Thursday, September 16, 2010

Primary care and health disparities

One of the ugliest incidents in my career occurred during my faculty development fellowship year, when I spent two days each week seeing patients at several federally qualified community health centers in inner city Washington, DC. Midway through the year, I was transferred from a health center that served an African-American population to one serving a mostly Spanish-speaking clientele. Nearly all of the permanent primary care clinicians at this health center spoke fluent Spanish, and I saw it as a sign of the center's desperate need for clinicians that they willingly accepted a family physician who had never managed to learn enough Spanish to ask any questions more complex than "where does it hurt?"

The plan had been for me to be paired with a Spanish-speaking medical assistant who could also function as an interpreter, but due to staffing changes and the reality that medical assistants have many responsibilities, that never worked out. So I found myself spending hours using awkward telephone translation services, pressing patients' relatives and children into service as translators (a big no-no), or as a last resort, deliberately avoiding picking up the medical charts of patients who knew no English.

None of these actions endeared me to the other clinicians, but one in particular, a short-tempered Latino family doctor who had worked at the health center for many years, seemed offended by my presence from the outset. After weeks of giving me the silent treatment, one day he literally exploded and told me in no uncertain terms that I had absolutely no business seeing patients there (especially "his" patients) when I couldn't speak the language, and that the constant influx of temporary physicians from academic medical centers like me who moved on to other things was what gave health centers for the underserved a reputation for poor quality.

Several years removed from that professionally and personally distressing incident, I came across a study in the Archives of Internal Medicine that examined the relationship between proportions of minority patients served by 96 U.S. primary care clinics and elements of their workplace and organizational environments. Consistent with my experience, clinics that served at least a 30% minority population reported that their patients often spoke little or no English, had lower health literacy, and had more complex and chronic medical problems such as depression, pain syndromes, and substance abuse. To address these challenges, these clinics had access to fewer resources (medical supplies, referral specialists, pharmacy services, and examination rooms) and were more likely to have "chaotic" work environments and low job satisfaction than clinics serving less than 30% minorities. The authors concluded that primary health care for minority populations in this country is both "separate and unequal," and suggested that health disparities may be due as much to disadvantages built into the provision of care as to patient-centered factors.

And last week, JAMA published an important analysis of Health Plan Employer and Data Information Set (HEDIS) performance measures of 162 primary care physicians in a practice-based research network in eastern Massachusetts. The authors concluded: "Among primary care physicians practicing within the same large academic primary care system, patient panels with greater proportions of underinsured, minority, and non-English-speaking patients were associated with lower quality rankings for primary care physicians."

My hat is off to family physicians and other primary care clinicians who care for underserved patients. Every day, you make do with less, manage more challenging clinical problems, and to add insult to injury, apparently are now getting dinged on the quality of care you provide. There is no excuse for the way I was treated in that clinic many years ago, but I have come to understand my antagonist's "us versus them" mentality as a coping mechanism. Making a real dent in health disparities will require more than expanding Medicaid coverage and building new community health centers. Creative programs are also needed to attract top-flight family physicians to practices for the underserved and keep them there by providing the necessary support for them to thrive, professionally and emotionally.

1 comment:

  1. This JAMA study is indeed a must read.
    One suggestion when reading studies of quality, particularly involving primary care physicians. Use the following quality equation to critique the study:

    Quality = social determinants/barriers/environment + health care team + system + other/unknown + physician

    If the study does not attempt to collect or include controls or other considerations for the factors in the equation beyond physicians, this strongly biases the equation toward too much credit or blame given physician factors.

    Quality is definitely not just the physician factor even though this is tough for the physician dominated workforce culture to understand (cultural immersion is always a major barrier to good research).

    It is also likely as noted in the JAMA study, that the populations in most need of health access have the most non-physician factors shaping quality.

    Also during your reviews please include a look at the primary care definition (none in this one) and the measures used as this can impact performance, particularly if pap smears are a measure and ob-gyn is somehow included as primary care.

    Another factor is whether the care is dominated by acute care due to shortage or discontinuity or whether it is scheduled care.

    Patient care in 30,000 zip codes with primary care shortages (that will be worsening) will be rated as lower in quality. This is a location outside of the 3400 zip codes with top physician concentrations. Locations outside have 65% of the US population and these locations are served by 53% of family physicians but have only 22% of the non-family practice workforce. Family physicians are also by far the physicians most likely to share origins with this 65% of the population left behind. Another potential quality indicator in many studies is common background.

    This JAMA study is one of few that includes patient sociodemographics and not surprisingly the associations are noted between physicians caring for lower income populations and ratings of lower quality.

    This is important for Community Health Center physicians and also for family physicians that are more likely to be the CHC physicians and are also the physicians most likely to be caring for the poor, near poor, elderly, lower income, middle income, rural and other populations with the lowest support and the most barriers to care – by design.

    Perhaps the most important quality indicators are not linked to encounters. Movement from no access to some access is of course is the ultimate increase possible in both quality and in access. This is an increase from no quality to some and from no access to access. Family physicians are responsible for the greatest movement of those left behind in the US population from no access to some.

    The lack of expansion of family physician annual graduates for 30 years is also an indication that the United States has consistently avoided most needed health access workforce as well as the better health access needs of most Americans.