PERSPECTIVES The Role That Graduate Medical Education Must Play in Ensuring Health Equity and Eliminating Health Care Disparities Maria E. Maldonado1,2, Ethan D. Fried3,4, Thomas D. DuBose, Jr.5, Consuelo Nelson6, and Margaret Breida6 1
Department of Medicine, Stamford Hospital, Stamford, Connecticut; 2Columbia University’s College of Physicians and Surgeons, New York, New York; 3Department of Medicine, Lenox Hill Hospital, New York, New York; 4North Shore/LIJ Health System, Hofstra North Shore – LIJ School of Medicine, Manhasset, New York; 5Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina; and 6Academic Affairs, Alliance for Academic Internal Medicine, Alexandria, Virginia
Abstract Despite the 2002 Institute of Medicine report that described the moral and financial impact of health care disparities and the need to address them, it is evident that health care disparities persist. Recommendations for addressing disparities include collecting and reporting data on patient race and ethnicity, supporting language interpretation services, increasing awareness of health care disparities through education, requiring cultural competency training for all health care professionals, and increasing diversity among those delivering health care. The Accreditation Council on Graduate Medical Education places strong emphasis on graduate medical education’s role in eliminating health care disparities by asking medical educators to objectively evaluate and report on their trainees’ ability to practice patient-centered, culturally competent care. Moreover, one of the objectives of the Accreditation Council on Graduate Medical Education Clinical Learning Environment Review visits as part of the Next Accreditation System is to identify how sponsoring institutions engage residents and fellows in the use of data to improve systems of care, reduce health care disparities, and
improve patient outcomes. Residency and fellowship programs should ensure the delivery of meaningful curricula on cultural competency and health care disparities, for which there are numerous resources, and ensure resident assessment of culturally competent care. Moreover, training programs and institutional leadership need to collaborate on ensuring data collection on patient satisfaction, outcomes, and quality measures that are broken down by patient race, cultural identification, and language. A diverse physician workforce is another strategy for mitigating health care disparities, and using strategies to enhance faculty diversity should also be a priority of graduate medical education. Transparent data about institutional diversity efforts should be provided to interested medical students, residents, and faculty. Graduate medical education has a clear charge to ensure a generation of physicians who are firmly grounded in the principles of practicing culturally competent care and committed to the reduction of health care disparities. Keywords: graduate medical education; health care disparities; cultural competency; health equity
(Received in original form February 16, 2014; accepted in final form March 19, 2014 ) Correspondence and requests for reprints should be addressed to Maria E. Maldonado, M.D., Department of Medicine, Stamford Hospital, 30 Shelburne Road, Stamford, CT 06902. E-mail: [email protected] Ann Am Thorac Soc Vol 11, No 4, pp 603–607, May 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201402-068PS Internet address: www.atsjournals.org
Despite the seminal report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” released in 2002 by the Institute of Medicine, which concluded “though a myriad of sources contribute to (health care) disparities, some evidence suggests that bias, prejudice, and stereotypes on the part of healthcare providers may contribute to differences in care,” (1), it is evident that health care disparities persist.
Perspectives
According to the most recent Agency for Healthcare Research and Quality National Healthcare Disparities Report, although the quality of care is improving for all populations, access to health care is deteriorating, and disparities are not changing (2). By 2060, it is estimated that 57% of the U.S. population will be composed of members of underrepresented groups, including those who are most subject to the
consequences of disparities in health care (3). The Institute of Medicine recommended that strategies be used to increase awareness about health care disparities to health care professionals and the public, diversify the workforce of health care professionals, and ensure language interpretation. The American College of Physicians underscores the principle that all patients deserve highquality health care, regardless of race,
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PERSPECTIVES culture, primary language, socioeconomic status, sexual orientation, and age in their position paper on racial and ethnic disparities in health care (4). Their recommendations for addressing disparities include a focus on patientcentered communication, clinician sensitivity to cultural diversity, and efforts to create a diverse health care workforce. Besides the moral imperative to address health equity, there is an economic imperative to use all strategies to eliminate health care disparities. As underrepresented groups increase in proportion of the U.S. population, their health status will define the nation’s health. As payment becomes more dependent on outcomes, it will not be financially viable to ignore poor outcomes in patients. In 2003 and 2006, 30.6% of direct medical expenses for African Americans, Asians, and Hispanics excess costs were due to health care disparities, and it is estimated that eliminating health care disparities would decrease medical expenditures by at least 29.4 billion dollars (5). Hospital accreditation will likely become increasingly dependent on their approach to addressing health care disparities; The Joint Commission released disparities and cultural competence accreditation standards and released a bulletin on resources related to effective communication (6). Finally, it is clear that provisions of the Affordable Care Act are designed to address racial and ethnic disparities in health care. Examples include requiring data collection by patient race, ethnicity, and language preferences by federally funded health care; expanding research on health and health care disparities; encouraging racial and ethnic diversity in the health care workforce; supporting cultural competency programs for clinicians; and improving access to health care by expanding coverage (7). The ACGME has delivered an explicit educational imperative for residency and fellowship programs to address health care disparities. Improving communication between the physician and patient and ensuring that the next generation of physicians is equipped with the best tools to maximize patient-centered communication with a culturally, racially, and socioeconomically diverse patient population is increasingly becoming a critical objective of residency and fellowship training. Here we describe the role that graduate medical education must 604
play to promote health equity by describing accreditation requirements for addressing health care disparities, curricular approaches to equip trainees with the tools needed to serve an increasingly diverse patient population, and strategies that graduate medical education can use to create and support a diverse health care workforce.
