I AM DR. JOYCE HUNTER, AND I AM

DEPUTY DIRECTOR OF THE NATIONAL

INSTITUTE OF MINORITY HEALTH AND

HEALTH DISPARITIES.

AND WE COORDINATE THESE SEMINAR

SERIES EACH MONTH.

THERE'S A DIFFERENT THEME AND WE

TRY VERY HARD TO BRING IN

EXPERTS IN HEALTH DISPARITIES,

BOTH NATIONALLY AND

INTERNATIONALLY KNOWN.

MOST ARE -- SOME ARE SUPPORTED

BY THE NIH.

QUITE A FEW ARE SUPPORTED BY

NIMHD, AND THEY COME TO TELL US

ABOUT ADVANCES IN HEALTH

DISPARITIES RESEARCH AS WELL AS

THE GAPS THAT MAY EXIST.

SO WE HAVE A VERY EXCITING

SEMINAR PLANNED FOR TODAY.

AND WE'LL START BY BRINGING UP

DR. JOHN RUFFIN WHO IS THE

DIRECTOR OF THE NATIONAL

INSTITUTE ON MINORITY HEALTH AND

HEALTH DISPARITIES.

[APPLAUSE]

>> DR. JOHN RUFFIN:

GOOD AFTERNOON.

I'M PLEASED TO WELCOME YOU TO

OUR OCTOBER SEMINAR FOCUSED ON

HEALTH CARE DISPARITIES.

ONE OF THE REASONS THAT I ALWAYS

ENJOY THESE SEMINARS IS BECAUSE

OF THE WIDE RANGE IN TOPICS THAT

ARE COVERED.

AND YOU'LL SEE THIS -- AND THIS

IS AN ADVERTISEMENT FOR OUR NEXT

SEMINAR.

MANY OF YOU WHO WERE HERE BEFORE

REMEMBER THAT IT WAS HISPANIC

MONTH, SO WE BROUGHT IN SOME

PEOPLE AND SEMINAR SPEAKERS WHO

CAN TALK TO US A LITTLE BIT

ABOUT HISPANICS.

I THINK OUR NEXT ONE'S GOING TO

BE ON NATIVE AMERICAN ISSUES,

AND SO WE WANT TO MAKE SURE THAT

WE MAKE A PITCH FOR YOUR

PRESENCE AT THAT ONE AS WELL.

AND THE REASON WE COVER SUCH A

BROAD RANGE OF TOPICS, IT'S A

REFLECTION OF THE COMPLEX NATURE

OF HEALTH DISPARITIES AND THE

MULTI-FACETED APPROACHES THAT WE

HAVE TO TAKE TO ADDRESS THEM.

CONTRIBUTING FACTORS SUCH AS

BIOLOGY AND ACCESS TO CARE HAVE

BEEN WELL DOCUMENTED, BUT THE

AFFECTS OF PHYSICIAN BIAS ON

HEALTH DISPARITIES HAS YET TO BE

FULLY EXPLORED, AS OUR SPEAKER

WILL SURELY DEMONSTRATE FOR YOU

TODAY.

TODAY HE WILL DELVE INTO THE

QUESTION OF BIAS, A TOPIC THAT

IS OFTEN DIFFICULT FOR THE

SCIENTIFIC AND MEDICAL

COMMUNITIES TO DISCUSS OR

ACKNOWLEDGE EXISTS, BUT IS ONE

THAT WE CANNOT AFFORD TO IGNORE.

I THINK THAT IF WE WERE TO JUST

SIMPLY FOCUS ON THE BIOLOGICS,

THEN WE'RE NOT GOING TO REALLY

GET TO THE WHOLE BUSINESS OF

TRYING TO ELIMINATE HEALTH

DISPARITIES.

THE 2002 IOM REPORT, "UNEQUAL

TREATMENT," VIVIDLY DOCUMENTED

AND BROUGHT THIS ISSUE TO THE

FOREFRONT IN A MANNER WE HAD NOT

SEEN BEFORE.

UNFORTUNATELY, BIAS IS A MAJOR

INFLUENCING FACTOR IN THE

QUALITY OF HEALTH CARE THAT

RACIAL AND ETHNIC MINORITIES

RECEIVE, WHETHER IT IS IN MAKING

DIAGNOSES, PRESCRIBING TREATMENT

OR PROCEDURES, MAKING REFERRALS,

OR EVEN COMMUNICATING WITH THE

PATIENT.

WE SEE TOO MANY OCCURRENCES OF

BIAS.

WE OFTEN TALK ABOUT MOVING

TOWARD AN ERA OF PERSONALIZED

MEDICINE WHERE MEDICAL

PROFESSIONALS CUSTOMIZE CARE

BASED ON THE INDIVIDUAL NEEDS OF

THEIR PATIENTS, BUT PERSONALIZED

MEDICINE IS NOT POSSIBLE UNLESS

PHYSICIANS APPRECIATE PATIENTS

AS INDIVIDUALS.

SO TODAY OUR SPEAKER, DR.

AUGUSTUS WHITE III, WILL DISCUSS

SOME OF THE RESEARCH THAT HE HAS

DONE IN THIS AREA AND THE

INTIMATE EXPERIENCES THAT HE HAS

ENCOUNTERED WITH BIAS IN THE

CLINICAL SETTING.

DR. WHITE IS A VERY, VERY GOOD

FRIEND OF MINE.

HE IS AN ELLEN AND MELVIN GORDON

DISTINGUISHED PROFESSOR OF

MEDICAL EDUCATION AND PROFESSOR

OF ORTHOPEDIC SURGERY AT HARVARD

MEDICAL SCHOOL.

HE IS THE AUTHOR OF "SEEING

PATIENTS:

UNCONSCIOUS BIAS IN HEALTH

CARE."  RAISED IN MEMPHIS DURING

THE ERA OF SEGREGATION, DR.

WHITE IS A TRUE PIONEER.

HE WAS THE FIRST AFRICAN

AMERICAN GRADUATE OF THE

STANFORD UNIVERSITY SCHOOL OF

MEDICINE, THE FIRST BLACK

SURGICAL RESIDENT AT YALE

MEDICAL CENTER, AND THE FIRST

AFRICAN AMERICAN PROFESSOR OF

SURGERY AT YALE.

HE ALSO RECEIVED THE BRONZE STAR

FOR HIS WORK AS A COMBAT SURGEON

DURING THE VIETNAM WAR.

DR. WHITE IS ONE OF THE

PREEMINENT ORTHOPEDIC SURGEONS

IN THE WORLD.

A FORMER MEMBER OF THE NIMHD

ADVISORY COUNCIL -- THAT'S WHERE

I LEARNED EVERYTHING THAT I

KNOW, GUS -- HE HAS RECEIVED

COUNTLESS HONORS AND AWARDS,

INCLUDING THE STANFORD MEDICAL

SCHOOL'S LIFETIME ACHIEVEMENT

AWARD FOR EXCEPTION CONTRIBUTION

TO MEDICINE, THE AMERICAN

ACADEMY OF ORTHOPEDIC SURGEONS'

WILLIAM TIPTON LEADERSHIP AWARD,

AND THE MARTIN LUTHER KING, JR.

MEDICAL ACHIEVEMENT AWARD.

TODAY, AS WE PREPARE TO

MEMORIALIZE THE LEGACY OF DR.

KING WITH THE UNVEILING OF THE

KING MONUMENT LATER THIS WEEK, I

THINK ON OCTOBER 16TH, DR. WHITE

WILL SHARE WITH US TODAY WHAT HE

BELIEVES DR. KING WOULD HAVE

WANTED US TO KNOW ABOUT HEALTH

AND EQUITY, WHICH HE DEEMED,

QUOTE, "THE MOST SHOCKING AND

INHUMANE," END OF QUOTE, FORM OF

ALL INEQUALITIES.

SO PLEASE JOIN ME TODAY IN

WELCOMING MY FRIEND, DR.

AUGUSTUS WHITE.

[APPLAUSE]

>> DR. AUGUSTUS A. WHITE III:

GOOD AFTERNOON, MY FELLOW

HUMANS.

JOHN, THANK YOU SO MUCH FOR YOUR

KIND INTRODUCTION AND FOR THE

PRIVILEGE AND THE HONOR TO BE

ABLE TO SHARE SOME THOUGHTS AND

IDEAS WITH SUCH A DISTINGUISHED

GROUP OF HEALTH CARE SCIENTISTS

AND HEALTH CARE ADVOCATES AND

HEALTH CARE LEADERS.

IT'S A REAL PRIVILEGE TO BE ABLE

TO SHARE SOME IDEAS WITH YOU.

ONE OF THE THINGS I TELL MY

STUDENTS IS TO CLAIM YOUR

HERITAGE.

AND, YOU KNOW, WHATEVER IT IS

YOU FEEL HAS CONTRIBUTED TO YOUR

HERITAGE, MAINLY YOUR EDUCATION,

BUT YOUR PERSONA, YOUR

PROFESSIONAL PERSONA, CLAIM IT

WITH ENTHUSIASM AND PRIDE.

AND I HAD THE OPPORTUNITY

ACTUALLY TO SPEAK AT HOPKINS A

WEEK AGO, AND THAT WAS A VERY

INSPIRING EXPERIENCE, REALLY.

BUT I DO CLAIM SOME HERITAGE

WITH HOPKINS JUST IN TERMS OF MY

EDUCATION, AND I WON'T GO INTO

THE DETAILS OF THAT, BUT IT HAD

TO DO WITH THE FACT THAT

PROFESSORS THAT I HAD WERE

TRAINED BY PROFESSORS ALL THE

WAY BACK TO SIR WILLIAM OSLER

AND PROFESSOR HALSTED.

AND SO, WE CLAIM THAT, SO I TELL

MY ASPIRING FELLOWS SO YOU CAN

CLAIM IT TOO, YOU KNOW, BECAUSE

YOU -- YOU KNOW, WE'RE WORKING

TOGETHER.

WELL, I HAVE SOME HERITAGE AT

NIH THAT I WANT TO CLAIM, THAT

I'M VERY PROUD OF.

AND MY FRIEND JOHN HERE HAS

ALREADY MENTIONED THE MAIN ONE,

ACTUALLY.

AND THAT WAS THE HONOR AND

PRIVILEGE AND THE EDUCATIONAL

EXPERIENCE OF SITTING ON THE

ADVISORY COUNCIL FOR THE

NATIONAL CENTER FOR MINORITY

HEALTH AND HEALTH DISPARITIES.

NOT ONLY THE ACTUAL EXPERIENCE

OF THE WORK WE WERE DOING, BUT

THE COLLECTIVE WISDOM AND

KNOWLEDGE THAT I HAD LEARNED

FROM JOHN AND FROM HIS STAFF AND

FROM MY FELLOW ADVISORY BOARD

MEMBERS -- VERY ENRICHING,

EDUCATIONAL EXPERIENCE,

PRACTICAL, REALISTIC,

STATE-OF-THE-ART.

AND SO I CLAIM THAT HERITAGE

WITH GREAT PRIDE.

I ALSO, GOING BACK A LITTLE BIT

FARTHER, HAD A VERY POSITIVE NIH

EXPERIENCE AS I SERVED -- I WAS

AN AD HOC REVIEWER A FEW TIMES

FOR SOME OF THE

ORTHOPEDIC-RELATED RESEARCH, BUT

I ENDED UP ALSO BEING ASKED TO

BE ON THE ADVISORY COUNCIL FOR

THE NATIONAL CENTER FOR

DIGESTIVE, KIDNEY AND

MUSCULOSKELETAL DISEASES.

AND THAT WAS, AGAIN, A VERY

ENRICHING EXPERIENCE.

AND EVEN MORE, I GUESS,

IMPORTANT, IS THAT I CLAIM THE

HERITAGE OF NIH AND I HAD THE

PRIVILEGE OF BEING AN NIH

TRAINEE UNDER PROFESSOR WILLIAM

SOUTHWICK WHO HAD BEEN A STUDENT

OF PROFESSOR ROBINSON AT

HOPKINS, AND PROFESSOR ROBINSON

WAS ALSO INVOLVED AT NIH.

AND WE HAD A TRAINEESHIP WHICH

ACTUALLY ALLOWED ME TO STUDY IN

SWEDEN, IN GOTHENBURG, SWEDEN,

AND AT KAROLINKSA WITH A

PROFESSOR, CARL HIRSCH, WHO AT

THAT TIME WAS THE LEADING

PROFESSOR OF ORTHOPEDIC

BIOMECHANICS, IN A SENSE, AND

GAVE US OPPORTUNITIES TO GET A

LAB STARTED AT YALE WHERE WE

CAME BACK.

AND ACTUALLY, I DON'T KNOW WHERE

THE STATISTICIANS AND THE

RESEARCHERS ARE, BUT IF YOU'RE

HERE, I HAD A R01 AT YALE, AND

IT WAS DUE TO THE TRAINEESHIP

OPPORTUNITY THAT I HAD AT NIH.

SO I JUST WANTED TO SHARE THAT

IN THE SENSE OF OUR COMMON

BACKGROUND TO THE EXTENT THAT I

WANT TO CLAIM THIS HERITAGE, AND

I DO IT WITH JOY.

AND I JUST -- I DO IT TO HELP

YOU ALSO UNDERSTAND HOW HAPPY

AND PLEASED AND WELCOME I AM TO

BE HERE NOW.

SO, JUST A LITTLE BIT ABOUT WHAT

WE'LL TRY TO DO IN THE NEXT 45

MINUTES OR SO.

AND I DON'T KNOW -- IN THE

HANDOUT, THERE WAS ONE PAGE THAT

TRIED TO SORT OF INTRODUCE THE

TALK, AND IT -- BUT BASICALLY IT

SAID ONE OF THE THINGS WE WANT

TO TRY TO LOOK AT TODAY IS THE

THEME OF HUMANITARIANISM OR OUR

COMMON HUMANITY.

AND I THINK THAT'S IMPORTANT.

AND THE OTHER THING WHAT I HOPE

TO DO -- I DON'T HAVE ANSWERS

AND SOLUTIONS, BUT I HOPE TO

SORT OF LAY OUT SOME REALITIES

THAT I THINK ARE IMPORTANT FOR

US TO BE AWARE OF AROUND ISSUES

OF HEALTH CARE DISPARITIES.

