What is virtual care?
As healthcare organizations look for ways to increase value, reduce costs, and improve access to services, the industry has begun to embrace digital technologies, including video, audio, mobile apps, and text messaging.
As healthcare organizations look for ways to increase value, reduce costs, and improve access to services, the industry has begun to embrace digital technologies, including video, audio, mobile apps, and text messaging.
As the country absorbs the loss of hundreds of thousands of lives, we face a bereavement crisis borne disproportionately by minority communities. New data show that in 2020, deaths among non-Hispanic white people have been 11.9% higher than average. In contrast, the increases have been much more severe in the Latinx community (53.6% higher), the Asian community (36.6% higher), the Black community (32.9% higher), and in American Indians and Alaskan Natives (28.9% higher). These death rates correlate with racial and ethnic disparities in the incidence of Covid-19 and reflect the disproportionate burden experienced by communities of color.
During June of 2020, Quality Interactions held a weekly live webcast series of conversations on how to provide culturally-competent healthcare amid the Covid-19 pandemic and social unrest due to racial injustice. Led by Dr. Joseph Betancourt, and moderated by Michele Courton Brown, these candid discussions drew on Dr. Betancourt's experience leading the pandemic response at Massachusetts General Hospital and his longtime leadership in the fight against racial and ethnic healthcare disparities.
Our country is in a pivotal moment. Against the backdrop of a pandemic that has disproportionately impacted communities of color at staggering rates, tens of thousands of Americans in all fifty states are protesting to demand an end to racial injustice and police brutality. We can no longer turn away from the reality of racism and racial inequality in America.
Racial health disparities have been magnified dramatically by the COVID-19 crisis. In the Boston area, where Quality Interactions is based, we see that the hardest-hit communities are ones of color, where social distancing is a luxury not available to most residents. The epidemic is disproportionately affecting our most vulnerable populations, while also widening the gaps in preexisting health disparities. One of the most shocking amplifications of this is in maternal healthcare.
Top media outlets, including NPR and CNN, have turned to Quality Interactions Co-Founder, Dr. Joseph Betancourt, to better report on the critical issue of health disparities and the COVID-19 pandemic.
Even in the absence of adequate race and ethnicity data, a clear picture of disparities in COVID-19's impact has nonetheless emerged: Black and Latino communities are the hardest hit. This is not due to features of the virus itself, but is an indicator of social conditions—including population density and socioeconomic status—which put black and Latino individuals at higher risk for contracting and perishing from the respiratory illness.
Dr. Betancourt is on the front lines of the epidemic at Massachusetts General Hospital, where he serves as Vice President and Chief Equity and Inclusion Officer, as well as a primary care physician. As a leading expert in health equity, Dr. Betancourt has been named to the City of Boston COVID-19 Health Inequities Task Force, alongside Quality Interactions CEO, Michele Courton Brown.
This summary of Dr. Betancourt's recent interviews provides a primer on how COVID-19 has created a perfect storm for communities of color and offers direction for how municipalities and institutions should apply immediate efforts to stem the tide.
The COVID-19 pandemic is disproportionately affecting the most vulnerable among us. This includes the elderly and those with underlying health conditions. It also includes communities of color, immigrant communities, low-income workers, and the prison population.
As more data emerges that show how social inequities are fueling the pandemic in the United States, it is clear that cultural competency and bias awareness in healthcare is more important than ever.
The healthcare system in many states is overwhelmed by cases of COVID-19 and struggling to secure the resources it needs to safely and effectively treat patients. It may seem like too much to ask for physicians and caregivers to be mindful of cross-cultural communication issues and unconscious bias in such hectic conditions.
But this is precisely the time when skills in cultural competency are most needed. The Three Tenets of Cross-Cultural Communication presented below are a helpful touchstone for all of us to keep in mind as we move forward in our professional interactions—whether they be in the most critical care settings or in other roles no doubt touched by our current reality. They may seem like simple recommendations, but there are concrete ways clinicians can actively exhibit them for maximum effect. They are empathy, curiosity, and respect.
As healthcare moves toward a value-based system that rewards positive outcomes over procedures, social determinants of health (SDOH) are a central part of the effort to improve overall health and reduce health disparities.