The ACGME’s Role in Eliminating Health Care Disparities The ACGME’s Next Accreditation System designed to prepare physicians for practice in the 21st century was implemented in July 2013 for internal medicine and will be implemented in July 2014 for all of the other specialties (8). One of the attributes of the Next Accreditation System is the Clinical Learning Environment Review (CLER). An important goal of CLER is to identify how sponsoring institutions engage residents in the use of data to improve systems of care, reduce health care disparities, and improve patient outcomes (9). The ACGME recently released the “CLER Pathways to Excellence,” and two of the Health Care Quality Pathways are explicit in what education on disparities should entail. It is expected that trainees and faculty receive education on identifying and reducing health care disparities and training in cultural competency relevant to the institution’s patient population. Furthermore, trainees should be engaged in quality improvement activities addressing health care disparities for vulnerable populations served by the clinical site (10). These requirements underscore that the ACGME views itself as a partner with other governing agencies such as the Department of Health and Human Services to prioritize elimination of health care disparities. Moreover, the ACGME has established cultural competency milestones expected of residents and fellows by the conclusion of their training. For example, a trainee who is ready for unsupervised practice should be able to “quickly establish a therapeutic relationship with patients and caregivers, including persons of different socioeconomic and cultural backgrounds” and “effectively obtains and documents informed consent in challenging circumstances (e.g.; language or cultural barriers)” (11).
Surveys of internal medicine program directors indicate that they agree that knowledge about health care disparities is important and that resident interest is not a barrier to teaching about disparities. However, barriers to teaching effectively in this area include shortages of qualified faculty and lack of standardized curricula (12). In 2005, a national survey of resident physicians revealed that although 96% of respondents believed that it was important to consider patients’ culture when delivering care, 66% of them reported little or no evaluation on the cross-cultural aspects of the doctor–physician communication (13). Presently, it is uncertain to what degree residency programs are incorporating curricula on health care disparities and cultural competency training. Time and resources to develop faculty to ensure adequate medical educators competent to train and support culturally competent residents may not be sufficient. There is a lack of standardized tools to objectively evaluate residents on their ability to practice culturally competent care as well as measure meaningful patient outcomes. Although there are some data on how implementation of cultural competency curriculum can improve learners’ confidence in their preparedness to deliver culturally competent care (14, 15), data are needed to measure whether education and objective assessment of residents translate into improved patient outcomes. A clear idea of the present state in graduate medical education as it relates to curricula and trainee assessment in cultural competence and health care disparities is essential if we are to ensure the appropriate intersection between education and the needs of the health care system. Determining the stages of program engagement with their institutions around the area of quality improvement initiatives as it relates to site-specific health care disparities will allow for information sharing and strategy development for programs to engage their institutions. The Alliance of Academic Internal Medicine (AAIM) represents a consortium of five academic organizations, the Association of Professors of Medicine (APM), the Association of Program Directors in Internal Medicine, the Clerkship Directors in Internal Medicine, the Association of Specialty Professors, and the Administrators in Internal Medicine.
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PERSPECTIVES The Diversity and Inclusion Committee, which is overseen by AAIM, is readying a survey to be disseminated to Internal Medicine program directors and their trainees to appraise how programs deliver curricula on health care disparities and cultural competency, evaluate their trainees on their ability to practice culturally competent care, and measure the percentage of programs engaged in meaningful quality improvement initiatives given these regulatory mandates, to determine whether national support, curricula, and tools are needed to assure best practices in care for vulnerable populations.
Curricular Approaches to Reducing Health Care Disparities Although it is important to realize that education alone cannot eliminate health care disparities, CLER demands that teaching institutions develop educational content that is intended to illuminate disparities and convey strategies that could potentially mitigate them. Both the Liaison Committee on Medical Education and the ACGME have standards for undergraduate and graduate medical education in cultural competence (16, 17). The ACGME’s common program requirements, which impact all U.S. residency and fellowship training programs, state that “residents/fellows are expected to communicate effectively with patients, families, and the public, as appropriate across a broad range of socioeconomic and cultural backgrounds,” as well as demonstrate a “sensitivity and responsiveness to a diverse patient population” (17). In a report from the Society of General Internal Medicine’s Task Force for Residency Reform, it was recommended that “to honor the social contract and embrace our professional obligations, programs should explicitly address health disparities and incorporate teaching in the social sciences” (18). The Society of General Internal Medicine Health Disparities Task Force provides recommendations on learning objectives and methods for teaching, with a focus on identifying and examining bias, acknowledging the existence of health care disparities and solutions for mitigating them, and acquiring the appropriate communication and negotiation skills Perspectives
