Category: Doctor-Patient Communication

Discrimination and Health Part II: People of Color

Last week, I talked about how discrimination faced in healthcare settings can impact LGBTQ+ individuals’ attitudes towards healthcare, and how facing discrimination in everyday life can negatively impact their health outcomes. People of color (PoC) in the U.S., including immigrants, refugees, and Indigenous Peoples, face this double-barreled oppression as well.

Of course, one way racism affects health is through the broad structures that have placed many PoC groups at disadvantaged positions, intersecting with poverty – one study found that almost 100,000 black people die prematurely each year who would not die were there no racial disparities in health.

But discrimination itself, even on an individual level, can impact the health and healthcare experiences of PoC. Microaggressions, or everyday interactions rooted in racism, are a daily stressor for PoC, and these stressors can lead to premature illness and mortality.

Of course, this discrimination doesn’t just happen in daily interactions, but also in medical settings, which rightfully leads to mistrust and under-use of healthcare for PoC. Language and cultural barriers faced by immigrants can have similar effects.

Because race, socioeconomic status, and health are so intertwined, it may never be possible to know what levels of discrimination have the greatest ultimate effects on health outcomes. But we know they all have at least some, which should be enough to demand action.

Sources: https://www.ncbi.nlm.nih.gov/pubmed/12042611

https://www.hindawi.com/journals/tswj/2013/512313/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2821669/#!po=2.38095

https://health.usnews.com/health-news/patient-advice/articles/2016-02-11/racial-bias-in-medicine-leads-to-worse-care-for-minorities

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2696665/

https://www.ncbi.nlm.nih.gov/pubmed/17001262

Doctors are humans too

In binge watching the newest medical show “The Resident” this past weekend, the show made me consider the role of medical error and transparency. The show portrays an arrogant surgeon with a secret tremor unwilling to give up his career despite his inability to perform successful surgeries. While the story plot line is dramatized and designed to pull viewers in for higher ratings, it highlights the importance of medical error and transparency. According to The BMJ, medical error is the third leading cause of death in the United States. Examples of medical error include medication errors (wrong dose, wrong drug) and hospital infections. Medical errors are challenging to comprehend since healthcare providers are only human and they are bound to make mistake just like the rest of us. The amount of stress and pressure these providers face all while working at all hours undoubtedly will result in mistakes. However, their mistakes have much more severe consequences. The show discusses transparency as a way to address the stigma surrounding medical error and by having more transparency could result in lower rates of medical error. An interesting fact to note is that these are errors are not recognized as cause of death on death certificates. To me, this further stigmatizes the errors and places blame on the healthcare provider and doesn’t change the narrative that providers are human and errors will happen. We treat these healthcare providers as superhuman but we need to remember that they are just like us and as a humans we make mistakes and hopefully we learn from them.

References:

https://health.usnews.com/health-news/patient-advice/slideshows/5-common-preventable-medical-errors?slide=4

https://www.bmj.com/content/353/bmj.i2139.full

Stethoscopes and Smartphones? How Doctors are Using mHealth Apps for Patient Care

By Elizabeth Adams, MA

There was a time when doctors circulated the hallways of hospitals with nothing but a beeper pinned to the waistline of their scrubs.

But today, you might notice your doctor enter the exam room clutching a more advanced communication device – a Smartphone or tablet. A 2014 survey reported that 85% of medical faculty, 90% of medical residents, and 85% of medical students used a Smartphone in a clinical setting1. Modern doctors are increasingly replacing laptops or desktops with Smartphones and tablets2.

Doctors are constantly on their feet, moving throughout hospitals, emergency rooms, or clinics.  They use these devices for variety of job-related tasks, including remote patient monitoring, electronic health record access, e-prescribing, drug reference calculations, reading medical news, and decision-making support3. Now there is a marketplace for health professionals to locate apps designed specifically for clinical practice. In 2011, the iPhone App Store introduced the “Apps for Health Care Professionals” section, which has expanded to include more than 80 app options4.

