>> 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: Yes.
>> KOPELOW: So,
>> 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.
This is a transcript of Addressing Health Care Disparities with CME
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