AND I'M NOT HERE TO BEAT UP ON

ANYBODY OR TO MAKE ANYBODY FEEL

GUILTY OR TO ACCUSE ANYBODY OF

ANYTHING, BUT I'M HERE TO TRY TO

SHARE WHAT I SINCERELY BELIEVE

ARE CERTAIN REALITIES THAT OUGHT

TO BE ON THE TABLE AS WE LOOK TO

GO FORWARD IN THIS VERY

CHALLENGING ARENA OF HEALTH CARE

DISPARITIES.

SO, MY FRIEND JOHN, AS USUAL, IS

AHEAD OF THE CURVE AND IS

ALREADY HELPED TO INTRODUCE THIS

SITUATION HERE IN TERMS OF DR.

KING.

I SORT OF BACKED INTO THIS.

I KIND OF STUMBLED ONTO THIS

REALLY.

I WAS INVITED TO SPEAK AT ONE OF

THE HOSPITALS IN NORTHERN

MASSACHUSETTS, IN WORCESTER,

WORCESTER HOSPITAL AND FOR THE

MARTIN LUTHER KING DAY

CELEBRATION.

AND I THOUGHT, WELL, I THOUGHT I

WAS SORT OF BEING CUTE.

I SAID, WELL, WHY DON'T WE CALL

IT, YOU KNOW, "WHAT DR. KING

WOULD LIKE US TO KNOW."  AND I

REALLY, AT THAT TIME, HAD NOT

RUN ACROSS THIS QUOTE THAT DR.

RUFFIN HAS ALREADY MENTIONED TO

US: "OF ALL THE FORMS, THAT

INEQUALITY, INJUSTICE IN HEALTH

IS THE MOST SHOCKING AND

INHUMANE."  ANYBODY WANT TO HELP

ME OUT A LITTLE BIT AND SORT OF

SUPPORT THIS?

WHY DO YOU THINK DR. KING SAID

THAT?

WHY IS IT THE MOST SHOCKING AND

INHUMANE?

WELL, WHEN ARE WE MOST

VULNERABLE AS HUMAN BEINGS?

WHEN ARE WE MOST VULNERABLE?

WHEN WE'RE SICK, WHEN WE'RE

HAVING PAIN, WHEN WE'RE SCARED,

WHEN WE DON'T KNOW WHAT'S GOING

TO HAPPEN TO US.

AND WE GO TO SOMEONE WHO MAY BE

A STRANGER, WHO SPEAKS A

DIFFERENT LANGUAGE, AND WE ARE

LOOKING FOR HELP.

WE'RE LOOKING FOR CONSOLATION.

WE'RE LOOKING FOR PROGRESS.

AND SO, I THINK THAT'S PROBABLY

WHAT DR. KING, IN ALL OF HIS

WISDOM, WAS AWARE OF.

YOU KNOW, THIS WAS THE MOST

UNFORTUNATE, THE MOST SHOCKING

AND INHUMANE, BECAUSE IT'S WHEN

WE NEED HUMANITY THE MOST, WHEN

WE GO TO SEEK HELP WITH VARIOUS

DISEASES AND PROBLEMS WE MAY

HAVE.

OKAY, AGAIN, MAYBE I SHOULD JUST

LET YOU GIVE THE LECTURE.

[LAUGHS]  HERE AGAIN, MY FRIEND

JOHN HAS ALREADY MENTIONED THIS

VERY IMPORTANT REFERENCE.

AND I MENTION IT JUST TO SAY

THERE'S NO DEBATE ANYMORE ABOUT

IS THERE OR IS THERE NOT A

REALITY OF HEALTH CARE

DISPARITIES.

THERE IS SO VERY WELL AND

THOROUGHLY DOCUMENTED WITH

NUMEROUS, ADDITIONAL

PUBLICATIONS SINCE THIS

PUBLICATION THAT DEMONSTRATES

THIS REAL UNFORTUNATE REALITY OF

HEALTH CARE DISPARITIES.

SO, JUST TO SAY THERE IT IS AND

WE KNOW THAT WE'RE DEALING WITH

THIS PARTICULAR REALITY.

NOW, THE HEALTH CARE DISPARITIES

LIST WE HAVE HERE.

I'D JUST LIKE TO MENTION A FEW

OTHER THINGS.

I COME UP WITH 13, BUT I

WOULDN'T ARGUE IF SOMEONE WANTS

TO ADD ONE OR TWO OR THREE MORE.

BUT IT'S JUST KIND OF

INTERESTING TO GO OVER THESE.

SOME PEOPLE HAVEN'T PERHAPS

THOUGHT SO MUCH ABOUT THE

APPALACHIAN POOR, BUT THAT'S NOT

ONLY THE MATTER OF NOT HAVING

RESOURCES AND FUNDS, BUT THOSE

CULTURES ARE VERY, VERY

DIFFERENT.

ASIAN AMERICANS, OF COURSE, THE

ELDERLY, GLBT, VERY MUCH A

REALITY, IN SOME CASES, FOR

SLIGHTLY DIFFERENT REASONS,

THESE DISPARITIES OCCUR --

IMMIGRANTS, LATINOS, NATIVE

AMERICANS.

AND, YOU KNOW, WHO WANTS TO BE

THE FIRST OR THE WORST BUT

PERHAPS NATIVE AMERICANS, OF ALL

THESE VARIOUS GROUPS, HAVE THE

MOST MONUMENTAL DISPARITIES --

OBESE PEOPLE, PEOPLE LIVING WITH

DISABILITIES, SOME RELIGIOUS

GROUPS, WOMEN, AND NOT JUST

MINORITY WOMEN, AS WE POINT OUT.

AND ALSO, SOMETIMES WHEN I

MENTION THIS, I MENTION THAT AS

WE SIT HERE AND COMMUNICATE WITH

ONE ANOTHER, THERE ARE PATIENTS

SITTING IN EMERGENCY ROOMS,':–

SITTING IN DOCTOR'S OFFICES,

LYING IN HOSPITAL BEDS, ABOUT TO

RECEIVE DISPARATE CARE IN THE

NEXT SECONDS AS WE GO FORWARD.

AND THIS IS AN UNFORTUNATE

REALITY.

AND WOMEN, AND NOT JUST MINORITY

WOMEN, AND ALSO OUR

GRANDDAUGHTERS AND OUR DAUGHTERS

AND OUR SISTERS AND OUR MOTHERS

AND OUR GRANDMOTHERS AND OUR

WIVES, ALL EXPERIENCE HEALTH

CARE DISPARITIES, OR IN THE

GROUP THAT RECEIVES HEALTH CARE

DISPARITIES.

SO, HOW MANY PEOPLE BELIEVE IN

THE TEN COMMANDMENTS?

HELP ME OUT, YEAH.

OKAY.

HOW MANY BELIEVE IN THE ELEVEN

COMMANDMENTS?

YOU GUYS DON'T KNOW ABOUT THE

ELEVENTH COMMANDMENT?

WELL, AS YOU SEE HERE, MOSES HAS

THE TWO TABLETS.

HE'S COMING DOWN THE MOUNTAIN,

AND ALL THOSE STONES ARE AROUND.

AND HE SLIPPED.

AND HE FELL, AND ONE OF THE

TABLETS CRACKED OFF.

THE BOTTOM OF IT CRACKED OFF,

AND IT SLID DOWN THE

MOUNTAINSIDE, NEVER TO BE FOUND

AGAIN.

AND THE ELEVENTH COMMANDMENT WAS

ON THAT -- ON THE ONE THAT WENT

DOWN.

AND DO YOU KNOW WHAT IT SAID?

THOU SHALT NOT COMMIT ISMS.

THAT WAS THE 11TH ONE.

AND I SAW THIS ON TELEVISION A

FEW WEEKS BACK WHEN THE WORLD

CUP COMPETITION WAS GOING ON.

AND IT REALLY IMPRESSED ME.

IT IMPRESSED ME FOR A LOT OF

REASONS, BUT ONE OF THE REASONS

IS -- AND AS YOU'LL SEE, WE LIKE

TO TRY TO KIND OF EXPAND THIS A

LITTLE BIT TO BE A GLOBAL ISSUE

WHEN WE TALK ABOUT

HUMANITARIANISM.

AND THIS IS GLOBAL.

IT'S A WORLD CUP.

AND SOMEWHERE BETWEEN THE

PLAYERS AND THE COACHES AND THE

ORGANIZERS, THEY WANTED TO GET

TOGETHER AND MAKE THIS STATEMENT

ON GLOBAL TELEVISION, A MAJOR,

MAJOR GLOBAL SPORTING EVENT.

THEY WANTED TO PUT THIS BEFORE

THE OBSERVERS AND THE

PARTICIPANTS.

SO I THOUGHT THAT WAS AN

IMPORTANT RESPONSE.

I HAD THE PLEASURE -- AGAIN, I

DIDN'T CLAIM THIS PART OF MY

HERITAGE BUT I COULD HAVE.

HAD THE PLEASURE LAST WEEK OF

BEING HERE WITH A GROUP OF

COLLEAGUES TO LOOK AT ISSUES OF

DISCUSSIONS ABOUT SUGGESTIONS

AND FUTURE ACTIVITIES FOR THE

NATIONAL CENTER -- FOR THE

NATIONAL INSTITUTE FOR MINORITY

HEALTH AND HEALTH DISPARITIES.

AND THIS SLIDE WAS I THINK VERY

HELPFUL JUST AS A WAY OF

REMINDING US OF THE TREMENDOUS

COMPLEXITY OF THE ISSUE THAT WE

ARE ATTEMPTING TO UNDERSTAND AND

CORRECT AND CHANGE.

AND SOME OF THOSE THINGS ARE

HARD TO READ, BUT IT JUST SHOWS

THE HEALTH PRACTICES, VARIOUS

TYPES OF ENVIRONMENTAL

STRESSORS, VARIOUS TYPES OF

INTERNAL RESPONSES, AND THEN

FINALLY -- YES, IN THE OVERALL

CHAIN OF THINGS, THE INTERACTION

BETWEEN THE CAREGIVER AND THE

PATIENT IS WHERE THAT ULTIMATE

OUTCOME IS CENTERED.

ANOTHER WAY TO LOOK AT IT IS

JUST -- IS WE LOOK AT THE

QUALITY OF CARE DIFFERENCE OVER

TO THE LEFT OF THE SLIDE, AND WE

SEE THAT THAT IS IN PART DUE TO

APPROPRIATENESS OF PATIENT'S

RESPONSES AND, AS WE SEE AT THE

BOTTOM, DISCRIMINATION, BIAS,

STEREOTYPING, AND UNCERTAINTY.

SO THERE ARE MANY DIFFERENT

NODES OF ATTACK, NODES TO STUDY,

NODES TO UNDERSTAND, NODES TO

TRY TO CHANGE IN THIS COMPLEX

ISSUE.

SO LET'S GO BACK A LITTLE BIT

AND JUST, AS A REMINDER, JUST A

FEW OF MANY, MANY EXAMPLES THAT

WERE IN THE "UNEQUAL TREATMENT"

IOM REPORT.

AFRICAN AMERICANS -- FEWER

KIDNEY AND LIVER TRANSPLANTS.

WITH DIABETES, MORE AMPUTATIONS.

WITH PROSTATE CANCER, MORE

CASTRATIONS.

AMONG ALL WOMEN, COMPARED WITH

MEN, FEWER JOINT REPLACEMENTS,

LESS MEDICATION FOLLOWING HEART

ATTACK.

WOMEN HEART ATTACK PATIENTS

ACTUALLY TAKE MORE TIME TO GET

THEM TO THE EMERGENCY FACILITY

IN THE EMT TRANSPORT SYSTEM.

THIS IS ACTUALLY A DIFFERENCE

THAT HAS BEEN NOTED IN THAT

SYSTEM.

FOR HISPANICS, LESS PAIN

MEDICATION FOR MAJOR FRACTURES,

LESS BYPASS SURGERY FOR HEART

DISEASE, LESS BASIC RECOMMENDED

SERVICES SUCH AS FLU SHOTS AND

FLU VACCINATIONS.

LET'S GO BACK TO THAT FRACTURE A

LITTLE BIT INVOLVED WITH

ORTHOPEDICS.

I COULDN'T HELP BUT NOTICE THAT.

AND THIS IS A SITUATION IN WHICH

A STUDY WAS DONE IN SOUTHERN

CALIFORNIA, AND LATINO MEN

SHOWING UP IN THE EMERGENCY ROOM

WITH A FRESH LONG BONE FRACTURE.

THAT'S A MAJOR BONE IN YOUR ARM,

YOUR HUMERUS, YOUR THIGH, YOUR

LEG BELOW THE KNEE, MAJOR LONG

BONE FRACTURE.

NOT A DIFFICULT DIAGNOSIS TO

MAKE.

NOT A VERY DEBATABLE DIAGNOSIS.

IT'S OBJECTIVE, CLEAR ON X-RAY,

AND VERY, VERY PAINFUL.

AND AS IT TURNS OUT, THE STUDY

REVEALED THAT THE LATINO MALES

COMPARED WITH CAUCASIAN MALES–r

HAD 50 PERCENT LESS CHANCE OF

GETTING NARCOTIC PAIN MEDICATION

FOR A FRESH LONG BONE FRACTURE

PRESENTING IN THE EMERGENCY

ROOM.

SO, THIS WAS PRETTY DRAMATIC AND

PRETTY SHOCKING.

AND IT WAS DONE -- A COMPARABLE

STUDY WAS DONE IN ATLANTA.

HERE, THIS TIME, THEY LOOKED AT

AFRICAN AMERICAN MALES COMPARED

WITH CAUCASIAN MALES AND HAD

ESSENTIALLY THE SAME OUTCOME AS

WITH THE OTHER GROUP.

SO THIS IS JUST DRAMATIC AND, OF

COURSE, PAIN MEDICATION IS A

FREQUENT AREA OF DISPARATE CARE.

SO, JUST TO KIND OF RETRACE SOME

OF THIS AND SUMMARIZE IT, I

GUESS YOU WOULD SAY.

THE LADY SAYS, "GIVE IT TO ME

STRAIGHT, DOC," YOU KNOW,

"WHAT'S WRONG WITH ME?"  AND

THERE IT IS.

YOU'RE NOT A WHITE MALE.

AND YOU KNOW, YOU CAN LOOK AT

THAT, AND IF YOU REALLY -- YOU

KNOW, YOU THINK ABOUT IT, YOU

COULD CONVINCE YOURSELF THAT

THIS LADY IS AN ELDERLY LADY AS

WELL.

AND MAYBE SHE'S A BIT OVERWEIGHT

AS WELL.

