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Cheung K. Using curiosity to render the invisible, visible. THEORETICAL MEDICINE AND BIOETHICS 2024:10.1007/s11017-024-09665-3. [PMID: 38767830 DOI: 10.1007/s11017-024-09665-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/05/2024] [Indexed: 05/22/2024]
Abstract
Virtues commonly associated with physicians and other healthcare professionals include empathy, respect, kindness, compassion, trustworthiness, and many more. Building upon the work of Bortolloti, Murphy-Hollies, and others, I suggest that curiosity as a virtue has an integral role to play in healthcare, namely, in helping to make those who are invisible, visible. Practicing the virtue of curiosity enables one to engage with and explore the experiences of patients and contributes toward building a physician-patient relationship of trust. As the perspectives and experiences of patients can be too often dismissed or lost within medical settings, curiosity can allow physicians to deeply know their patients, and thus provide better care. However, caution must be exercised so as to not to venture into inappropriate curiosity, where questions are asked for improper reasons or to help satisfy the personal interest of physicians. Finally, I sketch out two cases-on chronic pain and on vaccine hesitancy-to illustrate where curiosity can play a valuable role.
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Affiliation(s)
- Katherine Cheung
- Department of Bioethics, New York University, New York City, USA.
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2
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Thomas JJ, Johnson S, Holden KB, Hutchins S. Treating black patients as "knowers". J Natl Med Assoc 2023; 115:584-588. [PMID: 37968177 DOI: 10.1016/j.jnma.2023.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/25/2023] [Accepted: 09/30/2023] [Indexed: 11/17/2023]
Abstract
Recent trends in healthcare policy from high-volume service models to "high-value" delivery systems have refocused the need for patient-centered approaches to quality care. However, benchmarks of how to define and evaluate successful patient-centeredness have not been sufficiently established. Such ill-defined evaluation criteria can further exacerbate systemic inequities in maximum quality health care delivery, especially based on the intersectional diversity of various patient populations. In this context, applying a phenomenology of medicine framework or perspective-driven analysis is useful in defining cross-cultural patient-centeredness. This reframing from a naturalistic or objective/biological viewpoint to a phenomenological viewpoint may aid in placing greater epistemic or knowledge authority in the hands of vulnerable and/or marginalized patients- allowing these patients to become key "knowers" in the clinical interaction. Moreover, treating Black patients as "knowers" emphasizes the prioritization of patient values at the core of providing valuable healthcare. Such an academic, policy, and clinical approach to medicine agrees with well-established principles of medical ethics. In addition, the framework of a phenomenology of medicine can better facilitate physician-patient communication and interaction by delineating often muddled hermeneutics.
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Affiliation(s)
- Justin J Thomas
- School of Medicine, Morehouse, 720 Westview Dr SW, NCPC, Room 324-B, Atlanta, GA, USA.
| | - Shaneeta Johnson
- School of Medicine, Morehouse, 720 Westview Dr SW, NCPC, Room 324-B, Atlanta, GA, USA
| | - Kisha B Holden
- School of Medicine, Morehouse, 720 Westview Dr SW, NCPC, Room 324-B, Atlanta, GA, USA
| | - Sonja Hutchins
- School of Medicine, Morehouse, 720 Westview Dr SW, NCPC, Room 324-B, Atlanta, GA, USA
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Cheung K. A role for kindness and curiosity in healthcare. JOURNAL OF MEDICAL ETHICS 2023:jme-2023-109499. [PMID: 37620019 DOI: 10.1136/jme-2023-109499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Accepted: 08/15/2023] [Indexed: 08/26/2023]
Abstract
In his paper 'Ethical problems with kindness in healthcare', Jesudason sets out an interesting examination of the concept of kindness, arguing that it poses significant ethical challenges due to its discretionary nature. I suggest that kindness, a concept difficult to define, may still have a role to play in healthcare. Different treatments of kindness show us that it need not be discretionary, and that kind care can be provided to all. Finally, curiosity may also have a role to play in medicine to help promote inclusiveness.
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Affiliation(s)
- Katherine Cheung
- Department of Bioethics, New York University, New York City, New York, New York, USA
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Training for the future: Introducing foundational skills necessary to promote patient-centered care practice in medical physics graduate programs. Tech Innov Patient Support Radiat Oncol 2022; 24:54-58. [PMID: 36217347 PMCID: PMC9547290 DOI: 10.1016/j.tipsro.2022.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/05/2022] [Accepted: 09/27/2022] [Indexed: 11/23/2022] Open
Abstract
Current medical physics graduate training in the United States seldom explicitly includes education on foundational skills necessary to produce Patient-Centered Care (PCC)-focused healthcare providers. Such abilities include effective communication, critical reflection, and ethical decision-making. In this article, we present examples of curricula used to purposefully introduce these skills into graduate training to fill this gap. Presented didactic activities include an introduction to patient communication, ethics in medical physics, and a primer in health disparities for medical physicists. Although development of new curricula is resource-intensive when left to individual programs, we here propose resource-sharing and interprofessional collaboration to overcome these barriers.
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Towle S. 'Poorly relaxed women': A situational analysis of pelvic examination learning materials for medical students. MEDICAL EDUCATION 2022; 56:716-723. [PMID: 35086164 DOI: 10.1111/medu.14737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 01/04/2022] [Accepted: 01/17/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Certain clinical pelvic examination (PE) teaching methods have been critiqued for prioritising student learning over patient autonomy and for not accurately representing diverse patient communities. As such, patient-centred and culturally competent approaches to the PE may need further emphasis in the medical curriculum-in particular, in content delivered to students before patient interaction. Classroom materials serve as students' first exposure to the sensitive procedure. This research explores how patients are represented in these materials. METHODS A situational analysis was conducted on 10 purposively sampled PE learning materials for the 2019/20 academic year from five undergraduate medical schools in Canada. Situational analysis focuses on analysing discourse but is epistemically aligned with post-structuralism (most notably Foucault's theories involving discursive power) and allows for specific consideration of 'silences' in the data. Collected data were analysed using cartographic approaches according to this methodology, with particular attention paid to the tenets and frameworks of patient-centred and culturally competent care. RESULTS Overall, content in these materials misrepresented and under-represented patients. Materials contained both outdated and unnecessarily sexualised language, in addition to a lack of patient diversity. Clinical authority was often centred over patient agency, and several updated PE techniques known to improve patient experience were absent. Patient-centred and culturally competent approaches were therefore inadequately highlighted in most of the materials. CONCLUSIONS Depictions contained in these materials may be perpetuating stereotypes and biases in medicine and may be working to maintain teaching practices that cause harm to patients (standardised and regular) who students interact with in both clinical and educational settings. Efforts may be needed to improve classroom materials on the PE so that they more adequately centre patients and provide opportunities to discuss culturally competent approaches to the procedure that (i) may not be covered in other parts of the PE curriculum and (ii) can reduce known health disparities.
