Marc Imhotep Cray, M.D

8/14/2019 Marc Imhotep Cray, M.D.

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Marc Imhotep Cray, M.D.Link to the video enhanced version of this presentation
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Goals of this Presentation To demonstrate/document racial disparities in health

care exist

To show how trust is important to good healthoutcomes

To explain why African Americans tend to mistrust the

medical profession (and this mistrust is notunfounded)

To emphasize why the medical profession needs to

demonstrate its trustworthiness. Some initial ideas... 2
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Disparities Across

Health Care

Disparities have been recognized among variousminority groups, but are best documented amongAfrican Americans

Adjusted for disease severity and socioeconomic

status, African Americans experience: Fewer referrals for renal transplant evaluation and

fewer transplants (Ayanian 99, Epstein 00) Less adequate pain medication for cancer (Cleeland 97) Inferior HIV Care (Moore 94, Shapiro 99) Fewer admissions to CCU and fewer revascularization

procedures, especially CABG (Ayanian 93, Peterson 97,Schneider 01)

Fewer eye examinations in DM, B-blockers after MI,and follow-up after hosp. for mental illness (Schneider 02)

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Due to Coverage?

Breast cancer screenings

62.9% vs. 70.9% (P


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Transplantation

Disparities

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Median Waiting Time (in Months) to Kidney Transplant By Race

Source of Data for 1998 HHS OIG Report: Organ Procurement and Transplantation Network (OPTN), 1997

OPTN/SR AR 1988-1996. UNOS; DOT/HRSA/DHHS.

Year Black Recipients White Recipients Difference

8.8

8.711.6

13.7

13.8

16.2

19.6

11.3

12.713.3

14.1

16.0

18.7

20.1

20.1

21.424.9

26.7

29.8

34.9

39.7

1988

19891990

1991

1992

1993

1994
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Who You Are InfluencesWhat You Think

6The Washington Post, the Henry J. Kaiser Family Foundation and Harvard University Racial Attitudes Survey (April 2001)

Do you think the average African American is better off,worse off, or just as well off as the average white Americanin terms of access to health care?

Worse Off: White Americans 35% African Americans 61%

How much discrimination do African Americans face in oursociety today?

A Lot: White Americans 20% African Americans 48%

Do you feel that African Americans have more, less, orabout the same opportunities in life as white Americanshave?

Less Opportunities: White Americans 27% African Americans 74% 74%


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Unfair Treatment

25% of White physicians

29% of Physicians overall

33% of Asian physicians

52% of Latino physicians

77% of African American physicians

7The Kaiser Family Foundation National Survey of Physicians (March 2002)

believe that the health care system treatspeople unfairly based on their racial or ethnicbackground very or somewhat often.


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Views on Health Disparities

Most whites (70%-76%) believe that African Americans andLatinos receive the same quality of care as they do.

68% of whites, 75% of Latinos, 80% of African Americans

say racism is a problem in health care

56% of Latinos, 64% of African Americans

believe they receive lower quality health care than whites

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Results of a Kaiser Family Foundation survey conducted in 1999 of 3,884 whites,African Americans, and Latinos. (Lillie-Blanton et al. 2000)

Doctors say the health care system treats people unfairly veryoften or somewhat often based on health insurance status(72%) more than any other factor.

The Kaiser Family Foundation National Survey of Physicians (March 2002)


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Fueling DisparitiesPatient-Level Variables

Patient preferences, mistrust, comfort level

Seeking treatment (or not)

Adherence to treatment (or not)

Effectiveness of treatment

Healthcare Systems-Level Factors

Language barriersAvailability and access to health care

Ability to navigate clinical bureaucracies

Lack of insurance, differences in insurance

Managed care limitationsCare Process-Level Variables

Bias, prejudice, stereotyping, clinical uncertainty

Decisions made with limited time and information

Effect of patient response on physician9Institute of Medicine Report (2002) Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care


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Importance of Trust

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Intrinsic value of trust in the Patient-PhysicianRelationship

The physician-patient relationship often reflects[intimate bonds] and contains strong elements of

transference, particularly during times of criticalillness when patients are vulnerable and frightened.(Mechanic 1996)

Instrumental Value of Trust in Health Care

Trust predicts a patients loyalty to their physician.(Thom 1999, Safran 2001, Keating 2002)

Higher levels of trust between patients and theirphysicians are correlated with positive health

outcomes. (Thom 1999, Safran 1998)