AND MAYBE SHE'S A LESBIAN.

AND SO, WITH ALL OF THAT, WHAT

KIND OF CUMULATIVE EXPECTATION

DO WE ACCRUE FOR SUCH A PATIENT?

I'D LIKE TO SPEND A LITTLE BIT

OF TIME ON THIS.

THIS IS CALLED THE RACIAL

ICEBERG.

AND I THINK THIS IS ONE KIND OF

IMPORTANT BRICK IN WHAT I WANT

TO SHARE WITH YOU THIS

AFTERNOON.

AND THAT IS TO SHARE THIS

CONCEPTUALIZATION OF RACE AS

DEPICTED IN THIS DIAGRAM.

SO LET'S START WITH THE RACIAL

ICEBERG IN THE CENTER.„i

AND CHARACTERISTICALLY, AN

ICEBERG IS 90 PERCENT BELOW THE

SURFACE, 10 PERCENT ABOVE.

AND THE BOAT CRASHES INTO THE

ICEBERG, AND WE CAN THINK OF

THAT AS A RACIAL INCIDENT.

YOU KNOW, WE SEE THEM ALL THE

TIME.

IF YOU HAPPENED TO SEE THE

MOVIE, "CRASH," IT WAS A FULL

MOVIE OF EVERY KIND OF

CONCEIVABLE RACIAL/ETHNIC

CONFLICT, MISUNDERSTANDING,

STEREOTYPING YOU CAN HAVE.

AND SO, ONE OF THOSE INCIDENTS

OCCURS, BUT THE POINT IS THAT

THAT'S NOT JUST AN INCIDENT.

THERE'S THE IMPACT OF THE BOAT

TO THE ICE, BUT THAT IS

OCCURRING IN THE SEA OF HISTORY.

SO YOU GO DOWN TO THE BOTTOM

HERE, THE SEA OF HISTORY.

SO WHAT IS IT IN THE SEA OF

HISTORY THAT'S RELEVANT?

AND WE BELIEVE, OR AT LEAST

THESE AUTHORS BELIEVE, AND I

AGREE WITH THEM, I BELIEVE THAT

IMPACTS, THAT RACIAL INCIDENT,

WHAT IMPACT IS THERE FROM THE

SEA OF HISTORY?

SO WHAT'S IN THE SEA OF HISTORY?

SLAVERY, IRAN-CONTRA, CHINESE

EXCLUSION ACT, THE MONROE

DOCTRINE -- ALL OF THESE THINGS

ARE STILL HAVING AN EFFECT, AS

WE ARE HERE TODAY, STILL HAVING

AN IMPACT ON THE DAY-TO-DAY

REALITIES OF RACE --

MEXICAN-AMERICAN WAR, LYNCHINGS,

IMMIGRATION, JAPANESE INTERNMENT

ACT, THE CIVIL WAR, COLONIALISM,

AND JIM CROW.

SO, ALL OF THOSE THINGS ARE

IMPACTING OUR DAY-TO-DAY

ACTIVITIES.

THEY ARE PRESENT IN OUR

ENVIRONMENT.

THEY'RE ON AUTOMATIC PILOT.

THEY ARE REALITIES THAT ARE

CONSTANTLY OPERATIVE.

AND THIS COMES FROM THE WORK

FROM THE CENTER AT STANFORD, AT

STANFORD UNIVERSITY, THE CENTER

FOR COMPARATIVE STUDIES IN RACE

AND ETHNICITY.

AND IT'S A COMBINED INSTITUTE

THAT BRINGS TOGETHER PROFESSORS,

GRADUATE STUDENTS, UNDERGRADUATE

STUDENTS FROM A VARIETY OF

DISCIPLINES, AND THEY STUDY

PRACTICALLY EVERY CONCEIVABLE

KIND OF RACIAL INCIDENT YOU CAN

THINK OF IN THE WORLD.

AND I THINK IT'S A RELEVANT

MESSAGE.

THE TITLE OF THE BOOK IS CALLED

"DOING RACE," AS YOU SEE DOWN AT

THE BOTTOM.

THE EDITORS ARE MARKUS AND MOYA,

AND IT'S PUBLISHED BY NORTON

PRESS.

BUT JUST TO EMPHASIZE THIS A

LITTLE BIT MORE, I'D LIKE TO

SHARE WITH YOU THEIR DEFINITION

OF RACE.

RACE IS DOING A DYNAMIC SET OF

HISTORICALLY DERIVED AND

INSTITUTIONALIZED IDEAS AND

PRACTICES -- AND OBVIOUSLY,

THEY'VE CHOSEN THESE WORDS VERY,

VERY CAREFULLY -- PRACTICES THAT

SORTS PEOPLE INTO ETHNIC GROUPS

ACCORDING TO PERCEIVED PHYSICAL

AND BEHAVIORAL HUMAN

CHARACTERISTICS THAT ARE OFTEN

IMAGINED TO BE NEGATIVE, INNATE,

AND SHARED.

MOREOVER, RACE ASSOCIATES

DIFFERENTIAL VALUE, POWER, AND

PRIVILEGE WITH THESE

CHARACTERISTICS, ESTABLISHES A

HIERARCHY AMONG THE DIFFERENT

GROUPS, AND CONFERS OPPORTUNITY

ACCORDINGLY.

SO, "DOING RACE," WE CAN ALL

THINK OF NUMEROUS EXAMPLES, BUT

LET'S JUST VERY BRIEFLY MENTION

A FEW.

THESE ARE ANECDOTAL, BUT I THINK

THEY ARE BASED ON RESEARCH.

EMPLOYMENT -- THE STUDY THAT WAS

DONE, PEOPLE TOOK A RESUME THAT

WAS A VERY POSITIVE, IMPRESSIVE

RESUME, AND THEY PUT AFRICAN

AMERICAN NAMES AT THE TOP, A

VARIETY OF AFRICAN AMERICAN

NAMES AT THE TOP -- SAME RESUME,

THEY PUT CAUCASIAN NAMES AT THE

TOP.

AND THEY SENT THEM OUT TO A

BUNCH OF PEOPLE ASKING THEM IF„i

THEY WOULD CALL THESE PEOPLE

BACK FOR AN INTERVIEW OR NOT

CALL THEM BACK FOR AN INTERVIEW.

WELL, THE ONES WITH THE AFRICAN

AMERICAN NAMES GOT CALLED BACK,

OR WERE LISTED TO BE CALLED BACK

AT A MUCH SIGNIFICANTLY LOWER

RATE THAN THE SAME RESUMES WITH

CAUCASIAN NAMES AT THE TOP.

THAT'S JUST ONE EXAMPLE.

HOUSING, WE'LL COME BACK TO

HOUSING, SAY A LITTLE BIT MORE

ABOUT THAT.

BUT FOR NOW, WE CAN SAY THAT OUR

COUNTRY IS AS SEGREGATED

RESIDENTIALLY AS IT EVER WAS AT

ANY TIME IN ITS EXISTENCE.

AND THAT CONTINUES.

SCHOOLING, THE WORK OF GLORIA

WHITE-HAMMOND, I BELIEVE, WHO

SHOWED THAT SO MANY OF THE

SCHOOLS IN LESS WELL-FINANCED

NEIGHBORHOODS OR LOWER-ZIP CODE

TYPE NEIGHBORHOODS REALLY ARE

PREPARING THE STUDENTS TO GO TO

JAIL IN LARGE PERCENTAGES SOONER

OR LATER.

MEDICINE, WE'RE TALKING ABOUT

MEDICINE.

 JUSTICE, SIMPLE ONE.

IF YOU'RE AFRICAN AMERICAN AND

YOU'RE UNFORTUNATELY CONVICTED

OF MURDER OF A WHITE PERSON,

YOUR CHANCES OF HAVING THE DEATH

PENALTY IS SIGNIFICANTLY GREATER

THAN IF YOU KILLED A BLACK

PERSON.

SPORTS, BLACK REFS CALL MORE

FOULS ON WHITE PLAYERS, AND

WHITE REFS CALL MORE FOULS ON

BLACK PLAYERS.

MEDIA, SOMEONE BOTHERED TO STUDY

MOVIES PRODUCED IN THE U.S.

SINCE WE HAD SOUND MOVIES,

STARTING WITH NO SOUND AND

STARTING THERE, GOING ALL THE

WAY THROUGH, AND THEY REVIEWED

600 MOVIES LOOKING FOR WHETHER

OR NOT ARABS WERE DEPICTED IN A

POSITIVE LIGHT, A NEUTRAL LIGHT,

OR A NEGATIVE LIGHT.

AND 22 OF THOSE WERE REVIEWED,

AND THEY WERE DEPICTED IN A

POSITIVE LIGHT.

TWELVE OF THEM WERE REVIEWED AND

DEPICTED IN A NEUTRAL LIGHT.

THE OTHER 500-PLUS WERE DEPICTED

NEGATIVELY.

SO THESE THINGS ARE HAPPENING A

LOT.

I'D LIKE TO GO BACK TO HOUSING

JUST FOR A MINUTE, AND WE TALKED

ABOUT NEIGHBORHOODS.

WELL, THIS WAS A NEIGHBORHOOD,

YOU KNOW, UPPER CLASS KIND OF A

ZIP CODE NEIGHBORHOOD WHERE A

BLACK FAMILY WAS LIVING NEXT TO

A WHITE FAMILY.

AND, YOU KNOW, THE AMERICAN

TRADITION, I GUESS, OF KEEPING

UP WITH THE JONESES KIND OF

BEGAN TO EVOLVE.

SO THE WHITE GUY PUT IN A NICE

POOL ON HIS SIDE AND REALLY

VERY, VERY NICE.

SO THE BLACK GUY DID THE SAME

THING, PUT IN A NICE POOL.

AND THEN WHITE GUY ADDED TO HIS

HOUSE IN THE BACK A NICE SECOND

STORY, VERY NICE, ELEGANT.

AND BLACK GUY DID THE SAME

THING.

AND LO AND BEHOLD, A FEW MORE

MONTHS WENT BY, AND THE WHITE

GUY BOUGHT THIS VERY UPSCALE,

CLASSIC, EXPENSIVE AUTOMOBILE.

THE BLACK GUY SAID, "ALL RIGHT,

I'M TIRED.

I CAN'T PUT UP WITH THIS.

I GOT TO END THIS."  SO HE TOLD

HIS WIFE, "I'LL BE RIGHT BACK."

SHE SAID, "WELL, WHAT ARE YOU

GOING TO DO?"  HE SAID, "DON'T

WORRY, I'LL BE RIGHT BACK."  SO

HE GOES NEXT DOOR.

HE KNOCKS ON THE DOOR, AND HIS

WHITE NEIGHBOR OPENS THE DOOR,

AND HE SAY, "LOOK, YOU CAN'T

KEEP UP WITH ME.

I DON'T KNOW WHY YOU KEEP DOING

THIS.

WHY DON'T YOU JUST GIVE UP?"  HE

SAID, "I DON'T HAVE NO BLACK

FOLKS LIVING NEXT DOOR TO ME."

[LAUGHTER]

OKAY, WELL, SO, WHAT ABOUT THE

ROLE OF STEREOTYPING, CONSCIOUS

AND UNCONSCIOUS BIASES IN THIS

DIFFICULT, CHALLENGING PROBLEM

OF HEALTH CARE DISPARITIES?

AND IT IS A MAJOR ITEM.

AND IF I HAD TO TRY TO PICK ONE

THING TO KIND OF LEARN IN MY

INCREMENTAL KNOWLEDGE IN KIND OF

READING OF THIS AREA AND TALKING

TO PEOPLE, IS THE TREMENDOUS

POWER OF OUR SUBCONSCIOUS AND

WHAT A MAJOR ROLE IT PLAYS AND

WHAT KINDS OF TRICKS IT PLAYS ON

US AND HOW WE THINK WE'RE

THINKING ONE WAY A LOT OF TIMES

WHEN WE'RE REALLY THINKING

ANOTHER WAY.

OR WE THINK WE'RE IN CONTROL,

AND WE REALLY AREN'T.

SO THIS IS SOMETHING THAT I

THINK IS VERY REAL AND WORTH

SPENDING A LITTLE BIT OF TIME

ON.

PROFESSOR BANAJI AND OTHER

ASSOCIATES HAVE DEVELOPED

SOMETHING CALLED THE IMPLICIT

ASSOCIATION TEST.

AND I'D ENCOURAGE YOU TO JUST

JOT DOWN, IF YOU WOULD, THE URL

FOR THAT, IMPLICIT.HARVARD.EDU.

AND WHAT IT IS, IT'S A

COMPUTER-BASED TEST THAT YOU CAN

TAKE, AND YOU CAN TEST WHETHER

OR NOT YOU MIGHT HAVE

SUBCONSCIOUS BIAS IN A VARIETY

OF DIFFERENT SETTINGS AGAINST

WOMEN, YOU CAN ASK THAT

QUESTION, AGAINST AFRICAN

AMERICANS YOU CAN ASK THAT

QUESTION, AGAINST OBESE PEOPLE

YOU ASK THAT QUESTION, AGAINST

ELDERLY PEOPLE, ET CETERA.

AND THERE ARE ABOUT EIGHT OR SO

DIFFERENT CATEGORIES THAT YOU

CAN TEST SOME OF THE TRADITIONAL

"ISMS" IF YOU WILL, AND IN THE

PRIVACY, AS I'VE SAID, OF YOUR

OWN COMPUTER INTERACTION.

AND I THINK IT'S INTERESTING AND

IT BRINGS UP SOME VERY REALISTIC

REALITIES.

HERE'S AN EXAMPLE.

OH, BY THE WAY, THIS IS -- I

THOUGHT I WAS KIND OF LEARNING

ABOUT, OH, ISN'T THIS

INTERESTING?

I'VE DISCOVERED THE SUBCONSCIOUS

IS VERY ACTIVE AND SO FORTH.

A GENTLEMAN BY THE NAME OF

SHANKAR VEDANTAM WROTE A WHOLE

BOOK ON IT CALLED "THE HIDDEN

BRAIN," AND IT'S AN EXCELLENT

BOOK, AND IT HAS NUMEROUS,

NUMEROUS EXAMPLES OF HOW OUR

SUBCONSCIOUS CAN PLAY TRICKS ON

US.

AND THIS IS ONE THAT'S HERE

ACTUALLY.

AND IF YOU LOOK TO THE RIGHT,

YOU'LL SEE SORT OF A GRAPH.

