217 Health Care Disparities and Diversity in Emergency Medicine
Key Points• The U.S. population is changing rapidly and becoming more diverse.
• Improvement in access to care for racial and ethnic minorities has not proved effective in ameliorating health care disparities.
• A diverse workforce that mirrors the patient population is a key and important step toward reducing health care disparities.
• Cultural competency helps health care providers understand how to approach patients from different backgrounds by improving communication and building trust in the doctor-patient relationship.
Introduction
As the globalization of trade, technology, investment, and migration create a more diverse U.S. population, we are increasingly becoming aware of disparities in economics, health care, and human rights. Our nation was founded on the concept that “all men are created equal,”1 and equal treatment and equal access are the goals toward which we strive. Nowhere else in medicine is the commitment to equality as obvious as it is in emergency departments (EDs), where the sole criteria for moving to the front of the line is severity of illness. Other specialties now restrict the days and hours during which they are available to patients and tell their patients at discharge from the hospital to go the ED if they have any problems or concerns. Changes in the economy have resulted in a significant increase in the percentage of uninsured.2 Only the ED provides medical care 24 hours a day, 365 days a year for every patient with any complaint. As advocates for our patients, emergency physicians (EP) are at the forefront of the promotion of diversity and the elimination of disparities in health care, not just at home but throughout the world.
The definitions of some important terms, broadly and more specifically as they relate to emergency medicine (EM), will help provide a common understanding and language for the reader3 (Box 217.1). Awareness of the history of disparities in access to quality health care (Box 217.2),4–17 the benefits of clinical research (Table 217.1),18–23 and medical education and EM practice (Box 217.3) will create a contextual framework within which the reader can appreciate all that has been accomplished, as well as the tasks that remain, as we work toward the ideals of diversity and cultural competency.
Box 217.1 Definitions
Culture: Customary beliefs, social forms, and material traits of a racial, religious, or social group; also, the characteristic features of everyday existence shared by people in a place
Disparity: Lack of parity, the state of being dissimilar or unequal
Diversity: Inclusion of different types of people in a group or organization
Box 217.2 History of Health Care Disparities
1619-1865: Contaminated drinking water led to frequent outbreaks of disease among slaves.4 Slaves develop a system of care involving indigenous herb root doctors and midwives.5
1824: The Bureau of Indian Affairs is established and provides limited health care to Native Americans on reservations.6
1852: The first hospital for the care of blacks is opened: Jackson Street Hospital, Augusta, Georgia.7
1862: The only government-funded hospital for blacks, Freedmen’s Hospital in Washington, DC, is established.8
1948: Executive Order 9981 mandates the integration of Veterans Administration hospitals.9
1955: The Indian Health Service is commissioned.10
1965: The Johnson administration announces that federal Medicaid and Medicare payments will be denied to segregated hospitals.11
1990: A metaanalysis of 485 articles confirms that migrant health care is confined almost exclusively to charity migrant clinics and virtually nothing is known about the health status of the workers.12
2004: At every age, blacks have higher blood pressure than nonblacks.13
2005: A total of 16.5% of American Indians, 10.4% of Hispanics, and 6.6% of whites are diabetic.14
2006: African Americans are more likely than whites to die of coronary artery disease. They and Hispanics are less likely to be offered bypass or angioplasty. Blacks have worse cancer survival rates, are more likely to undergo amputation for complications of diabetes, and are less likely than whites to be referred for transplant evaluation. Hispanics and Native Americans are least likely to be offered cholesterol management services.15
2009: Of all patients in whom human immunodeficiency virus infection was diagnosed this year, 52% were black.16
2010: Twenty percent of the population lives in rural areas, where only 9% of physicians practice.17
Table 217.1 History of Disparities in Research
| Nazi human experimentation: 1938-1945 | Josef Mengele, MD, was one of the notorious physicians who performed burning, boiling, freezing, beating, hanging, and poisoning experiments on human prisoners of war who were predominantly racial and ethnic minorities in Europe.18 |
| Tuskegee Study of Untreated Syphilis in the Negro Male: 1932-1972, Taliaferro Clark, MD | The U.S. Public Health Service conducted a study on the natural course of syphilis in black males; they were often not informed of their diagnosis and were deliberately prevented from seeking and obtaining treatment, even after penicillin became widely available.19 |
| Willowbrook: 1963-1966 | Saul Krugman, PhD, deliberately infected mentally handicapped children with hepatitis B virus to study the effects of gamma globulin on the disease.20 |
| Nuremberg Code: 1948 | It arose from the trials of Nazis for crimes against humanity and addressed consent by and protection of subjects of human research.21 |
| Declaration of practice, Helsinki: 1964 | The World Medical Association establishes good clinical practices in human research (standards revised in 1975, 1983, 1989, 1996, 2000, 2002, 2004, and 2008).22 |
| Belmont Report: 1979 | Boundaries were established between practice and research and basic ethical principles of human research.23 |
Box 217.3 History of Disparities in Medical Education
1783: Dr. James Durham, a former slave, becomes the first African American physician. He sets up practice in New Orleans after apprenticeship training.
1837: Dr. James McCune Smith is the first African American to obtain an MD degree. He has to go to the University of Glasgow to do so. He sets up practice in New York City.
1847: Dr. David J. Peck is the first African American to graduate from a U.S. Medical School (Rush Medical College).
1849: Two African American men receive MD degrees from Bowdoin College, Maine.
1850: There are 13 African American doctors: 9 in New York City and 4 in New Orleans.
1857: Dr. Elizabeth Blackwell becomes the first woman to graduate from a U.S. medical school and founds the New York Infirmary for Women and Children.
1867: Dr. Blackwell founds the Women’s Medical College of Pennsylvania
1868 and 1876: Eight Negro medical schools were established, but only two are still open: Meharry, Tennessee (1876), and Howard, Washington, DC (1868).
1889: Dr. Susan La Flesche Picotte is the first American Indian woman to earn an MD degree; she receives it from the Women’s Medical College of Pennsylvania.
1890: There are 909 African American doctors, as compared with 1734 in 1900 and 4500 in 1960.
1891: Dr. Daniel Hale Williams opens the first black-owned hospital (Provident Hospital in Chicago).
1905: Being denied membership in “mainstream” medical associations, Dr. Williams establishes the National Medical Association.
Identifying Issues of Disparity
In 2003 the Institute of Medicine (IOM) was charged by Congress to examine racial and ethnic disparities in health care. Their landmark report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare,”24 brought the issue of health care disparities to national attention. The report concluded that “Racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities, even when access-related factors, such as patients’ insurance status and income, were controlled.” The report defined disparities as “racial or ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention.”24
According to the U.S. Census Bureau, there are currently more than 300 million Americans: 65% white, 16% Hispanic, 13% black, 5% Asian, and 1% American Indian.25 Yet according to a report by the American Medical Association, only 6.4% of practicing physicians are Hispanic and 4.5% are black.26 Recognizing the changing patient demographics and the unchanging demographics of the physician workforce, the Association of American Medical Colleges (AAMC) Executive Council adopted a definition of underrepresented in medicine (URM) as “those racial and ethnic populations that are under-represented in the medical profession relative to their numbers in the general population.” Before this, the AAMC used the term “under-represented minority,” which specifically targeted African Americans, Mexican Americans, Native Americans, and mainland Puerto Ricans. A much broader definition of diversity includes race, ethnicity, socioeconomic status, sexual orientation, religion, disability, age, language, and geographic diversity.27
