AN RANCISCO EDICINE S F M VOL.82 NO.9 November 2009 $5.00
JOURNAL OF THE SAN FRANCISCO MEDICAL SOCIETY
Diversity in Medicine
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In This Issue
SAN FRANCISCO MEDICINE November 2009 Volume 82, Number 9 Diversity in Medicine
FEATURE ARTICLES
10 Improving Quality and Equality: Eliminating Racial and Ethnic Disparities in Health Care Joseph R. Betancourt, MD, MPH 11 Diversity in Medicine: A Student’s Perspective Tonantzin Rodriguez, MPH
13 Minority Doctors in Short Supply: A Report on California Elizabeth Fernandez
MONTHLY COLUMNS
4 Membership Matters 7 President’s Message Charles J. Wibbelsman, MD
9 Editorial Mike Denney, MD, PhD 21 Hospital News
14 Ethic Physician Leadership Summit Satinder Swaroop, MD
16 Politics 101: Highlights from the Ethnic Physician Leadership Summit Politics 101 Workshop Randal Pham, MD, FACS
17 Ethnic Minorities in Clinical Trials: An Important Consideration Owen Garrick, MD
19 Diversity at UCSF: Addressing Current and Future Health Disparities J. Renee Navarro, Pharm D, MD OF INTEREST
24 Policy and Progress at the CMA Stephen Follansbee, MD, and Steve Heilig, MPH
Editorial and Advertising Offices 1003 A O’Reilly San Francisco, CA 94129 Phone: 415.561.0850 ext.261 Fax: 415.561.0833
Email: adenz@sfms.org Web: www.sfms.org Subscriptions: $45 per year; $5 per issue Advertising information is available on our website, www.sfms.org, or can be sent upon request. Printing: Sundance Press P.O. Box 26605 Tuscon, AZ 85726-6605
25 Health Policy Perspective: Still Sick Steve Heilig, MPH
www.sfms.org
November 2009 San Francisco Medicine 3
Membership Matters November 2009 A Sampling of Activities and Actions of Interest to SFMS Members
Volume 82, Number 9 Editor Mike Denney
Managing Editor Amanda Denz Copy Editor Mary VanClay Editorial Board Chairman Mike Denney
Obituarist Nancy Thomson
Stephen Askin
Shieva Khayam-Bashi
Gordon Fung
Ricki Pollycove
Toni Brayer
Linda Hawes-Clever Erica Goode
Gretchen Gooding
Arthur Lyons
Terri Pickering
Stephen Walsh
SFMS Officers
President Charles J. Wibbelsman
President-Elect Michael Rokeach
Secretary George A. Fouras Treasurer Gary L. Chan Editor Mike Denney
Immediate Past President Steven H. Fugaro SFMS Executive Staff
Executive Director Mary Lou Licwinko
Director ofPublicHealth &Education Steve Heilig
Director of Administration Posi Lyon
Director of Membership Therese Porter
Director of Communications Amanda Denz
Board of Directors Term:
Jeffrey Newman
Andrew F. Calman
Michael H. Siu
Jan 2009-Dec 2010 Jeffery Beane
Lawrence Cheung Peter J. Curran
Thomas H. Lee
Richard A. Podolin Rodman S. Rogers Term:
Jan 2008-Dec 2010 Jennifer H. Do
Keith E. Loring
William A. Miller
Thomas J. Peitz
Daniel M. Raybin Term:
Jan 2007-Dec 2009 Brian T. Andrews Lucy S. Crain
Jane M. Hightower Donald C. Kitt Jordan Shlain Lily M. Tan
Shannon UdovicConstant
CMA Trustee Robert J. Margolin AMA Representatives
H. Hugh Vincent, Delegate
Robert J. Margolin, Alternate Delegate
SFMS Members: Save The Date for the Annual Dinner Next year’s annual dinner will take place at the Concordia-Argonaut Club Thursday, January 21, 2010. PresidentElect Michael Rokeach, MD, will be installed as 2010 SFMS President. SFMS Members will receive an invitation to the 2010 SFMS Annual Dinner in December. Please return the RSVP card promptly. Contact Posi Lyon (415) 561-0850, extension 260, with questions.