ACAP is a national trade association representing not-for-profit Safety Net Health Plans. ACAP’s goal is to support and strengthen Safety Net Health Plans as they work with communities and providers to improve the health of vulnerable populations. ACAP members represent over 50 percent of individuals enrolled in Medicaid-based programs. The Preferred Vendor Program connects ACAP members with vendors who are optimized to meet their unique needs.
Culture impacts every mental health patient—and every mental health practitioner. Culture is a key factor that we all bring to every interaction, and it can be especially influential in times of emotional distress. Culture, including beliefs, values, norms, and behaviors, affects how we experience and interpret the world, including the meaning we impart to mental illness. In a clinical setting, cultural meanings of mental illness can account for whether and how a patient:
Massachusetts General Hospital (MGH) is one of the nation's top medical institutions and a leader in the practice and research of medicine. It was established a community hospital charged with serving the medical needs of Boston's diverse population. Over 200 years later, people travel from all over the world to seek medical care at MGH, and serving diversity is still central to its mission.
Religion and spirituality are key cross-cultural issues that can impact the way patients react to disease and illness. They also affect the way patients approach medical management. Learn how healthcare providers can expand social history questioning to include religious and spiritual considerations. View and share the infographic.
Culture is a complex concept. It includes people’s beliefs, values, behaviors, and ways of understanding their world. In medicine, managing cultural differences—including customs—is essential to providing high-quality health care. One challenge is that patients may not realize they have customs that could jeopardize their wellness. Culture is largely invisible to people who share it. But to outsiders, the customs and ways of life of different cultures are often obvious—and sometimes strange. Here's an example from my own experience:
Great news here at Quality Interactions. Our industry-leading cultural competency training for healthcare organizations just got even better. We've updated and enhanced our popular course catalog, starting with the ResCUE ModelTM for effective cross-cultural interactions. With powerful new features that increase engagement and deepen learning, now is a great time to utilize our proven eLearning courses for your clinical and non-clinical staff.
How can clinicians help ease the stress of chronic disease? Recent healthcare news stories published in The New York Times draw attention to the incredible burden of serious illness and chronic disease on critically sick patients. Not only are they physically uncomfortable and often fighting for their lives—they are also baffled by a confusing healthcare system and swamped by medical bills. Now imagine adding a language barrier to the mix! The challenges of serious illness are compounded when there are cross-cultural issues at play. Quality Interactions' EFST Model is designed to help clinicians uncover and address these issues and provide culturally-sensitive care to all patients with chronic disease.
In the 1990s, before I started my second year of medical school at University of California, San Diego (just 30 minutes north of the Mexican border) I made a decision that would change my life. The second-year curriculum allowed for a number of elective courses. We were supposed to select from a catalogue of options—radiology, advanced anatomy, medical ethics, and many others. Most students chose two per semester. I chose one that spanned the entire year: Medical Spanish.
We have known for decades that income, education, race, gender, and other social factors have a bigger impact than medical care on people’s health and life expectancy. Social determinants of health (SDOH) are well documented by respected organizations such as the Centers for Disease Control (CDC) and World Health Organization (WHO).
The U.S. spends more on healthcare than any other country. Yet we struggle with healthcare access and quality, and our overall population is less healthy than other developed nations. One possible solution to this problem is value-based care. This article provides an overview of value-based care models and shows how cultural competency training is essential for doctors and healthcare organizations to provide high-value care for patients.
This content was originally presented as part of our live learning event, "Expanding the Role of Interpreters in a Value-Based System," by Dr. Alexander Green. View the recorded event here.
As a primary care physician, I take care of a large Spanish-speaking population, among other culturally and socioeconomically diverse patients. I’m fluent in medical Spanish and communicate directly with my Spanish-speaking patients. But regardless of whether I’m speaking Spanish or working with a medical interpreter, visits with limited English proficiency (LEP) patients always leave me with a worried feeling in the pit of my stomach. I’m keenly aware that most healthcare takes place outside of the doctor’s office, and this is where LEP patients fall through the cracks. I wonder, “Did Mrs. Ramirez really understand how to prep for her colonoscopy next week?” or “Was Mr. Luan actually convinced that he needs to take the medication I prescribed for his diabetes?”