across a culturally and linguistically diverse patient population (12). Several task forces and academic groups have disseminated excellent curricular sources for education around health care disparities and cultural competency. The following are some examples. The Society of General Internal Medicine’s Health Disparities Task Force describes a strategy for improving health disparities education in medicine through a curriculum featuring five modules, “Disparities Foundations,” “Teaching Disparities in the Clinical Setting,” “Disparities beyond the Clinical Setting,” “Teaching about Disparities through Community Involvement,” and “Curriculum Evaluation,” meant to “train the trainer” (19). The content areas of the modules focus on some of the important areas impacting health care disparities, including social determinants of health, role of health care, including access, and addressing bias. This comprehensive curriculum is meant to increase the competency of faculty in health disparities education and can be accessed online (20). The American Medical Association Foundation created a curriculum that includes a brief review of the Executive Summary of the 2003 Institute of Medicine report “Unequal Treatment,” which focuses on enumerating some of the disparities and presents a set of recommended interventions to reduce them. The report provides a review of techniques, including “creating a shame-free environment,” avoidance of jargon, use of visual aids, and using “teachback” to check for understanding of medical information, which were originally designed to enhance communications between doctors and patients with low health literacy (21). Examples are provided that illustrate common themes that are influenced by culture, including religious beliefs and practices, distrust of nonminority clinicians, socioeconomic factors, and challenges to adherence and good self-care practices. The Academic Alliance for Internal Medicine provides links to e-learning resources for its community on cultural competency including the U.S. Department of Health and Human Services, “A Physicians Practical Guide to Culturally Competent Care” (22). This is a series of online modules designed to heighten awareness, knowledge, and skills to treat an
increasingly diverse patient population as well as ensure awareness of the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care. Those who access these modules can receive up to nine AMA/PRA Category 1 CME credits. An expert panel composed of the Association of American Medical Colleges and the Association of Schools of Public Health specified a series of cultural competencies common to medical and public health students that delineate expected outcomes by the end of the program of study for medical and public health students and mapped these outcomes to ACGME competency-based outcomes (23). Moreover, the panel described two activities relating to cultural competency and health disparities that resident physicians should be able to perform in unsupervised fashion by the end of their training. Several resources are provided in this report designed to inculcate trainees with the knowledge, skills, and ability needed to be competent in culturally competent care. Other curricular resources for teaching on health disparities through web seminars and case studies can be accessed through the Disparities Solutions Center for teaching on health disparities (24). Finally, there are books available on curricular resources in health disparities and cross-cultural care that are case-based, designed to assist clinicians to achieve proficiency in these areas (25, 26).
Increasing Diversity in Health Professions: The Role of Graduate Medical Education An important strategy for eliminating health care disparities is increasing the diversity of the physician workforce. African Americans, Hispanics, and Native Americans compose only 12.3% of the nation’s physician workforce despite representing 37% of the U.S. population at the present time (3, 27). Health care professionals from underrepresented groups are more likely to work in medically underserved areas, and race concordance in patient–physician relationships results in higher patient satisfaction and trust in the health system (28, 29). A recent study found that nonwhite physicians provide a disproportionate share of care to underserved populations, providing more 605
PERSPECTIVES evidence that increasing the racial and ethnic diversity of the physician workforce is a critical key for addressing disparities by increasing access to patients (30). Residency candidates from underrepresented groups place strong emphasis on the ethnic diversity of the city, patients, house staff, and faculty and are interested in an academic environment that supports ethnic minorities (31). The 2013 National Resident Matching Program Applicant Survey revealed that almost onefourth of U.S. medical student seniors and 43% of independent candidates cited that cultural/racial-ethnic/gender diversity at a residency program’s institution was a highly important factor in deciding where to train (32). However, very little transparent accurate program-specific data exist for candidates on factors that may be of great importance to underrepresented group candidates. Developing a “diversity scorecard” for each residency program/ institution could be enormously useful for medical students. In 2006, the Diversity Committee of the APM published a perspectives piece in the American Journal of Medicine in which they outlined more than 30 “best practices” for departments of internal medicine to achieve diversity. These practices ran the full spectrum of academic stages from medical student recruitment to the transition from medical school to residency and fellowship to the recruiting, retention, and promotion of academic faculty (33). This catalog of proactive programs made it clear that academic departments could be more than just welcoming of diversity. Going well beyond schools, training programs, and departments advertising that “underrepresented minority candidates are welcome to apply,” the APM paper could be used as a roadmap for academic leaders who truly wish to commit to diversity as a core value. In 2013, Peek and colleagues published a study that used quantitative and qualitative methods to interview medicine departments to test the effectiveness of the
APM recommendations and to better understand the factors that might predict and enhance racial and ethnic diversity in academic settings (34). Qualitative evidence revealed that direct outreach to diverse populations through pipeline programs and career days, the establishment of academic support programs for high school and undergraduate students from underrepresented groups, sponsorship programs like loan repayment and scholarships, and both formal and informal mentoring helped many committed academic leaders to diversify their departments and programs. In 2013, AAIM elevated the APM Diversity Committee to the level of an alliance-level committee and renamed it the AAIM Diversity and Inclusion Committee to reflect an added commitment to supporting women in academic medicine as well as physicians from underrepresented groups. This committee has proposed the establishment of a scorecard that could capture medical schools, departments of medicine, and residency training programs’ proportion of diverse individuals, the growth of these groups over the last 2 years, and the number of outreach and support practices used to promote diversity. If publicized, these scores could be used by interested students, residents, and faculty to measure the impact of implementing best practices in increasing diversity to these organizations as well as send a strong message that achieving a standardized benchmark is desirable. The collection of these scorecard data is currently awaiting institutional review board approval and dissemination to schools, academic departments, and training programs.