Do We Have Your Correct Contact Information?
Most importantly, do we have your email address? Don’t miss out on important information from SFMS and CMA! You can update your records online or by contacting the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org.
New Ways to Pay Your Dues!
The 2010 dues statements have gone out. This year SFMS has added a new option to make paying your dues easy, safe, and convenient: You may now elect to pay your dues via credit card installments. Details and an authorization form have been included in your dues statements. As always, you may also use the online dues payment system on our website or you can pay by check or credit card via fax or U.S. mail. If you have any questions, please contact the Membership Department at (415) 561-0850 extension 268 or tporter@sfms.org.
Invite Your Peers to Join and Get a Break on Your SFMS Dues!
Members of the San Francisco Medical Society/California Medical Association know that participation in organized medicine benefits both physicians and their patients. SFMS members have been helping shape the future of medicine for nearly 150 years. If each member of the San Francisco Medical Society/California Medical Asso-
4 San Francisco Medicine November 2009
ciation encouraged just one new physician from among their peers to become a member, SFMS/CMA would become an even more powerful force in the legislature, the courts, the media, and on the local level. All it takes is each SFMS/CMA member recruiting just one new member to make a significant effect on membership. With SFMS’ “Connect the Docs” referral program, you can help grow membership in SFMS and CMA and give yourself a break on your SFMS dues, all at the same time. If you are a dues-paying member of SFMS/CMA: Recruit four or more new members to the San Francisco Medical Society/California Medical Association and receive a free SFMS membeship for the 2010 dues year. TPMG members’ dues are paid by Kaiser, but if a TPMG physician refers five or more members (TPMG or not), he or she will receive two free tickets to the SFMS Annual Dinner. Be sure the new member completes the “referred by” information so that you receive appropriate credit. Joining has never been easier, with our online application system. All a prospective member has to do is visit www.sfms. com and click on the “JOIN SFMS” button in the upper right-hand corner. If the new member has never been a member of CMA before, they may be eligible for a 50 percent discount on their first-year dues. You—or the prospective member— can also contact Therese Porter in the Membership Department at (415) 5610850 extension 268 or tporter@sfms.org with questions or to have a membership information packet sent.
Upcoming Event: A Mixer for Residents and Young Physicians
Thursday, November 19, 6:00–7:30 p.m. Residents and young physicians are invited to a mixer at the San Francisco Medical Society’s offices in the Presidio of San Francisco. Enjoy appetizers and wine in a comfortable, informal atmosphere while connecting with your young physiwww.sfms.org
cian peers and members of the San Francisco Medical Society. Let us know you’re coming! Please rsvp by Tuesday, November 17. Contact Therese Porter in the Membership Department at (415) 561-0850 ext. 268 or tporter@sfms.org to RSVP or learn more.
it makes sense to cancel a payor contract; how to make sense of your revenue stream; how to improve the patient experience; and much more. The Best Practices tool kit, available free to all physicians, is organized into nine chapters that can be read sequentially or on an as-needed basis. Download the tool kit today. Contact CMA’s reimbursement helpline at (888) Best Practices: Performing an EHR 401-5911 or fnavarro@cmanet.org.