After more than a year of in-depth reporting in Baltimore, The Atlantic has published a long read that explores why, as a group, black Americans are significantly less healthy than white Americans. The piece follows a woman named Kairra, who is 27, black, very overweight, and suffers from a host of health problems that are usually associated with people three times her age. In Baltimore, as well as other segregated cities like Chicago and Philadelphia, the low-income, mostly black neighborhoods have a life expectancy that is 20 years lower than more affluent, whiter neighborhoods. The gap can be attributed to several factors, including violence, diet, environmental hazards, substance abuse, and stress.
If you’re a healthcare provider who works with some of the 25 million limited English proficient (LEP) patients in the U.S., you know how important interpretation is to successful patient outcomes. Poor communication increases the chance of medical errors with any patient, and LEP individuals are especially vulnerable in this regard.
An in-depth piece from Politico Magazine explores how a small, rural hospital in Kansas has become an economic powerhouse by serving the local refugee/immigrant population and specializing in labor and delivery. Ben Anderson, the hospital's CEO, relies on community partnerships, infrastructure grants, and targeted recruiting. His recruiting model is especially interesting: He attracts young physicians who are interested in helping Third World populations. "You can do that work right here in Kansas," he says. Having a staff that actively seeks to work with diverse populations improves patient experience and outcomes.
The Congressional Tri-Caucus, made up of the Congressional Asian Pacific American Caucus, Congressional Black Caucus, and Congressional Hispanic Caucus, has introduced the Health Equity and Accountability Act of 2018 (HEAA), a bill that attempts to address health disparities based on race and ethnicity. The authors note several reasons for these disparities, including language and cultural barriers to care.
To date, 1,656 organizations, 51 state hospital associations, and 11 municipal hospital associations have signed onto the American Hospital Association's (AHA) #123forEquity Pledge to eliminate healthcare disparities. That means every state, and nearly 30% of our nation's hospitals, are represented in the movement to improve health equity. But the road between pledging good intention and effecting actionable change can be poorly marked, and dotted with unseen obstacles. In this post we'll review the key tenets of the AHA's Equity of Care Campaign, rationale for participation, and key actions hospitals and health systems can start to focus on today.
Unconscious (or implicit) bias training is in the spotlight. From the #MeToo movement to the chorus of outrage over the unwarranted arrests of two black men at a Starbucks, companies are facing increasing public pressure to address the roots of discriminatory treatment. But questions remain over whether bias training is an effective course of action, versus a perfunctory act taken to avoid bad press.
The maternal mortality rates in the U.S. are grim, but the number of women who suffer postpartum complications that nearly cause death are even worse. For every woman who dies after childbirth, at least 70 come close. Some estimates put the number of women who suffer "severe maternal morbidity" at around 80,000 per year. A report by NPR/ProPublica finds that many of these complications are preventable, and there's a common theme that postpartum mothers don't feel their concerns are taken seriously by healthcare providers.
We've reported extensively on the dismal maternal mortality rates in the U.S., and the crisis in black maternal mortality in particular. A new piece by NBC News follows the stories of two black mothers who experienced serious complications with their deliveries. Both women felt their medical teams were dismissive and brusque, and that their health problems may have been avoided with better communication. They are among the 32% of black women who feel they’ve been discriminated against in physicians’ offices. Unconscious (or implicit) bias on the part of healthcare providers has very real consequences for patient outcomes. Bias training may not be the complete solution, but it is part of the solution, and should become a standard practice in all medical schools and healthcare organizations.
Growing evidence shows that more empathetic care can keep people healthier and reduce hospital visits. A new piece by NPR's Marketplace profiles Philadelphia's Penn Center for Community Health Workers, which pairs community health workers with patients who frequent hospitals due to chronic illness, poverty, or mental health problems. The community health workers visit patients at their homes and help them navigate their health issues. The Penn Center makes an effort to match its staff with patients who share a similar background, in order to inspire trust. A randomized, controlled study showed the Center reduced hospitalizations by 30%.