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Affiliation(s)
- Sarah Towle
- Faculty of Medicine, McGill University, Montreal, Quebec, Canada
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Bejarano G, Csiernik B, Young JJ, Stuber K, Zadro JR. Healthcare students' attitudes towards patient centred care: a systematic review with meta-analysis. BMC MEDICAL EDUCATION 2022; 22:324. [PMID: 35477455 PMCID: PMC9047330 DOI: 10.1186/s12909-022-03371-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 04/11/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Patient centred care is commonly recommended in clinical practice guidelines to improve patient outcomes and reduce healthcare costs. Identifying measurement tools used to assess healthcare students' attitudes towards patient centered care and determining their attitudes is the first step to ensuring patient centred care is provided in the future. The primary aim of this review was to describe the measurement tools used to assess healthcare students' attitudes towards patient centred care. The secondary aim was to quantify healthcare students' attitudes towards patient centred care. METHODS An electronic database search was conducted in MEDLINE, EMBASE, CINAHL from inception until March 1, 2021, with combined terms relating to 'patient centred care', 'attitudes', and 'healthcare students'. Studies that quantitatively assessed healthcare students' attitudes towards patient centred care were included. Measurement tools used in the included studies were qualitatively described. Meta-analysis was conducted to quantify healthcare students' attitudes towards patient centred care and assess the respective influence of gender, profession, and study geographical location on healthcare students' attitudes towards patient centred care. RESULTS The electronic search identified 3948 total studies. One hundred twenty-nine full texts were screened, and 49 studies were included. There were 16 measurement tools used to assess healthcare students' attitudes towards patient centered care. Most studies (53%, n = 26) used the Patient-Practitioner Orientation Scale (PPOS) to assess patient centered care. Meta-analyses of 20 studies with 26 total groups resulted in a pooled mean PPOS score of 4.16 on a 0-6 scale (95% Confidence Interval [CI]: 3.95, 4.37), indicating low attitudes towards patient centered care. Additional analyses found that women have significantly higher attitudes towards patients centred care than men (pooled effect 0.14 [95% CI: 0.05, 0.23], n = 8 studies) and mean PPOS scores appear similar among sub-groups of only medical students (pooled mean 4.13, 95% CI: 3.85, 4.42, n = 13 studies) and only American healthcare students (pooled mean 4.49, 95% CI: 4.35, 4.64, n = 5 studies). CONCLUSIONS Several different measurement tools have been used to assess healthcare students' attitudes towards patient centred care, but the most commonly used is the PPOS. Our results indicate that healthcare students have low attitudes towards patient centred care. Future studies should evaluate if attitudes towards patient centred care can be improved during healthcare education.
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Affiliation(s)
- Geronimo Bejarano
- Michael & Susan Dell Center for Healthy Living, The University of Texas Health Science Center at Houston (UTHealth), 1616 Guadalupe Street, Austin, TX, 78702, USA.
| | - Ben Csiernik
- Canadian Memorial Chiropractic College, Toronto, Canada
| | - James J Young
- Canadian Memorial Chiropractic College, Toronto, Canada
- Center for Muscle and Joint Health, University of Southern Denmark, Odense, Denmark
| | - Kent Stuber
- Canadian Memorial Chiropractic College, Toronto, Canada
| | - Joshua R Zadro
- Sydney School of Public Health, Faculty of Medicine and Health, Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, New South Wales, Australia
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Thomas TH, Donovan HS, Rosenzweig MQ, Bender CM, Schenker Y. A Conceptual Framework of Self-advocacy in Women With Cancer. ANS Adv Nurs Sci 2021; 44:E1-E13. [PMID: 33181568 PMCID: PMC7894983 DOI: 10.1097/ans.0000000000000342] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Researchers define self-advocacy as the ability of an individual with cancer to overcome challenges in getting their preferences, needs, and values met. While imperative in all health care settings, self-advocacy is especially important in cancer care. The goal of this article is to present a conceptual framework for self-advocacy in cancer. We review foundational studies in self-advocacy, define the elements of the conceptual framework, discuss underlying assumptions of the framework, and suggest future directions in this research area. This framework provides an empirical and conceptual basis for studies designed to understand and improve self-advocacy among women with cancer.
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Affiliation(s)
- Teresa H Thomas
- School of Nursing, University of Pittsburgh, Pennsylvania (Drs Thomas, Donovan, Rosenzweig, and Bender); and Palliative Research Center (PaRC), Section of Palliative Care and Medical Ethics, Division of General Internal Medicine, University of Pittsburgh, Pennsylvania (Dr Schenker)
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Turner RE, Archer E. Patient-centred care: The patients' perspective - A mixed-methods pilot study. Afr J Prim Health Care Fam Med 2020; 12:e1-e8. [PMID: 33054274 PMCID: PMC7564840 DOI: 10.4102/phcfm.v12i1.2390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 07/16/2020] [Accepted: 07/23/2020] [Indexed: 11/30/2022] Open
Abstract
Background Patient centredness is a broad concept, a moral philosophy. Patient-centred care can be viewed as the actions of patient-centredness. One of the most pertinent actions that a healthcare practitioner can utilise to deliver patient-centred care is empathic communication. Whilst many medical programmes include empathetic communication skills as part of their curricula, the recipients of this care are not asked about the relevance of this teaching. Aim We attempted to determine whether the Western constructs of empathy were relevant in our context and also establish whether there were any parts of the medical interview which participants felt were especially important to be communicated to in their home language. Setting Two urban communities within the City of Cape Town, Western Cape Province, South Africa. Methods This was a mixed-methods pilot study using an explanatory sequential design. Participants who would typically make use of public health care facilities and whose first language was Afrikaans or isiXhosa were conveniently sampled. A subgroup of participants was invited to take part in a follow-up focus group discussion to add clarity to the survey responses. Results and Conclusion Western constructs for empathy appeared to be relevant within our multicultural context. Patients wanted to communicate with their doctors and understand the cause of their problems as well as the management plan. Finally, whilst the numbers in this pilot study were too small to be generalisable, it was evident that patient-centred care was not perceived to be implemented in some public healthcare facilities attended by the participants, which resulted in them feeling unseen and disrespected.
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Affiliation(s)
- Roseanne E Turner
- Centre for Health Professions Education, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town.
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Social networks, health and identity: exploring culturally embedded masculinity with the Pakistani community, West Midlands, UK. BMC Public Health 2020; 20:1432. [PMID: 32957934 PMCID: PMC7507824 DOI: 10.1186/s12889-020-09504-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 09/06/2020] [Indexed: 11/10/2022] Open
Abstract
Background Migrants from South Asia living in developed countries have an increased risk for developing cardiovascular disease (CVD), with limited research into underlying social causes. Methods We used social capital as an interpretive lens to undertake analysis of exploratory qualitative interviews with three generations of at-risk migrant Pakistani men from the West Midlands, UK. Perceptions of social networks, trust, and cultural norms associated with access to healthcare (support and information) were the primary area of exploration. Results Findings highlighted the role of social networks within religious or community spaces embedded as part of ethnic enclaves. Local Mosques and gyms remained key social spaces, where culturally specific gender differences played out within the context of a diaspora community, defined ways in which individuals navigated their social spheres and influenced members of their family and community on health and social behaviours. Conclusions There are generational and age-based differences in how members use locations to access and develop social support for particular lifestyle choices. The pursuit of a healthier lifestyle varies across the diverse migrant community, determined by social hierarchies and socio-cultural factors. Living close to similar others can limit exposure to novel lifestyle choices and efforts need to be made to promote wider integration between communities and variety of locations catering to health and lifestyle.
