It’s well past time to eliminate health care disparities

It’s well past time to eliminate health care disparities

AMA Leader Commentary. By Jeremy A. Lazarus, MD, Posted Feb. 4, 2013.

A message to all physicians from AMA President Jeremy A. Lazarus, MD, on the Association’s efforts to address unequal care, from access to outcomes.

That cardiovascular disease is the major cause of death in the U.S. is well-known. That minority populations are more at risk than English-speaking white populations — at least in part because of disparities in health care — is shameful.

We know there are disparities in care not only in cardiovascular disease, but also in asthma, diabetes, flu, infant mortality, cancer, HIV/AIDS, chronic lower respiratory diseases, viral hepatitis, chronic liver diseases and cirrhosis, kidney disease, injury deaths, violence, behavioral health and oral health.

According to the latest “National Healthcare Disparities Report,” both health care quality and access in the U.S. are “suboptimal,” especially for racial and ethnic minorities and low-income groups. The report further notes that access to care is not improving for minority groups and that disparities are not diminishing. In fact, there are several areas where disparities are worsening over time between minorities and whites — and between poor and high-income populations.

The Affordable Care Act has taken several major steps toward rectifying this disgraceful situation. It expands initiatives to increase diversity in the health care professions and strengthens cultural competency training. It makes improvements in preventive care and care coordination, and increases funding for community health centers. It ends insurance discrimination, and when health insurance exchanges are in place next year, everyone will have access to quality, affordable health insurance. In all, there are more than 60 provisions that could contribute toward ending disparities.

Outside Washington, a number of groups also are involved in trying to bring quality health care to underserved populations.

One of those groups is the Commission to End Health Care Disparities. I am looking forward to welcoming the commission to my hometown of Denver on March 22 and 23. This very significant meeting will focus on disparities in cardiovascular disease care, but it is a part of a much larger effort.

I am proud to be a member of the commission’s governing secretariat, but I am also pleased to know that other forces within the AMA are also intent on ending disparities, beginning with the AMA Principles of Medical Ethics.

A year ago, the AMA adopted a three-part strategy that includes a commitment to improving health outcomes and with it, an equal commitment to ending disparities in care.

The AMA’s current work toward ending disparities dates to 2000, when the Dept. of Health and Human Services launched a national effort called Healthy People 2010.

In March 2002, the Minority Affairs Section launched Doctors Back to School, a program that aims to show kids of all ages, especially those from underrepresented racial and ethnic groups, that medicine is an attainable career option for everyone. The need is great: While about 25% of the nation’s people are members of minority groups, only 7% of physicians are. Because this is such an important initiative, the Commission to End Health Care Disparities works closely to support Doctors Back to School.

That same year, the AMA House of Delegates approved a resolution to make the elimination of racial and ethnic disparities a high-priority issue.

In 2003, the AMA convened a task force to address care disparities, and in 2004, the Commission to End Health Care Disparities held its first meeting. Today, the commission includes more than 70 state and specialty medical societies and aligned organizations and is led by a secretariat that includes not only me, as the president of the AMA, but also presidents of the National Medical Assn. and the National Hispanic Medical Assn.

The commission works in four areas: educating and training physicians and health professionals about health care disparities and their impact on the quality and safety of care in diverse populations; increasing diversity in medical and allied health professions; advocating in behalf of policies that improve health outcomes for minority and multicultural populations; and improving the quality and availability of research and data resources necessary to support elimination of disparities in health care at national, regional, local and individual practice levels.

Just recently, the commission issued a white paper on promoting appropriate use of physicians’ non-English language skills in clinical care. This is an important subject, as miscommunication or misunderstood communication is a leading cause of health and health care disparities for populations with limited English proficiency.

The white paper makes specific recommendations for policymakers, health system leaders, care delivery organizations and clinicians on approaches to caring for patients with limited English proficiency. It includes recommendations that range from educating medical teams on effective use of trained interpreters to language training for physicians to hiring bilingual staff members.

