CHICAGO-Within the ongoing discussion on the need to reform the delivery of health care in the United States to better balance issues of cost, quality, and accessibility is an underlying issue that, if not sufficiently recognized, will undermine all efforts at reform.
Explore This Issue
December 2008This issue is the need to recognize the heterogeneity of the patients that the health care system serves, and the importance of addressing specific needs related to ethnicity, gender, age, and socioeconomic conditions that directly affect whether or not a person receives adequate care.
In recognition of the importance of issues pertaining to diversity, a miniseminar focusing on the main issues related to diversity was offered for the first time at the annual meeting of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). The AAO-HNS Diversity Committee also convened for the first time during the annual meeting. In addition, within the past year, the AAO-HNS leadership approved its first policy statement on diversity (www.entnet.org/Practice/Diversity.cfm ).
Key issues related to diversity presented during the miniseminar included cultural competency, health literacy, and health disparities.
All these issues can be related and are important for physicians to consider, as they have a significant impact on physician-patient communications, said Ronald B. Kuppersmith, MD, MBA, an otolaryngologist in College Station, TX, who moderated the session. Many otolaryngologists are aware of these issues, but they may not recognize the extent of the problem or how they can most effectively assess and overcome these problems in their personal practices.
Cultural Competency
According to Duane J. Taylor, MD, an otolaryngologist at Le Visage ENT and Facial Plastic Surgery LLC in Bethesda, MD, and Chair of the AAO-HNS Diversity Committee, cultural competency starts with the recognition that culture is a driving force for both physicians, who bring their own worldviews into the examination room, and patients, who bring their own fears and perceptions of life-and these views can be, and often are, vastly different.
It is important to realize that depending on our cultural/ethical background, we may all view the world through a slightly different lens and have a different perspective, he said. As a physician, it is important to remember empathy and, when possible, have more than one possible treatment plan.
Recognizing different behaviors and views in particular ethnic groups is an important first step in developing empathy and the ability to develop a trusting relationship with a patient. For example, Asian-Americans often avoid direct eye contact, minimize their symptoms, and distrust Western medicine.
Dr. Taylor, who works in a tri-county community practice that includes a county with a population that is 43% Latino, Asian-American, African-American, and non-US-born African, says that the biggest challenge is gaining the trust of patients who have been ignored by previous physicians who are unempathetic to, or at least who do not recognize, the language and cultural differences of these ethnic populations. Also challenging, he said, is getting physicians to understand and accept that diversity makes a society stronger and that recognition of this helps physicians to deliver more comprehensive and safe health care.
As it is estimated that minorities in the United States will become the majority within the next 20 years, Dr. Taylor urges physicians to become educated on cultural competency to understand a world outside our own that allows us to treat all patients with the same amount of caring, compassion, and dignity, which we as physicians all have the capacity and obligation to do.
Dr. Taylor offered the acronym LEARN-Listen, Explain, Acknowledge, Recommend, and Negotiate-to help physicians develop skills in cultural competency.
Reiterating the need to recognize and appreciate the different backgrounds of patients, Dr. Kuppersmith emphasized the importance of communication. It is easy to forget that not everyone communicates the same way, he said. The inability to communicate because of cultural competency issues or because the physician fails to appreciate reduced literacy results in suboptimal care, reduces patient compliance, and may result in poorer outcomes.
Health Literacy
Often going hand in hand with issues of cultural competency is health literacy-the ability to obtain and process health information to make an informed decision. According to Lisa Perry-Gilkes, MD, an otolaryngologist in Atlanta, many minorities and other populations are at risk because of health illiteracy. Rates of health illiteracy are 66% for Hispanics, 58% for African-Americans, 60% for persons on Medicaid, and 57% for those on Medicare. Affluent older people are also at risk, with 30% of this population reported to lack health literacy.