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Ibe C, Bowie J, Roter D, Carson KA, Lee B, Monroe D, Cooper LA. Intensity of exposure to a patient activation intervention and patient engagement in medical visit communication. PATIENT EDUCATION AND COUNSELING 2017; 100:1258-1267. [PMID: 28162812 DOI: 10.1016/j.pec.2016.12.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 11/17/2016] [Accepted: 12/17/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE We examined associations between intensity of exposure to a community health worker (CHW) delivered communication activation intervention targeting low-income patients with hypertension. METHODS We analyzed question-asking behaviors of patients assigned to the intervention arms (n=140) in a randomized controlled trial. Intensity of exposure to the intervention was operationalized as the duration of face-to-face coaching and number of protocol-specified topics discussed. Mixed effects models characterized the relationship between intensity of exposure and patients' communication in a subsequent medical visit. RESULTS The number of topics discussed during the coaching session was positively associated with patients' asking psychosocial-related questions during their visit. The duration of the coaching session was positively associated with patients' use of communication engagement strategies to facilitate their participation in the visit dialogue. Exposure to a physician trained in patient-centered communication did not influence these relationships. CONCLUSIONS A dose-response relationship was observed between exposure to a CHW- delivered communication activation intervention and patient-provider communication. PRACTICE IMPLICATIONS This study supports the use of CHWs in activating patients toward greater communication in the therapeutic exchange.
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Affiliation(s)
- Chidinma Ibe
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | - Janice Bowie
- Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Debra Roter
- Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Kathryn A Carson
- Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Bone Lee
- Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | - Dwyan Monroe
- Institute for Public Health Innovation, Washington, D.C., USA
| | - Lisa A Cooper
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA; Department of Health Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA; Division of General Internal Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, USA; Welch Center for Prevention, Epidemiology, and Clinical Research, Johns Hopkins University, Baltimore, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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Burgess DJ, Beach MC, Saha S. Mindfulness practice: A promising approach to reducing the effects of clinician implicit bias on patients. PATIENT EDUCATION AND COUNSELING 2017; 100:372-376. [PMID: 27665499 DOI: 10.1016/j.pec.2016.09.005] [Citation(s) in RCA: 96] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 09/13/2016] [Accepted: 09/15/2016] [Indexed: 05/22/2023]
Abstract
Like the population at large, health care providers hold implicit racial and ethnic biases that may contribute to health care disparities. Little progress has been made in identifying and implementing effective strategies to address these normal but potentially harmful unconscious cognitive processes. We propose that meditation training designed to increase healthcare providers' mindfulness skills is a promising and potentially sustainable way to address this problem. Emerging evidence suggests that mindfulness practice can reduce the provider contribution to healthcare disparities through several mechanisms including: reducing the likelihood that implicit biases will be activated in the mind, increasing providers' awareness of and ability to control responses to implicit biases once activated, increasing self-compassion and compassion toward patients, and reducing internal sources of cognitive load (e.g., stress, burnout, and compassion fatigue). Mindfulness training may also have advantages over current approaches to addressing implicit bias because it focuses on the development of skills through practice, promotes a nonjudgmental approach, can circumvent resistance some providers feel when directly confronted with evidence of racism, and constitutes a holistic approach to promoting providers' well-being. We close with suggestions for how a mindfulness approach can be practically implemented and identify potential challenges and research gaps to be addressed.
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Affiliation(s)
- Diana J Burgess
- Center for Chronic Disease Outcomes Research (A VA HSR&D Center of Excellence), Veterans Affairs Medical Center, Minneapolis, MN, USA; Department of Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - Mary Catherine Beach
- School of Medicine and Bloomberg School of Public Health, AT Johns Hopkins University, 2024 E Monument Street, Suite 2500, Baltimore, MD, USA
| | - Somnath Saha
- Section of General Internal Medicine, VA Portland Health Care System, 3710 SW US Veterans Hospital Rd, Portland, OR 97239, USA; Division of General Internal Medicine & Geriatrics, Oregon Health & Science University, Portland, OR, USA
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Hardeman RR, Burgess D, Phelan S, Yeazel M, Nelson D, van Ryn M. Medical student socio-demographic characteristics and attitudes toward patient centered care: do race, socioeconomic status and gender matter? A report from the Medical Student CHANGES study. PATIENT EDUCATION AND COUNSELING 2015; 98:350-5. [PMID: 25499003 PMCID: PMC4433154 DOI: 10.1016/j.pec.2014.11.013] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 09/16/2014] [Accepted: 11/08/2014] [Indexed: 05/07/2023]
Abstract
OBJECTIVE To determine whether attitudes toward patient-centered care differed by socio-demographic characteristics (race, gender, socioeconomic status) among a cohort of 3191 first year Black and White medical students attending a stratified random sample of US medical schools. METHODS This study used baseline data from Medical Student CHANGES, a large national longitudinal cohort study of medical students. Multiple logistic regression was used to assess the association of race, gender and SES with attitudes toward patient-centered care. RESULTS Female gender and low SES were significant predictors of positive attitudes toward patient-centered care. Age was also a significant predictor of positive attitudes toward patient-centered care such that students older than the average age of US medical students had more positive attitudes. Black versus white race was not associated with attitudes toward patient-centered care. CONCLUSIONS New medical students' attitudes toward patient-centered care may shape their response to curricula and the quality and style of care that they provide as physicians. Some students may be predisposed to attitudes that lead to both greater receptivity to curricula and the provision of higher-quality, more patient-centered care. PRACTICE IMPLICATIONS Medical school curricula with targeted messages about the benefits and value of patient-centered care, framed in ways that are consistent with the beliefs and world-view of medical students and the recruitment of a socioeconomically diverse sample of students into medical schools are vital for improved care.
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Affiliation(s)
- Rachel R Hardeman
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Medical Center, Minneapolis, USA; University of Minnesota Medical School, Department of Medicine, Minneapolis, USA.
| | - Diana Burgess
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Medical Center, Minneapolis, USA; University of Minnesota Medical School, Department of Medicine, Minneapolis, USA.
| | - Sean Phelan
- Division of Health Care Policy Research Department of Health Sciences Research, Mayo Clinic, Rochester, USA.
| | - Mark Yeazel
- University of Minnesota, Department of Family Medicine and Community Health, Minneapolis, USA.
| | - David Nelson
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Medical Center, Minneapolis, USA; University of Minnesota Medical School, Department of Medicine, Minneapolis, USA.
| | - Michelle van Ryn
- Division of Health Care Policy Research Department of Health Sciences Research, Mayo Clinic, Rochester, USA.
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Davey MP, Waite R, Nuñez A, Niño A, Kissil K. A snapshot of patients' perceptions of oncology providers' cultural competence. JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2014; 29:657-664. [PMID: 24504662 DOI: 10.1007/s13187-014-0619-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
In this paper, we describe an anonymous cross-sectional survey with a sample of 100 racially diverse adult oncology patients using a newly developed patient-reported measure of providers' cultural competence, the Physicians' Cultural Competence for Patient Satisfaction Scale (PCCPS) [1, 2], which was developed using a US midwestern sample of primary care patients. Our primary aims were to examine the reliability of the PCCPS in a more racially diverse urban oncology clinical setting and to identify salient domains of oncology provider cultural competence based on patient-reported satisfaction with direct clinical encounters. Results suggest that patient-reported satisfaction was significantly associated with one of the four domains measured by the PCCPS, physician's patient-centered cultural competence (r = 0.40, p = 0.01), and female patients were more satisfied (t (91) = 5.23, p = 0.02). The PCCPS demonstrated good reliability in an urban diverse cancer patient population. Results help to inform the development of clinical tools that can improve oncology providers' cultural competency.