The AMA also has launched a number of other initiatives to address health care disparities:

  • “Educating Physicians on Controversies and Challenges in Health” is a series of brief informational online streaming programs — developed by the commission in conjunction with the AMA — that targets primary care physicians (
  • The AMA Foundation has a program to help physicians become aware of and appropriately manage low health literacy among patients.
  • The AMA also participates in the American Hospital Assn.’s Equity of Care Group that looks for ways to improve hospital care for minority populations and lobbies for relevant changes in regulation and legislation.
  • Through our Minority Scholars Awards program, among others, the AMA Minority Affairs Section and AMA Foundation awards $100,000 annually in scholarships to medical students.

None of these initiatives can bear fruit anytime too soon.

While progress is being made on many fronts, there is still much more we can do to improve health outcomes. That is why groups like the Commission to End Healthcare Disparities are so important: For those individuals who do not have access to medical care, who do not receive treatment in a timely manner or who are unable to make themselves understood to their clinicians, change cannot come soon enough.

Dr. Lazarus is a Denver psychiatrist. Learn more about Dr. Lazarus at the AMA’s biography page or contact him by email.

Missed diagnoses common in the doctor’s office

NEW YORK (Reuters Health) – Missed or wrong diagnoses are common in primary care and may put some patients at risk of serious complications, a new study suggests.

Although mistakes during surgery and in medication prescribing have been at the center of patient safety efforts, researchers said less attention has been paid to missed diagnoses in the doctor’s office.

Because of how common they are, those errors may lead to more patient injuries and deaths than other mistakes, according to Dr. David Newman-Toker from Johns Hopkins University School of Medicine in Baltimore, who co-wrote a commentary on the new study.

“We have every reason to believe that diagnostic errors are a major, major public health problem,” Newman-Toker told Reuters Health.

“You’re really talking about at least 150,000 people per year, deaths or disabilities that are resulting from this problem.”

For the new study, researchers used electronic health records to track 190 diagnostic errors made during primary care visits at one of two healthcare facilities. In each of those cases, the misdiagnosed patient was hospitalized or turned up back at the office or emergency room within two weeks.

The study team found the type of missed diagnosis varied widely. Pneumonia, heart failure, kidney failure and cancer each accounted for between five and seven percent of conditions doctors initially diagnosed as something else.

Most diagnostic errors could have caused moderate or severe harm to the patient, the researchers determined. Of the 190 patients with diagnostic errors, 36 could have had serious, permanent damage and 27 could have potentially died, according to findings published Monday in JAMA Internal Medicine.

One of the difficulties in making an accurate diagnosis is certain common symptoms – such as stomach ache or shortness of breath – could be signs of a range of illnesses, both serious and not, researchers said.

“If you look at the types of chief complaints that these things occur with, they’re fairly common chief complaints,” said Dr. Hardeep Singh, who led the new study at the Houston VA Health Services Research and Development Center of Excellence.

“If somebody would come in with mild shortness of breath and a little bit of cough, people would think you might have bronchitis, you might have phlegm… and lo and behold they would come back two days later with heart failure,” he told Reuters Health.

Most of the missed diagnoses were traced back to the office visit and the doctor not getting an accurate patient history, doing a full exam or ordering the correct tests, Singh’s team found.

Cutting down on those errors may require changes in doctor training, for example. One thing patients can do, the researchers agreed, is come to the office prepared to give their doctor all of the relevant information about the nature and timing of their symptoms.

“I do think it’s important for a patient to question or observe the doctor,” Newman-Toker said. “Ask pointed questions: ‘What else could this be? What things are you most concerned about?'”

In addition, he told Reuters Health, patients should “not just assume that once the diagnosis has happened the first time, that everything is said and done and that it’s all over. You just can’t have blind obedience to the doctor’s diagnosis.”

For example, Newman-Toker said, if people develop new symptoms or their symptoms worsen, they shouldn’t assume everything is fine because their doctor initially diagnosed something not serious.

Patients should understand there is some uncertainly involved in a diagnosis, Singh said, especially because symptoms and conditions can change over time.

“We need to get patients more engaged in the conversation with the providers,” he said. “I think the main message is: how do we effectively (make diagnoses) together?”

SOURCE: JAMA Internal Medicine, online February 25, 2013.

(This story has been corrected to change the eighth paragraph to say that permanent damage and death could have happened, not that they did happen in story posted Feb 26, 2013.)