AND WHAT THIS IS, THIS IS

CHARTING -- IF YOU JUST BACK UP

A MINUTE AND THINK ABOUT, OKAY,

THIS IS A OFFICE SETTING WHERE,

IN THE CORNER OF THE OFFICE

WHERE, KIND OF EXCLUDED WHERE NO

ONE CAN SEE IT, THERE'S A SET UP

WHERE YOU CAN GO IN AND YOU CAN

HAVE A CUP OF COFFEE WITH CREAM

AND SUGAR, AND THEN YOU'RE

SUPPOSED TO PUT IN X AMOUNT OF

MONEY IN THE KITTY, ON THE HONOR

SYSTEM.

AND SO THAT'S THE WAY IT WORKED.

SO THIS EXPERIMENT, THOUGH, GOT

PEOPLE TO DO THIS, TO DO THEIR

USUAL ROUTINE ACTIVITY WITH THE

COFFEE, BUT THE EXPERIMENTER WAS

ABLE TO MANIPULATE THINGS SO

THAT ON ONE WEEK, THE BLACK DOTS

-- EVERY OTHER WEEK IS A BLACK

DOT -- PEOPLE CAME VERY CLOSE TO

PAYING WHAT YOU OUGHT TO BE

PAYING ON THE HONOR SYSTEM, FULL

FARE FOR YOUR COFFEE.

BUT IN ALTERNATE WEEKS, WITH THE

WHITE DOTS YOU SEE THERE, THEY

WERE PAYING MUCH LESS, LESS THAN

50 PERCENT OF THE OTHER WEEKS.

AND SO WHAT WAS HAPPENING?

WELL, WHAT WAS HAPPENING WAS

THAT IN ONE WEEK, SEE, AT THE

TOP, THE VERY TOP, YOU SEE

FLOWERS.

WELL, THERE WAS A POSTER ON THE

WALL WITH FLOWERS.

AND THEN THE NEXT WEEK THERE WAS

A POSTER ON THE WALL WITH EYES.

AND THEN ALTERNATELY, YOU HAD

FLOWERS AND YOU HAD EYES.

AND WHEN THE STUDY WAS OVER,

PEOPLE HADN'T EVEN NOTICED THERE

WAS ANYTHING ON THE WALL, BUT IT

HAD AN IMPACT PRESUMABLY ON

THEIR SUBCONSCIOUS AND MADE A

SIGNIFICANT DIFFERENCE IN THEIR

RESPONSE TO THE HONOR SYSTEM IN

THAT PARTICULAR SETTING.

AND IF YOU LOOK AT THE ONE DOWN

AT THE BOTTOM HERE, THE EYES

THERE, IT'S WAY OUT THERE.

[LAUGHS]  OKAY, SO, BUT THAT'S

MAKING IT OPERATIVE.

NOW, HERE'S ANOTHER MORE

SOBERING EXAMPLE, THOUGH.

THIS IS A PIVOTAL WORK BY ALEX

GREEN; WAS DONE SEVERAL YEARS

AGO.

BUT IT'S REALLY AN EXPERIMENTAL

DEMONSTRATION OF THE ACTUAL

INCIDENTS OF UNCONSCIOUS BIAS

AFFECTING A DOCTOR-PATIENT

RELATIONSHIP.

SO, VERY SIMPLY PUT, DR. GREEN

HAD A GROUP OF RESIDENTS AND HE

ASKED THEM IF THEY WERE BIASED

AGAINST AFRICAN AMERICANS, AND

THEY SAID NO.

AND HE SAID, OKAY.

AND THEN HE GAVE THE IAT TEST,

IMPLICIT ASSOCIATION TEST THAT

WE TALKED ABOUT.

AND IT WAS FOR PREJUDICE AGAINST

AFRICAN AMERICANS.

AND A NUMBER OF THEM SHOWED UP

POSITIVE FOR UNCONSCIOUS BIAS

AGAINST AFRICAN AMERICANS.

HE THEN GAVE A THEORETICAL

CLINICAL PICTURE FOR THE

RESIDENTS TO REVIEW AND

DETERMINE TREATMENT.

AND THIS CLINICAL PICTURE WAS OF

AFRICAN AMERICAN PATIENTS.

AND THE OUTCOME WAS, OOPS, SOME

OF THE RESIDENTS WHO HAD THOUGHT

THEY WERE NOT BIASED, WHO HAD

TESTED POSITIVE ON THE IAT TEST,

DID NOT PRESCRIBE

ANTI-COAGULATION THERAPY FOR

PATIENTS WHO HAD DISTINCT

SYMPTOMS OF A HEART ATTACK AND

SHOULD, BY ANY CLINICAL

CRITERIA, HAVE BEEN GIVEN

ANTI-COAGULATION THERAPY.

SO HERE'S AN EXPERIMENTAL

DEMONSTRATION OF UNCONSCIOUS

BIAS AGAINST A GROUP OF PATIENTS

IN THE CLINICAL SETTING.

SO I THINK THAT'S QUITE A

MILESTONE STUDY.

ANOTHER REALITY THAT WE WANT TO

PUT ON THE TABLE, AND WE CAN

TURN THIS A LOT OF WAYS.

THIS IS JUST ONE ITEM FROM A

VERY IMPRESSIVE STUDY BY LAVEIST

AND COLLEAGUES.

BUT ESSENTIALLY, THEY REVIEWED

BETWEEN 2003 AND 2006 THE EXCESS

COSTS INVOLVED IN LOOKING AT THE

AFRICAN AMERICAN PATIENTS,

EXCESS COSTS RELATED TO

DISPARATE CARE PROVIDED TO

AFRICAN AMERICAN PATIENTS.

THEY LOOKED AT ASIAN PATIENTS

AND HISPANIC PATIENTS.

THEY COMBINE ALL OF THOSE AND

THERE WAS A 30.6 PERCENT OVERAGE

ON THE COST OF CARE OF THESE

INDIVIDUALS.

SO WE EXPEND THE CARE -- WE

CREATE ADDITIONAL CLINICAL

PROBLEMS.

AND IT'S UNFORTUNATE.

THE PATIENTS SUFFER IN THE

MEANTIME, BUT SOONER OR LATER,

THE ECONOMICS ARE SUCH THAT WE

PAY FOR IT ON THE BACK END

NEVERTHELESS.

THE MOST OBVIOUS EXAMPLE OF THAT

WOULD BE A PATIENT WITH AN

INFECTED IN-GROWING TOENAIL THAT

GETS BLOWN OFF OR TREATED

INADEQUATELY OR NOT CAREFULLY

EVALUATED, AND THE PATIENT'S

DIABETIC, NOT COMMUNICATING

WELL.

THAT PATIENT IS MORE LIKELY TO

END UP WITH AN AMPUTATION THAN

IF THAT IN-GROWING TOENAIL, THAT

INFECTED TOENAIL IS TREATED

APPROPRIATELY INITIALLY.

AND, OF COURSE, THE AMPUTATION

IS MORE EXPENSIVE TO DO.

THE AMPUTATION IS MORE EXPENSIVE

TO TAKE CARE OF FOR THE REST OF

THE PATIENT'S LIFE, AND THE

PATIENT MAY BE LESS PRODUCTIVE

IN TERMS OF HIS OR HER

CONTRIBUTION TO SOCIETY, I.E.

ABILITY TO WORK.

SO IT -- THERE'S A GOOD ECONOMIC

CASE TO BE MADE IN ADDITION TO

THE MORE PREVAILING OR MORE

IMPORTANT ETHICAL/MORAL CASE.

AGAIN, TO BE REALISTIC, I'D LIKE

TO GO THROUGH SOME OF THE

DOCTOR'S STRESSORS.

AND I'M NOT TRYING TO COP OUT

FOR DOCTORS.

I JUST WANT TO MENTION SOME OF

THE REALITIES OF THE WHOLE

EQUATION OF WHAT WE'RE FACING

HERE.

ERROR PREVENTION -- YOU REMEMBER

THE INSTITUTE OF MEDICINE

PRODUCED A DOCUMENT MAYBE 15

YEARS AGO NOW, WHICH SAID,

"DOCS, YOU KNOW, YOU'RE MAKING A

LOT OF MISTAKES.

WE NEED YOU TO PAY MORE

ATTENTION -- WE SOMEHOW NEED TO

DIMINISH OUR ERRORS AND WE NEED

TO FOCUS ON THAT."  AND THAT WAS

TAKEN CONSCIENTIOUSLY, AND A

NUMBER OF PROGRAMS DEVELOPED TO

TRY TO ADDRESS THAT.

BUT THAT'S A STRESSOR.

THAT'S A STRESSOR.

WHAT ABOUT MALPRACTICE?

WELL, EVERYBODY KNOWS THAT

THAT'S A STRESSOR.

WE ORTHOPEDISTS KNOW IT ALSO.

SLEEP DEPRIVATION, A VERY

IMPORTANT ISSUE.

AND THAT IS A REALITY.

THAT'S PART OF A DOCTOR'S

REALITY AS WE SPEAK.

PROFESSIONALISM ENHANCEMENT --

NOW WHAT I MEAN HERE, AND I'LL

MENTION THIS AGAIN LATER, BUT

THE AMERICAN BOARD OF INTERNAL

MEDICINE, A FEW YEARS BACK, AND

I'LL HAVE THE DATE LATER, BUT

THEY RAISED THE BAR REALLY FOR

PROFESSIONAL RESPONSIBILITY.

THEY SAID NOT ONLY DOCTORS

CHARGED WITH PROFESSIONALLY

RESPONSIBLE FOR TAKING CARE OF

THEIR INDIVIDUAL PATIENTS, BUT

THEY REALLY SHOULD BE WORKING

WITHIN THE SOCIETY TO ADDRESS

ISSUES THAT IMPACT THE HEALTH

CARE OF THE PATIENTS THAT

THEY'RE TAKING CARE OF.

SO ADDED PROFESSIONAL

RESPONSIBILITY.

THE AMERICAN COLLEGE OF

SURGEONS, 40 PERCENT BURNOUT.

THIS IS A FAIRLY RECENT STUDY

WITHIN THE LAST FOUR YEARS -- 40

PERCENT BURNOUT, 30 PERCENT

DEPRESSION.

SO THAT WOULD SUGGEST SOME

STRESS.

PERSONAL FINANCIAL DEBT.

AS YOU KNOW, MEDICAL STUDENTS

CAN GRADUATE $150,000, $250,000

IN DEBT.

AND THAT'S NOT RARE.

CONFLICT OF INTEREST ISSUES,

THAT'S BEEN ADDRESSED RECENTLY,

BOTH IN THE ORTHOPEDIC IMPLANT

INDUSTRY AND IN THE

PHARMACEUTICAL INDUSTRY.

THERE IS, YOU KNOW,

INAPPROPRIATE FAVORS.

OUR STATE STEPPED UP TO THE BAT

AND SAYS, "YOU HAVE TO REPORT

ANY MEAL THAT YOU GIVE A DOCTOR

OVER $25."  AND APPARENTLY,

VARIOUS GROUPS STOPPED MEETING

IN MASSACHUSETTS, EFFECT OF THE

ECONOMY, SO THEY HAD TO RAISE

THE BAR A LITTLE BIT ON THAT.

BUT CLEARLY, THERE SHOULDN'T BE

THOSE KINDS OF SECONDARY

INCENTIVES.

PATIENT THROUGH-PUT RATES.

YOU KNOW, EVERY CLINIC WANTS

DOCTORS TO SEE MORE PATIENTS

FASTER.

CONFLICT OF INTEREST ISSUES, I

JUST MENTIONED.

MORE TEACHING TIME REQUESTED BY

THE DEANS.

OKAY.

WHAT ABOUT KEEPING UP WITH

KNOWLEDGE?

AND WE'RE HEARING WE NEED MORE

PRIMARY CARE DOCTORS.

AND FOR GENERAL PRACTITIONERS,

IN ORDER TO KEEP UP WITH THE

LITERATURE, THE DOCTOR NEEDS TO

READ ONLY 19 ARTICLES PER DAY,

365 DAYS A YEAR, SO THAT COULD

BE A BIT OF A DOCTOR STRESSOR.

MORE: STRUGGLE FOR REIMBURSEMENT

AFTER THE WORK IS DONE, ONE THEN

HAS TO THEN STRUGGLE WITH THE

INSURANCE COMPANY TO GET THROUGH

ENOUGH PAPERWORK TO HAVE THE

PAYMENT COME THROUGH.

AND THIS CAN COST UP TO $85,000

A YEAR TO HIRE ONE FULL-TIME

PERSON PER DOCTOR TO MANAGE AND

NEGOTIATE THE INSURANCE

TRANSACTIONS AFTER THE CARE HAS

BEEN PROVIDED.

THIS ONE REALLY SURPRISED ME --

VIOLENCE IN HEALTH FACILITIES

ARE FOUR TIMES AS COMMON AS IN

OTHER PRIVATE SECTOR INDUSTRIES.

THAT WAS REALLY QUITE A SURPRISE

TO ME.

BUT THERE IT IS, JAMA, DECEMBER

2010.

OPERATING COSTS RISING FASTER

THAN REFERRALS.

REIMBURSEMENTS DECLINING.

DIFFICULTY COLLECTING FROM

SELF-PAY PATIENTS.

SO THESE ARE ALL DOCTOR

STRESSORS, AND HERE'S THE LAST

COUPLE HERE.

UNCERTAIN THAT MEDICARE RATES

AND THEN CHOOSING AND

IMPLEMENTING ELECTRONIC HEALTH

RECORDS.

CERTAINLY THIS IS IMPORTANT, AND

EVERYONE AGREES THAT THIS NEEDS

TO BE DONE.

BUT APPARENTLY IT TAKE A LOT OF

TIME AND A LOT OF EFFORT AND A

LOT OF STRESS TO FIRST CHOOSE

THE SYSTEM THAT ONE IS GOING TO

USE, BUT THEN A LOT TO IMPLEMENT

IT.

SO WE'RE LOOKING AT ALL OF THESE

THINGS, AND THEN SOME GUYS COMES

ALONG AND SAYS, "OH, AND BY THE

WAY, YOU'RE A RACIST."

[LAUGHTER]

SO, IT IS A CHALLENGE.

OKAY, SO, THIS IS SOMETHING JUST

ONE OF MY GOOD COLLEAGUES AND

FRIENDS HELPED US TO PUT

TOGETHER A PAPER.

