Zero tolerance for disparity begins with primary care

Observations on the state of medical practice and medical life

By Edmond Blum, MD, amednews correspondent— Posted Feb. 9, 2004.

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Zero tolerance for racial and ethnic disparities in health care is a standard that has been widely endorsed in medicine, as the AMA and the Health and Human Services Dept. joined in doing some three years ago. Yet as a physician serving on the front lines -- I practice primary care in the inner city -- I find that these disparities continue unabated.

These disparities are an integral part of a long history of discrimination. In addition, certain racial and ethnic populations carry a disproportionate share of major chronic disease burdens such as diabetes, asthma, hypertension, congestive heart failure, HIV and hepatitis. Contributing to the problem are various barriers to care -- linguistics, culture, socioeconomics and health illiteracy -- which cannot be ignored if care is to be effective.

Disparities may present as unequal treatment; that is, the unequal allocation of resources to individuals or communities. Or they may present as the "disparate impact" of various health care infrastructures and policies that, while not obviously discriminatory -- "facially neutral" as lawyers would say -- are especially detrimental for certain racial and ethnic populations.

This disparate impact can be both subtle and pervasive, as the practice of primary care in the inner city illustrates. Primary care is the window on the health care system for these at-risk patients, the foundation of the care delivered to them and their gateway to specialty care. As elsewhere, the vast majority of patients -- over 90% of diabetics, for instance -- are cared for by primary care physicians.

In the inner city, however, primary care physicians face what is becoming an insurmountable problem. The extent of chronic disease in this population has reached epidemic proportions. Meanwhile, the institutions that serve these patients are failing to meet that challenge.

Diabetes is a good example. In my hospital, every other primary care clinic visit is by a diabetic -- many times the national average. Diabetes is among the leading causes of death in the United States, primarily from associated cardiovascular disease. In addition, it is the leading cause of nontraumatic amputations, blindness among working-age adults and end-stage renal disease. And, of course, it is responsible for an extremely high number of emergency department visits and hospitalizations.

Yet these disastrous complications and outcomes are to a large extent preventable by comprehensive diabetic care. This includes secondary prevention -- controlling risk factors -- and tertiary prevention -- screening for early complications, followed by appropriate treatment and prevention strategies.

But in spite of the validated efficacy and economic benefits of comprehensive diabetic care, it has failed to take hold in the clinical management of diabetics, especially in the inner city. The reasons for this failure are twofold.

First, health care resources allotted to the inner city are inadequate to meet the needs. Second, and perhaps more important, the model of primary care used in the inner city -- essentially, what has become the "standard" model used throughout the country -- is structurally incapable of meeting the needs of its population.

What is this standard model of primary care? It is essentially what we have become used to as the managed care model.

It consists of one-size-fits-all time frames -- usually 10 to 15 minutes -- and is focused on standardized tasks and protocols, as opposed to patient-centered, interpersonal skills. The communication style is paternalistic, and patient participation in decision-making or as self-management is virtually nil. The overall effect is that of an assembly-line style and tempo of care.

Comprehensive diabetic care, which is by nature patient-centered, time-consuming and dependent on a skilled-team approach, no more fits into this model of care than the proverbial square peg into the round hole.

In comprehensive diabetic care, the contents of an outpatient visit consist of five bulky agendas that now must all be fitted into one minuscule time frame.

First, there is the lengthy and complex agenda of diabetic care as defined by American Diabetes Assn. standards.

Second, there is the comorbidity agenda -- an especially large item in high-risk populations -- which means that the coexisting illnesses must be treated in their own right.

Third, there is the agenda of general preventive medicine, a time-consuming list of tasks usually delegated to the primary care physician.

Fourth, there is the patient's own agenda. Each patient comes with a personal set of problems that must be addressed here and now -- the so-called "tyranny of the urgent."

Fifth, there is the growing agenda of clerical work routinely assigned to physicians in some settings. New York City's municipal hospitals, for instance, now require typed input by the physician of all clinical data into the paperless electronic medical record.

So when trying to dispense comprehensive diabetic care, the primary care physician is in the untenable position of having to fit bulky agendas into undersized containers (i.e., time frames). This is an excellent example of a structural defect that, given the prevalence of diabetes in certain racial and ethnic populations, must necessarily lead to disparate care for these populations.

Therefore, zero tolerance for racial and ethnic disparity in health care must begin with a realistic redesign of the primary care model. For that to happen, primary care must be focused on two goals. One is patient-centered care for all patients. The other is disease management for all major chronic illnesses.

Patient-centered care is that which is responsive to the patient's values, needs and preferences. It emphasizes interpersonal skills -- communication, relationship, partnering and counseling -- that should be the cornerstone of a patient-physician relationship in primary care.

In practice, it is inseparable from the technical skills of diagnosis and treatment and contributes much to their effective use. The basic premise of patient-centered care is that it is not sufficient to know only the facts; it also is necessary to approach our patients with sympathy and imagination. Strong evidence links that approach to valued patient outcomes, including improvements in markers of disease control, increased patient satisfaction and greater patient compliance. Continuity of care and adequate face-to-face time are obvious prerequisites.

Disease management is the organized, systematic and team approach to the management of chronic illness. Again, diabetic comprehensive care is a good example. In practice, it is only possible through a continuous process of self-management by the patient in close partnership with a skilled team of health care professionals. That approach is generally lacking in the inner city.

I believe that the price of redesigning primary care pales against the human and socioeconomic costs of mismanaged chronic illness. If we truly want zero tolerance for racial and ethnic disparity in health care, this is where to begin.

Edmond Blum, MD, amednews correspondent—

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