Report from the SFMS Health Information Technology Meeting
On October 22 the San Francisco Medical Society hosted an informational session on Health Information Technology at CPMC. Dr. Paul Tang addressed a very full, attentive crowd from all over the city. Dr. Tang is chief medical information officer for the Palo Alto Medical Foundation, vice chair of the Federal HIT Policy Committee, and co-chair of the California Needs Assessment Selecting and implementing an elec- Webinar Schedule HIE Advisory Board. In addition, Dr. Tang tronic health record (EHR) system is one of CMA offers a wide variety of webinars, is a Board Certified Internist, an associate the most complex and resource-intensive both live and recorded, to help you address professor at Stanford University, and an activities a medical practice can under- crucial health care issues and mange electrical engineer. He explained to the take. Before taking on this challenge, it your practice. Registration is free for room that the United States spends more is important for you to assess your EHR members and their staff. Space is limited, on health care ($6,102 per person) than needs, with an eye for what will work best so register soon. Visit the CMA calendar Canada ($3,165) or Japan ($2,249) and for your specialty, the size of your practice, at www.cmanet.org/calendar/ for more that our mortality is greater than all other the stage in your career, and your comfort information. Most webinars are available countries except Finland (due to their level with technology. for on-demand playback shortly following high suicide rate). With many of the “baby Chapter 7 of CMA’s Best Practices tool the live presentations in the webinar boomers” reaching sixty-five by 2011, kit will show physicians how to perform archives at CMA’s members-only website. Medicare will likely be bankrupt by 2017. an EHR needs assessment and create For more information, contact Shan- This over sixty-five population will double a road map for the EHR selection and non Navarra-Lujan at the CMA at (800) by 2030. In February President Obama implementation process. CMA published 786-4CMA or slujan@cmanet.org . mandated that to achieve improved outthe 140-page Best Practices tool kit with comes all patient health records must be generous support from the Physicians’ M e d i c a r e R e i m b u r s e m e n t electronic (EHR) by 2014 with penalties Foundation to help physicians improve Assistance in payments to non-compliant eligible Palmetto is offering helpful webinars professionals by 2015. The National prithe efficiency, and in turn the quality, of their practices. In addition to helping on Medicare reimbursement. Go to orities of this system are to improve the you learn how to perform an EHR needs www.palmettogba.com/j1 and then quality and safety of patient care, to enassessment, the tool kit will teach you click on Learning & Education in the gage patients and their family by providhow to find and keep qualified staff; how tool bar for a choice of workshops, ing access to specific health information to build a defensible fee schedule; when contractor teleconferences, and more. with progress notes for each encounter, to improve care coordination and public health of the population—all this within a framework of privacy and security 2009-10 SFMS Directory and Desk Reference Available Now! protection. There ARE $39 million dollars available to get the systems installed in This important and trusted healthcare California. The vendors of EHR systems, resource contains a comprehensive their fees and ongoing support, are a key listing of SFMS Members with their specialties and contact information. It is issues. The San Francisco Medical Society also packed with helpful resources that is working with the California Medical no medical office should be without! Association on these issues. In addition SFMS Members receive one copy free as a membership benefit; additional copies are only the SFMS is working with local hospitals, $45 each. Nonmembers pay $75 per copy. clinics, medical groups, the public health Order your copy today! Contact Carol Nolan at department and physicians to develop a (415) 561-0850 ext. 0 or cnolan@sfms.org. SFMS Health Information Exchange (SFHEX) Interested in advertising in next year’s Directory? as a means of securely exchanging health For more information contact Jonathan Kyle at (415) 561-0850 ext. 240 or jkyle@sfms.org. care data across disparate entities. —Nancy Thomson, MD www.sfms.org
November 2009 San Francisco Medicine 5
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President’s Message Charles J. Wibbelsman
Diversity in Medicine
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s you will see in the following pages of our journal this month, there are many well-written articles submitted from the 2009 Ethnic Physician Leadership Summit recently convened in September in Santa Clara by the California Medical Association (CMA) Foundation and the Network of Ethnic Physician Organizations. When one considers the topic of diversity in medicine, there are many different levels of thought that come to mind. Often, as a physician, one first contemplates the diversity in race, ethnicity, and cultural backgrounds that our physician colleagues bring to their own unique practice of medicine. Indeed, the San Francisco Medical Society, in our 140-year history, reflects the diversity of our city and county in our membership and the leadership of our elected Board of Directors, our Executive Board, and past presidents. I am honored