I've given hundreds of presentations on culturally-competent care to busy clinicians around the world. At the end of my talk, someone always asks the "time question." I know plenty of other clinicians are thinking it, but don’t want to appear insensitive. So I wait for a brave soul to say, “Dr. Green, you’re telling me that if I want to be culturally competent, I have to do all of these things on top of what I already have to cover? I have to ask my patients how they understand their condition? What their religious practices are? Whether they trust me? I’d love to—but I just don’t have time!”
If you've grown up in the U.S., you're probably familiar with the concept of a patient's "right to know." American culture holds that patients are entitled to be fully informed in their own medical care, including the decision-making process. In some cultures, however, autonomy in decision-making is not the norm. For many people, it is essential to involve (or even defer to) others, particularly family members, in important health decisions. In such families, it's common to look to an authority figure (determined by gender, position in the family, or level of acculturation) as the primary decision-maker within the group. In some cases, these families may wish to exclude the patient from decisions in order to avoid what is perceived as undue stress. This can cause friction between health providers, patients, and their relatives.
A video of two black men getting arrested at a Starbucks in Philadelphia has sparked widespread outrage directed at both Starbucks and the police. In response, Starbucks announced that it will close 8,000 stores in May so employees can engage in racial bias training. "While this is not limited to Starbucks, we're committed to being a part of the solution," said CEO Kevin Johnson. The problem certainly isn't limited to one company, or one industry, or one region of the country. There are any number of examples of white Americans calling the police on black Americans without real justification. Deeply ingrained and unconscious racial bias routinely leads to instant, often fear-based judgements about people that can have dire consequences. The question is, what can we do to break this cycle?
Unconscious bias leads to health disparities for patients, and has a negative effect on healthcare workers as well. Unconscious bias can cause both patients and staff to be treated differently based on gender, race, language spoken, lifestyle choices, and more. This results in higher staff attrition and and lower patient satisfaction—and in turn, it negatively effects healthcare organizations' bottom line.
This past week marked the 50th anniversary of Dr. Martin Luther King Jr.'s death. Dr. King famously said, "Of all the forms of inequality, injustice in health is the most shocking and inhumane." He said that in 1966. In 2018, the US still struggles with pervasive health inequality that weakens our overall healthcare system, and reduces our standing compared to other developed nations. The city of Atlanta, where Dr. King grew up and went to college, is a national healthcare hub, boasting world-class healthcare facilities. It is home to the Centers for Disease Control (CDC), the American Cancer Society, the Arthritis Foundation, and several schools of medicine and public health. But Atlanta also has some of the widest gaps in black and white health outcomes in the country. Among these disparities are:
Implicit bias, and especially the Implicit Association Test (IAT), has been the subject of recent debate in both scientific and popular press. Is the IAT accurate? Are its findings useful? Does the concept of implicit bias impede efforts to address explicit bias? A new piece in Scientific American argues that the controversy around implicit bias and the IAT is based on fundamental misunderstandings. For example, the IAT isn't designed to predict individual behavior, like how a particular physician will interact with a particular patient. Rather, the aggregate data can help predict (and correct) big-picture functions.
Trust in the healthcare system is at an all-time low—only 34% of Americans have “great confidence” in medical leaders, as compared to 73% in 1966. So if you are a health professional, you're wise to assume patient mistrust, rather than the other way around. Depending on your role and the setting, mistrust can present itself in very different ways. But I've learned that you can respond effectively to patient mistrust in any scenario using three simple communication techniques.
As reported in previous News Roundups, a lack of diversity in clinical trials results in disparities in care among under-served populations. Recruiting different racial and ethnic groups, especially African-Americans, remains a challenge. A focus-group study conducted by Louisiana State University Health Sciences Center sought to learn what it would take to address this problem. Results show that trust and communication are key to increasing minority participation in clinical trials.
The Tsimane people are an isolated tribe in Bolivia with a life-expectancy of only 50 years. Researchers from the Integrated Anthropological Sciences Unit at UC Santa Barbara published a paper analyzing why the Tsimane often refuse medical care, even when it's free and offered by people they trust. Their findings provide insights into why so many people around the world, regardless of background and education, resist going to the doctor even when they know they should.