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Declining Trust

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Teachers 86%

Clergymen or priests 85%Doctors 83%Scientists 79%Judges 79%Professors 77%Police officers 75%

Ordinary man or woman 71%(The) President 54%Business leaders 49%Members of Congress 46%Journalists 43%

Trade union leaders 37%

Teachers 84%

Military officers 73%Police officers 71%Protestant ministers 68%Doctors 66%Catholic priests 45%Government officials 26%

Lawyers 25%CEOs of large corporations 23%Managers of HMOs 20%

Harris and Associates Poll (1998) USA Today/CNN/Gallup Poll (2002)

Eroding trust means that the health care system must work to maintain

not only trust in physicians, but trust in the health care system overall.


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Links to Health Outcomes

Lower patient and physician satisfaction

Increased disenrollment

Increased demand by patients for referrals and diagnostictests

Poorer patient adherence to treatment recommendations

Increased litigation

Possibly lower health status

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Decreased trust has been associated with:

Thom and Campbell 1997, Safran et al. 1998


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Trust andPatient Satisfaction Patients with 95th percentile trust scores

were about 5 times more likely than thosewith median levels of trust to express

complete satisfaction with their physician.(Safran et al. 1998)

Thom et al. (1999) found trust to be asignificant predictor of patients

satisfaction with care received from theirphysician.

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Trust:Mediator of the Placebo Effect?

Trust may have therapeutic value, enhancing the

efficacy of prescribed treatment. (Faden andBeauchamp, in Goold 2002)

Trust is important in reducing anxiety, increasing

a patients sense of being cared for, which in turn

may improve the patients sense of well-being and

improve functioning.(Thom and Campbell 1997)

Side query: What might be the economic costof losing the placebo effect?

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Trust May Be Fragile

Trust is easy to breakTrust is particularly fragile because negative eventsare more visible, they carry greater psychologicalweight, they are perceived as more credible. (Slovac inMechanic 1996)

Trust can be disconfirmed at any time. Although patients discount small lapses becausethey appreciate that doctors, like others, can havegood and bad days, a serious failure to be responsive

when needed can shatter even the strongest ofrelationships. (Mechanic 1996)

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Trust:Interpersonal InstitutionalTrust in the medical profession can be: Interpersonal: Patients trusting their physicians,

health care professionals.

Institutional: Patients trusting their hospital, clinic,

or the medical profession.(Mechanic and Schlesinger 1996)

Interpersonal and Institutional trust are related:

Beginning a relationship with a new physician

requires some level of institutional trust. Institutional trust can be cultivated by building on

existing trust between patients and physicians.

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American MinoritiesHave Less Trust Interpersonal Trust

Whites generally have higher levels of trust intheir physicians (Kao 1998)

Trust scores are especially low for Latino andAfrican American men (Doescher 2000)

When asked if they trust their primarynephrologists' judgment about their medical careAfrican Americans responded somewhat or not

at all more often than whites (men 22% vs. 12%,women 24% Vs 11%). (Ayanian 1999)

Still, most patients trust their own physician a greatdeal.

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Less Institutional Trust Major Differences

African American men and women are less trusting ofhospitals. (Boulware 2002)

African Americans are less trusting of the reasons

physicians use or withdraw life sustaining therapies.(Hauser 1997, Blackhall 1999)

African Americans are less trusting of the organ donationsystem. (Yuen 1998, Siminoff 1999)

African Americans have less trust in the health caresystem in general. (Gamble 1997, Freedman 1998, Minniefield 2001)

African Americans have profound mistrust of medicalresearch. (Freedman 1998, Freimuth 2001, Shavers 2001, Corbie-Smith 1999 and 2002)

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Trust vs. Trustworthiness

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Physicians should be concerned with demonstrating thatthey are trustworthy; the trust of patients will follow.

There is a difference between a physician who is trustedand one who is trustworthy. Patients are often the mostvulnerable when they are most in need of health careservices, and granting too much trust to a physician canlimit their ability to discern what is in their own best interest.

Unquestioned trust in clinicians may discourage orhinder patients from acting autonomously and takingan active role in their own health care. (Waterman inAnderson and Dedrick 1990)


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Extreme Mistrust The government introduced drugs into African Americancommunities.

AIDS/HIV is a man made form of genocide.

African Americans are used as guinea pigs in medicalexperiments.

Physicians withdraw life-support to African Americans forfinancial/racial reasons over medical reasons.