to follow such outstanding previous presidents as Rolland Lowe, MD, who was born in San Francisco’s Chinatown and not only served as the first Asian American president of the SFMS in 1982 but also joined the California Medical Association’s Board of Trustees, and then was elected president of the CMA in 1997. During his tenure as CMA president, Dr. Lowe gave minority physicians a place at the table, creating a voting section for ethnic physicians with the CMA. He later helped start the Network of Ethnic Physician Organizations to address disparities in health care. Another former president, Xavier Barrios, MD, not only headed up the SFMS in 1972 but today is still in practice at St. Luke’s Hospital and is a strong advocate for Hispanic patients. We also have had many women take the helm of leadership in this Medical Society. In 1960 Roberta Fenlon, MD, was our first woman president; Judith Mates became our first Chinese American female president in 1995. Some of most recent presidents include Ann Myers, MD, in 2004 and Rita Melkonian, MD, in 2003—both of whom have inspired me and been my mentors. Our diversity has also embraced sexual orientation, including openly gay and lesbian members of our Board of Directors, some of whom have served and are now serving as presidents. Yet not only as president this year but as an active member of the Medical Society for the past fifteen years, I am acutely aware that, in many ways, our organization could reach out to more members. Long gone are the Board of Directors meetings where everyone was a white, heterosexual male in a suit and striped tie; www.sfms.org
still, as president, I would like to realize and welcome more African American physicians, more physicians with diverse Hispanic backgrounds, and other members of differing cultural and ethnic backgrounds into the Medical Society and on our Board of Directors. Diversity in medicine also means, poignantly, the diversity of the patient population whom we care for in our everyday practices and how we relate to patients of the same race and ethnicity and, in particular, those patients of a different race and ethnicity who speak another primary language than our own. Communicating with and understanding the culture of these patients from a different background presents us with many challenges in our practice of medicine. San Francisco, as a city and county offering medical care, does a yeoman’s task of reaching out to and offering culturally competent and language-specific services to our patients. In the past ten years, many of our health care delivery systems in this city and county have developed patient education materials now printed in Spanish, Chinese, and other languages so that our patients can understand their own health just as well as a white English-speaking patient can. Many hospitals and medical offices in San Francisco have on-duty interpreters and now telephone access to interpreter services for all languages. Being president of the San Francisco Medical Society has given me an opportunity to represent the Medical Society in many different forums. Most recently, last year’s president, Steve Fugaro, MD, and I were invited to attend a focus group of health care providers by the Hepatitis B Free Coalition. After the session was well underway, I became acutely aware that many physicians and health care providers in San Francisco are not routinely screening patients born in China for the hepatitis B surface antigen. I became aware that we as physicians must embrace the diversity of our patient populations, their needs, and what screening and preventative medicine they deserve. As a physician in adolescent medicine, I routinely perform a urine screen for chlamydia on all sexually active adolescents. I truly wish that all of my colleagues who care for adolescent patients would also embrace the diversity of sexual activity among teens. We, as physicians, have a long way to go to fully meet the challenges that diversity presents among us, and in meeting the diversity issues of our patients; but we have made some giant leaps thus far. We need to do continue to take big steps in the future, in order for all of us to be better doctors.
November 2009 San Francisco Medicine 7
Strength.
Mark R. Laret, CEO of UCSF Medical Center, Steve McDermott, CEO of Hill Physicians Medical Group, Dr. Sam Hawgood, President of UCSF Medical Group and Interim Dean of UCSF School of Medicine, and Dr. Thomas F. Long, Chief Medical Officer of Hill Physicians Medical Group announce a new affiliation between UCSF and Hill Physicians.
The doctors of UCSF are joining Hill Physicians Medical Group effective January 1, 2010. One of the nation’s best medical centers and one of the nation’s largest physician association are coming together to improve the future of health care in San Francisco. Independence and strength are not mutually exclusive. Hill Physicians’ providers enjoy autonomy and flexibility while receiving exceptional technological, case management, preventive care and claims processing support. That’s why so many of the best join Hill Physicians.
Your health. It’s our mission.
If you’re a physician in San Francisco, South San Francisco or Daly City and want to know more about joining Hill Physicians, contact: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com or visit www.HillPhysicians.com/Providers. Hill Physicians’ 3,000 healthcare providers accept many HMO plans including: Aetna, Alliance CompleteCare (Alameda County), Anthem, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage.