THIS IS NOT A META-ANALYSIS, BUT

JUST LOOKING THROUGH THE

LITERATURE AT STRATEGIES AND

THINGS THAT ARE BEING DONE,

THINGS THAT ARE BEING SUGGESTED,

THINGS THAT ARE BEING TRIED TO

ELIMINATE HEALTH CARE

DISPARITIES.

AND IT'S KIND OF A LONG LIST,

BUT I THINK IT'S WORTH GOING

THROUGH AND THIS ISN'T THE WHOLE

LIST.

AND WE CALL IT -- WELL, WE FOUND

OVER 100 SOLUTIONS ACTUALLY, IF

YOU COUNT SOME OF THE VARIOUS

EFFORTS.

BUT JUST LET'S LOOK AT A FEW.

THIS ONE'S VERY IMPORTANT.

IMPROVE HEALTH LITERACY.

AND WE COULD PUT IN PARENTHESES,

HAVE MORE LAY EDUCATION, MORE

UNDERSTANDING ON THE PART OF LAY

PATIENTS ABOUT THE REALITIES OF

HEALTH CARE DISPARITIES, AND

PROVIDE SOME BASIC FUNDAMENTAL,

REASONABLE KNOWLEDGE TO HELP

THEM TO COPE WITH IT, TO HELP

THEM TO HELP THE DOCTOR HELP

THEM.

AND IT'S IN THEIR BEST INTERESTS

TO DO THAT.

SO HEALTH LITERACY SEEMS TO MAKE

SENSE.

EDUCATE THE CAREGIVERS.

THAT IS, TRY TO TEACH CULTURALLY

COMPETENT CARE TO DOCTORS,

NURSES, AND OTHERS IN THE

HOSPITAL SETTING WHO ARE LOOKING

AFTER PATIENTS -- EMERGENCY

MEDICAL TECHNICIANS, ET CETERA.

INCREASED DIVERSITY AMONG

CAREGIVERS.

THIS WAS -- THE SULLIVAN

COMMISSION REPORT SORT OF MADE

THAT ARGUMENT LOUD AND CLEAR AND

CONVINCINGLY, I BELIEVE.

AND THAT IS GOING TO BE VERY

HELPFUL AND VERY IMPORTANT TO

DIMINISHING AND ELIMINATING

HEALTH CARE DISPARITIES.

MORE NURSES, MORE DENTISTS, MORE

DOCTORS WHO ARE FROM THE

UNDERREPRESENTED MINORITY

GROUPS.

HERE'S JUST A LITTLE FOLLOW-ON

TO THAT.

THIS STUDY, DONE AT UC DAVIS

MEDICAL SCHOOL, COMPARED A

NUMBER OF ITS MEDICAL SCHOOL

GRADUATES WHO HAD BEEN ADMITTED

ON THE AFFIRMATIVE ACTION

PROGRAM THAT THEY HAD, AND THEY

COMPARED THEM WITH THE STUDENTS

WHO WERE ADMITTED IN THE ROUTINE

MANNER THAT THEY HAD BEEN

ADMITTING THEIR MEDICAL

STUDENTS.

AND THE GRADUATION RATE WAS 94

PERCENT FOR THE AFFIRMATIVE

ACTION AND 97 PERCENT FOR THE

ROUTINE; A VERY, I BELIEVE,

INSIGNIFICANT DIFFERENTIAL.

AND ALSO THEY LOOKED AT

SPECIALIZATION RATES, RESIDENCY

PERFORMANCE, WHICH IS PROBABLY

THE MOST IMPORTANT, AND HONORS

RECEIVED.

AND IN THOSE THREE CATEGORIES,

THERE WAS NO DIFFERENCE BETWEEN

THESE GROUPS OF STUDENTS AT THAT

PARTICULAR MEDICAL SCHOOL THAT

HAD BEEN ADMITTED ON AFFIRMATIVE

ACTION OR ON A ROUTINE BASIS.

OTHER SOLUTIONS:

PROFESSIONALISM, WE MENTIONED

THAT.

AND THAT WAS -- THE REFERENCE IS

LANCET, AS YOU CAN SEE, 2002.

INCREASING PROFESSIONALISM TO

INCLUDE ETHICS AND SOCIAL

RESPONSIBILITY.

PROMOTE COMMUNITY-BASED EFFORTS.

THIS SEEMS TO BE SOMETHING

THAT'S VERY POSITIVE AND SEEMS

TO RESONATE WELL AND SEEMS TO BE

VERY HELPFUL.

I DON'T THINK A LOT OF EVIDENCE

BASIS EXIST FOR IT YET, BUT

CLEARLY IT RESONATES WITH PEOPLE

AND IT SEEMS TO BE AN EFFECTIVE

OPPORTUNITY.

LEVERAGE GOVERNMENT INFLUENCE AS

PAYERS.

FOR BETTER OR FOR WORSE, STILL,

OUR GOVERNMENT SPENDS AN AWFUL

LOT OF MONEY ON HEALTH CARE,

CLINICAL HEALTH CARE SERVICES.

AND IT COULD DEMAND MORE

EVIDENCE OF EQUITABLE CARE FOR

THE BILLS THAT ITS PAYING IN

THAT AREA.

THIS ONE'S QUITE INTERESTING IN

MY OPINION.

AND THAT IS THAT THE STATE OF

NEW JERSEY NOW, FOR ABOUT THREE

YEARS, HAS REQUIRED DOCTORS, IN

ORDER TO GET THEIR LICENSE

RENEWED OR IN ORDER TO GET A NEW

LICENSE TO PRACTICE IN THE

STATE, THEY MUST SHOW SOME

EVIDENCE OF CULTURALLY COMPETENT

CARE EDUCATION THAT THEY HAVE

HAD.

AND THERE'S SOME CRITERIA THAT

IS SPECIFICALLY DONE.

NO OTHER STATE IN THE UNION, TO

MY KNOWLEDGE, HAS DONE THIS.

CALIFORNIA HAS STEPPED UP AND

SAID ALL GRADUATE MEDICAL

EDUCATION COURSES, CONTINUING

MEDICAL EDUCATION COURSES,

SHOULD HAVE SOME COMPONENT

INCLUDING CULTURALLY COMPETENT

CARE EDUCATION.

SOME OTHER STATES HAVE TRIED TO

DO WHAT NEW JERSEY DID, BUT THEw

LAWS DIDN'T PASS, AND I IMAGINE

SOME OF THOSE WILL BE REVISITED

AT SOME POINT.

BUT I THINK THAT THAT IS A VERY

GOOD WAY TO HELP DOCTORS TO BE

ABLE TO CHANGE SOME OF THE

PRACTICES AND TO INCENTIVIZE

THEM.

THIS ONE IS QUITE INTERESTING.

VERIZON CORPORATION.

AS WE KNOW, CORPORATIONS

PURCHASE CONTRACTS AND HAVE

AGREEMENTS WITH VARIOUS

INSURANCE COMPANIES AS TO WHOSE

GOING TO COVER THEIR EMPLOYEES.

AND VERIZON HAS SAID, OKAY, TELL

US WHAT YOU'RE GOING TO DO TO

PROVIDE EQUITABLE CARE AND THEN

WE'LL CHOOSE, WE'LL MAKE OUR

DECISION AS TO WHOSE GOING TO DO

THAT.

I THINK IF MORE CORPORATIONS DID

THAT, THAT TOO WOULD BE

ENORMOUSLY HELPFUL.

I MEAN, THAT'S A DISTINCT

ECONOMIC INCENTIVE.

THE ACGME, WHICH IS THE AGENCY

WHICH MONITORS AND ASSESSES THE

REQUIREMENTS FOR RESIDENT

EDUCATION, AND THEY DO REQUEST

SOME EVIDENCE OF CULTURAL

COMPETENCY AS PART OF THEIR

TRAINING.

HOWEVER, AS FAR AS I KNOW, THEY

DO NOT EXAMINE FOR THIS

INFORMATION AND THESE SKILLS,

AND THAT'S SOMETHING THAT IS

BEING LOOKED AT AS MAYBE AN

IMPROVEMENT.

THE LIAISON COMMITTEE ON MEDICAL

EDUCATION IS THE ORGANIZATION

THAT APPROVES ALL MEDICAL

SCHOOLS IN THE U.S. AND CANADA.

AND THEY HAVE TWO DIRECTIVES

THAT ADDRESS CULTURALLY

COMPETENT CARE EDUCATION.

THE FIRST ONE IS 21, AND IT SAYS

STUDENTS SHOULD HAVE SOME

KNOWLEDGE, SOME GENERAL

KNOWLEDGE OF THE PATIENT

POPULATIONS THAT CONSTITUTE A

SUBSTANTIAL PORTION OF THE

PATIENTS THEY'RE LOOKING AFTER.

IN OTHER WORDS, IF YOU'RE IN A

COMMUNITY WITH A LOT OF ARAB

PATIENTS, YOU SHOULD HAVE SOME

SENSE OF WHAT SOME OF THOSE

CULTURAL ISSUES MIGHT BE OR

WHATEVER GROUP YOU MIGHT WANT TO

ENGAGE IN THIS WAY.

AND EDUCATIONAL DIRECTIVE 22 IS

ONE THAT SAYS STUDENTS MUST BE

TAUGHT SOMETHING ABOUT THEIR OWN

BIASES.

THAT IS, THEY SHOULD STUDY

THEMSELVES AND HAVE SOME SENSE

OF WHAT THEIR BIASES MIGHT BE

AND SHOULD GAIN SOME DEGREE OF

COMPETENCE AND ABILITY TO

RECOGNIZE THE BIASES OF OTHERS

AND TO BE ABLE TO DISCUSS SOME

OF THESE ISSUES.

NOW, ANOTHER LITTLE THING IS A

STUDY THAT WE DID TO LOOK AT

REGARDING WHAT WORKS.

CULTURALLY COMPETENT CARE

PEDAGOGY, WHAT WORKS.

WELL, IN THIS REVIEW, 2011, WE

DID NOT FIND ANYTHING THAT HAD

EVIDENCE BASIS THAT IT COULD

CHANGE PATIENT OUTCOMES.

THERE ARE A NUMBER OF THINGS

THAT CAN CHANGE PHYSICIANS'

KNOWLEDGE, PHYSICIANS' ATTITUDES

AND PHYSICIANS' COMFORT, ET

CETERA.

BUT SO FAR, THERE IS NOT

SOMETHING THAT HAS BEEN

DEMONSTRATED TO ACTUALLY CHANGE

OUTCOMES.

SO WE DO STILL HAVE A MAJOR

PROBLEM, A REAL CHALLENGE, BUT I

THINK WE CAN LOOK AND WE CAN

STUDY AND WE CAN MAKE PROGRESS

BECAUSE THAT IS CRUCIAL.

AND AS WE SAW FROM ONE OF OUR

EARLIER GRAPHS, NO MATTER HOW

YOU LOOK AT IT, SOME OF THESE

DISPARITIES OCCUR BASED ON THE

LACK OF FULL AWARENESS AND

ABILITY ON THE PART OF THE

CAREGIVERS.

THIS IS JUST KIND OF A LITTLE

TEXTBOOK APPROACH, VERY WELL

DONE AND AUTHORED BY THE

DEPARTMENT OF HEALTH AND HUMAN

SERVICES AND IT IS THE NATIONAL

STANDARDS FOR CULTURALLY AND

LINGUISTICALLY APPROPRIATE

SERVICES.

AND IT'S KIND OF A COOKBOOK

THING, THAT SAYS, YOU KNOW, IF

YOU DO ALL THESE THINGS IN YOUR

CLINIC OR IN YOUR HOSPITAL OR IN

YOUR AREA, IN YOUR HEALTH

FACILITY, YOU'LL BE MOVING

FORWARD TOWARDS CULTURAL

COMPETENCE.

AND IT SAYS, YOU KNOW, THEY HAVE

SOME EVIDENCE OF RECOGNITION OF

THE CULTURES INVOLVED, SOME

PICTURES ON YOUR WALL, MAGAZINES

ON THE TABLE THAT RELATE TO THE

CULTURES YOU ENGAGE WITH,

SOMEONE IN YOUR OFFICE MAYBE WHO

LOOKS LIKE THE PATIENTS YOU'RE

TAKING CARE OF -- ALL OF THOSE

THINGS CAN BE HELPFUL.

AND, OF COURSE, THEY EMPHASIZE

TREMENDOUSLY, WHICH I HAVE NOT

DONE SO FAR, THE IMPORTANCE OF

TRANSLATORS IN ORDER TO BE ABLE

TO BETTER UNDERSTAND WHAT WE'RE

DOING AND WHAT WE'RE TRYING TO

DO TO TAKE CARE OF OUR PATIENTS.

AND WE TELL OUR MEDICAL STUDENTS

ACTUALLY THAT THE FIRST

PROCEDURE IN PATIENT CARE,

PROCEDURE NUMBER ONE, IS

COMMUNICATIONS BECAUSE TO THE

EXTENT THAT THAT GETS DISCOUNTED

OR MISUNDERSTOOD, OR  YOU'RE

SORT OF BEHIND THE EIGHT BALL

BEFORE YOU EVEN GET STARTED IN

YOUR CARE.

THIS IS AN ATTEMPT, A BOOK THAT

WE COMPLETED ABOUT A YEAR AGO,

AND IT ATTEMPTS TO ADDRESS SOME

OF THESE HUMAN ISSUES.

IT ATTEMPTS TO HELP FOLKS TO

UNDERSTAND MAYBE OR TO TRY TO

ANALYZE HOW ACTUALLY THESE

THINGS ARE OCCURRING, WHAT'S

REALLY HAPPENING IN THE

DOCTOR-PATIENT RELATIONSHIP, AND

WHAT ARE SOME OF THE THINGS WE

CAN DO TO THINK ABOUT TO TRY TO

IMPROVE THAT.

AND ONE OF THE THINGS THAT WE

EMPHASIZE, AS WE'VE ALREADY

SAID, IS HUMANITY.

BUT WE ACTUALLY SUGGESTED

DOCTORS TRY TO HUMANIZE THEIR

PATIENTS; THAT IS, TRY TO

RECOGNIZE AND TRY TO IN SOME WAY

INTERACT WITH THE PATIENT ON A

HUMAN-TO-HUMAN BASIS, ALONG WITH

THE OTHER THINGS THAT YOU'RE

DOING.

AND THAT RESONATES WITH YOUR OWN

HUMANITY AND YOUR OWN PLEASURE

AND SATISFACTION AND ABILITY TO

DO THE JOB THAT YOU'RE DOING AS

A CAREGIVER AS WELL AS YOU CAN

DO IT.