Conclusions This is a pivotal time in health care. Provisions of the Affordable Care Act have underscored the importance of a diverse health care workforce and the need to ensure
References 1 Smedley BD, Stith AY, Nelson AR, editors. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press; 2002. 2 U.S. Department of Health and Human Services. National healthcare quality & disparities report 2012. 2012 [accessed 2014 Jan]. AHRQ Publication No. 13-0003. Available from: www.ahrq.gov/research/ findings/nhqrdr/index.html
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delivery of culturally competent care. It is clear that health care disparities persist and that there are several imperatives and an economic motivation to meaningfully promote health equity. A multipronged approach to graduate medical education’s role in addressing health care disparities is needed. There should be an assessment of the present state of graduate medical education’s approach in developing and implementing curricula around health care disparities and cultural competency care. Residency and institutional leadership should collaborate to ensure that quality and patient satisfaction data are reported out by patient race, identified cultural group, and preferred language for communicating. Trainees must be engaged in the process of ensuring equitable care to all of their patients as well as institutional quality improvement initiatives designed to mitigate health care disparities and improve health care access. Best practices for delivering curricula on health care disparities and culturally competent care as well as objective resident/fellow assessment tools should be shared among the graduate medicine educational community. Research on the impact that training in culturally competent care and health care disparities has on patient outcomes must be performed. Medical students, trainees, and faculty are interested in receiving information about the culture of residency programs as it relates to institutional leadership, faculty, house staff, and patient diversity, and a transparent institutional “diversity scorecard” would achieve this purpose as well as send a strong message that achieving minimum benchmarks in this area is desirable. Graduate medical education can further the goal of achieving a diverse physician workforce by demonstrating a palpable and concerted commitment to diversity. n Author disclosures are available with the text of this article at www.atsjournals.org.
3 U.S. Census Bureau Website. U.S. Population Projections: 2012. 2012 Dec 12 [accessed 2014 Mar 17]. U.S. Census Bureau Projections Show a Slower Growing, Older, More Diverse Nation a Half Century From Now. Available from: http://www.census.gov/newsroom/ releases/archives/population/cb12.243.html 4 American College of Physicians. Racial and ethnic disparities in health care, Updated 2010. Philadelphia: American College of Physicians; 2010. Policy Paper (Available from American College of Physicians, 190 N. Independence Mall West, Philadelphia, PA 19106).
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PERSPECTIVES 5 LaVeist TA, Gaskin DJ, Richard P. The economic burden of health inequalities in the United States, September 2009. Joint Center for Political & Economic Studies. 2009 Sept [accessed 2014 Jan 31]. Available from: http://www.jointcenter.org/hpi/sites/all/files/ Burden_Of_Health_FINAL_0.pdf 6 The Joint Commission. Advancing effective communication, cultural competence and patient- and family-centered care: a roadmap for hospitals. Oakbrook Terrace, IL: The Joint Commission, 2010. 7 Robert Wood Johnson Foundation. How does the Affordable Care Act address racial and ethnic disparities in health care. 2011 Dec [accessed 2014 Mar 14]. Health Policy Snapshot Series. Available from: http://www.rwjf.org/en/research-publications/find-rwjfresearch/2011/12/how-does-the-affordable-care-act-addressracial-and-ethnic-dispa.html 8 Nasca TJ, Philibert I, Brigham T, Flynn TC. The next GME accreditation system—rationale and benefits. N Engl J Med 2012,366:1051–1056. 9 Accreditation Council for Graduate Medical Education. Clinical Environment Review (CLER) Program. [accessed 2014 April 17] Available from: http://www.acgme.org/acgmeweb/tabid/436/ ProgramandInstitutionalAccreditation/NextAccreditationSystem/ ClinicalLearningEnvironmentReviewProgram.aspx 10 Accreditation Council for Graduate Medical Education. Clinical learning environment review (CLER). CLER pathways to excellence. Expectations for an optimal clinical learning environment to achieve safe and high quality care. 2014 [accessed 2014 Feb 15]. Available from: http://www.acgme.org/acgmeweb/portals/0/PDFs/CLER/ CLER_Brochure.pdf 11 A Joint Initiative of the Accreditation Council for Graduate Medical Education and the American Board of Internal Medicine in Collaboration with Alliance for Academic Internal Medicine. The Internal Medicine Subspecialty Milestones Project. February 2014 [accessed 2014 April 18] Available from: http://www.acgme.org/acgmeweb/Portals/0/PDFs/ Milestones/InternalMedicineSubspecialtyMilestones.pdf 12 Smith WR, Betancourt JR, Wynia MK, Bussey-Jones J, Stone VE, Phillips CO, Fernandez A, Jacobs E, Bowles J. Recommendations for teaching about racial and ethnic disparities in health and health care. Ann Intern Med 2007;147:654–665. 13 Weissman JS, Betancourt JR, Campbell EG, Park ER, Kim M, Clarridge B, Blumenthal D, Lee KC, Maina AW. Resident physicians’ preparedness to provide cross-cultural care. JAMA 2005;294: 1058–1067. 14 Staton LJ, Estrada C, Panda M, Ortiz D, Roddy D. A multimethod approach for cross-cultural training in an internal medicine residency program. Med Educ Online 2013;18:20352. 15 Crenshaw K, Shewchuk RM, Qu H, Staton LJ, Bigby JA, Houston TK, Allison J, Estrada CA. What should we include in a cultural competence curriculum? An emerging formative evaluation process to foster curriculum development. Acad Med 2011;86:333–341. 16 Association of American Medical Colleges. Cultural competence education. 2005 [accessed 2014 Jan 31]. Available from: https:// www.aamc.org/download/54338/data/culturalcomped.pdf 17 Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in internal medicine. ACGME approved categorization: 2012. Sept 30 [accessed 2014 Jan 30]. Available from: http://acgme.org/ acgmeweb/Portals/0/PFAssets/2013-PR-FAQ-PIF/ 140_internal_medicine_07012013.pdf 18 Holmboe ES, Bowen JL, Green M, Gregg J, DiFrancesco L, Reynolds E, Alguire P, Battinelli D, Lucey C, Duffy D. Reforming internal medicine residency training. A report from the Society of General Internal Medicine’s task force for residency reform. J Gen Intern Med 2005;20:1165–1172.