Editorial Mike Denney, MD, PhD
Dharma, Genius, and Diversity
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mong some Eastern African peoples, an ancient ritual around childbirth was practiced. When a pregnant woman came near to term, the members of the community gathered around her to celebrate. After fires were lit, dances were performed, and the ancestors were called in, the elders encircled the woman to welcome the unique gift that this child would bring to enhance the future of the tribe. This image of the divine child has manifested itself in cultures throughout the world. In Buddhism, the idea of dharma signifies that each individual is born with inimitable talents that, with the right practice, can be actualized during a lifetime; and in ancient Greece the word genius applied not only to those whose life work coincided perfectly with their god-given talents but meant that every single human being had a unique genius and thereby brought a distinctive offering to the world. As in this issue of San Francisco Medicine we explore the notion of diversity in healing, as we pay attention to the special needs and qualities of both caregivers and patients in a diverse population, might these concepts of dharma, genius, and the divine child offer deeper meaning? The idea of diversity has evolved naturally in the United States, this land of immigrants and opportunity. The twentieth century brought sweeping new ethics, politics, and social changes through affirmative action and equal opportunity employment, which resulted in a democratic culture more inclusive of all diverse people regardless of ethnic, racial, gender, age, sexual-orientation, religious, physical, and mental differences. Today, at all levels of government, business, and education, diversity programs promote the rights, privileges, and talents of a diverse population by educating managers and implementing the high ideals of liberty and justice for all. In medicine, the variables in diversity seem even more important since they are pertinent not only to equality among disparate populations but, indeed, are essential to health and well-being, even life and death, of individuals. Research centers such as the Center for Cross-Cultural Health at the University of Minnesota and the Center for the Study of Race and Ethnicity in Medicine at the University of Wisconsin are actively assembling data that are essential to understanding the special health needs of various groups. The University of California at San Francisco has an active www.sfms.org
program in Culture and Medicine and holds regular sessions in Perspectives of Difference. In government, the U.S. Department of Health and Human Services now has Minority Health Resource Centers serving indigenous Americans, and private entities such as the Transcultural Nursing Society and National Medical Association promote equality in healing for various groups. These and a host of other organizations across the country are devoted to fairness, equality, and excellence in medical care. In this issue of San Francisco Medicine, we offer some of the ideas presented at a recent gathering of the forty groups in the Network of Ethnic Physician Organizations in California, a project of the California Medical Association Foundation that addresses health disparities of diverse populations, diversity in the workplace, access to medical care, and cultural competency at the local community and state levels. If we focus again upon the individual, we may find an even more compelling reason to honor diversity in medicine. We may notice that in myths and fairy tales it is often the different “other” who provides the essential wisdom for the fulfillment of the story. The Little Prince brought his wisdom from another planet. Humpty Dumpty introduced new language to Alice inside her looking glass, Jack and his extraordinary bean stalk led us to a world of giants and magic harps, and the cackling wise crones always showed the lost children the way out of the deep, dark forest. Yes, if we value our differences and tend diversity in medicine we may not only achieve affirmation, equal opportunity, and better health care for all, but our hospitals, clinics, offices, and, indeed, our communities can become enriched by the unique gift brought by each human being, no matter how “different” she or he may seem. In his book I and Thou, the twentieth-century philosopher and mystic Martin Buber put it this way: “We gaze toward the train of the eternal You; in each we perceive a breath of it; in every You we address the eternal You.” Thus we may offer the ultimate expression of diversity when we cherish and honor the dharma, genius, and divine child in each and every one of us. November 2009 San Francisco Medicine 9
Diversity in Medicine
Improving Quality and Equality Eliminating Racial and Ethnic Disparities in Health Care
Joseph R. Betancourt, MD, MPH
I