AND THIS IS A QUOTE FROM BISHOP

TUTU WHICH PUTS THAT VERY

CLEARLY.

AND ONE OF THE THINGS THAT WE --

WHEN WE HAVE AN OPPORTUNITY TO

TALK TO PATIENTS IN TERMS OF

PATIENT EDUCATION, IS WE

ENCOURAGE THE PATIENT TO

HUMANIZE THE DOCTOR AS WELL AND

TRY TO RELATE SOMEHOW TO THE

DOCTOR'S HUMANITY.

AND EVEN SIMPLE THINGS LIKE TO

BREAK THE ICE OR TO TALK ABOUT

JUST EVEN TALKING ABOUT THE

WEATHER.

I MEAN, EVERYBODY EXPERIENCES

THE WEATHER ONE WAY OR ANOTHER,

AND YOU CAN SORT OF SAY

SOMETHING AND THE PERSON, THE

DOCTOR REALIZES THAT YOU'RE

TRYING TO REACH OUT TO HIM OR

HER AND VICE VERSA WITH THE

PATIENT.

SO I THINK THAT'S WHAT MAYBE IS

PART OF WHAT'S RECOGNIZED IN

THIS QUOTATION.

SO, JUST A FEW SUGGESTIONS FOR

CAREGIVERS THAT WE TRY TO OFFER.

ONE IS, FIRST OF ALL, BELIEVE

THAT BIASES EXIST.

BELIEVE THAT HEALTH CAREF(

DISPARITIES EXIST.

I THINK THERE ARE A LOT OF

DOCTORS STILL WHO SAY "I DON'T

KNOW WHAT YOU'RE TALKING ABOUT.

I TAKE GOOD CARE OF ALL OF MY

PATIENTS," CASE CLOSED.

AND I BELIEVE THAT MANY DO, BUT

UNFORTUNATELY THERE'S A LOT OF

UNCONSCIOUS THINGS THAT ARE

GOING ON.

BELIEVE THAT THESE DISPARITIES

CAN BE DIMINISHED, AND THEY CAN

BY CHANGING OUR BEHAVIOR AND

DOING OTHER THINGS TO HELP DO

THAT.

REVIEW AND SELECT FROM THIS

CLINICALLY AND LINGUISTICALLY

APPROPRIATE SERVICES DOCTRINE --

BY THE WAY, THAT HAS BEEN

UPDATED AND IS AVAILABLE OR SOON

WILL BE AVAILABLE WITH AN

UPDATE.

EXPLORE SELF AWARENESS.

THAT'S THAT EDUCATIONAL

DIRECTIVE 22.

MEDICAL STUDENTS AND DOCTORS

SHOULD BE AWARE, SHOULD TRY TO

BECOME AWARE OF THEIR OWN

BIASES, WHICH CAN BE HELPFUL.

AND ONCE YOU KNOW THIS, YOU CAN

KNOW WHAT THE YELLOW LIGHTS ARE.

IT CAN BE A RESPONSE.

MAYBE YOU'RE BIASED AGAINST

ELDERLY PEOPLE, AND YOU WALK IN

A ROOM AND YOU SEE AN ELDERLY

PERSON, YOU CAN SORT OF -- A

YELLOW LIGHT WILL FLASH ON, SO

TO SAY, AND YOU JUST KIND OF

RE-DOUBLE YOUR EFFORTS TO MAKE

SURE YOU PROVIDE THE BEST CARE

YOU CAN FOR THAT PARTICULAR

PATIENT.

AND ANOTHER VERY HELPFUL THING

IS ACTUALLY IF WE ALL COULD

PRACTICE EVIDENCE-BASED MEDICINE

100 PERCENT OF THE TIME, WE

PROBABLY WOULD ELIMINATE HEALTH

CARE DISPARITIES THAT WAY EVEN

IF WE DIDN'T DEVELOP

CROSS-CULTURAL SKILLS BECAUSE WE

DO GO A LONG WAY IN TERMS OF

QUALITY OF CARE IF IT CAN BE

EVIDENCE-BASED.

HUMANIZE OUR PATIENTS, WE SAID

THAT.

AND YOU KNOW, WE CAN DO POLICY

CHANGES AND THOSE KINDS OF

THINGS.

AND AS I SAY, THAT THE PEOPLE

WHO ARE EXPERIENCING THESE

THINGS ARE SITTING IN DOCTORS'

OFFICES RIGHT NOW AS WE SPEAK,

IN EMERGENCY ROOMS RIGHT NOW,

AND LYING IN HOSPITAL BEDS,

ABOUT TO RECEIVE DISPARATE CARE.

SO WE DON'T HAVE TIME FOR A LOT

OF POLICY CHANGES.

WHAT WE WANT TO DO IS KIND OF

APPLY THE DOUBLE F CRITERIA, IF

YOU WILL, TREAT PATIENTS AS

FAMILY OR FRIENDS.

ANOTHER TECHNIQUE THAT CAN BE

HELPFUL IN COMMUNICATIONS IS THE

TEACH-BACK.

SO AT THE END OF THE VISIT, WE

CAN KIND OF REVIEW WITH THE

PATIENT, "MS. JONES, YOU KNOW,

WHAT DO YOU UNDERSTAND ABOUT

WHAT WE TALKED ABOUT TODAY AND

WHAT YOUR DIAGNOSIS IS AND HOW

WE ARE GOING TO TRY TO TREAT IT,

ET CETERA.

CAN YOU JUST BRIEFLY TELL ME?"

AND THEN MS. JONES GIVES YOU

SOME IDEA THAT SHE UNDERSTANDS,

THAT'S FINE.

IF SHE DOESN'T, YOU CAN SORT OF

CORRECT HER AND SAY, "WELL,

REMEMBER, WE ALSO TALKED THING

A, B, AND C, AND THEN BEFORE YOU

LEAVE NOW, WOULD YOU JUST TELL

ME AGAIN WHAT YOU UNDERSTAND."

AND YOU KEEP GOING UNTIL YOU GET

IT RIGHT.

I THINK THAT CAN BE HELPFUL.

QUICK CLEAN [SPELLED

PHONETICALLY], THERE'S A LOT

MORE TO IT THAN THIS, BUT JUST

AS A START, SUPPOSE YOU GET

INVOLVED AS A PHYSICIAN IN SOME

CRUSTY INTERACTION, YOU KNOW,

SOME CONFLICT WITH A PATIENT.

THE PATIENT ACCUSES YOU OF BEING

PREJUDICED IN SOME WAY.

WELL, JUST STEP BACK, RELAX,

APOLOGIZE WITHOUT MAKING ANY

EXCUSES, AND SAY, "OKAY, I'M

SORRY, MS. JONES, BUT I WANT TO

TAKE CARE OF YOU.

I WANT TO LOOK AFTER YOU, SO CAN

WE GET STARTED AGAIN, CAN WE GO

FORWARD, YOU KNOW, AND I THINK I

CAN HELP YOU."  AND THAT CAN

SOLVE A LOT OF THE PROBLEMS BUT

NOT ALL PERHAPS.

ANOTHER SIMPLE THING, TREAT ALL

PATIENTS WITH RESPECT.

ASPIRE TO PATIENT-CENTERED CARE.

ESTABLISH DIVERSITY IN BOTH THE

CLINICAL AND THE SUPPORT STAFF.

AND JUST A FEW SUGGESTIONS FOR

PATIENTS: WE ALREADY TALKED

ABOUT ONE.

HUMANIZE YOUR DOCTOR.

TRY TO HELP THINK ABOUT BUILDING

A BRIDGE TO MEET THE DOCTOR

HALFWAY.

HE OR SHE, YOU KNOW, ISN'T

NECESSARILY CULTURALLY SENSITIVE

AND ADEPT TO ALL OF THESE

NUANCES, SO TRY TO HELP THEM,

AND I THINK THAT CAN BE VERY

HELPFUL.

IF THINGS AREN'T WORKING FOR YOU

WITH YOUR DOCTOR AND YOU THINK

THERE MAY BE A BIAS OF SOME

SORT, I THINK DO A FRANK CHECK,

YOU KNOW.

KIND OF SAY, "WELL, YOU KNOW,

DOCTOR, I CAME HERE BECAUSE OF

YOUR REPUTATION, BECAUSE I KNEW

OF YOU OR SOMEONE RECOMMENDED

YOU, AND I WAS REALLY LOOKING

FORWARD TO GETTING SOME HELP,

BUT, YOU KNOW, IT SEEMS LIKE

YOU'RE NOT LISTENING OR YOU'RE

BUSY OR THINKING ABOUT SOMETHING

ELSE.

YOU KNOW, HAVE YOU HAD ASIAN

PATIENTS BEFORE OR" -- YOU KNOW,

IF THE DOCTORS DOESN'T GIVE YOU

A COMFORTING RESPONSE TO THAT,

YOU MAY WANT TO HAVE ANOTHER

DOCTOR, PARTICULARLY IF THEY

BECOME ANNOYED OR IRRITATED OR

AGGRAVATED IN THAT KIND OF

SETTING.

OKAY, THIS IS VERY IMPORTANT,

MAYBE THE MOST IMPORTANT FOR

PATIENTS, AND THAT IS THE STUDY

OF DISEASE.

YOU'RE NOT GOING TO TRY TO

MANAGE IT BY YOURSELF, BUT STUDY

IT SO THAT YOU UNDERSTAND IT AS

MUCH AS YOU CAN, AND YOU WILL

HAVE MUCH BETTER CARE.

YOU WILL BE ABLE TO COOPERATE

AND HELP YOUR DOCTOR TO HELP YOU

MUCH BETTER.

AND THERE, AS I MENTIONED, TWO

WEBSITES THERE.

THERE'S ALSO A HARVARD MEDICAL

SCHOOL WEBSITE, A HOPKINS

WEBSITE, AND OTHERS.

AND AGAIN, IF YOUR DOCTOR

DOESN'T DO A TEACH-BACK, YOU MAY

WANT TO TRY TO DO A TEACH-BACK

AND SAY, YOU KNOW, JUST BEFORE I

LEAVE, DOCTOR, MAY I MAKE SURE I

UNDERSTAND, YOU KNOW, WHAT WE'RE

DOING AND WHY.

AND TAKE A FRIEND WITH YOU.

IF CONFIDENTIALITY IS NOT AN

ISSUE, BY ALL MEANS, TAKE A

FRIEND WITH YOU.

SO, IN SUMMARY, I WOULD SAY THAT

THIS IS A FORMIDABLE NATIONAL

PROBLEM WE MUST IMPROVE.

WE MUST IMPROVE IT.

WE MUST SYNERGIZE OUR COMMON

HUMANITIES.

THIS SITUATION IS NOT YOUR

FAULT.

AND IT'S NOT MY FAULT.

BUT IT IS YOUR RESPONSIBILITY

AND MY RESPONSIBILITY TO DO WHAT

WE CAN TO IMPROVE IT AS

EXPEDITIOUSLY AS POSSIBLE.

THIS IS A PHOTO THAT I HAPPENED

TO GET AND SAVE FROM BACK IN

1963.

THERE WAS A BRUNCH IN OAKLAND,

CALIFORNIA TO HONOR DR. KING.

AND I WISH I COULD TELL YOU THAT

HE TAUGHT ME ALL THESE THINGS.

I CAN'T.

BUT I CAN TELL YOU THAT HE'S

CERTAINLY INSPIRED ME IN A WAY

THAT -- I DIDN'T REALLY TALK

WITH HIM THAT MUCH, BUT JUST

BEING PRESENT WITH HIM IN THAT

SETTING HAS BEEN AN ONGOING

SOURCE OF INSPIRATION.

I BELIEVE THAT DR. KING WOULD

WANT US TO CONTINUE TO STRIVE TO

BE A MORE HUMANE SOCIETY AND FOR

DOCTORS, NURSES, AND OTHERS TO

BE HUMANITARIAN ROLE MODELS.

BE WELL AND THANK YOU.

THANK YOU VERY MUCH.

[APPLAUSE]

DR. JOYCE HUNTER:

I THINK WE DEFINITELY HAVE TO

GIVE DR. WHITE ANOTHER ROUND OF

APPLAUSE FOR A VERY INFORMATIVE

PRESENTATION.

[APPLAUSE]

AT THIS POINT, WE'RE GOING TO

OPEN THE FLOOR TO QUESTIONS.

AND I'M GOING TO ASK YOU TO

PLEASE GO TO THE MICROPHONES

THAT ARE ON EITHER SIDE OF THE

STAIRWELL.

SO WE'LL OPEN THE FLOOR FOR

QUESTIONS NOW.

AND AS I ALWAYS SAY, DON'T BE

SHY.

COME ON.

DR. AUGUSTUS A. WHITE III:

THERE'S SOMEBODY UP THERE AT THE

MICROPHONE.

MALE SPEAKER:

HI.

I WAS WONDERING -- YOU WERE

TALKING ABOUT THE RELATIONSHIP

BETWEEN THE PATIENT AND THE

DOCTOR AND THE DOCTOR RESPECTING

THE PATIENT AND SO FORTH.

HOW DOES A DOCTOR BALANCE, LIKE

A PATIENT LIKE -- COULD BE

OBESITY, COULD BE SMOKING, WHERE

THEY KEEP GIVING THEM ADVICE,

"YOU NEED TO DO THIS TO HELP

YOUR HEALTH," AND THEY SEE THEM

YEAR AFTER YEAR AND THEY DON'T

DO IT.

DOES THE DOCTOR JUST KEEP

INSISTING, OR DOES THE DOCTOR

SAY, OKAY, THEY'RE NOT LISTENING

TO ME.

I SHOULD JUST STOP INSISTING.

I SHOULD RESPECT THEIR CHOICES.

I MEAN, HOW DO YOU BALANCE

RESPECTING WHAT A PERSON WANTS

TO DO WITH THEIR BODY VERSUS

WHAT YOU MEDICALLY KNOW THEY

NEED TO DO AND SO FORTH?

DR. AUGUSTUS A. WHITE III:

THAT'S AN EXCELLENT QUESTION.

AND I THINK IT'S A VERY COMPLEX

ETHICAL QUESTION THAT YOU COULD

DEBATE AT LENGTH, REALLY.

WELL, I GUESS ALL I CAN DO IS

SORT OF TELL YOU THE WAY I DID

IT, JUST TAKING THAT PARADIGM.

