M.D.ea Culpa

Sometimes playing the blame game is the right thing to do. Recent research is pointing an accusing finger at doctors who fail to obtain appropriate health tests and interventions for…well, let’s just say certain patients. As in, specifically, African American patients. Is this racism? Class-ism? Sexism? Do your doctor’s biases affect your health? Or is a difference in healthcare delivery between people somehow appropriate? We’ll look at four almost-simultaneously-published reports that all examine this important issue from different angles. Our final, fourth study gives a nice perspective on how things can improve for everyone. Check out this bumper crop of data review to see how you or your loved ones may be missing out on life-saving care – and what can be done to prevent this from happening. And if you’re a doc, read on and take a moment to do that important internal check we all need from time-to-time. Ask yourself, could this be me? Or do you disagree with the researchers? Post your (civil) comments and join in the discussion.

1) Doctors are responsible for who gets colon cancer screening – and we’re doing a sucky job. Here are the grim stats from the Medscape summary of this study: “Compared with whites, African Americans have a 20% higher incidence of color-rectal cancer (CRC) and a 40% higher disease-related mortality, which is at least partly attributable to differences in screening practices. Following national screening guidelines for CRC could reduce CRC-related mortality by up to 80%. Although CRC screening rates have increased slightly during the last decade, they remain low in all racial groups and especially in African Americans.” This research study in Maryland shows that comparably-insured African Americans with the highest risk of colo-rectal cancer (those with a known first-degree relative who already had it) were much less likely to get appropriate, life-saving screening than whites with elevated risk. High-risk means screening early, and these high-risk African Americans were actually even less likely to get appropriately screened than other African-Americans at regular risk. So what was the biggest factor in who got appropriate screening tests when you look at all the variables? Simply the doctor’s recommendation. Ouch.

2) Same folks, same bad outcome, new possible complicating factor. Here’s another twist on these study subjects. A news report by these same researchers shows that they are in the process of phone-calling a group of these higher-risk African American Maryland patients. They found (not surprisingly) the same sucky results, but a bit more: “The completion rate for risk-appropriate, timely CRC screening was 53.4% for African Americans without a family history of CRC and 39.8% for those with a family history. The completion rate was 65.5% among 293 white respondents with a family history of CRC. By contrast, the authors observed that perception of cancer risk and cancer concern were greater in African Americans who had a family history of CRC, even though this did not translate into higher screening rates. They therefore recommend a prospective study to explore the influence on screening decisions of perceived risk of cancer and fatalism.” Before anyone gets excited and claims it’s really the patient’s fault (hurry, let’s blame the victim!), keep in mind this last point from these authors –

“In multivariate analysis, individuals with a family history of CRC were found to be 24 times more likely to undergo screening when it was recommended by their physician.” That physician recommendation is pretty powerful, isn’t it?

3) Now, looking even closer to home…here’s data analyzing racial differences in diabetes care at the per doctor level, as reported by heartwire. Brace yourselves for some bad results: “Black patients with diabetes are less likely than white patients to achieve long-term control of blood pressure, blood glucose, and lipids even when the same doctor treats them. The variation in care was not related to overall performance or the volume of black patients treated by an individual physician, nor was it related to just a small cluster of clinicians. ‘Rather, we found that all physicians across the board contribute in a moderate way,’ lead author Dr Thomas D Sequist (Brigham and Women’s Hospital, Boston, MA) told heartwire. The findings are reported in the June 9, 2008 issue of the Archives of Internal Medicine. Also, while 90% of the doctors in the study thought that racial disparities in diabetes care were a problem in the US in general, only 40% of them acknowledged that it was a problem among their own patients.” Despite all evidence to the contrary…

I’m sorry, but that result’s just bad. So what do you, as a patient or doctor, do with this kind of information? For one thing, the researcher says, “‘The concept of disparities is an abstract one to us as we practice in our daily lives–we recognize that it’s there, but it’s a policy-level issue. We are trying to show doctors that we can be more aware of this and work with our patients better to overcome some of these barriers. But until we recognize it, we probably aren’t going to work any harder to help our patients,’ he notes.”

Not to sound too cynical, but is being “aware” and “working harder” likely to help?

4) According this next report, that might be all that’s necessary. Here’s the good news: there are now, finally, comparable survival rates after liver transplantation. “Caucasians, African Americans, Hispanics, and Asians who undergo primary liver transplantation now have comparable 5- and 10-year patient and graft survival rates, new research suggests. In the 1980s and early 1990s, by contrast, several studies reported lower patient and graft survival rates for African Americans and Asians.” Many of you readers may also remember that there were also lower referral rates – justified, in part, by the belief that certain people couldn’t do as well as others to meet the demanding requirements of post-transplant care. Awareness of these racial discrepancies, attention to the problem, and sustained efforts to improve the situation have resulted in this long-overdue great news. Which is all the more reason to keep discussing the topic of racial inequalities in healthcare – awareness is the first step in the curative process.