n the latter half of the twentieth century, this country has witnessed dramatic improvements in health due to initiatives in health promotion and disease prevention. Our ability to detect and treat medical conditions in their early stages has been the hallmark of this progress and has allowed us to prevent premature and costly morbidity and mortality. Despite interventions that have improved the overall health of the majority of Americans, racial and ethnic minorities have benefited less from these advances. Data from the National Center for Health Statistics has consistently shown that racial and ethnic minorities suffer worse health outcomes from preventable and treatable conditions such as cardiovascular disease, diabetes, asthma, cancer, and HIV/AIDS, among others. There is no doubt that these disparities in minority communities are linked to the adverse impact of social determinants—such as lower levels of education, poor housing, unemployment, and overall low socioeconomic status—on health outcomes. Similarly, lack of insurance or access to medical care clearly contributes to poorer health status. However, evidence suggests there are the racial/ethnic disparities in quality of care for those with access to the medical system. These disparities have been shown to exist in the use of cardiac diagnostic and therapeutic procedures; prescription of analgesia for pain control; surgical treatment of lung cancer; referral to renal transplantation; treatment of HIV, pneumonia, and congestive heart failure; and the use of general services covered by Medicare (such as immunizations and mammograms). Countless studies have documented racial/ethnic disparities in
the diagnosis and treatment of various conditions, even when controlling for socioeconomic status, insurance status, site of care, stage of disease, comorbidity, and age, among other potential confounders. In fact, some seven years ago now the prestigious Institute of Medicine (IOM) released its landmark report, Unequal Treatment: Confronting Racial/Ethnic Disparities in Healthcare, cementing this issue into the health care community’s consciousness. Since this time, we have also been able to understand the impact of disparities on quality, safety, and cost. For instance, research has shown that minorities and patients with limited English proficiency suffer from more medical errors with greater clinical consequences while hospitalized than do their white counterparts, have longer lengths of stay for the same clinical condition, are more likely to have preventable hospitalizations, and are more frequently readmitted for chronic conditions (such as congestive heart failure) than their white peers. Just last month the Joint Center on Political and Economic Studies, a Washington think tank, in collaboration with Johns Hopkins University and the University of Maryland, released a report highlighting that racial inequalities in health care access and quality added more than $50 billion a year in direct U.S. health care costs over a four-year period. Furthermore, they found that more than 30 percent of direct medical expenditures for African Americans, Asian Americans, and Hispanics were excess costs linked to health inequalities. Between 2003 and 2006, these excess costs were $229.4 billion, and the indirect costs of racial inequalities associated with
10 San Francisco Medicine November 2009
illness and premature death amounted to more than a trillion dollars over the same time period. Similarly, the Urban Institute calculated that if African Americans and Hispanics suffered from diabetes, hypertension, stroke, renal disease, and other ailments at the same rate as whites, the U.S. health care system could save $23.9 billion this year. Over a ten-year span, health disparities will cost Medicare, Medicaid, private insurance companies, and individuals $337.4 billion. What does this mean for health care? Clearly, the IOM report Unequal Treatment has had and will continue to have a great impact on how we adapt our health care systems to assure that we deliver the highest quality of care to any patient we encounter, regardless of race, ethnicity, culture, class, or language proficiency. The key lesson is that eliminating racial and ethnic disparities shouldn’t be an “add-on” to the long list of competing interests we face every day. On the contrary, efforts to eliminate disparities are central to quality improvement and should be integrated into all such endeavors. This includes activities to promote efficiency, effectiveness, patient safety, patient-centeredness, timeliness, and equity—the pillars of quality health care laid out by another influential IOM report, Crossing the Quality Chasm. We can invest now and integrate this work into the quality portfolio, or pay dearly later. Ultimately, having a greater understanding of the root causes of disparities should allow us to intervene accordingly, whether in our roles as executives, administrators, managers, opinion leaders, teachers, or caregivers. In the clinical Continued on page 12 . . . www.sfms.org
Diversity in Medicine
Diversity in Medicine A Student’s Perspective
Tonantzin Rodriguez, MPH
A