Gamble 1997, Freedman 1998, Freimuth 2001

The Tuskegee Study (USPHS Study of Untreated Syphilis in

the Negro Male) involved deliberate infection with Syphilis.(Gamble 1997, Freimuth 2001)

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Guinea Pigs & Unethical Tests They always use our race as guinea pigs. (Corbie-Smith 1999)

They treat us like guinea pigs. They are trying stuff out on us -stuff they learned in school. (Corbie-Smith 1999)

We have always had a concern about what white peoplehave done to black people. Doing things without consent.These are the things that make us back off even more. Asblack people we become the guinea pig for white people. It isas simple as that. (Freedman 1998)

Guinea Pigs. I have a strong belief that syphilis and AIDSoriginated from a laboratory experiment. Thats what they usedpeople for. (Freimuth et al. 2001)

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HIV & Genocide The AIDS virus was deliberately created in a laboratory in order

to infect black people. (NY Times/WCBS Poll 1990)

Believed to be true by 10% of African Americans

Believed might be true by another 20%

AZT is a plot to poison African American people. Urging condom use is a scheme to prevent African Americanbirths.

Distributing clean needles is designed to encourage drug abuse.

Well, this is just my opinion. The population is growing. People

are dying at slower rates. So they said, lets see what happens ifwe infect this (HIV) out there. (Corbie-Smith 1999)

I think [experimentation on Blacks] is still going on now. LikeAIDS, it was man-made but it kind of got out of hand. (Freimuth2001)

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Views Reflect a HistoryThese opinions did not arise from nowhere... Slavery, sharecropping, peonage, lynching, Jim Crow laws,

disfranchisement, residential segregation, and jobdiscrimination formed the substance to which many BlackAmericans reduced all American history, forming a saga of

hatred, exploitation, and abuse. (Jones 1991)

For many blacks, the Tuskegee Study became a symbol oftheir mistreatment by the medical establishment, a metaphor fordeceit, conspiracy, malpractice, and neglect, if not outright racial

genocide. (Jones 1991)

81% know something about the USPHS Study at Tuskegee(Shavers 2001)

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A Study of Untreated Syphilis:A Failure of Professional Ethics

Begun in 1932, continued until 1972.

Approximately 400 African American men in Alabama withSyphilis were observed to autopsy.

Most received some ineffective treatment(s), but no reliabletreatments were given, including after Penicillin was inwidespread use in the 1950s.

Patients were not told of their diagnosis, but were told they

would receive free care and a burial stipend. Patients remained infectious, underwent lumbar punctures and

other invasive testing.

May 16, 1997, President Clinton apologizes on behalf of the

US Government.(Reverby 2000)

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Untreated Syphilis It was difficult to hold the interest of the group of Negroes inMacon County unless some treatment was given Dr. R.

Vonderlehr, 1968. (Brandt 1978)

In interviews with four survivors: (Department of Health, Educationand Welfare, 1973 - in Reverby 2000)

All remembered receiving shots, ointments, pills, ormedicines.

The USPHS ensured that the subjects did not receivetreatment from other sources. (Brandt 1978)

While the men did not get treated for syphilis, they did getgood medical carecare they would not have receivedotherwise because of their socioeconomic status. (As perceivedby Nurse Rivers in Hammonds, 1994)

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Contemporary ExperienceThe legacy of the Tuskegee Study endures, in part, because the

racism and disrespect for black lives that it entailed mirror blackpeoples contemporary experiences with medicine. (Blendon et al1995)

Negative experiences cited by African American and Latino focus

groups (Thom and Campbell 1997) lack of respect lack of privacy deaths of friends or relatives due to what was perceived to be

poor medical care

Minorities report more communication problems with physicians(Commonwealth Fund, 2002)

African American patients rate their visits with physicians as lessparticipatory than whites. (Cooper-Patrick et al. 1999)

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Building Trust is theProfessions Responsibility Trust confers health benefits

Minorities mistrust the profession

There are reasons, both historic and contemporary forthis mistrust, which reflect failures of professionalethics

To reduce health disparities and improve outcomes,

the profession must build trust among minoritypopulations

How can the profession build trust that has beenbreached?