AND THAT IS I TRIED HARD, REALLY

HARD, TO GET THE PATIENT TO DO

WHAT I THOUGHT WAS IN THEIR BEST

INTERESTS.

AND I MADE A JUDGMENT CALL

SOMEWHERE ALONG THE WAY THAT I

SHOULD KEEP TRYING OR I SHOULD

GIVE UP.

AND I THINK IT'S A VERY

REALISTIC QUESTION.

YOU KNOW, YOU MAKE A JUDGMENT

CALL.

BUT IN GOOD FAITH, OBVIOUSLY,

YOU DON'T WANT TO JUST BLOW THEM

OFF WITHOUT REALLY TRYING VERY,

VERY HARD.

BUT I THINK THAT SOME PEOPLE

EITHER CAN'T OR JUST THEY MAKE A

CHOICE.

YOU KNOW, THEY SAY, "OKAY, I

WANT TO TAKE THE RISK.

I WANT TO BE THE WAY I AM AND

LIVE WITH THE CONSEQUENCES."  I

THINK THEY HAVE THAT RIGHT.

FEMALE SPEAKER:

HI.

I THINK A LOT OF PEOPLE HAVE

DIFFERENT IDEAS AND DEFINITIONS

OF WHAT CULTURAL COMPETENCY IS.

I WAS WONDERING IF YOU COULD

PROVIDE US WITH YOUR DEFINITION

OF CULTURAL COMPETENCY.

DR. AUGUSTUS A. WHITE III:

WELL, THAT'S ANOTHER GOOD

QUESTION.

I GUESS I HAVE SEVERAL.

ONE IS THAT YOU'RE ABLE TO TAKE

CARE OF A PATIENT AND PROVIDE

THE SAME QUALITY OF CARE OF A

PATIENT THAT IS OF AN

IDENTIFIABLE GROUP THAT'S

DIFFERENT THAN YOUR OWN GROUP

AND THAT YOU CAN PROVIDE CARE

THAT IS AS GOOD AS YOU PROVIDE

FOR YOUR OWN GROUP.

AND I THINK IF YOU CAN DO THAT,

I BELIEVE YOU'RE CULTURALLY

COMPETENT.

THERE ARE THOUGHTS THAT SAY, YOU

KNOW, YOU SHOULD CARRY SOME

HUMILITY WITH THAT AND SAY,

"WELL, YOU KNOW, MAYBE I'M NOT

GOING TO BE CAPABLE OF BEING A

REALLY, REALLY GOOD CULTURALLY

COMPETENT CARE DOC FOR EVERY

CULTURE AND THAT THIS IS SUCH A

CHALLENGING AND DIFFICULT

ENVIRONMENT OR CLINICAL ISSUE

THAT IT'S HARD TO BE TOTALLY

COMPETENT IN THAT ISSUE."  I

LIKE THE FIRST DEFINITION BETTER

THAN SAYING, YOU KNOW, IT'S TOO

HARD.

I SHOULDN'T KEEP TRYING TO BE AS

GOOD AS I CAN BE IN THIS ARENA.

FEMALE SPEAKER:

HI.

MY NAME IS DAHLIA.

I JUST MOVED HERE A COUPLE OF

MONTHS AGO FROM TUSKEGEE,

ALABAMA.

AND I WAS THERE FOR A COUPLE OF

YEARS.

THERE WAS A HOSPITAL IN OPELIKA,

ALABAMA THAT WAS GENERALLY

ACCEPTED TO BE A MORE RACIALLY

CHARGED AREA, RACIALLY CHARGED

HOSPITAL.

SO A LOT OF THE BLACKS AND

LATINOS WOULD ACTUALLY GO TO

MONTGOMERY TO RECEIVE MEDICAL

CARE.

SO I WAS WONDERING IF YOU HAVE

ANY SUGGESTIONS FOR HOW WE WOULD

GO ABOUT EDUCATING AND

EMPOWERING LESS INFORMED

RELATIVES OR FRIENDS OR FAMILY

ABOUT ISSUES THAT CAN AFFECT

THEM WHEN THEY'RE IN THE

HOSPITAL AND HOW THEY APPROACH

THEIR DOCTORS, HOW TO TALK TO

THEM, HOW DO THEY ENSURE THEIR

CARE IS APPROPRIATE, THINGS LIKE

THAT.

DR. AUGUSTUS A. WHITE III:

YEAH.

WELL, I THINK THAT'S AN

EXTREMELY COMPLEX QUESTION.

AND THERE'S SO MANY ISSUES

INVOLVED, SO MANY SKILLS

INVOLVED.

AND IT RELATES IN A WAY, IN

PART, TO FUTURE AMBITIONS OR A

FUTURE AREA FOR MAKING PROGRESS,

WHICH IS TO BE ABLE TO MAKE

AVAILABLE TO THOSE PATIENTS SOME

WELL-THOUGHT-OUT GUIDELINES THAT

CAN WORK, THAT THEY CAN

PRACTICE, THAT WILL ALLOW THEM

TO KNOW WHAT KIND OF SITUATION

THEY'RE IN AND TO GIVE THEM SOME

IDEAS.

I MEAN, I MENTIONED A COUPLE OF

THINGS, THAT IF YOU ARE IN A

SITUATION WHERE YOU CAN GO

SOMEWHERE ELSE, YOU CERTAINLY

CAN EXPLORE WHETHER OR NOT YOUR

DOCTOR CARES ENOUGH TO RECOGNIZE

THE CULTURAL DIFFERENCES AND TRY

TO HELP YOU.

I MEAN, YOU DON'T WANT TO DO

THAT IF THAT'S THE ONLY DOCTOR

YOU HAVE, THE ONLY DOCTOR WHO'S

AROUND.

BUT I THINK YOU CAN SHOP AROUND

AND YOU CAN -- YOU CAN BE FRANK

AND YOU CAN SAY, YOU KNOW, THAT

"IT'S WELL KNOWN THAT THERE ARE

DIFFERENCES AND, YOU KNOW, I

REALIZE I'M A DIFFERENT CULTURE

THAN YOU ARE AND I'M A LITTLE

WORRIED.

DO YOU FEEL LIKE YOU'RE GOING TO

BE COMFORTABLE AND WE CAN WORK

TOGETHER, ET CETERA."  I MEAN,

THAT'S EASIER TO DO IF YOU, YOU

KNOW, IF YOU'RE CONFIDENT, WELL

EDUCATED AND YOU'VE READ ABOUT

YOUR DISEASE AND ALL THOSE

THINGS.

BUT, YOU KNOW, IT ISN'T AS EASY

FOR EVERYBODY TO DO.

BUT THERE'S SOME FUNDAMENTAL

THINGS THAT I THINK YOU CAN --

CERTAINLY ASK QUESTIONS, YOU

KNOW.

AND I THINK THAT CAN BE HELPFUL.

MALE SPEAKER:

HELLO.

I WAS WONDERING IF YOU COULD

SHARE YOUR THOUGHTS AND COMMENTS

ON THE ROLE OF INCREASING

DIVERSITY TRAINING AS FAR AS

M.D. PH.D.'S AND HOW THAT CAN

AFFECT HEALTH DISPARITIES ON TWO

FRONTS, BOTH ON THE RESEARCH

SIDE AS WELL AS WHAT YOU SEE AS

FAR AS OBSERVATION IN THE

CLINIC.

BECAUSE YOU KNOW, YOU TALK ABOUT

A DIVERSE WORKFORCE AS FAR AS

PHYSICIANS, MOST LIKELY IF

YOU'RE FROM -- IF YOU'RE AFRICAN

AMERICAN, YOU'RE INTERACTING

WITH AN AFRICAN AMERICAN

PATIENT, HE OR SHE MAYBE FEEL

MORE COMFORTABLE WITH YOU OR

INITIALLY THERE MIGHT BE SOME

BARRIERS OF APPREHENSION THAT

THEY MAY NOT PUT UP.

SO COULD YOU SHARE YOUR

THOUGHTS?

DR. AUGUSTUS A. WHITE, III:

SURE.

WELL, IF I UNDERSTOOD THE FIRST

PART OF YOUR QUESTION, AND I --

YOU'RE SAYING WHAT ABOUT

AFFIRMATIVE ACTION FOR MORE

DIVERSITY AMONGST PH.D.

INDIVIDUALS.

MALE SPEAKER:

NO, LIKE M.D./PH.D.'S.

DR. AUGUSTUS A. WHITE, III:

OH, YOU MEAN, COMBINING.

MALE SPEAKER:

YES, YES.

DR. AUGUSTUS A. WHITE, III:

WELL, OKAY.

ALL RIGHT, WELL, ASK THE

QUESTION AGAIN.

I MISUNDERSTOOD YOU.

MALE SPEAKER:

SO WHAT ARE YOUR THOUGHTS ABOUT

LIKE -- YOU HAVE AN M.D./PH.D.

-- YOUR THOUGHTS ABOUT

INCREASING THAT -- THOSE NUMBERS

AND HOW THEY CAN AFFECT HEALTH

DISPARITIES, BOTH ON THE

RESEARCH SIDE AS WELL AS THE

CLINICAL SIDE?

DR. AUGUSTUS A. WHITE, III:

YEAH.

WELL, THAT -- I GUESS THERE'S A

LOT OF DISCUSSION AS TO WHETHER

OR NOT, YOU KNOW, THERE ARE

PEOPLE WHO ARE M.D.'S AND THERE

ARE PEOPLE WHO ARE M.D./PH.D.'S,

AND THEN THERE ARE PEOPLE WHO

ARE PH.D.'S AND THE QUALITY AND

QUANTITY OF THEIR RESEARCH

VARIES TREMENDOUSLY.

AND I THINK -- I DON'T KNOW IF

ANYONE HAS A REAL GRASP, ANYONE

CAN SAY, "WELL, M.D./PH.D.'S DO

BETTER RESEARCH THAN PH.D.'S OR

BETTER RESEARCH THAN M.D.'S."  I

DON'T THINK YOU CAN SAY THAT.

IF YOUR QUESTION IS DO WE NEED

MORE OF ALL OF THOSE, THE ANSWER

IS YEAH, IT WOULD BE GOOD TO

HAVE.

BUT GO AHEAD.

MALE SPEAKER:

YEAH, BUT YOU KNOW, YOU SEE A

MEASURE PUSHED TO INCREASE THE

DIVERSITY IN MEDICAL SCHOOLS AND

YOU SEE A PUSH TO INCREASE

DIVERSITY IN PH.D. TRAINING, BUT

YOU ALMOST NEVER SEE A PUSH TO

INCREASE THE NUMBER OF

M.D./PH.D.S.

AND I THINK YOU KNOW, I THINK,

YOU KNOW, IT'S MORE OPPORTUNITY

TO INCREASE THE COMMUNICATION

BETWEEN BOTH SIDES, YOU KNOW, IN

REGARDS TO HEALTH DISPARITIES.

AND SO, I WAS TRYING JUST TO SEE

IF YOU HAVE ANY THOUGHTS ABOUT

WHY THERE MAY NOT BE A PUSH OR

ARE WE JUST NOT THERE YET AND

WE'RE WORKING ON THE FIRST TWO

FIRST AS FAR AS PH.D.S AND

M.D.S.

DR. AUGUSTUS A. WHITE III:

YEAH, YEAH.

I DON'T -- IT'S NOT SOMETHING

I'VE REALLY GIVEN A LOT OF

THOUGHT TO IN TERMS OF WHETHER

WE SHOULD BE ADVOCATING TO HAVE

MORE M.D./PH.D.'S.

THAT'S SOMETHING THAT ENDS TO

COME FROM THE INDIVIDUALS.

YOU KNOW, THEY ARE INCENTIVIZED

FOR ONE REASON OR ANOTHER TO

WANT TO DO BOTH, AND THEY GO

AHEAD AND DO IT.

I THINK THAT CERTAINLY MANY

RESEARCH-INTENSIVE MEDICAL

SCHOOLS WILL ENCOURAGE STUDENTS

AND ENCOURAGE OTHERS WHO HAVE

INCLINATIONS TO DO THAT.

I DON'T THINK THERE'S ANY

QUESTION ABOUT THAT.

AND I THINK THAT'S HAPPENING,

BUT IN TERMS OF THE KINDS OF

PROGRAMS THAT EXIST FOR

UNDERREPRESENTED MINORITY

MEDICAL STUDENTS, I DON'T THINK

THAT THAT'S SPECIFIC.

BUT I THINK ENCOURAGING TO BE

GOOD SCIENTISTS, TO BE GOOD

DOCTORS, TO DO RESEARCH, IN A

SENSE, COVERS THAT, I THINK.

YES.

FEMALE SPEAKER:

THANK YOU FOR YOUR TALK, VERY

INFORMATIVE.

YOU MENTIONED CULTURALLY

COMPETENT CARE EDUCATION AND

BEING IN SUPPORT OF THAT AND

SOME STATES THAT HAVE ADOPTED

LICENSURE.

WOULD YOU RESPOND TO 4 W'S?

WHERE IN THE CURRICULA SHOULD

CULTURALLY COMPETENT EDUCATION

FALL?

WHEN SHOULD IT BE TAUGHT?

BY WHOM SHOULD IT BE TAUGHT?

AND WHAT DO YOU SEE NEEDING TO

BE TAUGHT IN TERMS OF CULTURALLY

COMPETENT CARE EDUCATION?

AND I'LL SIT FOR YOUR RESPONSE.

DR. AUGUSTUS A. WHITE III:

YEAH, WELL, WE'D NEED TO SIT

TOGETHER FOR A WEEK.

[LAUGHTER]

BUT THOSE ARE ALL VERY, VERY

IMPORTANT QUESTIONS.

AND MY SENSE IS, AND MAYBE

OTHERS HAVE HAD DIFFERENT

EXPERIENCE, DIFFERENT KNOWLEDGE,

BUT MY SENSE IS, YOU KNOW, GOING

BACK TO THIS PAPER, YOU KNOW,

WHAT WORKS -- PEDAGOGY, WHAT

WORKS.

I THINK WE ARE WAY OUT OF THE

RANGE OF BEING ABLE TO BE VERY

PRECISE ABOUT THESE THINGS.

WE'RE STILL IN THE RANGE WHERE

ANYTHING IS BETTER THAN NOTHING,

AND ANYTHING HELPS, FRANKLY, IN

MY OPINION.

I MEAN, THERE'S SO LITTLE THERE

THAT I THINK ANYTHING WE CAN DO

HELPS.

WHO SHOULD TEACH IT?