Perspectives
19 Ross PT, Wiley Cene´ C, Bussey-Jones J, Brown AF, Blackman D, Fernandez ´ A, Fernandez ´ L, Glick SB, Horowitz CR, Jacobs EA, et al. A strategy for improving health disparities education in medicine. J Gen Intern Med 2010;25:S160–S163. 20 Society of General Internal Medicine. A train the trainer guide: health disparities education. Society of General Internal Medicine’s Disparities Task Force, 2008. [accessed 2014 Mar 17] Available from: http://www.sgim.org/File%20Library/SGIM/Communities/ Task%20Forces/Disparities/SGIM-DTFES-Health-DisparitiesTraining-Guide.pdf) 21 American Medical Association Foundation. Health literacy and patient safety. Help patients understand. Reducing the risk by designing a safer shame-free health care environment. 2007 [accessed 2014 Feb 15]. Available from: http://www.ama-assn.org/resources/doc/ ama-foundation/hl_monograph.pdf 22 U.S. Department of Health and Human Services. A physician’s practical guide to culturally competent care. [accessed 2014 Apr 17] Available from: https://cccm.thinkculturalhealth.hhs.gov/ 23 Expert Panel on Cultural Competence Education for Students in Medicine and Public Health. Cultural competence education for students in medicine and public health. Report of an expert panel. Washington, D.C.: Association of American Medical Colleges and Association of Schools of Public Health. 2012. 24 Massachusetts General Hospital. Disparities Solutions Center website [accessed 2014 Mar 16] Available from http://www2.massgeneral. org/disparitiessolutions/resources.html 25 Ring JM, Nyquist JG, Mitchell S, Flores H, Samaniego L. Curriculum for culturally responsive health care. The step-by-step guide for cultural competence training. New York: Radcliffe Publishing; 2008. 26 Hark LA, DeLisser HM, Morrison G. Achieving cultural competency. A case-based approach to training health professionals. UK: Wiley-Blackwell; 2009. 27 Association of American Medical Colleges. Diversity in the physician workforce: facts and Figures. 2010. [accessed 2014 Mar 16]. Available from: https://members.aamc.org/eweb/upload/Diversity% 20in%20the%20Physician%20Workforce%20Facts%20and% 20Figures%202010.pdf 28 Center for American Progress. Equal health care for all: opportunities to address health care disparities in health care reform. 2009 Dec [accessed 2014 Mar] Available from http://www.americanprogress.org/ wp-content/uploads/issues/2009/12/pdf/racialhealthdisparities.pdf 29 Komaromy M, Grumbach K, Drake M, Vranizan K, Lurie N, Keane D, Bindman AB. The role of black and Hispanic physicians in providing health care for underserved populations. N Engl J Med 1996;334: 1305–1310. 30 Marrast LM, Zallman L, Woolhandler S, Bor DH, McCormick D. Minority physicians’ role in the care of underserved patients: diversifying the physician workforce may be key in addressing health disparities. JAMA Intern Med 2014;174:289–291. 31 Aagaard EM, Julian K, Dedier J, Soloman I, Tillisch J, Perez-Stable ´ EJ. Factors affecting medical students’ selection of an internal medicine residency program. J Natl Med Assoc 2005;97:1264–1270. 32 National Resident Matching Program. Results of the 2013 NRMP Applicant Survey by Preferred Specialty and Applicant Type. National Resident Matching Program, Washington, DC. September 2013. 33 Wesson DE, King TE Jr, Todd RF, Torres EA, Hellmann DB, Flack JM, Dubose TD Jr, Schuster VL. Achieving diversity in academic internal medicine: recommendations for leaders. Am J Med 2006;119: 76–81. 34 Peek ME, Kim KE, Johnson JK, Vela MB. “URM candidates are encouraged to apply”: a national study to identify effective strategies to enhance racial and ethnic faculty diversity in academic departments of medicine. Acad Med 2013;88:405–412.