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Individual Physicians Can... Thoroughly Evaluate Problems Understand the Patients Individual Experience

Express Caring

Provide Appropriate and Effective Treatment

Communicate Clearly and Completely

Build a Partnership

Demonstrate Honesty and Respect for the

Patient

Address Structural/Staffing Factors

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Thom and Campbell 1997


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H1N1 Swine Flu 2009 Virus and Vaccination-

Historical and Political Considerations

IVMS -The Tuskegee Syphilis Experiment

IVMS-From the Tuskegee Syphilis Experiment to

Mandatory H1N1 Vaccinations

IVMS-H1N1 Swine Flu Virus2009 FAQ

IVMS-Intro to Clinical Medicine-

Communication Skills

Related Online iPapers by Dr. Cray
http://www.scribd.com/doc/20946872/H1N1-Swine-Flu-2009-Virus-and-Vaccination-Historical-and-Political-Considerationshttp://www.scribd.com/doc/20946872/H1N1-Swine-Flu-2009-Virus-and-Vaccination-Historical-and-Political-Considerationshttp://www.scribd.com/doc/20983187/IVMS-The-Tuskegee-Syphilis-Experimenthttp://www.scribd.com/doc/21020651/IVMS-From-the-Tuskegee-Syphilis-Experiment-to-Mandatory-H1N1-Vaccinationshttp://www.scribd.com/doc/21020651/IVMS-From-the-Tuskegee-Syphilis-Experiment-to-Mandatory-H1N1-Vaccinationshttp://www.scribd.com/doc/20786518/IVMS-H1N1-Swine-Flu-Virus2009-FAQhttp://www.scribd.com/doc/20372624/IVMS-Intro-to-Clinical-Medicine-Communication-Skillshttp://www.scribd.com/doc/20372624/IVMS-Intro-to-Clinical-Medicine-Communication-Skillshttp://www.scribd.com/doc/20372624/IVMS-Intro-to-Clinical-Medicine-Communication-Skillshttp://www.scribd.com/doc/20372624/IVMS-Intro-to-Clinical-Medicine-Communication-Skillshttp://www.scribd.com/doc/20372624/IVMS-Intro-to-Clinical-Medicine-Communication-Skillshttp://www.scribd.com/doc/20372624/IVMS-Intro-to-Clinical-Medicine-Communication-Skillshttp://www.scribd.com/doc/20372624/IVMS-Intro-to-Clinical-Medicine-Communication-Skillshttp://www.scribd.com/doc/20372624/IVMS-Intro-to-Clinical-Medicine-Communication-Skillshttp://www.scribd.com/doc/20786518/IVMS-H1N1-Swine-Flu-Virus2009-FAQhttp://www.scribd.com/doc/20786518/IVMS-H1N1-Swine-Flu-Virus2009-FAQhttp://www.scribd.com/doc/20786518/IVMS-H1N1-Swine-Flu-Virus2009-FAQhttp://www.scribd.com/doc/21020651/IVMS-From-the-Tuskegee-Syphilis-Experiment-to-Mandatory-H1N1-Vaccinationshttp://www.scribd.com/doc/21020651/IVMS-From-the-Tuskegee-Syphilis-Experiment-to-Mandatory-H1N1-Vaccinationshttp://www.scribd.com/doc/21020651/IVMS-From-the-Tuskegee-Syphilis-Experiment-to-Mandatory-H1N1-Vaccinationshttp://www.scribd.com/doc/21020651/IVMS-From-the-Tuskegee-Syphilis-Experiment-to-Mandatory-H1N1-Vaccinationshttp://www.scribd.com/doc/20983187/IVMS-The-Tuskegee-Syphilis-Experimenthttp://www.scribd.com/doc/20983187/IVMS-The-Tuskegee-Syphilis-Experimenthttp://www.scribd.com/doc/20983187/IVMS-The-Tuskegee-Syphilis-Experimenthttp://www.scribd.com/doc/20946872/H1N1-Swine-Flu-2009-Virus-and-Vaccination-Historical-and-Political-Considerationshttp://www.scribd.com/doc/20946872/H1N1-Swine-Flu-2009-Virus-and-Vaccination-Historical-and-Political-Considerationshttp://www.scribd.com/doc/20946872/H1N1-Swine-Flu-2009-Virus-and-Vaccination-Historical-and-Political-Considerationshttp://www.zimbio.com/RBG+Afrikan-+Centered+Cultural+Development+and+Education/articles/1528/KEMETIC+SCIENCE+STUDIES+IMHOTEP+MEDICINE+HISTORY


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Marc Imhotep Cray, M.D