting for age, gender, education and insurance coverage.

Source: Institute of Medicine, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, 2002

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