The consequences of health illiteracy are significant. Patients with limited understanding of their medical condition and treatment recommendations are less likely to comply with treatment. Physicians and institutions who do not recognize health illiteracy in their patients and fail to improve communication may be at increased risk of lawsuits, with estimates showing that up to 75% of lawsuits for medical malpractice are the result of poor communication.
If you understand the problem, you can fashion your practice to accommodate the issues, [such as] making your office appointment/visit user-friendly to all patients and recognizing the patient population that may have difficulties.-Lisa Perry-Gilkes, MD
For Dr. Perry-Gilkes, raising awareness of health illiteracy and how it affects patient care and compliance is nearly half the battle in getting physicians to better serve patients low in health literacy. Part of this awareness is simply recognizing clues in patient behavior that may indicate health illiteracy, such as missed appointments and noncompliance to medication.
If you understand the problem, you can fashion your practice to accommodate the issues, she said, such as making your office appointment/visit user-friendly to all patients and recognizing the patient population that may have difficulties. Other techniques that can be used are showing or drawing pictures to convey information, slowing down when talking, listening more, and sitting versus standing when talking to the patient. When using written material, physicians should use information written at a sixth-grade level and limit content.
Dr. Kuppersmith suggested incorporating techniques to evaluate health literacy into one’s practice and to provide materials to ensure effective communication with patients. While best practices may not be currently available, there are a lot of existing resources, he said, adding that these issues are ripe for research efforts.
The inability to communicate because of cultural competency issues or because the physician fails to appreciate reduced literacy results in suboptimal care, reduces patient compliance, and may result in poorer outcomes.-Ronald B. Kuppersmith, MD, MBA
Health Disparities
One of the more difficult issues to resolve is that of health disparities in the United States based on access to health care. With the current high rates of uninsured, along with unsustainable, skyrocketing insurance premiums, the problem of access is only growing and contributes to both the reduction in quality care and the rise in cost.
Unequal access to health care will lead to suboptimal health care for all, as there will be increasingly limited resources to provide quality health care, said Amy Y. Chen, MD, MPH, of the Department of Otolaryngology at Emory University in Atlanta, adding that a disproportionate amount of resources will be used for acute health care rather than preventive, which is often less expensive.
As with issues of cultural competency and health literacy, Dr. Chen emphasized the need to raise awareness of health disparities among otolaryngologists and head and neck surgeons.
It is important to realize that depending on our cultural/ethical background, we may all view the world through a slightly different lens and have a different perspective. As a physician, it is important to remember empathy and, when possible, have more than one possible treatment plan.-Duane J. Taylor, MD
An example of health disparity among otolaryngologic practices is a study published in 2004 that showed unequal access to tonsillectomies and adenoidectomies for children based on the type of insurance coverage (Pediatrics 2004;114:e584-90). The study showed that 97% of providers would offer an office evaluation to a child covered by private insurance, whereas only 27% would provide the service for a child covered by government-funded insurance.
A study of head and neck cancer also highlights the effect of access to health care on diagnosis and outcomes. Studies by Chen and colleagues showed that the odds of both presenting with and dying from advanced-stage laryngeal cancer were significantly higher in uninsured patients or those covered by Medicaid insurance compared with patients covered by private insurance (Arch Otolaryngol Head Neck Surg 2007;133:1270-6; Arch Otolaryngol Head Neck Surg 2007;133:784-90).
Unequal access to health care will lead to suboptimal health care for all, as there will be increasingly limited resources to provide quality health care.-Amy Y. Chen, MD, MPH
For Dr. Chen, these disparities are correctable and need to be addressed. We have a moral and ethical imperative to provide medical care to all who need us, she said.
Acknowledging the need to recognize and address this issue, Dr. Kuppersmith also emphasized that resolving health disparities goes beyond the practitioners of health care. The presence of these disparities raises a question that society needs to answer regarding whether health care is a right or a privilege, he said.
Try Out Your Health Literacy
These terms are commonly used among various populations to denote specific health conditions. Do you know what they mean?
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©2008 The Triological Society