Every moment, your brain processes incredible amounts of information. This processing allows you function: to make decisions and take actions. The majority of this goes on behind the scenes, a necessary efficiency that means you don’t have to “think” about most of your activity. For example, the minute calculations your brain makes to accomplish simple things, like walking across the room to open a door. Or more complicated things, like assessing a fellow human being.
In the United States, the recommended age for women to begin routine mammograms for cancer screening was recently increased to 50 years of age. This was based on a study of 747,763 mostly white women showing that breast cancer diagnoses peaked in their 60s. But researchers from Massachusetts General Hospital (MGH) have published a new study in JAMA Surgery that shows black, Hispanic, and Asian women tend to get breast cancer earlier than white women. A lack of data from racially diverse populations could put nonwhite women at risk for delayed diagnosis. According to David Chang, PhD, MBA, MPH, of the MGH department of surgery and an associate professor of surgery at Harvard Medical School, "The situation with breast cancer is one of the best examples of how science done without regard to racial differences can produce guidelines that would be ultimately harmful to minority patients."
Unconscious bias can lead to negative outcomes for disadvantage patient populations, even when that bias occurs behind-the-scenes in research settings. A new report from Data & Society identifies several ways that datasets can become biased, including historical bias, analytical bias, and access to different types of genetic data. “Bias through invisibility—such as lack of data on certain factors—can trigger discriminatory outcomes just as easily as explicitly problematic data,” note the authors.
The transgender population is underserved by the healthcare system, and one reason may be provider hesitancy. To meet the medical needs of transgender people, healthcare organizations, together with medical schools and residency programs, must incorporate training and content on how to care for transgender patients.
In our live learning event Unconscious Bias in Medical Decision-Making, Quality Interactions co-founder Dr. Joseph Betancourt used data from the Implicit Association Test (IAT) to illustrate that nearly everyone has unconscious biases that impact our judgment and behavior. By nature of being unintended, or “unconscious,” it is essential to have a way to uncover our biases as a first step toward changing them. This is where the IAT comes in.
A report from the Accreditation Council for Graduate Medical Education (ACGME) presents data from medical residency and fellowship programs, which shows that clinical learning environments (CLEs) vary widely in their application of strategies to address healthcare disparities. Among other findings, the data demonstrate a lack of comprehensive training in cultural competency.
Last week our live learning event, Unconscious Bias in Medical-Decision Making, was attended by 225 organizations from 40 states in the U.S., Canada, and Switzerland. In this blog post, Dr. Joseph Betancourt responds to seven questions we didn't have time to answer during the event.
Dr. Adil Haider, a trauma surgeon at Harvard Medical School, has been studying disparities in emergency care outcomes for over 10 years. “People have always had this iconic image of emergency departments as the great equalizers,” Haider says. “There’s a perception that no matter who you are, if you have a trauma injury, you’re going to get picked up and receive the same level of care.” However, Dr. Haider's research identified large gaps in patient survival rates based on race. Compared to white patients with similar injuries, he found that black and Hispanic patients have a 20% and 50% greater chance of death, respectively. Socioeconomic factors, insurance status, and access to immediate emergency care all contribute to this disparity. But unconscious bias is also a likely culprit.
The Center for American Progress released a new report on the high death rates among black mothers and infants in the U.S. As previously reported here, black mothers die at at rate three to four times higher than white mothers, and infants born to black women die at twice the rate of those born to white women. The disparity is driving the country's overall maternal mortality rate, which is the worst in the developed world. This growing crisis can't be explained by socioeconomic factors. The report presents research showing that risk factors including income, education, and physical and mental health cannot account for the disparity in outcomes. Instead, the report points to systematic racial bias, including within the healthcare system.
The country was shocked this week by the sentencing of Dr. Larry Nassar, formerly the USA Gymnastics team doctor and an osteopathic physician at Michigan State University. Dr. Nassar confessed to serial child molestation after being accused of abusing at least 150 underage girls during his career. A piece in The Atlantic argues that Nassar's behavior was sheilded by the tendency of medical providers to doubt female pain. This tendency stems from unconscious bias that labels women as "hysterical," "emotional," and inherently less trustworthy than men.
