2002-03 Broadcast Season
Broadcast Program Transcripts
Episode #1808
Health Care Inequity

Brown: Natalie Bullock Brown, Host
Ballin: Dwayne Ballin, UNC-TV
Pullen-Smith: Barbara Pullen Smith, NC Department of Health and Human Services
Scales: Jeffery Scales, M.D., Durham Academy of Medicine
Corbie-Smith: Giselle Corbie-Smith, M.D., UNC-Chapel Hill Faculty
Bright: Cedric Bright, M.D., Durham VA Hospital / Duke University Medical Center

Brown: A new report released by the Institute of Medicine confirms what may have been long suspected: discrimination in the doctor's office is alive and well. We'll talk about how you can guard your health next on Black Issues Forum.

Voiceover: This program was made possible by contributions to UNC-TV from viewers like you. Thank you.

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Brown: Good evening and welcome to Black Issues Forum. I'm Natalie Bullock Brown. If you've ever wondered whether or not you were receiving the best treatment in the doctor's office, you're concerns are justified. Independent producer/reporter Dwayne Ballin brings us revelations from a recent study from the National Academies Institute of Medicine.

Ballin: Dell McKendrick and Mary Mallard are white-collar employees of the same company. They fall within the same salary range. But according to a report from the Institute of Medicine at the National Academy of Sciences, Kendrick, who is black, is more likely to receive lower quality health care than Mallard, who is white.

The Congressionally mandated report presents overwhelming evidence that regardless of income level and insurance coverage, disparities in the health care delivered to racial and ethnic minorities are real.

Pullen-Smith: I think it's a good thing that the information is out there..

Ballin: Barbara Pullen Smith is the director of the state's Office of Minority Health.

Pullen-Smith: .It documented what we, as minority people, experienced over our history and what we've always understood.

Ballin: The report states that some white health care providers, well meaning though they may be, typically demonstrate unconscious negative racial attitudes when dealing with patients of color.

Pullen-Smith: You cannot deny that racism is one of the contributing factors to poor health status for poor people, but I also think just cultural barriers, just providers who don't understand, who don't get it, who don't understand to talk to people who look differently from them.

Ballin: That's something Dr. Jeffery Scales, a member of the Durham Academy of Medicine, and organization committed to improving the healthcare of African Americans, is acutely aware of.

Scales: We need to be honest about ourselves as a group of professionals that, perhaps there are some things that we can do better, and studies like this are a great step in that direction. I think it's going to take several generations to see us become a bit more sensitive to some of these issues.

Ballin: How is it that in 2002 this is an issue that's being addressed in this country?

Scales: I think it still a topic that we're addressing because we have a great deal of difference between the make-up of the professional class of people-the physicians-and much of the populace. This is an issue that we've struggled with in this country for over 200 years and I think we'll continue to struggle with it, but I'd at least like to applaud the medical field for at least addressing this issue now, as opposed to pretending that it doesn't exist.

Ballin: When you say the difference in the make-up of the professional class as opposed to the populace, are you saying simply, you need more black doctors?

Scales: Certainly having a more diverse group of doctors would be helpful, but a more culturally sensitive group of doctors, regardless of their background, would be helpful for medical care in general in the future.

Ballin: Hopefully that would alleviate horror stories like some of those referred to in the report.

Scales: There were some documented cases that, frankly, are disturbing-say for diabetes-and amputation as opposed to exploring medication more. I'm assuming that you're not shocked at that.

Smith: I'm not shocked at that. As a black person, I know my history and experience in trying to access health care systems, and for the most part, with having adequate insurance. I know what it feels like sometimes to be mistreated-to really not be taken seriously or to say, "Well, you know, maybe you don't even understand what your symptoms are."

Ballin: In the end, are you optimistic?

Smith: No, not at all. I don't have a whole lot of hope that a lot of the powers that be will take this seriously and will actually respond to it in a significant way-in a way that will make a difference for the next individual who goes to that individual doctor's office.

Brown: There's no question that a disparity exists, but there is a question as to what can and will be done about it. Joining me here in the studio to examine this question, I'd like to welcome Dr. Giselle Corbie-Smith, a faculty member at UNC-Chapel Hill who has conducted her own research in the area of health disparities, and Dr. Cedric Bright, a physician with the Durham VA Hospital/Duke University Medical Center.

Now let's start off with, I guess, what the young lady said at the end of the piece that we saw. She's not optimistic that anything is going to be done. Are physicians, in general, taking this report seriously?