Here are a few ways doctors are using apps to improve patient care:

 Retrieving Information. Doctors increasingly rely on mhealth to inform complex clinical assessments and decisions. One survey indicated that two-thirds of doctors use medication-interaction assistance apps to aid in the prescription decision-making process5. In addition, medical residents rely on mobile phones in clinical consultation to look up drug information, perform clinical calculations, take notes, or look up clinical guidelines4. Instantaneous access to information can help doctors and trainees make more accurate decisions regarding treatment.

 Communicating with Patients. Electronic health record software, such as Epic (link to: https://www.inova.org/for-physicians/epiccare-apps) – the program used by UNC HealthCare – incorporate apps Haiku and Canto, which facilitate direct correspondence between patients and health care teams. Other third-party apps, such as OhMD (link to: https://www.ohmd.com), TigerText (link to: https://www.tigertext.com/), and Hale (link to: http://hale.co/), are compatible with electronic health record programs and connect patients to doctors through text messaging platforms.

Continuing Education. Mobile continuing education curricula promises to supply doctors and trainees with current medical information and impart recent standards of practice without the time-consuming requirement of sitting at a desktop or in a classroom. In addition, top-tier medical journals, including the New England Journal of Medicine’s This Week app (link to: http://www.nejm.org/doi/full/10.1056/NEJMe1201837) and the American Medical Association’s CPT QuickRef app (link to: https://www.ama-assn.org/practice-management/applying-cpt-codes), deliver scientific articles and guidelines.

 More research is necessary to understand the relationship between mhealth app adoption and improved clinical care outcomes. Smartphones could be considered impediments to patient care, so they must be used with some discretion. But next time your doctor walks in with a tablet or glances at a Smartphone, remember that he or she might be using an app to make better decisions for your health.

References

  1. Ventola, C. Lee. “Mobile Devices and Apps for Health Care Professionals: Uses and Benefits.” Pharmacy and Therapeutics5 (2014): 356–364.
  2. Murfin, M. Know your apps: an evidence-based approach to evaluation of mobile clinical applications. Journal of Physician Assist Education. 2013; 24(3):38-40.
  3. Kaufman, Michele B,PharmD., R.Ph. “Mobile Health Increases as Physicians Seek New Ways to Manage Patients.”Formulary, vol. 47, no. 4, 2012, pp. 161-162, ProQuest, http://libproxy.lib.unc.edu/login?url=https://search-proquest-com.libproxy.lib.unc.edu/docview/1145903653?accountid=14244.
  4. Dolan, B. Apple’s Top 80 Apps for Doctors, Nurses, and Patients. [Online] November 27, 2012. http://www.mobihealthnews.com/19206/apples-top-80-apps-for-doctors-nurses-patients/
  5. Boruff, J. T. M., & Storie, D. M. M. A. Mobile devices in medicine: a survey of how medical students, residents, and faculty use smartphones and other mobile devices to find information. Journal of the Medical Library Association, (2014): 102(1), 22-30.

What’s going on with the HPV vaccine?

HPV is the most common STI, and 9 of every 10 people will have an infection at some point in their lives (1).  This virus can cause cancers in the cervix, penis, mouth, and oropharynx (2), and it also causes genital warts (3).  Even though a vaccine exists against HPV, less than half of teens are up to date on all of their doses of these shots (2).

Part of the reason behind these low vaccination rates are due to parents concerns regarding vaccine safety and fear that vaccination will encourage sexual activity (4).  Though all vaccines, including this one, have potential side effects, the HPV vaccine is considered safe (4). Additionally, studies have shown that the HPV vaccine does not make teens more likely to start having sex (4).

The way providers approach talking about the HPV has also influenced vaccine rates, and strong provider endorsement seems to improve vaccinations (5).  On Monday, March 19, Chris Noronha spoke with the Interdisciplinary Health Communications Class about the work he is doing with Noel Brewer on provider communication regarding the HPV vaccine.  They have found that when providers mention the HPV vaccine in the same list as other vaccines that are due at age 11, vaccination rates increase.

If you’re interested in the HPV vaccine, it may not be too late.  You can receive the series through age 26 (1).  Contact your provider if you’re interested.