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Affiliation(s)
- Maureen P Davey
- Department of Couple and Family Therapy, Drexel University, 7th Floor, Room 718, 1601 Cherry Street, Mail Stop 71042, Philadelphia, PA, 19102, USA,
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Kalam-Salminen L, Valkonen MR, Aro I, Routasalo P. Client-centeredness of Finnish and Estonian nursing students and the support from nursing education to develop it. Students' self-evaluation. NURSE EDUCATION TODAY 2013; 33:1112-1118. [PMID: 23498724 DOI: 10.1016/j.nedt.2013.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Revised: 01/27/2013] [Accepted: 02/11/2013] [Indexed: 06/01/2023]
Abstract
PURPOSE The purpose of this comparative study is to describe the differences between Finnish and Estonian students evaluations about their client-centeredness and educational support they received to develop it. BACKGROUND Client-centeredness has many positive effects on the quality and effectiveness of care. However, some deficiencies have been identified in the client-centeredness of nursing staff. Research on the subject has been limited, and we lack knowledge of graduating students' competence in client-centeredness and the support of their education to develop it. METHODS The sample consisted of 390 undergraduate nursing students, 195 from Finland and 195 from Estonia. The data were collected in 2009 using the structured five-point scale questionnaire. The questionnaire was designed to measure students' client-centeredness and the educational support they received from nursing education. The data were analyzed by the PASW Statistics 18-programme using descriptive statistics, Kolmogorov-Smirnov test and Mann-Whitney U-test. RESULTS Predominantly, students in both countries evaluated their level of client-centeredness high. The Estonian students generally evaluated their client-centeredness higher compared to the Finnish students. The same applied to support provided by nursing education. The greatest differences were related to education and particularly theoretical teaching. In Estonia, students' client-centeredness manifested itself more in politeness and willingness to serve clients, whereas respecting the clients' values was emphasized in Finland. Students' requisites, referred here as knowledge, skills and abilities to implement client-centered nursing, for client-centeredness had deficiencies, and the support from education was also the weakest regarding these aspects. CONCLUSION In future, education on development of nursing activities, acquisition of knowledge and services provided by health care as well as legislation should be enhanced, since these areas proved the most difficult for the students.
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Affiliation(s)
- Ly Kalam-Salminen
- Metropolia University of Applied Sciences, Helsinki, Finland, P.O. Box 4030, 00079 Metropolia, Finland
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Borkhoff CM, Hawker GA, Kreder HJ, Glazier RH, Mahomed NN, Wright JG. Influence of Patients' Gender on Informed Decision Making Regarding Total Knee Arthroplasty. Arthritis Care Res (Hoboken) 2013; 65:1281-90. [DOI: 10.1002/acr.21970] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Accepted: 01/18/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Cornelia M. Borkhoff
- The Hospital for Sick Children and University of Toronto; Toronto Ontario Canada
| | - Gillian A. Hawker
- University of Toronto and Women's College Research Institute, Women's College Hospital; Toronto Ontario Canada
| | - Hans J. Kreder
- University of Toronto and Sunnybrook Health Sciences Centre; Toronto Ontario Canada
| | - Richard H. Glazier
- University of Toronto and St. Michael's Hospital; Toronto Ontario Canada
| | - Nizar N. Mahomed
- University of Toronto and University Health Network; Toronto Ontario Canada
| | - James G. Wright
- The Hospital for Sick Children and University of Toronto; Toronto Ontario Canada
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Francis G. Developing the Cultural Competence of Health Professionals Working with Gypsy Travellers. ACTA ACUST UNITED AC 2013. [DOI: 10.1002/jpoc.21074] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Avetisyan R, Cabral H, Montouris G, Jarrett K, Shapiro GD, Berlowitz DR, Kase CS, Kazis LE. Evaluating racial/ethnic variations in outpatient epilepsy care. Epilepsy Behav 2013; 27:95-101. [PMID: 23399943 DOI: 10.1016/j.yebeh.2012.12.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2012] [Revised: 12/07/2012] [Accepted: 12/08/2012] [Indexed: 11/28/2022]
Abstract
This study evaluated the quality of epilepsy care in an ambulatory population of a major medical center and determined if there were any racial/ethnic variations. The well-established 'Quality Indicators in Epilepsy Treatment (QUIET)' study dataset was used. Medical record, phone interview, and mail-out survey data of 311 patients with epilepsy were linked and analyzed. Evaluation of care from provider and patient perspectives was performed. Overall, the patients with epilepsy received 40.9% of QI recommended care. The black patients were more likely to receive 50% or more QI recommended care compared with non-Hispanic whites (odds ratio [OR]=2.16, 95% confidence interval [CI] 1.09-4.27). Black patients scored significantly worse than non-Hispanic whites for two patient-reported measures--perceived racial/ethnic disparities (OR=3.14, 95% CI 1.15-8.53) and difficulties getting follow-up appointments (OR=3.37, 95% CI 1.55-7.32). The results indicate the need to evaluate both provider- and patient-centered measures in quality-of-care studies in disparities research.
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Affiliation(s)
- Ruzan Avetisyan
- Department of Health Policy and Management, Boston University School of Public Health, Boston, MA, USA
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Dauvrin M, Derluyn I, Coune I, Verrept H, Lorant V. Towards fair health policies for migrants and ethnic minorities: the case-study of ETHEALTH in Belgium. BMC Public Health 2012; 12:726. [PMID: 22938597 PMCID: PMC3520724 DOI: 10.1186/1471-2458-12-726] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Accepted: 08/24/2012] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND In Europe, progress in the development of health policies that address the needs of migrants and ethnic minorities has been slow. This is partly due to the absence of a strategic commitment by the health authorities. The Ministry of Public Health commissioned the ETHEALTH (EThnicity &HEALTH) group to formulate relevant recommendations to the public authorities with a view to reducing health inequalities among ethnic minorities. This paper describes the political process and the outcomes of the ETHEALTH expert group. RESULTS After ten meetings, the ETHEALTH group came up with 46 recommendations, which were presented at a national press conference in December 2011. Target groups concerned by these recommendations covered both irregular migrants and migrants entitled to the national insurance coverage. Recommendations were supported by the need of combining universal approaches to health care with more specific approaches. The scope of the recommendations concerned health care as well as prevention, health promotion and access to health care. When analysing the content of the recommendations, some ETHEALTH recommendations were not fully measurable, and time-related; they were, however, quite specific and realistic within the Belgian context. The weak political commitment of an executive agency was identified as a major obstacle to the implementation of the recommendations. CONCLUSIONS The ETHEALTH group was an example of scientific advice on a global health issue. It also demonstrated the feasibility of coming up with a comprehensive strategy to decrease ethnic health inequalities, even in a political context where migration issues are sensitive. Two final lessons may be highlighted at the end of the first phase of the ETHEALTH project: firstly, the combination of scientific knowledge and practical expertise makes recommendations SMART; and, secondly, the low level of commitment on the part of policymakers might jeopardise the effective implementation of the recommendations.