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Department of Medicine, Stamford Hospital, Stamford, Connecticut; 2Columbia University’s College of Physicians and Surgeons, New York, New York; 3Department of Medicine, Lenox Hill Hospital, New York, New York; 4North Shore/LIJ Health System, Hofstra North Shore – LIJ School of Medicine, Manhasset, New York; 5Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina; and 6Academic Affairs, Alliance for Academic Internal Medicine, Alexandria, Virginia
Abstract Despite the 2002 Institute of Medicine report that described the moral and financial impact of health care disparities and the need to address them, it is evident that health care disparities persist. Recommendations for addressing disparities include collecting and reporting data on patient race and ethnicity, supporting language interpretation services, increasing awareness of health care disparities through education, requiring cultural competency training for all health care professionals, and increasing diversity among those delivering health care. The Accreditation Council on Graduate Medical Education places strong emphasis on graduate medical education’s role in eliminating health care disparities by asking medical educators to objectively evaluate and report on their trainees’ ability to practice patient-centered, culturally competent care. Moreover, one of the objectives of the Accreditation Council on Graduate Medical Education Clinical Learning Environment Review visits as part of the Next Accreditation System is to identify how sponsoring institutions engage residents and fellows in the use of data to improve systems of care, reduce health care disparities, and
improve patient outcomes. Residency and fellowship programs should ensure the delivery of meaningful curricula on cultural competency and health care disparities, for which there are numerous resources, and ensure resident assessment of culturally competent care. Moreover, training programs and institutional leadership need to collaborate on ensuring data collection on patient satisfaction, outcomes, and quality measures that are broken down by patient race, cultural identification, and language. A diverse physician workforce is another strategy for mitigating health care disparities, and using strategies to enhance faculty diversity should also be a priority of graduate medical education. Transparent data about institutional diversity efforts should be provided to interested medical students, residents, and faculty. Graduate medical education has a clear charge to ensure a generation of physicians who are firmly grounded in the principles of practicing culturally competent care and committed to the reduction of health care disparities. Keywords: graduate medical education; health care disparities; cultural competency; health equity
(Received in original form February 16, 2014; accepted in final form March 19, 2014 ) Correspondence and requests for reprints should be addressed to Maria E. Maldonado, M.D., Department of Medicine, Stamford Hospital, 30 Shelburne Road, Stamford, CT 06902. E-mail: [email protected] Ann Am Thorac Soc Vol 11, No 4, pp 603–607, May 2014 Copyright © 2014 by the American Thoracic Society DOI: 10.1513/AnnalsATS.201402-068PS Internet address: www.atsjournals.org
Despite the seminal report, “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care” released in 2002 by the Institute of Medicine, which concluded “though a myriad of sources contribute to (health care) disparities, some evidence suggests that bias, prejudice, and stereotypes on the part of healthcare providers may contribute to differences in care,” (1), it is evident that health care disparities persist.
Perspectives
According to the most recent Agency for Healthcare Research and Quality National Healthcare Disparities Report, although the quality of care is improving for all populations, access to health care is deteriorating, and disparities are not changing (2). By 2060, it is estimated that 57% of the U.S. population will be composed of members of underrepresented groups, including those who are most subject to the
consequences of disparities in health care (3). The Institute of Medicine recommended that strategies be used to increase awareness about health care disparities to health care professionals and the public, diversify the workforce of health care professionals, and ensure language interpretation. The American College of Physicians underscores the principle that all patients deserve highquality health care, regardless of race,
603
PERSPECTIVES culture, primary language, socioeconomic status, sexual orientation, and age in their position paper on racial and ethnic disparities in health care (4). Their recommendations for addressing disparities include a focus on patientcentered communication, clinician sensitivity to cultural diversity, and efforts to create a diverse health care workforce. Besides the moral imperative to address health equity, there is an economic imperative to use all strategies to eliminate health care disparities. As underrepresented groups increase in proportion of the U.S. population, their health status will define the nation’s health. As payment becomes more dependent on outcomes, it will not be financially viable to ignore poor outcomes in patients. In 2003 and 2006, 30.6% of direct medical expenses for African Americans, Asians, and Hispanics excess costs were due to health care disparities, and it is estimated that eliminating health care disparities would decrease medical expenditures by at least 29.4 billion dollars (5). Hospital accreditation will likely become increasingly dependent on their approach to addressing health care disparities; The Joint Commission released disparities and cultural competence accreditation standards and released a bulletin on resources related to effective communication (6). Finally, it is clear that provisions of the Affordable Care Act are designed to address racial and ethnic disparities in health care. Examples include requiring data collection by patient race, ethnicity, and language preferences by federally funded health care; expanding research on health and health care disparities; encouraging racial and ethnic diversity in the health care workforce; supporting cultural competency programs for clinicians; and improving access to health care by expanding coverage (7). The ACGME has delivered an explicit educational imperative for residency and fellowship programs to address health care disparities. Improving communication between the physician and patient and ensuring that the next generation of physicians is equipped with the best tools to maximize patient-centered communication with a culturally, racially, and socioeconomically diverse patient population is increasingly becoming a critical objective of residency and fellowship training. Here we describe the role that graduate medical education must 604
play to promote health equity by describing accreditation requirements for addressing health care disparities, curricular approaches to equip trainees with the tools needed to serve an increasingly diverse patient population, and strategies that graduate medical education can use to create and support a diverse health care workforce.
The ACGME’s Role in Eliminating Health Care Disparities The ACGME’s Next Accreditation System designed to prepare physicians for practice in the 21st century was implemented in July 2013 for internal medicine and will be implemented in July 2014 for all of the other specialties (8). One of the attributes of the Next Accreditation System is the Clinical Learning Environment Review (CLER). An important goal of CLER is to identify how sponsoring institutions engage residents in the use of data to improve systems of care, reduce health care disparities, and improve patient outcomes (9). The ACGME recently released the “CLER Pathways to Excellence,” and two of the Health Care Quality Pathways are explicit in what education on disparities should entail. It is expected that trainees and faculty receive education on identifying and reducing health care disparities and training in cultural competency relevant to the institution’s patient population. Furthermore, trainees should be engaged in quality improvement activities addressing health care disparities for vulnerable populations served by the clinical site (10). These requirements underscore that the ACGME views itself as a partner with other governing agencies such as the Department of Health and Human Services to prioritize elimination of health care disparities. Moreover, the ACGME has established cultural competency milestones expected of residents and fellows by the conclusion of their training. For example, a trainee who is ready for unsupervised practice should be able to “quickly establish a therapeutic relationship with patients and caregivers, including persons of different socioeconomic and cultural backgrounds” and “effectively obtains and documents informed consent in challenging circumstances (e.g.; language or cultural barriers)” (11).