Bottom Line Here’s the Doc Gurley take for providers on this important, complex, life-or-death issue:

1) If you’re a healthcare provider like me, I try to remember to check myself. I call it the Dick Cheney check. Ask yourself – if this patient was Dick Cheney, would I refer him for this test? If the answer is yes, and I haven’t referred, then I ask myself – why the double standard? I see patients in a homeless clinic – and it’s surprising how often a patient comes through and get something difficult done, when, as a provider, my bias might be to think that it wasn’t possible (the patient has no phone, no way to get a letter, no way to get the bowel prep done while living on the street, etc.). The bottom line is – if I don’t refer, it sure as hell will never happen. In practical terms, we providers should all be using those pre-printed checklists for screening tests in our clinics – those lists don’t say except for African Americans at the top. What’s harder is to then keep stats on who is failing their screening/improvement rates by race/age/gender. Often the only way to be honest is to use numbers to keep yourself honest.

2) Let’s assume you’re not a racist doctor who is either subconsciously or blatantly different in how you treat your patients [Maybe a lot of readers are saying ha! like that’s possible. Even so, let’s just assume it’s true]. How do you then get a good referral/screening test result when you do recommend? The most important issue for appropriate test compliance for many patients boils down to this one question- does your patient see you as a trustworthy doctor with their best interest at heart? It is an act of faith to let someone do something invasive to you (even if it’s as simple as drawing blood) when you feel fine. If your patient sees you as “experimenting” on them, or not caring, or out-to-just-make-money, then you can refer/recommend until you’re blue in the face. It won’t happen. You might think a homeless person in my clinic would be grateful for a high-tech test. The fact is, homeless or not, paying or not, no one wants to be taken advantage of – so the trust issue is still (always) there. This is when I use the Dick Cheney example again. I actually tell patients, “If you were Dick Cheney (or whoever), we’d want you to get this test. I try hard to make sure everyone gets the same standard of care,” Or I use actual examples – “Katie Couric had a colonoscopy done – did you see her on TV? (bless her heart)” I also explicitly tell people my financial arrangements. I say “I don’t get money for sending you to the GI doctor.” I say, “I do get paid for seeing people fast, not for spending time talking about this test, but I’m taking the time today to talk a lot with you because I’m worried about your health.” People want to know about the money – they may act like they don’t care, but they do. I believe that telling a patient that you actually get paid for something won’t mean they refuse the test, it just gives them information on how to take your recommendation – especially when you point out that the reimbursement is the same for everyone, or that you’re happy to refer to someone else if they prefer, or – especially – that you are, in fact, paid more for NOT doing these tests, as is so often the case these days. I find people are often imagining much worse financial kickbacks than actually exist (or are legal).

3) Doctors have all kinds of different styles (see this Doc Gurley San Francisco Chronicle magazine article for more on this topic). I personally believe in saying the worst-case scenario up front when someone has refused a life-saving test – and getting the topic out on the table. I ask patients who keep refusing/not going to referrals, “Are you worried we’ll find cancer?” I often discover that people say they are – and that talking it through works. I don’t promise anyone there won’t be any cancer found – obviously that would be wrong when you don’t know. Here are some of the obvious (but often neglected) kinds of things I gently say in response to the horribly scary “cancer” word – “but it can be a cure if we get it early – kind of like a skin cancer,” or “your kids/family/partner would want us to find that and take it out as fast as we could” or “if we don’t look, that doesn’t mean it goes away,” or “you’re too young to give up like this,” or even “this is what medicine is good at – refusing this test is like living in the 1800’s – why miss out on all the scientific advances?” Talking it through tends to help, as well as framing the test as a necessary part of taking good care of your body – “we’re just checking under your hood.”

4) Finally, if all else fails, I’ll tell the patient I want to get their family involved. Legally no one can do that without the patient’s permission – and I wouldn’t either, and I explain that to patients. But saying those words out loud (“I think your family should know”) will often communicate (in a way nothing else will) the importance of the situation. I also explain that I don’t want the family (who loves this person) angry at me when something bad might happen and I’m forced to explain how it was that their mother/dad/grandma didn’t get the kind of test that could find and fix the problem. I also say that sometimes it helps to put more heads together on a topic like this. Usually, the family’s concern helps.

5) If all of these attempts fail, I try to ask the hard questions about why. Are you feeling down? Do you feel like nothing is worth doing? In other words, are you depressed? It is clearly wrong to tell every patient who declines a test that something is psychiatricly wrong with them, but depression and poor outcomes go together for a reason. Refusing logical, relatively-safe interventions for high-risk disease can be a marker of depression. Sometimes surprising (and heartbreaking) factors emerge – the physically-abusive partner, the anniversary of a loved-one’s death, the PTSD from sexual abuse at the hands of parent who died from this very same disease, etc. The doctor-patient transition from “why won’t you do this test I want” to “you may need help” is fraught with pitfalls and emotional land-mines, but it is well worth the considerable effort and time it takes to navigate this path sensitively.

6) Finally, quality improvement (QI) interventions work by being time limited and focused. Each of us has an opportunity in our practices to suggest QI topics – we are required to do an individual one for our Internal Medicine Boards renewal, almost all hospitals, clinics and insurance programs require them. February was Black Future Month here at Doc Gurley.com, just to make sure some often-neglected topics got pushed to the front. Each of us might want to consider looking at differences in an outcome measure, by race, as a part of our next round of QI interventions, even though, based on this week’s research, the results may make us feel like squirming.

Do you have more tips or another perspective? Add your voice to the comments below.

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