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Affiliation(s)
- Marie Dauvrin
- Institute of Health and Society IRSS, Université catholique de Louvain, Clos Chapelle aux Champs 30 boite 1.30.15, 1200, Brussels, Belgium
- Fonds de la Recherche Scientifique-FNRS, rue d’Egmont 5, 1000, Brussels, Belgium
| | - Ilse Derluyn
- Department of Orthopedagogics, Ghent University, Henri Dunantlaan 2, 9000, Gent, Belgium
| | - Isabelle Coune
- Intercultural Mediation Cell and Support to the Policy, Ministry of Public Health, Service des soins de santé psychosociaux, SPF Santé publique, Sécurité de la chaîne alimentaire et Environnement, Eurostation bloc II - 1D210, Place Victor Horta 40 boite 10, 1060, Brussels, Belgium
| | - Hans Verrept
- Intercultural Mediation Cell and Support to the Policy, Ministry of Public Health, Service des soins de santé psychosociaux, SPF Santé publique, Sécurité de la chaîne alimentaire et Environnement, Eurostation bloc II - 1D210, Place Victor Horta 40 boite 10, 1060, Brussels, Belgium
| | - Vincent Lorant
- Institute of Health and Society IRSS, Université catholique de Louvain, Clos Chapelle aux Champs 30 boite 1.30.15, 1200, Brussels, Belgium
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Partin MR, Burgess DJ. Reducing health disparities or improving minority health? The end determines the means. J Gen Intern Med 2012; 27:887-9. [PMID: 22592356 PMCID: PMC3403147 DOI: 10.1007/s11606-012-2108-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Melissa R. Partin
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive (152/2E), Minneapolis, MN 55417 USA
- Department of Medicine, University of Minnesota, Minneapolis, MN USA
| | - Diana J. Burgess
- Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Health Care System, 1 Veterans Drive (152/2E), Minneapolis, MN 55417 USA
- Department of Medicine, University of Minnesota, Minneapolis, MN USA
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Teal CR, Gill AC, Green AR, Crandall S. Helping medical learners recognise and manage unconscious bias toward certain patient groups. MEDICAL EDUCATION 2012; 46:80-8. [PMID: 22150199 DOI: 10.1111/j.1365-2923.2011.04101.x] [Citation(s) in RCA: 106] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
CONTEXT For the last 30 years, developments in cognitive sciences have demonstrated that human behaviour, beliefs and attitudes are shaped by automatic and unconscious cognitive processes. Only recently has much attention been paid to how unconscious biases based on certain patient characteristics may: (i) result in behaviour that is preferential toward or against specific patients; (ii) influence treatment decisions, and (iii) adversely influence the patient-doctor relationship. Partly in response to accreditation requirements, medical educators are now exploring how they might help students and residents to develop awareness of their own potential biases and strategies to mitigate them. METHODS In this paper, we briefly review key cognition concepts and describe the limited published literature about educational strategies for addressing unconscious bias. DISCUSSION We propose a developmental model to illustrate how individuals might move from absolute denial of unconscious bias to the integration of strategies to mitigate its influence on their interactions with patients and offer recommendations to educators and education researchers.
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Affiliation(s)
- Cayla R Teal
- Office of Undergraduate Medical Education, Baylor College of Medicine, Houston, Texas 77030-3411, USA.
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21
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Peiris AN, Bailey BA, Peiris P, Copeland RJ, Manning T. Race and vitamin D status and monitoring in male veterans. J Natl Med Assoc 2011; 103:492-7. [PMID: 21830632 DOI: 10.1016/s0027-9684(15)30363-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
African Americans have lower vitamin D levels and reduced health outcomes compared to white Americans. Vitamin D deficiency may contribute to adverse health outcomes in African Americans. We hypothesized that race would be associated with vitamin D status and testing in African Americans veterans, and that vitamin D status is a major contributor to health care costs in African American veterans compared to white veterans. A retrospective analysis of the medical data in the Veterans Integrated Service Network 9 (southeastern United States) was performed, and 14148 male veterans were identified. Race was designated by the patient and its relationship to vitamin D levels/status and costs was assessed. Vitamin D levels were significantly lower and the percent of patients with vitamin D deficiency was significantly higher in African American veterans. This difference was independent of latitude and seasonality. Vitamin D testing was done significantly more in white veterans compared to African American veterans (5.4% vs 3.8%). While follow-up testing was 42% more likely if a patient was found to be vitamin D deficient, white veterans were 34% more likely than African American veterans to have at least 1 follow-up 25-hydroxyvitamin D performed. African American veterans had significantly higher health care costs, which were linked to lower vitamin D levels; however, the cost differential persisted even after adjusting for vitamin D status. Vitamin D deficiency is highly prevalent in African American veterans and needs improved management within the Veteran Administration system. Vitamin D status appears not to be the sole contributor to increased health care costs in African American veterans.
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Affiliation(s)
- Alan N Peiris
- Department of Internal Medicine, East Tennessee State University, Johnson City, USA.
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Borkhoff CM, Hawker GA, Wright JG. Patient gender affects the referral and recommendation for total joint arthroplasty. Clin Orthop Relat Res 2011; 469:1829-37. [PMID: 21448775 PMCID: PMC3111793 DOI: 10.1007/s11999-011-1879-x] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Rates of use of total joint arthroplasty among appropriate and willing candidates are lower in women than in men. A number of factors may explain this gender disparity, including patients' preferences for surgery, gender bias influencing physicians' clinical decision-making, and the patient-physician interaction. QUESTIONS/PURPOSES We propose a framework of how patient gender affects the patient and physician decision-making process of referral and recommendation for total joint arthroplasty and consider potential interventions to close the gender gap in total joint arthroplasty utilization. METHODS The process involved in the referral and recommendation for total joint arthroplasty involves eight discrete steps. A systematic review is used to describe the influence of patient gender and related clinical and nonclinical factors at each step. WHERE ARE WE NOW?: Patient gender plays an important role in the process of referral and recommendation for total joint arthroplasty. Female gender primarily affects Steps 3 through 8, suggesting barriers unique to women exist in the patient-physician interaction. WHERE DO WE NEED TO GO?: Developing and evaluating interventions that improve the quality of the patient-physician interaction should be the focus of future research. HOW DO WE GET THERE?: Potential interventions include using decision support tools that facilitate shared decision-making between patients and their physicians and promoting cultural competency and shared decision-making skills programs as a core component of medical education. Increasing physicians' acceptance and awareness of the unconscious biases that may be influencing their clinical decision-making may require additional skills programs.
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Affiliation(s)
- Cornelia M. Borkhoff
- Centre for Global Health, Institute of Population Health, University of Ottawa, 1 Stewart Street, Ottawa, ON K1N 6N5 Canada ,Canadian Osteoarthritis Research Program, Women’s College Hospital, Room 817, 76 Grenville Street, Toronto, ON M5S 1B2 Canada
| | - Gillian A. Hawker
- Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON Canada ,Department of Medicine, Women’s College Hospital, Toronto, ON Canada
| | - James G. Wright
- Departments of Public Health Sciences and Health Policy, Management and Evaluation, University of Toronto, Toronto, ON Canada ,Department of Surgery, The Hospital for Sick Children, Toronto, ON Canada
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Mulvaney-Day NE, Earl TR, Diaz-Linhart Y, Alegría M. Preferences for relational style with mental health clinicians: a qualitative comparison of African American, Latino and Non-Latino White patients. J Clin Psychol 2010; 67:31-44. [PMID: 20939021 DOI: 10.1002/jclp.20739] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The goal of this study is to analyze preferences for relational styles in encounters with mental health providers across racial and ethnic groups. Four primary themes describe what patients want from a mental health provider: listening, understanding, spending time, and managing differences. However, using contextual comparative analysis, the findings explicate how these themes are described differently across African Americans, Latinos, and non-Latino Whites, uncovering important qualitative differences in the meaning of these themes across the groups. The article suggests that closer attention to qualitative preferences for style of interaction with providers may help address disparities in mental health care for racial and ethnic minorities.
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Affiliation(s)
- Norah E Mulvaney-Day
- Center for Multicultural Mental Health Research, Cambridge Health Alliance and Harvard Medical School, Somerville, MA 02143, USA.