 

Works Cited
  1. Centers for Disease Control and Prevention. Human Papillomavirus (HPV) Vaccine Safety. Centers for Disease Control and Prevention. [Online] January 30, 2018. https://www.cdc.gov/vaccinesafety/vaccines/hpv-vaccine.html.
  2. Aubrey, Allison. This Vaccine Can Prevent Cancer, But Many Teenagers Still Don’t Get It. National Public Radio. [Online] February 19, 2018. https://www.npr.org/sections/health-shots/2018/02/19/586494027/this-vaccine-can-prevent-cancer-but-many-teenagers-still-dont-get-it.
  3. Centers for Disease Control and Prevention. What is HPV. Centers for Disease Control and Prevention. [Online] December 20, 2016. https://www.cdc.gov/hpv/parents/whatishpv.html.
  4. —. Talking to Parents About HPV vaccine. Centers for Disease Control and Prevention. [Online] December 2016. https://www.cdc.gov/hpv/hcp/for-hcp-tipsheet-hpv.pdf.
  5. Narula, Tara. HPV vaccine: Why aren’t children getting it? CBS News. [Online] July 23, 2017. https://www.cbsnews.com/news/hpv-vaccination-cancer-prevention-dr-tara-narula/.

 

 

Just Trust Me (Part IV)

In the past few weeks, I have illustrated how trust (or lack thereof) shapes the relationship between individuals and healthcare, and how mistrust is historically justified. In this last segment, I want to talk about potential solutions from a social justice standpoint.

Trust is often cited in public health from the angle of paternalism, something that public health is often associated with. When we think of optimal paternalism – using scientific knowledge to influence the health decisions of the general public – we ask ourselves: are we abusing trust, or using it for good?

Public health, while sometimes paternalistic, already stresses to its students the importance of working with oppressed communities as equals to identify and solve problems. Medicine needs to catch up. Many medical students already participate in racial and cultural training, but they need to be trained from a structural angle – to gain an understanding of oppression and policy – too.

We need to support training for healthcare providers that doesn’t shy away from the tough stuff. Hands-on learning, such as tactful poverty simulations, can help. This will allow them to understand things like how the cycle of poverty makes some patients less talkative with authority figures (such as doctors) than others. We need to support minority students in medicine, so that patients can see representation of themselves and feel understood. We need to provide incentives for students to stay in their own communities for residencies. Of course, broad class mobility-enabling policy is the ultimate solution.

Many times, our work seeks to increase trust, but that puts the burden on the patient instead of addressing the reasons behind mistrust. Teaching trust in and of itself is a paternalistic objective: we should instead focus on deserving it.

Electronic Health Record Coming to a Phone Near You

When I go for my yearly check-up, my doctor asks me things like “When was your last tetanus shot” and “What was your last Pap smear.” Since these services only happen every 3, 5, or 10 years, my answer is usually an “I don’t know.  I’d have to track down the records.”

Apple has realized that most of us have foggy memories when it comes to our healthcare.  In January, Apple announced that they are extending their AppleHealth app to interface with people’s electronic health records.  This means that instead of having to request records to be sent from office to office, you will be able to see your medical history on your phone.

This version of the app is currently still in beta-testing, and therefore is only available to patients of Johns Hopkins Medicine in Baltimore, MD, Cedars-Sinai in Los Angeles, CA, Penn Medicine I Philadelphia, PA, Geisinger Health System in Danville, PA, UC San Diego Health in San Diego, CA, UNC Health Care in Chapel Hill, NC, Rush University Medical Center in Chicago, IL, Dignity Health in AZ, CA, and NV, Ochsner Health System in Jefferson Parrish, Louisiana, and MedStar Health in Washington D.C., MD, and VA, OhioHealth in Columbus, OH, and Cerner Health Clinic and Kansas City, MO.

Hopefully this will allow people to take more ownership of their healthcare in the future.

