Strategies to Reduce Health Disparities

Access to Providers

Presenters: Joseph R. Betancourt, M.P.H., M.D., Senior Scientist, Institute for Health Policy, Program Director for Multicultural Education, Multicultural Affairs Office, Massachusetts General Hospital-Harvard Medical School, Boston, MA Ralph Forquera, M.P.H., Executive Director, Seattle Indian Health Board, Seattle, WA

Sociocultural factors affect health care because they have an impact on health beliefs, behaviors, and treatments. These factors affect:

• Variation in symptom presentation.
• Expectations of care.
• Bias, mistrust, prejudice, stereotyping.
• Ability to maneuver within the system.
• Diagnostic and treatment choices.

Lack of diversity in the health care workforce may result in an inability to handle these impacts. It is in the interest of health care systems to increase workforce diversity, as this can increase market share and lower costs. The cost reduction will be achieved by reducing the need for expensive tests when language barriers impede the ability to understand the presentation of symptoms and by decreasing medical errors that are the result of communication gaps and misunderstandings.

Minority leadership in health policy development helps to set guidelines for providers and health care workers that consider minority needs. Leadership can spread lessons learned from the data:

• Providers who speak the same language as their patients receive higher patient satisfaction ratings.
• Black and Hispanic physicians have major roles in providing health care for underserved populations.

In 1997, academic health centers had 79-percent white faculties, and 68 percent of medical school graduates were white. Anti-affirmative action sentiment has decreased the number of racial/ethnic minority students applying to and graduating from medical schools. Policymakers have options to increase diversity at medical schools through both incentives (e.g., awards programs and partnerships) and regulations (through accreditation and funding). Various strategies increase the numbers of racial/ethnic minority medical school students, among them:

• Educational pipelines involving partnerships and collaborations (e.g., the Robert Wood Johnson Foundation and the American Association of Medical Schools have adopted primary and secondary schools through the Health Professions Partnership Initiative).
• Effective recruitment models such as the Faculty Diversity Development Program at Harvard University.

Workforce diversity can also be increased through programs for foreign-born clinicians. The J1 visa program places foreign doctors in underserved communities after completion of a training program.

Keys to effective interventions that policymakers can make to increase the diversity of student bodies in medical schools and in the health care workforce include:

• Incorporating student perspectives (e.g., asking what they see as barriers to attending medical school).
• Providing grassroots and formal support for those making efforts in this area.
• Developing opinion leaders.
• Aiming for institutional change.
• Balancing incentives and regulations.

The American Indian/Alaska Native (AI/AN) Native Family Practice Residency Program, developed by the Seattle Indian Health Board (SIHB) and the Providence Family Practice Residency Program (part of the University of Washington Medical School), is an example of a creative model to increase the numbers of AI/AN doctors.

SIHB's rationale for starting this residency program included:

• Shortage of physicians trained to serve Indian communities.
• Existing community relationships made the project a possibility.
• Indian Health Service (IHS) interest and support.
• Mandate from the Board to increase the number of Indian providers at SIHB.

The goals of the program include:

• Training physicians for careers working with AI/AN populations (if physicians are trained in a special setting, they are more likely to practice successfully in that setting in the long-term).
• Exposing trainees to cultural sensitivity and appropriateness and health issues particular to AI/AN populations.
• Recruiting AI/AN medical students. The highest retention rate for physicians working with minority populations is among those having a personal membership in a minority population.

Operating since 1994, the program is the only AI/AN residency program in the United States. Applicants are required to either be AI/AN or to have extensive experience in AI/AN communities. Six residents participate at SIHB; two each in their first, second, and third years of residency. Residents complete several rotations at SIHB. They spend two half-days onsite during their first year, three half-days during their second year, and four or five half-days during their third year.

Thus far, eight residents have graduated; five are themselves AI/AN. Six work in AI/AN health care facilities. Two work in community health centers with large numbers of AI/AN patients.

Challenges to making this project work include:

• Bridging the requirements/rules of a working clinic and an educational program.
• Funding.
• Recruiting, including the effects of affirmative action on medical school enrollment, lower numbers interested in family medicine, student biases about Seattle's weather, and limited resources for recruitment.

Future concerns include:

• Challenges with money and recruitment.
• Health system change effects on medical education
• Minority recruitment/effects of changes in affirmative action.
• Medicine no longer seen as a desirable profession.

Additional Resources

Betancourt JR, Jacobs EA. Language barriers to informed consent and confidentiality: The impact on womens' health. JAMWA 2000;55(5):294-95.

Betancourt JR, King RK. Editorial: Diversity in health care: expanding our perspectives. Arch Pediatr Adolesc Med 2000;154(1):871-72.

Betancourt JR, Like RC. Editorial: A new framework of care. Patient Care 2000 May.

Carrillo JE, Green AR, Betancourt JR. Cross-cultural primary care: A patient-based approach. Annals Intern Med 1999;130(10):829-34.

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