Serena Williams's birth experience has added to the growing chorus of concern and outrage over black maternal mortality rates. In a cover story for Vogue, the tennis star describes her life-threatening post-birth complications. When she started to feel short of breath after her delivery, her concerns (based on a history of pulmonary embolisms) were initially dismissed by her caregivers.
Perceived discrimination, based on race, gender, and other factors, causes patients to distrust the healthcare system and medical practitioners. They are then less likely to seek treatment, and less likely to follow through on medical advice. In response to a recent study on this topic, Quality Interactions co-founder Dr. Joseph Betancourt published an editorial in the Journal of General Internal Medicine (JGIM).The study, by Nguyen et al., found that rates of perceived discrimination in healthcare declined among black patients between 2008 and 2014. While this could be promising news, Dr. Betancourt argues that it is not time to celebrate yet.
A report from the American Psycholological Association finds that lower-income and racial minority populations suffer more stress than affluent and white populations. This greater stress leads to disparities in mental and physical health, and shortens life expectancy. According to Elizabeth Brondolo, PhD, chair of an APA working group that wrote the report, stress is "one of the top 10 social determinants of health inequities." The report recommends interventions to help ease the impact of stress on health, including improved communication between patients and caregivers.
In the U.S., black and brown women are more likely to experience medical complications in pregnancy than white women, and their babies are more likely to die or have serious health problems. This disparity is one reason why the U.S. has such high maternal and infant mortality rates compared with other developed countries.
As recent reporting shows (see past Roundups 12/4/17 and 12/18/17), this gap is rooted in healthcare providers' unconscious biases surrounding race and ethnicity, and cannot be explained by socioeconomic differences.
In the U.S., black babies die at twice the rate of white babies. According to Arthur James, an OB-GYN at Wexner Medical Center at Ohio State University in Columbus, the majority of black infants that die are born premature, because black mothers have a higher risk of early labor. Research has shown that this gap can't be explained by poverty, education, or genetics. Around the world, women of similar economic and genetic histories routinely give birth to healthy, full-term babies. But there's something about growing up black in America that leads African-American mothers to have babies that are comparatively smaller and less healthy.
Boston is a renowned center for medicine and boasts several of the country's best and most trusted hospitals. But the city's black residents are less likely than white residents to receive treatment at the elite hospitals in the area. The Boston Globe's Spotlight Team investigated the disparity and found that part of it is due to geography: People tend to seek healthcare close to where they live. However, geography alone does not explain the disparities. While some factors are straightforward - such as the reality that lower-cost health plans often do not cover care at the city's academic medical centers - others are far more complex, based on perceptions of mistrust and bias, that are intertwined with Boston's complicated racial history.
Black women are far more likely than white women to die of childbirth-related complications—and the gap is widening. In fact, the disproportionate number of black maternal deaths in the U.S. is one of the reasons our overall maternal mortality rate is so high compared to countries with similar economies.
In the United States, a person's access to quality healthcare can be affected by income, education, language barriers, and other obstacles. Health inequity impacts life expectancy and quality of life, and it places a financial burden on all tax payers. While many Americans are aware of this problem, it can be difficult to understand how health inequity comes about—and even harder to know how to address it.
This has been a banner year for Moffitt Cancer Center, with five national distinctions honoring their steadfast commitment to equitable care, including recent recognition from the American Hospital Association (AHA) naming Moffitt an Equity of Care Award honoree.
Maria Pérez is a 46 year-old woman, originally from the Dominican Republic, who reports to her primary care provider (PCP) because she has been feeling fatigued and dizzy for several months. Exploring this further, Mrs. Pérez acknowledges that she has also had trouble sleeping and has been feeling less "herself" lately. She has lost some weight.
Effective communication is essential to the healthcare interactions at all levels. When patients have limited-English proficiency (LEP), or speak different languages, it is nearly impossible for clear communication to take place. Interpreters provide an essential bridge to effective communication with LEP patients. However, simply having a qualified interpreter in the room (or on the phone) will not automatically guarantee success. Make the most of interpreter-mediated patient interactions with our five tips for working with interpreters.
Health literacy describes one's ability to obtain and understand the medical information needed to make informed healthcare decisions. This includes the ability to understand medical explanations of symptoms and illnesses; follow directions for medications, tests, and procedures; and ask relevant questions.