 

Reference:

Apple, Inc. (2018, January 24). Apple announces effortless solution bringing health records to iPhone. Retrieved from Apple.com: 2018

Just Trust Me: Part III

“You can’t health care-access your way out of this problem. There’s something inherently wrong with the system that’s not valuing the lives of black women equally to white women.” -Raegan McDonald-Mosley

Last week, my post scratched the surface of the history of oppression disguised as medical treatment. Today, I want to talk about how this mistreatment, and the historical trauma that ensues, exhibits itself in patient-practitioner relationships.

Many of us have experienced the helplessness of not knowing how much a medical procedure will cost until it’s over. It’s a terrible feeling: it feels like everyone is communicating without you; ‘above’ you. For many non-white and immigrant patients, this feeling lasts for the entire appointment: from scheduling to decision-making to discharge.

Traditionally, there are four types of patient-physician relationships, each with varying levels of patient power and involvement in decision-making. There is also a distinction between patients preferring an active or passive role in decision-making. Acknowledging the relationship between trust and decision-making preference, these researchers suggest that, for black patients, race may impact both: such that a patient who trusts her individual physician “may have residual mistrust of the health care system that limits [her] ability to relinquish decision-making control.” Cultural differences, as well as fear that the doctor does not have one’s best interests at heart, can influence the relationship between patients and their physicians in Hispanic populations as well.

Racial bias, conscious or otherwise, has been found to influence treatment decisions. Black patients are systematically under-treated for pain due to false beliefs of biological differences between blacks and whites: such as black people’s skin being thicker, or blood coagulating more quickly. This is exacerbated by existing power structures between whites and non-whites, as well as between doctors and patients. In over 200 personal stories from black women of their childbirth experiences, NPR found a constant theme of being devalued and dismissed by medical providers.

Read Part IV here.

STOP Act: Implementation and Effects on the Opioid Epidemic in North Carolina

The rise of the opioid epidemic nationwide has led to an increase of attention from both media and policy makers. Here in North Carolina, a recently passed policy is the Strengthen Opioid Misuse Prevention, or STOP Act, which aims to reduce the amount of Opioids prescribed a one approach to tackle the epidemic. The STOP Act was signed into law by Governor Roy Cooper on June 29, 2017, and since then its four stage implementation has been put into effect, which will continue until 2020.

The first step of implementation occurred almost immediately after the law’s passage, on July 1st 2017, requiring Physician Assistants (PAs) and Nurse Practitioners (NPs) to personally consult with a supervising physician. This applied to Pas and NPs at facilities that primarily engage in treating pain, and the prescription will, or is expected to, last longer than 30 days. Additionally, PAs and NPs have to consult with a supervising physician every 90 days for patients for are continuously prescribed opioids.  Providers are also required to provide information on the disposal of controlled substances, both written and orally, when a patient concludes a course of treatment. The second aspect, implemented on September 1st, 2017, requires that pharmacies report targeted prescriptions to the North Carolina Controlled Substance Reporting System within a day of the prescription is dispensed.

The most recent aspect of the STOP Act was implemented on January 1st, 2018, and limits the amount of opioids prescribed for acute pain. Practitioners are not able to prescribe more than five days’ worth of any Schedule II or III Opioid or Narcotic, with an exception to things like pain after surgery, where the prescription cannot for longer than seven days. The final part of the law will be implemented on January 1st, 2020, and will require practitioners to electronically prescribed targeted controlled substances, with a few exceptions.

While it is still unclear what impact the law will have on overdose deaths in the state, it appears that the State government is attempting to address this issue. While more resources could be devoted to mental health services, naloxone access and syringe exchanges, and more programs geared toward injecting drug users rather than only those who use prescription drugs, it’s commendable that a joint effort was reached to combat this ongoing epidemic.