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Dehlendorf C, Ruskin R, Grumbach K, Vittinghoff E, Bibbins-Domingo K, Schillinger D, Steinauer J. Recommendations for intrauterine contraception: a randomized trial of the effects of patients' race/ethnicity and socioeconomic status. Am J Obstet Gynecol 2010; 203:319.e1-8. [PMID: 20598282 DOI: 10.1016/j.ajog.2010.05.009] [Citation(s) in RCA: 175] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 02/25/2010] [Accepted: 05/05/2010] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Recommendations by health care providers have been found to vary by patient race/ethnicity and socioeconomic status and may contribute to health disparities. This study investigated the effect of these factors on recommendations for contraception. STUDY DESIGN One of 18 videos depicting patients of varying sociodemographic characteristics was shown to each of 524 health care providers. Providers indicated whether they would recommend levonorgestrel intrauterine contraception to the patient shown in the video. RESULTS Low socioeconomic status whites were less likely to have intrauterine contraception recommended than high socioeconomic status whites (odds ratio [OR], 0.20; 95% confidence interval [CI], 0.06-0.69); whereas, socioeconomic status had no significant effect among Latinas and blacks. By race/ethnicity, low socioeconomic status Latinas and blacks were more likely to have intrauterine contraception recommended than low socioeconomic status whites (OR, 3.4; and 95% CI, 1.1-10.2 and OR, 3.1; 95% CI, 1.0-9.6, respectively), with no effect of race/ethnicity for high socioeconomic status patients. CONCLUSION Providers may have biases about intrauterine contraception or make assumptions about its use based on patient race/ethnicity and socioeconomic status.
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Blatt B, LeLacheur SF, Galinsky AD, Simmens SJ, Greenberg L. Does perspective-taking increase patient satisfaction in medical encounters? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2010; 85:1445-52. [PMID: 20736672 DOI: 10.1097/acm.0b013e3181eae5ec] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
PURPOSE To assess whether perspective-taking, which researchers in other fields have shown to induce empathy, improves patient satisfaction in encounters between student-clinicians and standardized patients (SPs). METHOD In three studies, randomly assigned students (N = 608) received either a perspective-taking instruction or a neutral instruction prior to a clinical skills examination in 2006-2007. SP satisfaction was the main outcome in all three studies. Study 1 involved 245 third-year medical students from two universities. Studies 2 and 3 extended Study 1 to examine generalizability across student and SP subpopulations. Study 2 (105 physician assistant students, one university) explored the effect of perspective-taking on African American SPs' satisfaction. Study 3 (258 third-year medical students, two universities) examined the intervention's effect on students with high and low baseline perspective-taking tendencies. RESULTS Intervention students outscored controls in patient satisfaction in all studies: Study 1: P = .01, standardized effect size = 0.16; Study 2: P = .001, standardized effect size = 0.31; Study 3: P = .009, standardized effect size = 0.13. In Study 2, perspective-taking improved African American SPs' satisfaction. In Study 3, intervention students with high baseline perspective-taking tendencies outscored controls (P = .0004, standardized effect size = 0.25), whereas those with low perspective-taking tendencies did not (P = .72, standardized effect size = 0.00). CONCLUSIONS Perspective-taking increased patient satisfaction in all three studies, across medical schools, clinical disciplines, and racially diverse students and SPs. Perspective-taking as a means for improving patient satisfaction deserves further exploration in clinical training and practice.
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Affiliation(s)
- Benjamin Blatt
- Department of Medicine, CLASS Clinical Skills Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
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Hauer KE, Boscardin C, Gesundheit N, Nevins A, Srinivasan M, Fernandez A. Impact of student ethnicity and patient-centredness on communication skills performance. MEDICAL EDUCATION 2010; 44:653-61. [PMID: 20636584 DOI: 10.1111/j.1365-2923.2010.03632.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVES The development of patient-centred attitudes by health care providers is critical to improving health care quality. A prior study showed that medical students with more patient-centred attitudes scored higher in communication skills as judged by standardised patients (SPs) than students with less patient-centred attitudes. We designed this multicentre study to examine the relationships among students' demographic characteristics, patient-centredness and communication scores on an SP examination. METHODS Early Year 4 medical students at three US schools completed a 12-item survey during an SP examination. Survey items addressed demographics (gender, ethnicity, primary childhood language) and patient-centredness. Factor analysis on the patient-centredness items defined specific patient-centred attitudes. We used multiple regression analysis incorporating demographic characteristics, school and patient-centredness items and examined the effect of these variables on the outcome variable of communication score. RESULTS A total of 351 students took the SP examination and 329 (94%) completed the patient-centredness questionnaire. Responses indicated generally high patient-centredness. Student ethnicity and medical school were significantly associated with communication scores; gender and primary childhood language were not. Two attitudinal factors were identified: patient perspective and impersonal attitude. Multiple regression analysis revealed that school and scores on the impersonal factor were associated with communication scores. The effect size was modest. CONCLUSIONS In a medical student SP examination, modest differences in communication scores based on ethnicity were observed and can be partially explained by student attitudes regarding patient-centredness. Curricular interventions to enhance clinical experiences, teaching and feedback are needed to address key elements of a patient-centred approach to care.
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Affiliation(s)
- Karen E Hauer
- Department of Medicine, University of California, San Francisco School of Medicine, San Francisco, CA 94143-0120, USA.
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Wilkerson L, Fung CC, May W, Elliott D. Assessing patient-centered care: one approach to health disparities education. J Gen Intern Med 2010; 25 Suppl 2:S86-90. [PMID: 20352499 PMCID: PMC2847105 DOI: 10.1007/s11606-010-1273-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Patient-centered care has been described as one approach to cultural competency education that could reduce racial and ethnic health disparities by preparing providers to deliver care that is respectful and responsive to the preferences of each patient. In order to evaluate the effectiveness of a curriculum in teaching patient-centered care (PCC) behaviors to medical students, we drew on the work of Kleinman, Eisenberg, and Good to develop a scale that could be embedded across cases in an objective structured clinical examination (OSCE). OBJECTIVE To compare the reliability, validity, and feasibility of an embedded patient-centered care scale with the use of a single culturally challenging case in measuring students' use of PCC behaviors as part of a comprehensive OSCE. METHODS A total of 322 students from two California medical schools participated in the OSCE as beginning seniors. Cronbach's alpha was used to assess the internal consistency of each approach. Construct validity was addressed by establishing convergent and divergent validity using the cultural challenge case total score and OSCE component scores. Feasibility assessment considered cost and training needs for the standardized patients (SPs). RESULTS Medical students demonstrated a moderate level of patient-centered skill (mean = 63%, SD = 11%). The PCC Scale demonstrated an acceptable level of internal consistency (alpha = 0.68) over the single case scale (alpha = 0.60). Both convergent and divergent validities were established through low to moderate correlation coefficients. DISCUSSION The insertion of PCC items across multiple cases in a comprehensive OSCE can provide a reliable estimate of students' use of PCC behaviors without incurring extra costs associated with implementing a special cross-cultural OSCE. This approach is particularly feasible when an OSCE is already part of the standard assessment of clinical skills. Reliability may be increased with an additional investment in SP training.