Corbie-Smith: I think her lack of optimism sort of reflects the fact that these issues have been around for a while, that these are not new issues. There's been a lot of interest recently in documenting disparities-health disparities by race and ethnicity-but it's not new. And I think it's a really good question. What are we going to do? Her lack of optimism, I think, is also reflected in minority communities that, you know, we've been living this for a while and really, as health professionals, we're going to need to step up to the plate and really show that we're willing and able and interested in not only documenting the disparities, but looking at how to really try to address them.

Brown: Dr. Bright, is there a difference between how black physicians treat minority patients and white physicians treat minority patients? Or is this a problem-is this a disparity across the board?

Bright: Certainly the literature states that-or shows that there is some better outcomes in some instances where there is race congruence-meaning that the race of the physician and the race of the patient are similar. However, there's a lot of evidence to show that these disparities go totally across the board, irrespective of race, irrespective of insurance. So I think this is an issue that we, as a whole medical profession, need to address. It's not just a-it's not a Band-Aid solution just to increase diversity within the work force, although it would help, but that would be more of a Band-Aid solution. I think that the rather long-term solution is more acculturation between the whites getting to know-or the majority getting to know the minority type of issues, culture, language barriers, the ability to pay. These things affect the outcome of the experiences that they have within these physicians' offices.

Colby-Smith: I think that that is a really important point, particularly in North Carolina because we have a growing minority community, and a minority community that's growing-that does not even have the same language that native-people native to North Carolina have, and often not the same language as their physicians. So I think really while I, you know, while we would all agree that the number of minority physicians is small, it's really-we have to make sure that all of the physicians that are caring for patients in situations like North Carolina, which is, you know, representative of around the country, really understand the culture, really understand the language, or at least have things in place that can help patients communicate with their physicians at even the basic level of speaking the same language.

Brown: So this sounds like it's a much bigger issue than just black/white-I mean, this is-this has all kinds of implications in terms of socio-economic status, cultural background, like you were saying, Dr. Bright. I'm wondering, Dr. Corbie-Smith, does the disparity-or might HMOs have anything to do with the disparity and the pressures that physicians are put under as a result of HMOs?

Corbie-Smith: Well I think that's a good question. Often who is enrolled in a certain health plan can differ. I think that there's an opportunity with health plans, particularly those which do enroll a diverse group of people. Often those who are insured, as we know that in this state and other states, minorities tend to be more likely to be insured by Medicaid versus other types of insurance. There's this whole group of people-the working poor-that aren't insured at all. So that group, even if you're focused on HMOs, that group is not even-I mean they might not even be able to get to the doctor. So what happens within health plans really needs to be looked at closely. I think that the time that we have to see patients is growing shorter and shorter, and often when that happens, as physicians-minority or majority physicians-we tend to rely on stereotypes, when we don't have that time to be able to talk with people, or when people switch out of plans or physicians are switched out of plans, so that you don't even have a long-term relationship with people. So over time, even if each visit is shorter over time, you're not even getting to know the person or their situation. So I think examining what's happening within health plans is really important.

Brown: So Dr. Bright, based on what Dr. Corbie-Smith said, is the issue of insurance coverage a cultural issue? Is that a black/white issue, since I was understanding you to say that most African Americans, or that even most minorities, are enrolled in Medicaid and others-and perhaps the majority population-is enrolled in insurance plans like..

Bright: Blue Cross Blue Shield.

Brown: Yes.

Bright: Well, let us first state that when we look at poverty in America, the majority of people that are in poverty are not black. The majority of the people in poverty are still majority people because they're the majority of people. It's just that when you look at the proportion of blacks that are in poverty compared to the proportion of blacks that are out of poverty, it's where we see such a large number-where we see almost two thirds of households of blacks are headed by single women. Yes, that is an issue. The insurance is an issue, but I don't believe it strictly boils down to Medicaid versus-Medicaid/Medicare versus private insurance. Certainly we can still see the issues of disparities occurring even with proper insurance status. That's not really totally the whole issue. And it would be nice, it would be very nice if the simple issue were a national health plan that gave everybody health insurance and then everybody's health would be the same, but that's not the case. We would still have some disparities that would occur because people don't understand how certain blacks or how blacks relate to taking insulin, for instance, as opposed to taking pills for sugar. You know, one of the problems that I run into, and I don't know if you do, but I'm sure you do, Dr. Corbie-Smith, but we see patients that will come to us and tell us, "Well I'm not taking insulin, because when I start taking insulin, I'm going to lose my legs." Well it wasn't the insulin that led to them losing their legs, it was all the years not being on insulin that led to all the vascular disease that then led to them having to get their legs taken off, but it just so happened that they finally got tired of the doctor hounding them about needing to be on insulin and decided to go on it at that time.