 

Sources:

New! Summary of NC’s new opioids law, the STOP Act: North Carolina Medical Board – https://www.ncmedboard.org/resources-information/professional-resources/publications/forum-newsletter/notice/new-summary-of-ncs-new-opioids-law-the-stop-act

FAQs: The STOP Act of 2017: North Carolina Medical Board – https://www.ncmedboard.org/resources-information/professional-resources/publications/forum-newsletter/article/faqs-the-stop-act-of-2017

STOP Act Provision Takes Effect Jan. 1, Will Limit Opioid Prescriptions: NC Governor Roy Cooper – https://governor.nc.gov/news/stop-act-provision-takes-effect-jan-1-will-limit-opioid-prescriptions

STOP Act Bill Summary: North Carolina Medical Board – https://www.ncmedboard.org/images/uploads/article_images/The_STOP_Act_summary-OnLetterhead.pdf

 

Just Trust Me (Part II)

“Dr. X, or whoever she was, she must have been experimenting on me…she left a big scar on my neck … I don’t want that lady to ever touch me again. I don’t like her and I don’t trust her.

Last week, I introduced the issue of trust in the medical setting and how it may vary across scenarios and patient characteristics. But to truly understand why some patients don’t trust the healthcare system, we absolutely cannot ignore the history of their oppression by its hands.

The most well-known medical violation under the guise of research in the U.S. is the Tuskegee “study,” a 40-year-long theft of human rights that, brilliantly and viciously, utilized both government and community-level networks to recruit black men in Macon County, AL. Most had syphilis. The participants, many of whom had never seen a physician, were not made aware of the dangers, causes, and treatment options for their disease. They were not offered informed consent, nor the option to leave the study, and many died.

But Tuskegee is only the tip of the iceberg. Henrietta Lacks’ cells were cultured without her consent during her battle with cervical cancer in 1951 and are still widely used today. Gynecologist J. Marion Sims ran “practice runs” of his procedures on enslaved women. A common belief in the 20th century was that those who could not pay for medical care, many of them poor minorities and immigrants, “owed their bodies” to science. Harry Laughlin performed forced sterilizations on “socially inadequate” Puerto Rican women until the 1970s. The list could go on.

Today, this unfathomable history is manifested in mistrust in healthcare and scientific research. Evidence suggests that black patients are less likely to trust physicians, are more worried about medical privacy and experimentation than are white patients, and are less likely to participate in clinical trials. Some patients are not fully aware of the history to their mistrust – it is a cultural feeling that has been passed down through generations. This is called historical trauma. In addition, racism is still rampant in the healthcare system, both intentional and subconscious, which I will delve into in Part III. These features make this issue even more difficult to address.

Read Part III here.

Just Trust Me (Part I)

Well I’m not trained medically, so I’m taking a lot of what they say on faith.”

This was the response of a 47-year-old man, whose interview was part of a study on patients’ trust in hospitals.

There is no universal definition of trust that will apply to every scenario. Physician training, patient’s racial and cultural background, personalities, and expectations all come into play as their relationship evolves. One recurring theme in the study cited above was “sensing that you are in good hands.” Some mentioned that their trust developed from knowing the sheer amount of training required to be a medical provider. Other patients pointed out that being desperate, or having few other options, accelerates the formation of trust.

The Trust Project at Northwestern emphasizes the role that vulnerability plays in forming trust. Generally, once we come to trust someone, we open up to them; we expose vulnerability. In the healthcare system, it works backwards: being sick, worried, or simply confused by jargon (this is called information asymmetry), the patient often begins her relationship with her provider in a state of vulnerability.

Trust can also vary in different facets of the healthcare system. When we say that a patient has mistrust in the healthcare system, are we referring to his relationship with his provider, institutions like his hospital and insurance company, or the notion of Western medicine to begin with? One study suggests that repeated interactions are a key to building trust, and that patients do not see their providers as interchangeable. These findings suggest that we should enhance continuity, not just access.

Patients with low health literacy may reveal trust in a number of ways. One extreme is blind faith in the expertise of the provider, and another is mistrust and suspicion. One study found that blind trust in physicians was stronger in patients who were older, perceived their prognosis to be uncertain, or sometimes of low SES. Trust in the healthcare system tends to be lower among racial minorities, due to a history of unethical treatment. Could race moderate the relationship between SES and trust? Can these two extremes be reconciled, or even coexist in a single patient?

Read Part II here.