I THINK ANYONE WHO'S MOTIVATED

AND INSPIRED TO LEARN THE

BASICS.

I DON'T THINK -- I MEAN, IT'S

NOT LIKE CHEMISTRY OR

MATHEMATICS OR PHYSICS.

YOU KNOW, IT'S MORE COMMON SENSE

AND CONCERN AND INTEREST IN

TRYING TO CORRECT SOMETHING THAT

NEEDS TO BE CORRECTED.

BUT AGAIN, GETTING BACK TO THE

SUBCONSCIOUS, IF WE ASSUME THAT

A SUBSTANTIAL AMOUNT OF THIS IS

SUBCONSCIOUS, THEN I WOULD

INVITE ANYONE TO TELL US HOW YOU

COMMUNICATE WITH THE

SUBCONSCIOUS AND HOW YOU RETRAIN

THE SUBCONSCIOUS AND, YOU KNOW,

WHAT WE CAN DO IN THAT ZONE.

AND I WISH I KNEW MORE ABOUT

REALLY THE STATE-OF-THE-ART AS

TO WHAT'S GOING ON IN WHICH

MEDICAL SCHOOLS.

YOU KNOW, YOU HAVE A SENSE OF IT

IN SOME SCHOOLS THAT YOU MAY BE

FAMILIAR WITH INCLUDING YOUR

OWN, BUT I DON'T THINK -- I

THINK WE HAVE A LONG WAY TO GO

TO BE ABLE TO ANSWER THAT

QUESTION.

BUT IF OTHERS HAVE DIFFERENT

INFORMATION, I'D CERTAINLY WANT

TO HEAR IT.

FEMALE SPEAKER:

[INAUDIBLE]  SEVERAL YEARS AGO,

I DID A REVIEW OF CULTURALLY

COMPETENT MEDICAL EDUCATION IN

MED SCHOOLS ACROSS THE U.S.

AND WHAT I FOUND WAS THAT

MEDICAL -- THE CULTURALLY

COMPETENT MEDICAL EDUCATION,

THERE IS NOT STANDARDIZED PLACE

FOR IT.

THERE IS NO STANDARDIZED

CURRICULA FOR IT.

IT'S TAUGHT DIFFERENTLY

DEPENDING UPON THE RELATIVE

IMPORTANCE THAT IT IS GIVEN IN

MEDICAL EDUCATION.

FOR EXAMPLE, FIRST YEAR MED

STUDENTS MAY GET SOME SMALL

PIECE OF CULTURALLY COMPETENT

MEDICAL EDUCATION, BUT BY THE

TIME THEY'RE IN THAT FOURTH

YEAR, CULTURALLY COMPETENT

MEDICAL EDUCATION, WHAT'S

HAPPENING ONCE THEY'RE EVEN IN

RESIDENCY IS NO LONGER AN

EMPHASIS.

ALSO, I FOUND THAT SOMETIMES

WHERE CULTURAL COMPETENCE IS

TAUGHT IS IN VIGNETTES, IS IN

THAT DOCTOR-PATIENT DYNAMIC

WHERE WE'RE TRAINING PERSONS HOW

TO DO GOOD HEALTH COMMUNICATION.

SO THERE WAS NOT ANYTHING THAT

WAS CONSISTENT.

THERE WAS NO -- MAY HAVE BEEN

ONE OR TWO COURSES IF YOU WANTED

TO CALL THEM THAT.

OR IF A PARTICULAR PROFESSOR

WANTED TO PLACE SOMETHING ABOUT

CULTURAL COMPETENCE IN WHAT

THEY'RE TEACHING, THEN IT WOULD

SHOW UP IN CASE STUDIES, AS AN

EXAMPLE.

BUT I DID NOT FIND THAT THERE

WAS CONSISTENCY ACROSS THE MED

SCHOOLS FOR CULTURALLY COMPETENT

EDUCATION.

DR. AUGUSTUS A. WHITE III:

THANK YOU FOR THOSE COMMENTS.

I'D VERY MUCH APPRECIATE A COPY

OF YOUR PAPER, IF I MAY CONTACT

YOU.

I'M SORRY?

FEMALE SPEAKER:

IT'S NOT PUBLISHED YET.

DR. AUGUSTUS A. WHITE III:

OH, OKAY.

THAT'S VERY -- AND IT'S A

TREMENDOUS CONTRIBUTION BECAUSE

IT IS ALL OVER THE PLACE, AND

THERE ISN'T ENOUGH, IT SEEMS.

BUT THANK YOU FOR THAT.

FEMALE SPEAKER:

I HAVE A QUICK QUESTION.

DR. AUGUSTUS A. WHITE III:

YES.

FEMALE SPEAKER:

WE'VE ALL HEARD ABOUT BIASES.

WE'VE BEEN TALKING ABOUT BIASES

AND PERCEPTIONS, BUT COULD YOU

SPEAK TO BIASES THAT EXIST OF A

DOCTOR'S PERCEPTION OF A PATIENT

-- SAY INDIVIDUAL WALKS IN AND

THEY MAY BE OF AN ETHNIC OR

RACIAL GROUP BUT THE PERSON

TURNS OUT TO BE EDUCATED OR

THEY'RE OBESE OR THEY'RE SLIM OR

THEY'RE PRETTY OR HANDSOME.

YOU KNOW, THERE ARE -- WE OFTEN

HEAR OF THOSE BIASES THAT THE --

THE IMPRESSION OF THE DOCTOR MAY

CHANGE AS THE PATIENT BEGINS TO

SPEAK AND THEY SEE THAT THIS IS

AN EDUCATED PERSON OR YOU KNOW,

OF A HIGHER SOCIOECONOMIC LEVEL.

DR. AUGUSTUS A. WHITE III:

WELL, I THINK THOSE THINGS

HAPPEN, AS YOU SUGGEST, QUITE

FREQUENTLY.

AND AGAIN, I THINK A LOT OF IT

DEPENDS ON THE DOCTOR.

I DON'T THINK THERE'S ANY --

I'VE NEVER RUN ACROSS ANY

PATTERN OR METHOD FOR ADDRESSING

THAT.

ONE OF THE THINGS, A BOOK THAT I

THINK IS VERY HELPFUL IS JEROME

GROOPMAN'S BOOK ABOUT HOW

DOCTORS THINK AND HOW WE

SOMETIMES MAKE COGNITIVE ERRORS

BECAUSE WE'RE OVERREACTING TO A

FRIEND OR OVERREACTING TO

SOMEONE WHO'S A CORPORATE

EXECUTIVE AND WE'RE ASSUMING ALL

SORT OF THINGS MUST HAVE BEEN

TAKEN CARE OF IN THAT INDIVIDUAL

WHEN, IN FACT, THEY MAY NOT HAVE

BEEN.

AND THOSE THINGS I THINK CAN

OCCUR QUITE FREQUENTLY AND, YOU

KNOW, WE JUST RECENTLY IN A

CONVERSATION, YOU KNOW,

CELEBRITIES AND DOCTORS AND

DOCTORS' FAMILIES ARE ALL AT

RISK AS PATIENTS.

AND WE USED TO ALWAYS TRY TO

TELL OUR [UNINTELLIGIBLE]

FELLOWS, PEOPLE I'M WORKING

CLOSE WITH, YOU KNOW, AS SOON AS

YOU'VE TAKEN CARE OF SOMEONE,

PUT ON YOUR HAT AND MAKE SURE

THAT YOU'VE FOLLOWED

EVIDENCE-BASED MEDICINE.

MAKE SURE YOU FOLLOW YOUR USUAL

JUDGMENT.

DON'T SEE, "OH, GEE, YOU KNOW,

PROFESSOR JONES, WE DON'T WANT

TO STICK HIM AGAIN.

WE'VE STUCK HIM THREE TIMES.

YOU KNOW, WE WON'T WORRY ABOUT

THAT STUDY."  WELL, THAT STUDY

MIGHT BE VERY IMPORTANT.

AND THAT CAN HAPPEN, YOU KNOW.

AND DR. GROOPMAN GIVES A NUMBER

OF EXAMPLES OF HOW THESE THINGS

CAN HAPPEN.

SO YOU HAVE TO BE ALERT, AS YOU

SUGGESTED, AND TAKE THOSE THINGS

INTO CONSIDERATION WHEN DOCTORS

WILL PRESENT IN DIFFERENT WAYS.

IN FACT, I WAS IN A DISCUSSION

ABOUT WHETHER OR NOT, AS A

DOCTOR, WOULD YOU LIKE TO KNOW

IF A GIVEN PATIENT THAT YOU'RE

LOOKING AFTER IS A DOCTOR OR

ISN'T A DOCTOR, IS A NURSE OR

ISN'T A NURSE.

WOULD YOU LIKE TO KNOW THAT OR

WOULD YOU NOT LIKE TO KNOW THAT?

AND IT VARIES, DIFFERENT

OPINIONS.

BUT THIS IS ANOTHER AREA OF

SENSITIVITY AND CONCERN THAT WE

HAVE TO BE AWARE OF.

YES, JOHN.

DR. JOHN RUFFIN:

WE CAN LET YOU GO

[UNINTELLIGIBLE].

AND MY QUESTION HAS TO DO MORE

WITH OPTIONS.

AND IT'S THAT WE ALL SAY THINGS

AND DO THINGS THAT WE NO DOUBT

SHOULDN'T DO OR SHOULDN'T SAY,

BUT WE ALL ANSWER TO SOMEBODY.

AND SO, JUSTIN ASKED YOU AN

INTERESTING QUESTION ABOUT -- A

PATIENT COMES IN AND THE

PATIENT'S OBESE OR WHATEVER, AND

YOU KEEP TELLING THEM THAT THEY

GOT TO LOSE WEIGHT, BUT THEY

DON'T.

SO, WHAT ARE THE OPTIONS OF A

PATIENT, LET'S SAY, IF WE COME

ACROSS A SITUATION LIKE THE ONE

THAT WAS DESCRIBED IN OPELIKA IN

ALABAMA WHERE YOU'VE GOT DOCS

WHO THE WHOLE ISSUE OF BEING

BIASED EXISTS AND THE PATIENT

COMES IN.

THE DOC WORKS FOR A HOSPITAL, OR

WORKS FOR SOMEBODY, ANSWERS TO A

BOARD OR WHATEVER.

SO I'M TAKING IT ALMOST TO A

LEGAL STEP NOW TO SAY WHAT IS

THE OPTIONS?

WHAT OPTIONS DO I HAVE IF I GO

TO A HOSPITAL AND I'M SEEKING

GOOD MEDICAL CARE, BUT FOR

WHATEVER REASON, I'M NOT GETTING

IT OR I PERCEIVE MYSELF AS NOT

GETTING IT, WHAT OPTIONS DO I

HAVE?

DR. AUGUSTUS A. WHITE III:

WELL, CERTAINLY A VERY, VERY

GOOD QUESTION.

AND I THINK THERE ARE A LOT OF

OPTIONS.

WELL, SEVERAL ACTUALLY.

NO GUARANTEED OUTCOME.

BUT IT IS -- IF THE HOSPITAL'S

-- AGAIN, IF YOU HAVE EXPERTISE,

PLEASE HELP ME, BUT I THINK IF A

HOSPITAL HAS GOVERNMENT MONEY,

IT'S A CIVIL RIGHTS ISSUE.

THEY HAVE NO RIGHT TO

DISCRIMINATE AGAINST YOU.

IT'S ILLEGAL.

I THINK THE OTHER APPROACH,

THOUGH, IS MOST HOSPITALS DO

HAVE A BOARD OF DIRECTORS.

MOST HOSPITALS DO HAVE A CEO.

AND NO HOSPITAL WANTS TO GET BAD

PUBLICITY AT ALL.

AND SO I THINK THAT ONE CAN

POLITELY WRITE A LETTER.

ONE CAN POLITELY ASK TO MEET

WITH THE NURSE, WHOEVER THE

NURSE IS ON CHARGE ON THE FLOOR,

WHOEVER THE DEPARTMENT CHAIR IS

OF THE MEDICAL DEPARTMENT AND

JUST SAY, "HERE'S WHAT HAPPENED

AND I DON'T THINK THIS WAS FAIR

OR RIGHT.

WHAT DO YOU THINK?"  YOU KNOW,

AND IT WILL SPEAK -- THE

INCIDENT WILL SPEAK FOR ITSELF,

YOU KNOW, AND I THINK HOSPITALS

WILL TEND TO PURSUE THIS.

I DON'T THINK IT HAPPENS VERY

OFTEN, THOUGH.

BUT AND, YOU KNOW, MAYBE IT

SHOULD HAPPEN MORE OFTEN, OR AT

LEAST PATIENTS SHOULD TRY OTHER

THINGS TO HOPE THAT THERE WILL

BE ADEQUATE CHANGE, BUT I DON'T

THINK -- AND OF COURSE IT'S

DIFFERENT IN BOSTON THAN IT IS

IN SOME SMALL TOWN OUT IN RURAL

GEORGIA.

I MEAN, IT'S VERY, VERY

DIFFERENT BECAUSE YOU RUN THE

RISK OF NOT HAVING ANYTHING.

SO, ONE NEEDS TO BE CAREFUL.

IF YOU'RE IN A CITY WHERE THERE,

YOU KNOW, MANY, MANY DIFFERENT

HOSPITALS, YOU CAN GO SOMEWHERE

ELSE AND GET GOOD CARE.

BUT THAT'S A VERY IMPORTANT

QUESTION.

AND THE KIND -- THIS IS -- YOU

KNOW, ALL OF THESE QUESTIONS ARE

THE KINDS OF THINGS THAT, AS WE

TRY TO DEVELOP A PATIENT

LITERACY PROGRAM AROUND ISSUES

OF HEALTH CARE DISPARITIES THAT

WE WANT TO HAVE SOME REASONABLE,

WELL THOUGHT OUT ADVICE TO OFFER

PATIENTS.

YOU KNOW, I MEAN, I'M SURE THAT

JUST BEYOND THIS QUESTION AND

ANSWER PERIOD, WE CAN DO BETTER.

YOU KNOW, WE CAN BRING MORE

MINDS, PAY MORE ATTENTION, AND

OFFER SOME DOABLE BASIC

GUIDELINES.

DR. JOYCE HUNTER:

WE'D LIKE TO THANK DR. WHITE

AGAIN FOR THAT VERY INFORMATIVE

PRESENTATION.

[APPLAUSE]

DR. AUGUSTUS A. WHITE, III:

THANK YOU VERY MUCH.

[APPLAUSE]