Brown: Let me jump in her and ask you, because I have heard and read that in minority communities, especially in African-American communities, there is a mistrust between patients and doctors that exists to begin with. Most, especially I think older African-Americans seem not to want to go to the doctor at all. So once they get there, is that mistrust and the fact that it takes us perhaps so long to get to the doctor's office, a part of what is contributing to this disparity?

Bright: Yes. And we can look at this historically and then I'll let Dr. Corbie-Smith bring your forward, but historically if we look at what happened after the Civil War, the slaves were free and the main thing that was found out is that healthcare for those post-war slaves that were now free, was nonexistent, so what happened is that Northerners, freedmen from the North came down and started to set up various places for which these people could receive healthcare. And that has continued kind of since that time, in institutions such as Howard, which was founded by a corpsman out of Maine, and Meherry, which was founded by the brothers in Tennessee. And these were whites that saw an issue among the blacks that were being freed and their ability to get healthcare and they decided that there needed to be something done, and that's how we came up with this whole Howard and Meherry medical schools. Now, to bring that forward, when we look into the early 1900s with the Tuskegee experiment and how that affected our perception of the healthcare system, I think it warrants mistrust, it certainly does. And the issue of that mistrust is still being guided even now when we try to get people to enroll in clinical trials. I think one of the other issues that we have to consider though, is what is our perceptive of health? Is health the absence of any problems, of any pain? Or is health an active thing that we go about doing every day by eating properly, by exercising, by avoiding the things such as cigarette smoking and drinking and things of that nature? What I feel is that we have a tendency to say, "Nothing's wrong with me, what do I need to go to a doctor for?"

Brown: Dr. Corbie-Smith, what about this? I mean, it sounds like an interesting point.

Corbie-Smith: I think I would completely agree with what Dr. Bright has said, that this issue of distrust I think is an important one, and just as Dr. Bright suggested all we know is what has happened before. Really, the burden is on the healthcare system to show that they're trustworthy, to show that we're not going to ignore this wakeup call, we're not going to his the snooze button on this wakeup call. That we have more evidence, we have this amazing report that elegantly lays out all the problems and ways to make solutions, ways to start making inroads. And what are we going to do about it? Otherwise the distrust is warranted. We have lived experiences that really continue to validate our distrust. You walk into the grocer store and you know, one of the things that I think Dr. bright brought up is that health is not just confined tot he healthcare system; it's about how we live, lot's about where poverty is, what our environments are, do we have places to walk, do we have places to buy groceries? I mean, there was a recent report that came out this week that looked at, if there are more grocery stores in a black neighborhood, people are more likely to eat fruits and vegetables. Well you know, you've got to have them there. You have to be able to, you have to have access to the food, you have to have access to places to exercise; you have to have access to places to walk and feel safe. And so it's beyond just the healthcare system, and I think that there's an opportunity for the people that lead our states, or cities and our government to really get behind this, in addition to the folks that are in the healthcare system.

Brown: Well what can you and Dr. Bright do as physicians to try and encourage your own patients, especially since you know what you know, and in light of this report, to encourage them to take better care of themselves or to just do things differently so that they can be responsible for their own health.

Corbie-Smith: Right. I think my first obligation as a physician, when I see patients, is to listen and not make assumptions about what their life is like. Because I can tell them what I do, but my life is often very different from the lives that my patients. And so I need to listen and we need to be creative together about how to meet whatever their goals and our goals are. As a team we have to approach their health as a team. And so the advice is individualized for each patient. It really is about sort of where they are, what they're able and willing to take on in terms of their own health. And it's got to be an active process, it can't just be me telling them, well you need to walk 30 minutes a day, you need to eat more fruits and vegetables. My patients, I ask them, well what are you able to do, what are you willing to do, what are you doing now and how can we move forward slowly, and in a way that doesn't make you feel like you've failed yourself or me? So I think it really is individualized to the patient.

Brown: Right. Dr. Bright, how are physicians in general missing the mark with their patients, I mean, what can be changed?

Bright: Well, we're missing the mark in some very, very easy areas that can be easily quantified and corrected, I feel. We looked at hypertension and how well we're controlling hypertension in our patients, and the data suggests that over 75% of our patients that are on hypertensive medications are not at goal blood pressures. Well, that's just in general. So one thing that we need to do is to be more stringent about our goals. And reaching those goals. But what's the problem with that, is that medications have side effects and these side effects will often limit our ability to get our patients to their goal. How do we get around that? We have to talk to the patient. We have to educate the patient, we have to make sure that when that patient walks out of our office, they have more information about themselves and their lives than when they walked in. We have to educate. I liken it to being a consumer, consumer of health. You know, you go to get your car fixed, you're going to take it someplace that you trust the person and you're going to ask the questions and things of this nature, that will promote you to get the best service for your car. Well it's no different, I feel, about your healthcare.