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Affiliation(s)
- LuAnn Wilkerson
- UCLA David Geffen School of Medicine, Center for Educational Development & Research, University of California, Los Angeles, Los Angeles, CA 90095-1722, USA
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When best intentions aren't enough: helping medical students develop strategies for managing bias about patients. J Gen Intern Med 2010; 25 Suppl 2:S115-8. [PMID: 20352504 PMCID: PMC2847119 DOI: 10.1007/s11606-009-1243-y] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION/AIMS Implicit bias can impact physician-patient interactions, alter treatment recommendations, and perpetuate health disparities. Medical educators need methods for raising student awareness about the impact of bias on medical care. SETTING Seventy-two third-year medical student volunteers participated in facilitated small group discussions about bias. PROGRAM DESCRIPTION We tested an educational intervention to promote group-based reflection among medical students about implicit bias. PROGRAM EVALUATION We assessed how the reflective discussion influenced students' identification of strategies for identifying and managing their potential biases regarding patients. 67% of the students (n = 48) identified alternate strategies at post-session. A chi-square analysis demonstrated that the distribution of these strategies changed significantly from pre-session to post-session (chi(2)(11) = 27.93, p < 0.01), including reductions in the use of internal feedback and humanism and corresponding increases in the use of reflection, debriefing and other strategies. DISCUSSION Group-based reflection sessions, with a provocative trigger to foster engagement, may be effective educational tools for fostering shifts in student reflection about bias in encounters and willingness to discuss potential biases with colleagues, with implications for reducing health disparities.
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Ho MJ, Yao G, Lee KL, Hwang TJ, Beach MC. Long-term effectiveness of patient-centered training in cultural competence: what is retained? What is lost? ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2010; 85:660-4. [PMID: 20354383 PMCID: PMC3149805 DOI: 10.1097/acm.0b013e3181d296b0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
PURPOSE To determine whether the effects of a patient-centered cultural competence curriculum could be sustained for one year. METHOD In 2006, 57 fifth-year medical students at National Taiwan University were randomly assigned either to a group that received training in patient-centered cross-cultural communication skills or one that received no training. Students' scores on objective structured clinical exams (OSCEs) were compared in the realms of exploring (1) patient perspectives and (2) social factors related to illness, immediately after training (OSCE1) and one year after training (OSCE2). RESULTS Regarding students' exploration of patient perspectives, the intervention group scored significantly higher than the control group at OSCE1, but there was a significant decrease from OSCE1 to OSCE2 in the intervention group and no significant difference between the intervention and control group at OSCE2. Regarding students' exploration of social factors related to illness, the intervention group scored significantly higher than the control group at OSCE1, with a nonsignificant decrease from OSCE1 to OSCE2 in the two groups, such that the intervention group again scored higher than the control group in OSCE2. CONCLUSIONS The effect of a patient-centered cultural competence training curriculum on students' exploration of social factors related to illness was sustained to a significant degree after one year, whereas the effects on students' exploration of patient perspectives were not. Further research is needed to determine the extent to which additional training can prevent the loss of student skills.
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Affiliation(s)
- Ming-Jung Ho
- Department of Social Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
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Lynöe N, Juth N, Helgesson G. How to reveal disguised paternalism. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2010; 13:59-65. [PMID: 19672696 DOI: 10.1007/s11019-009-9218-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2009] [Accepted: 07/09/2009] [Indexed: 05/28/2023]
Abstract
In a Swedish setting physicians are unlikely to give explicitly paternalistic reasons when asked about their attitudes towards patients' involvement in decision-making. There is considerable risk that they will disguise their paternalism by giving 'socially correct answers'. We suggest that disguised paternalism can be revealed with the help of indexes based on certain responses in postal questionnaires. The indexes were developed using material from a study examining attitudes of Swedish physicians to physician-assisted suicide (PAS). Apart from being asked about their attitudes, they were asked to prioritize between different arguments for and against PAS. One argument for PAS was: "PAS should be permitted out of respect for patients' autonomy". One argument against PAS was: "PAS should not be permitted since the non-maleficence principle in this case takes precedence over respecting patients' autonomy". Responses to the latter argument formed the cornerstone of a disguised-paternalism index, while an autonomy index was based on answers to the former argument. Applying our indexes to data from the PAS survey, we found that female GPs, surgeons, and older male physicians were least paternalistic. Among female physicians one finds both the most autonomy-respecting groups (female surgeons and GPs) and the least autonomy-respecting groups (female oncologists and psychiatrists); together with older male physicians in general, female GPs are the group displaying least disguised paternalism. We suggest that questionnaires exploring paternalism might be improved by including case-specific questions or statements by which to explore disguised paternalism. Here our indexes might be useful tools.
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Affiliation(s)
- Niels Lynöe
- Stockholm Centre for Healthcare Ethics, LIME, Karolinska Institutet, 17177 Stockholm, Sweden
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Francis LP. The physician-patient relationship and a National Health Information network. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2010; 38:36-49. [PMID: 20446982 DOI: 10.1111/j.1748-720x.2010.00464.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
The growing use of interoperable electronic health records is likely to have significant effects on the physician-patient relationship. This relationship involves two-way trust: of the physician in patients, and of the patients in their providers. Interoperable records opens up this relationship to further view, with consequences that may both enhance and undermine trust. On the one hand, physicians may learn (from additional records) that information from their patients is - or is not - to be trusted. On the other hand, patients may learn from the increased oversight made possible by electronic records that their trust in their physicians is - or is not - warranted. Release of information through new methods of surveillance may also undermine patient trust. The article concludes that because trust is fragile, attention to transparency and confidentiality in the use of interoperable electronic records is essential.
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Getting to equal: strategies to understand and eliminate general and orthopaedic healthcare disparities. Clin Orthop Relat Res 2009; 467:2598-605. [PMID: 19655210 PMCID: PMC2745478 DOI: 10.1007/s11999-009-0993-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2008] [Accepted: 07/07/2009] [Indexed: 01/31/2023]
Abstract
The 2001 Institute of Medicine report entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care pointed out extensive healthcare disparities in the United States even when controlling for disease severity, socioeconomic status, education, and access. The literature identifies several groups of Americans who receive disparate healthcare: ethnic minorities, women, children, the elderly, the handicapped, the poor, prisoners, lesbians, gays, and the transgender population. Disparate healthcare represents an enormous current challenge with substantial moral, ethical, political, public health, public policy, and economic implications, all of which are likely to worsen over the next several decades without immediate and comprehensive action. A review of recent literature reveals over 100 general and specific suggestions and solutions to eliminate healthcare disparities. While healthcare disparities have roots in multiple sources, racial stereotypes and biases remain a major contributing factor and are prototypical of biases based on age, physical handicap, socioeconomic status, religion, sexual orientation or other differences. Given that such disparities have a strong basis in racial biases, and that the principles of racism are similar to those of other "isms", we summarize the current state of healthcare disparities, the goals of their eradication, and the various potential solutions from a conceptual model of racism affecting patients (internalized racism), caregivers (personally mediated racism), and society (institutionalized racism).