Surveys of internal medicine program directors indicate that they agree that knowledge about health care disparities is important and that resident interest is not a barrier to teaching about disparities. However, barriers to teaching effectively in this area include shortages of qualified faculty and lack of standardized curricula (12). In 2005, a national survey of resident physicians revealed that although 96% of respondents believed that it was important to consider patients’ culture when delivering care, 66% of them reported little or no evaluation on the cross-cultural aspects of the doctor–physician communication (13). Presently, it is uncertain to what degree residency programs are incorporating curricula on health care disparities and cultural competency training. Time and resources to develop faculty to ensure adequate medical educators competent to train and support culturally competent residents may not be sufficient. There is a lack of standardized tools to objectively evaluate residents on their ability to practice culturally competent care as well as measure meaningful patient outcomes. Although there are some data on how implementation of cultural competency curriculum can improve learners’ confidence in their preparedness to deliver culturally competent care (14, 15), data are needed to measure whether education and objective assessment of residents translate into improved patient outcomes. A clear idea of the present state in graduate medical education as it relates to curricula and trainee assessment in cultural competence and health care disparities is essential if we are to ensure the appropriate intersection between education and the needs of the health care system. Determining the stages of program engagement with their institutions around the area of quality improvement initiatives as it relates to site-specific health care disparities will allow for information sharing and strategy development for programs to engage their institutions. The Alliance of Academic Internal Medicine (AAIM) represents a consortium of five academic organizations, the Association of Professors of Medicine (APM), the Association of Program Directors in Internal Medicine, the Clerkship Directors in Internal Medicine, the Association of Specialty Professors, and the Administrators in Internal Medicine.
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PERSPECTIVES The Diversity and Inclusion Committee, which is overseen by AAIM, is readying a survey to be disseminated to Internal Medicine program directors and their trainees to appraise how programs deliver curricula on health care disparities and cultural competency, evaluate their trainees on their ability to practice culturally competent care, and measure the percentage of programs engaged in meaningful quality improvement initiatives given these regulatory mandates, to determine whether national support, curricula, and tools are needed to assure best practices in care for vulnerable populations.
Curricular Approaches to Reducing Health Care Disparities Although it is important to realize that education alone cannot eliminate health care disparities, CLER demands that teaching institutions develop educational content that is intended to illuminate disparities and convey strategies that could potentially mitigate them. Both the Liaison Committee on Medical Education and the ACGME have standards for undergraduate and graduate medical education in cultural competence (16, 17). The ACGME’s common program requirements, which impact all U.S. residency and fellowship training programs, state that “residents/fellows are expected to communicate effectively with patients, families, and the public, as appropriate across a broad range of socioeconomic and cultural backgrounds,” as well as demonstrate a “sensitivity and responsiveness to a diverse patient population” (17). In a report from the Society of General Internal Medicine’s Task Force for Residency Reform, it was recommended that “to honor the social contract and embrace our professional obligations, programs should explicitly address health disparities and incorporate teaching in the social sciences” (18). The Society of General Internal Medicine Health Disparities Task Force provides recommendations on learning objectives and methods for teaching, with a focus on identifying and examining bias, acknowledging the existence of health care disparities and solutions for mitigating them, and acquiring the appropriate communication and negotiation skills Perspectives
across a culturally and linguistically diverse patient population (12). Several task forces and academic groups have disseminated excellent curricular sources for education around health care disparities and cultural competency. The following are some examples. The Society of General Internal Medicine’s Health Disparities Task Force describes a strategy for improving health disparities education in medicine through a curriculum featuring five modules, “Disparities Foundations,” “Teaching Disparities in the Clinical Setting,” “Disparities beyond the Clinical Setting,” “Teaching about Disparities through Community Involvement,” and “Curriculum Evaluation,” meant to “train the trainer” (19). The content areas of the modules focus on some of the important areas impacting health care disparities, including social determinants of health, role of health care, including access, and addressing bias. This comprehensive curriculum is meant to increase the competency of faculty in health disparities education and can be accessed online (20). The American Medical Association Foundation created a curriculum that includes a brief review of the Executive Summary of the 2003 Institute of Medicine report “Unequal Treatment,” which focuses on enumerating some of the disparities and presents a set of recommended interventions to reduce them. The report provides a review of techniques, including “creating a shame-free environment,” avoidance of jargon, use of visual aids, and using “teachback” to check for understanding of medical information, which were originally designed to enhance communications between doctors and patients with low health literacy (21). Examples are provided that illustrate common themes that are influenced by culture, including religious beliefs and practices, distrust of nonminority clinicians, socioeconomic factors, and challenges to adherence and good self-care practices. The Academic Alliance for Internal Medicine provides links to e-learning resources for its community on cultural competency including the U.S. Department of Health and Human Services, “A Physicians Practical Guide to Culturally Competent Care” (22). This is a series of online modules designed to heighten awareness, knowledge, and skills to treat an
increasingly diverse patient population as well as ensure awareness of the National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care. Those who access these modules can receive up to nine AMA/PRA Category 1 CME credits. An expert panel composed of the Association of American Medical Colleges and the Association of Schools of Public Health specified a series of cultural competencies common to medical and public health students that delineate expected outcomes by the end of the program of study for medical and public health students and mapped these outcomes to ACGME competency-based outcomes (23). Moreover, the panel described two activities relating to cultural competency and health disparities that resident physicians should be able to perform in unsupervised fashion by the end of their training. Several resources are provided in this report designed to inculcate trainees with the knowledge, skills, and ability needed to be competent in culturally competent care. Other curricular resources for teaching on health disparities through web seminars and case studies can be accessed through the Disparities Solutions Center for teaching on health disparities (24). Finally, there are books available on curricular resources in health disparities and cross-cultural care that are case-based, designed to assist clinicians to achieve proficiency in these areas (25, 26).