Brown: But let me ask you a question, and Dr. Corbie-Smith, feel free to jump in here. I would figure that as physicians, you don't have the time, unfortunately, to really hand-hold the patients through the process of navigating the system and trying to get them to not only understand what they need to do with the healthcare system in general, but what they need to do for themselves, so how do you balance that work?

Bright: It has to be a team effort, it starts not only with the physician, but it starts with the nurses that we check our patients out to; it goes to the clerks who are at the desk to help the people make their appointments and tell them where they need to go to get a particular test done. It starts at the front desk when you first walk in to the hospital and who greets you and how you feel?

Brown: And do they greet you?

Bright: And do they greet you, right.

Corbie-Smith: I think to start thinking about this and looking at ways to address these disparities in health, we've got to think outside the box, it can't be business as usual, we have to really, if we're really going to demonstrate, as healthcare providers, as healthcare system, that we are worthy of people's trust, then we need to think about innovative ways, look to models that have worked. Where I was at another institution in Atlanta, there were community health centers, and the whole idea of navigating the public hospital was really scary, particularly for folks that didn't speak the language, or even those that did speak the language, but just didn't feel comfortable to come to this big hospital. And that one of the satellite clinics, one of these outlying clinics, had staff that would go with the patients to their appointment and help them navigate the system. I think there's an opportunity to really look to places that have made inroads and have really addressed these problems. And also look to our communities. As I said, we're all in this together, and it can't be just the doctors doing this-even though I do think a lot of the burden needs to fall on the shoulders of the people like physicians or healthcare systems, but I think we also have a lot of strengths in our communities also that we need to start capitalizing on.

Brown: Well it sounds like doctors in general, no matter color they may be, need training, diversity training, similar to what big corporations have for their employees. Do you think that sort of training would work, or what's necessary to get all doctors on board?

Bright: Well that's interesting, because both Giselle and I belong to the society of general internal medicine and it's a society of general internists who are about trying to make a change, about being politically active and doing things within the healthcare system and without the healthcare system. And one of the things that we have is a health disparities task force which we both serve on. And one of the things that I've actually been put in charge of, is in this particular instance is to look at, how do we implement a cultural competency curriculum in the medical system? There are various levels at which we would do this. I mean, you could do this at the medical student level, you could do it at the intern-resident level after they've come out of their medical school training and go to do their actual training for what they want to do in the future. And then you look at it as, then the faculty, how do we do that, and then how do we get to the folks in private practice, because once you're outside of the institution, education is mostly CME, which is continuing medical education, which we have to do in order to maintain our active licenses. So that's where the question becomes, because we could start working on just medical students, and that's great, but we won't really see the fruits of that labor for a long time. What we also have to understand, that these medical students were raised in an integrated society, where really maybe most of our issue may be those that were raised during the segregated society. And therefore we need to spend more time with the people that are out and older, teaching them about the issues that relate to cultural diversity and how that relates to doing, practicing medicine, because we do practice medicine, we have not perfected it, we practice it. And in that instance, it would help them to be able to practice medicine more culturally effectively.

Corbie-Smith: And it's a lifelong process. I think this different status that Dr. Bright talks about, at each stage, it's a lifelong process of cultural awareness. You never actually get there. There's always something else to learn. We might have a certain leg up because we're from a minority group and are closer to those issues, but as physicians, many of us have trained in institutions that sort of, in one way or another, have been influenced by the majority culture. And so in all of our textbooks and all of those things, are often written by members of the majority culture. And it needs to be reinforced; as I said, it's a lifelong process of cultural awareness and cultural sensitivity. So just one little course that people go to like, I don't think it's going to solve the problem.

Brown: Well believe it or not, we are out of time, and I'd like to thank our guests, Dr. Corbie-Smith and Dr. Bright, for making this house call tonight and joining us for our discussion. The state of your health is certainly an important issue to consider, so if you'd like to learn more about the Institute of Medicine's report, or obtain a transcript of today's program, please visit us online at www.unctv.org/bif. Or you can call us with your comments at 919-549-7167. We appreciate your feedback and your viewing support, so be sure to join us every Friday night at 9:30, right here on UNC-TV. For Black Issues Forum, I'm Natalie Bullock-Brown encouraging you to stay encouraged no matter what. Take care.

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