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Friedman DS, Hahn SR, Quigley HA, Kotak S, Kim E, Onofrey M, Eagan C, Mardekian J. Doctor-patient communication in glaucoma care: analysis of videotaped encounters in community-based office practice. Ophthalmology 2009; 116:2277-85.e1-3. [PMID: 19744715 DOI: 10.1016/j.ophtha.2009.04.052] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2008] [Revised: 04/29/2009] [Accepted: 04/30/2009] [Indexed: 01/01/2023] Open
Abstract
PURPOSE To assess doctor-patient communication in patients with glaucoma. DESIGN Observational cohort study. PARTICIPANTS Twenty-three ophthalmologists and 50 patients with glaucoma. METHODS Doctor-patient encounters were audio- and videotaped and analyzed using validated sociolinguistic approaches. After the visit, the doctor and the patient completed questionnaires, and patients were interviewed using a semistructured, patient-centered protocol. MAIN OUTCOME MEASURES Summary statistics about doctor-patient encounters, assessment of alignment of attitudes between patients and doctors, and patient admission to missing doses. RESULTS Physicians spent an average of 8.0 (standard deviation [SD], 3.1; median, 7.8) minutes in the room with the patient and an average of 5.8 (SD, 2.4; median, 7.5) minutes talking with the patient, delivering 70% of all spoken words and asking two thirds of all questions. Glaucoma-related discussion occupied 50% of talk time and was focused primarily on examinations and treatment (25%). One third of discussions addressed ocular issues other than glaucoma. Virtually all physician questions (94%) were closed ended. Most patient questions were about intraocular pressure (20% of visits), details of the medication regimen (20%), disease status (14%), and testing (12%). Although physicians and patients were aligned in believing that the physician should control the visit agenda, physicians tended to support greater physician control of decision making than did patients. Physicians failed to identify most patients who admitted to missing doses, a surrogate for nonadherence, stating that 10 of 13 in this category were taking drops "all" or "most" of the time. Physician interviews detected 3 of the 11 patients whose postvisit questionnaire indicated missing a dose in the last week compared with 11 of the 11 detected by the postvisit research interview. Patients who stated they had missed doses recently reported being less satisfied with the doctor-patient encounter than those who did not. CONCLUSIONS Doctor-patient dialogue was universally physician centered; physicians spoke 70% of the words and asked closed-ended questions that restricted the patient's contribution to "yes/no" or brief responses. A minority of physicians ever asked patients if they had questions. In contrast with the patient-centered research interview, doctors' physician-centered communication failed to identify most patients who had missed doses.
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Masi CM, Gehlert S. Perceptions of breast cancer treatment among African-American women and men: implications for interventions. J Gen Intern Med 2009; 24:408-14. [PMID: 19101776 PMCID: PMC2642574 DOI: 10.1007/s11606-008-0868-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Revised: 10/27/2008] [Accepted: 11/18/2008] [Indexed: 12/01/2022]
Abstract
BACKGROUND While breast cancer mortality has declined in recent years, the mortality gap between African-American and white women continues to grow. Current strategies to reduce this disparity focus on logistical and information needs, but contextual factors, such as concerns about racism and treatment side effects, may also represent significant barriers to improved outcomes. OBJECTIVE To characterize perceptions of breast cancer treatment among African-American women and men. DESIGN A qualitative study of African-American adults using focus group interviews. PARTICIPANTS Two hundred eighty women and 165 men who live in one of 15 contiguous neighborhoods on Chicago's South Side. APPROACH Transcripts were systematically analyzed using qualitative techniques to identify emergent themes related to breast cancer treatment. RESULTS The concerns expressed most frequently were mistrust of the medical establishment and federal government, the effect of racism and lack of health insurance on quality of care, the impact of treatment on intimate relationships, and the negative effects of surgery, radiation therapy, and chemotherapy. CONCLUSIONS In addition to providing logistical and information support, strategies to reduce the breast cancer mortality gap should also address contextual factors important to quality of care. Specific interventions are discussed, including strategies to enhance trust, reduce race-related treatment differences, minimize the impact of treatment on intimate relationships, and reduce negative perceptions of breast cancer surgery, radiation therapy, and chemotherapy.
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Affiliation(s)
- Christopher M Masi
- Section of General Internal Medicine, University of Chicago, 5841 S. Maryland Avenue, M/C 2007, Chicago, IL 60637, USA.
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Abstract
There has long been tension between bioethicists whose work focuses on classical philosophical inquiry and those who perform empirical studies on bioethical issues. While many have argued that empirical research merely illuminates current practices and cannot inform normative ethics, others assert that research-based work has significant implications for refining our ethical norms. In this essay, I present a novel construct for classifying empirical research in bioethics into four hierarchical categories: Lay of the Land, Ideal Versus Reality, Improving Care, and Changing Ethical Norms. Through explaining these four categories and providing examples of publications in each stratum, I define how empirical research informs normative ethics. I conclude by demonstrating how philosophical inquiry and empirical research can work cooperatively to further normative ethics.
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Abstract
Empathy is a provider attribute that has been a topic of increased clinical interest, particularly as it relates to pain. This article examines various dimensions of the pain and empathy literature: definitions of empathy, research regarding the psychophysiology of empathy for pain, and research related to empathy in psychological and medical care. Research regarding topics broadly related to empathy is also reviewed, including communication skills and patient-centered care. Although this literature supports the clinical value of provider empathy and/or behaviors likely to reflect empathy, little research has explicitly examined empathy in the treatment of pain. Nonetheless, when considered in the broader context, the evidence is sufficient to draw some conclusions regarding approaches to pain care that are likely to reflect and/or elicit provider empathy and are central to effective pain management.
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Affiliation(s)
- Raymond C Tait
- Department of Neurology and Psychiatry, Saint Louis University School of Medicine, 1438 South Grand Boulevard, St. Louis, MO 63104, USA.
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Fiscella K, Epstein RM. So much to do, so little time: care for the socially disadvantaged and the 15-minute visit. ARCHIVES OF INTERNAL MEDICINE 2008; 168:1843-52. [PMID: 18809810 PMCID: PMC2606692 DOI: 10.1001/archinte.168.17.1843] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
There is so much to do in primary care, and so little time to do it. During 15-minute visits, physicians are expected to form partnerships with patients and their families, address complex acute and chronic biomedical and psychosocial problems, provide preventive care, coordinate care with specialists, and ensure informed decision making that respects patients' needs and preferences. This is a challenging task during straightforward visits, and it is nearly impossible when caring for socially disadvantaged patients with complex biomedical and psychosocial problems and multiple barriers to care. Consider the following scenario.
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Affiliation(s)
- Kevin Fiscella
- Department of Family Medicine, University of Rochester School of Medicine & Dentistry, 1381 South Ave, Rochester, NY 14620, USA.
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Franks P, Fiscella K. Reducing disparities downstream: prospects and challenges. J Gen Intern Med 2008; 23:672-7. [PMID: 18214626 PMCID: PMC2324139 DOI: 10.1007/s11606-008-0509-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2007] [Revised: 12/04/2007] [Accepted: 01/04/2008] [Indexed: 10/22/2022]
Abstract
Addressing upstream or fundamental causes (such as poverty, limited education, and compromised healthcare access) is essential to reduce healthcare disparities. But such approaches are not sufficient, and downstream interventions, addressing the consequences of those fundamental causes within the context of any existing health system, are also necessary. We present a definition of healthcare disparities and two key principles (that healthcare is a social good and disparities in outcomes are a quality problem) that together provide a framework for addressing disparities downstream. Adapting the chronic care model, we examine a hierarchy of three domains for interventions (health system, provider-patient interactions, and clinical decision making) to reduce disparities downstream and discuss challenges to implementing the necessary changes.
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Affiliation(s)
- Peter Franks
- Center for Healthcare Policy and Research, Department of Family and Community Medicine, University of California at Davis, Sacramento, CA USA
| | - Kevin Fiscella
- Department of Family Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY USA
- Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY USA
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Ellison GTH, Smart A, Tutton R, Outram SM, Ashcroft R, Martin P. Racial categories in medicine: a failure of evidence-based practice? PLoS Med 2007; 4:e287. [PMID: 17896860 PMCID: PMC1989752 DOI: 10.1371/journal.pmed.0040287] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Race and ethnicity are imprecise markers of the genotypic and sociocultural determinants of health, argue the authors.
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