Wednesday, March 30, 2022

How does the model minority myth harm Asian American aspirations and health?

The medical profession, including family medicine, benefits from having a racially and culturally diverse workforce. In my current practice, I care for a disproportionate number of older Chinese American patients even though I was born in the United States and know fewer than a dozen words of Mandarin. Yet my common heritage allows me to relate to these patients in ways that my non-Chinese colleagues cannot and improves their comfort and trust in my clinical recommendations.

In the mid-1990s, I applied for an 8-week summer laboratory research program at an Ivy League university that explicitly recruited college students from minority groups. Although I am a child of Chinese and Taiwanese immigrants, there was then, and is now, no shortage of Americans of east Asian descent in medical and other health care professions, including in my own extended family. I wondered if being a member of an "overrepresented" group would work against my being accepted to the program. As it turned out, it did not. Although the majority of my fellow students were African American or Latino, there were several other Asian Americans and even one white student. Looking back, the program was a great success, as most of us ended up becoming doctors. A few years ago, I began mentoring underrepresented in medicine (URM) college students in a similar program at my own institution.

Asian Americans are often mischaracterized as the "model minority" to contrast us with other non-white groups that have not achieved comparable economic success and health status on a population level. But lumping all Asian Americans together obscures the fact that many subgroups are actually URM. In a Letter to the Editor in Family Medicine, Dr. Oanh Truong highlighted the importance of data disaggregation to reveal these disparities:

When Asian American data are aggregated, the conclusions misleadingly suggest that Asian Americans as a singular population are thriving, perpetuating the harmful myth of Asian Americans being the model minority, where they are assumed to be doing better than other minority groups. ... However, data disaggregation would reveal that while Filipinos make up 18% of the nation’s Asian American population, they made up only 4.3% of the Asian American medical school applicants in 2019. Additionally, Laotians, Indonesians, and Cambodians altogether made up only 0.5% of the Asian American applicants.

The National Institutes of Health (NIH) highlighted "knowledge gaps, challenges, and opportunities in health and prevention research" for Asian Americans, Pacific Islanders (AAPI) and Native Hawaiians in a 2021 workshop whose proceedings were reported in the Annals of Internal Medicine. Although these groups collectively comprise nearly 8% of the U.S. population, the NIH spent just 0.17% of its budget on researching them between 1992 and 2018. The most telling figure in the report was a "heatmap" that illustrated the known prevalence of chronic health conditions in various AAPI subgroups compared to the U.S. white population. Some were lower, the same, or higher, but nearly half of the cells were blank, indicating insufficient data. We can't take action to reduce a health disparity if we don't even know if it exists.

Recent commentaries in Health Affairs and the Milbank Memorial Fund Blog expanded the argument that poor data quality combines with racial stereotypes to "fuel scientific and societal misperceptions that Asian Americans do not experience health disparities, [codifying] racist biases against the Asian American population in a mutually reinforcing cycle." According to the Milbank Fund, "one in four Pacific Islander adults report problems paying medical bills ... and there is wide variation in uninsurance rates across Asian American subgroups."

An article in press in Academic Medicine by a group of medical students and residents traces the history of discrimination and racism that AAPI have experienced from the 1882 Chinese Exclusion Act to the rise in anti-AAPI rhetoric and hate crimes since the start of the COVID-19 pandemic. The authors point out that discrimination is associated with underutilization of health care services and increased risk of chronic illnesses among non-elderly AAPI immigrants. They recommend that U.S. medical schools implement antiracist policies that recognize unconscious biases against AAPI patients, students, and faculty (e.g., the "bamboo ceiling") and "use disaggregated AAPI data so that the designation of [URM] is appropriately used to recruit diverse individuals who are collectively representative of the whole AAPI disapora."

Tuesday, March 15, 2022

Debating colorectal cancer screening recommendations: too young, too often?

Last year, the U.S. Preventive Services Task Force (USPSTF) updated its colorectal cancer screening recommendations, lowering the starting age for average-risk adults from 50 to 45 years; this change was reflected in the Putting Prevention Into Practice case study in American Family Physician's September 2021 issue. However, after reviewing the USPSTF statement and supporting documents, the American Academy of Family Physicians (AAFP) concluded that the evidence was insufficient to recommend a starting age younger than 50. Two editorials in the February issue of AFP outlined the arguments for and against starting routine screening at 45 years of age.

In the first editorial, Dr. Richard Wender argued that "lowering the starting age is a settled issue," noting that several organizations, including the American Cancer Society, the National Comprehensive Cancer Network, and the American College of Gastroenterology have all independently reviewed the data and come to the same conclusion as the USPSTF. He pointed out that "the incidence of colorectal cancer in 45 year-olds today is ... almost identical to the risk in 50-year-olds in 1979 when colorectal cancer screening was first recommended," and that nearly a quarter of deaths from colorectal cancer in the U.S. occur in individuals diagnosed between 45 and 54 years of age. Four microsimulation models have also concluded that starting screening at 45 years of age is the most efficient strategy to maximize life-years gained per colonoscopy regardless of the initial screening test used.

The second editorial, by Drs. Corey Lyon, Alexis Vosooney, and Melanie Bird, elaborated on the AAFP's position. The authors noted that "many of the trials used in the modeling studies did not include individuals younger than 50 years or did not provide separate data for this younger age group, decreasing confidence in the data inputs." They also expressed concern about costs to patients and the health care system from implementing the USPSTF recommendation as opposed to optimizing screening in patients age 50 years and older: "Expanding screening to up to 80% of eligible patients 50 to 75 years of age would prevent three times as many colon cancer deaths at one-third of the cost [of routinely screening Americans 45 to 49 years of age]." Finally, they argued that persistent disparities in colorectal cancer incidence and mortality in Black patients would be more appropriately addressed by improving insurance coverage and access to care in this population rather than lowering the age to start screening.

While colorectal cancer screening tests remain underused by many patients, studies have also documented that screening colonoscopies are sometimes performed more often than necessary - for example, being repeated 9 or fewer years after an initial high-quality colonoscopy showed no significant pathology, in contrast to the American Gastroenterological Association's Choosing Wisely recommendation. I co-authored a recent systematic review of 6 studies that estimated the rate of overuse of screening colonoscopy in U.S. populations found that it ranged from 17% to 25.7%. Overuse occurs when endoscopists recommend that patients have subsequent colonoscopies at intervals shorter than those supported by their own guidelines, and primary care physicians (PCPs) defer to subspecialists' recommendations. In an editorial, Drs. Archana Radhakrishnan and Craig Pollack acknowledged the obstacles that PCPs face in going against subspecialist advice but argued that they can still "play an important role in preventing overuse of colorectal cancer screening and surveillance colonoscopies" by directing referrals appropriately and communicating with endoscopists about their rationales for deviations from evidence-based practices.


This post first appeared on the AFP Community Blog.