Increasing Diversity in Health Professions: The Role of Graduate Medical Education An important strategy for eliminating health care disparities is increasing the diversity of the physician workforce. African Americans, Hispanics, and Native Americans compose only 12.3% of the nation’s physician workforce despite representing 37% of the U.S. population at the present time (3, 27). Health care professionals from underrepresented groups are more likely to work in medically underserved areas, and race concordance in patient–physician relationships results in higher patient satisfaction and trust in the health system (28, 29). A recent study found that nonwhite physicians provide a disproportionate share of care to underserved populations, providing more 605
PERSPECTIVES evidence that increasing the racial and ethnic diversity of the physician workforce is a critical key for addressing disparities by increasing access to patients (30). Residency candidates from underrepresented groups place strong emphasis on the ethnic diversity of the city, patients, house staff, and faculty and are interested in an academic environment that supports ethnic minorities (31). The 2013 National Resident Matching Program Applicant Survey revealed that almost onefourth of U.S. medical student seniors and 43% of independent candidates cited that cultural/racial-ethnic/gender diversity at a residency program’s institution was a highly important factor in deciding where to train (32). However, very little transparent accurate program-specific data exist for candidates on factors that may be of great importance to underrepresented group candidates. Developing a “diversity scorecard” for each residency program/ institution could be enormously useful for medical students. In 2006, the Diversity Committee of the APM published a perspectives piece in the American Journal of Medicine in which they outlined more than 30 “best practices” for departments of internal medicine to achieve diversity. These practices ran the full spectrum of academic stages from medical student recruitment to the transition from medical school to residency and fellowship to the recruiting, retention, and promotion of academic faculty (33). This catalog of proactive programs made it clear that academic departments could be more than just welcoming of diversity. Going well beyond schools, training programs, and departments advertising that “underrepresented minority candidates are welcome to apply,” the APM paper could be used as a roadmap for academic leaders who truly wish to commit to diversity as a core value. In 2013, Peek and colleagues published a study that used quantitative and qualitative methods to interview medicine departments to test the effectiveness of the
APM recommendations and to better understand the factors that might predict and enhance racial and ethnic diversity in academic settings (34). Qualitative evidence revealed that direct outreach to diverse populations through pipeline programs and career days, the establishment of academic support programs for high school and undergraduate students from underrepresented groups, sponsorship programs like loan repayment and scholarships, and both formal and informal mentoring helped many committed academic leaders to diversify their departments and programs. In 2013, AAIM elevated the APM Diversity Committee to the level of an alliance-level committee and renamed it the AAIM Diversity and Inclusion Committee to reflect an added commitment to supporting women in academic medicine as well as physicians from underrepresented groups. This committee has proposed the establishment of a scorecard that could capture medical schools, departments of medicine, and residency training programs’ proportion of diverse individuals, the growth of these groups over the last 2 years, and the number of outreach and support practices used to promote diversity. If publicized, these scores could be used by interested students, residents, and faculty to measure the impact of implementing best practices in increasing diversity to these organizations as well as send a strong message that achieving a standardized benchmark is desirable. The collection of these scorecard data is currently awaiting institutional review board approval and dissemination to schools, academic departments, and training programs.
Conclusions This is a pivotal time in health care. Provisions of the Affordable Care Act have underscored the importance of a diverse health care workforce and the need to ensure
References 1 Smedley BD, Stith AY, Nelson AR, editors. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, DC: National Academies Press; 2002. 2 U.S. Department of Health and Human Services. National healthcare quality & disparities report 2012. 2012 [accessed 2014 Jan]. AHRQ Publication No. 13-0003. Available from: www.ahrq.gov/research/ findings/nhqrdr/index.html
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delivery of culturally competent care. It is clear that health care disparities persist and that there are several imperatives and an economic motivation to meaningfully promote health equity. A multipronged approach to graduate medical education’s role in addressing health care disparities is needed. There should be an assessment of the present state of graduate medical education’s approach in developing and implementing curricula around health care disparities and cultural competency care. Residency and institutional leadership should collaborate to ensure that quality and patient satisfaction data are reported out by patient race, identified cultural group, and preferred language for communicating. Trainees must be engaged in the process of ensuring equitable care to all of their patients as well as institutional quality improvement initiatives designed to mitigate health care disparities and improve health care access. Best practices for delivering curricula on health care disparities and culturally competent care as well as objective resident/fellow assessment tools should be shared among the graduate medicine educational community. Research on the impact that training in culturally competent care and health care disparities has on patient outcomes must be performed. Medical students, trainees, and faculty are interested in receiving information about the culture of residency programs as it relates to institutional leadership, faculty, house staff, and patient diversity, and a transparent institutional “diversity scorecard” would achieve this purpose as well as send a strong message that achieving minimum benchmarks in this area is desirable. Graduate medical education can further the goal of achieving a diverse physician workforce by demonstrating a palpable and concerted commitment to diversity. n Author disclosures are available with the text of this article at www.atsjournals.org.
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