migrant farmworker spends all day picking fruits and vegetables to feed our nation, but he lacks food security to feed his own family. An elderly Hmong grandfather sacrificed his homeland to protect our nation but cannot speak to his own doctor due to the lack of an interpreter. A black professor teaches our nation’s college students but waits years longer than his white counterpart for a kidney transplant. Our country prospers on the hard work and dedication of our rich cultures and diverse traditions. However, our current system discriminates against citizens based on education, race, ethnicity, geography, and socioeconomic status. For a country that values progress and innovation for the future, millions of its citizens lack access to basic preventive and primary health care services. Health disparities are a reality in the United States. As doctors, we can make a difference in addressing these health disparities through advocacy, community involvement, and cultural competency. Health disparities must be addressed in medical schools by increasing diversity within the student body and by educating medical students regarding health care disparities. Through my experience, I have learned about health care disparities and the importance of diversity in medical school. How can we improve care among high-risk populations, such as migrant farmworkers? Since 2000, I have volunteered at a student-run free clinic called Clinica Tepati. For more than thirty years, Clinica Tepati has provided care for uninsured patients from the Sacramento area. Mexican-American undocumented
immigrants make up the majority of our patient population. We provide culturally sensitive medical services, such as interpreters and health education workshops in Spanish with culturally modified physical activity and diet suggestions. When we see overweight diabetic patients, telling them to exercise is not enough. What if the patient can’t afford a gym membership, does not live in a “walkable” neighborhood, or doesn’t believe that being overweight is unhealthy? Telling the patient to eat healthier foods is not enough. What if the patient doesn’t cook for the family, can’t afford fresh fruit and vegetables, or prefers traditional cultural foods? Telling the patient to comply with treatment is not enough. What if the patient has no insurance or is underinsured to pay for prescriptions and procedures, prefers alternative healing methods, or doesn’t understand the purpose of the medications? Getting to know your patients, their beliefs, their lifestyles, and their resources serves as an important asset in providing quality health care for underserved communities. On a community level, physicians can advocate for healthy school lunches, sidewalks in lowincome neighborhoods, safe playgrounds, affordable fruits and vegetables in local supermarkets, healthy cooking preparation for cultural foods, and traditional healers as partners in care. How can health care disparities be addressed? Prior to medical school, I conducted a research project in Fresno among diabetic patients. I met an elderly African American patient who was a professor. He had been on dialysis for more than ten years due to diabetic nephropathy and was waiting for a kidney transplant. In a
www.sfms.org 11 San Francisco Medicine November 2009
literature review, I learned about racism and discrimination in medical care from the publication Unequal Treatment from the Institute of Medicine. When education and socioeconomic status were controlled, significant differences between racial/ethnic groups existed in the quality of medical care. My own patient is one of many African American patients waiting longer for organ transplants compared to whites with similar socioeconomic backgrounds. Does it matter that your patient has insurance? Yes. Does it matter that your patient has a college degree? Yes. Does the race/ethnicity of your patient matter? Yes. In the United States, your patients’ racial/ethnic background influences the quality of care that they receive. Through racial/ethnic bias competency workshops and educational programs, physicians ensure the highest quality of medical care for patients, regardless of their skin color. How can physician diversity improve health care disparities among underserved populations, such as the Hmong community? During my summer preceptorship, I had the opportunity to work with primary care providers in a federally qualified health center. My preceptor shared a friendly, caring relationship with his patients and their families. But in addition to cultural differences, a language barrier further distanced me from my patient. With non-English speaking Hmong patients, we used the telephone language interpreters due to the lack of any other kind—although sometimes we were able to call on another family member to serve as the interpreter. A diverse, professional workforce is needed to provide qual-
Continued on the following page . . .
November 2009 San Francisco Medicine 11 www.sfms.org
Diversity in Medicine Continued from the previous page . . .
ity communication and medical care for patients. Most medically underserved areas in the United States have diverse communities. In the medical field, many populations are underrepresented, including the Hmong, Mexican-Americans, African Americans, and Native Americans. How do we increase diversity in the health field? Disparities among underserved populations are not limited to health care but also extend to education. Latinos consist of nearly 40 percent of the population in California. However, only 13 percent graduate from college. During an outreach experience for the Latino Medical Student Association, we visited my hometown to talk to students about college. Ella Elementary School consists of predominantly Mexican and Hmong low-income students. On the first visit, we asked, “What do you want to be when you grow up?” Nearly all the girls said, “A mommy.” The students didn’t know anyone who went to college. More than 60 percent of the population has not graduated high school. The teachers face limited financial resources and language and cultural barriers when dealing with students’ families. The high school offers few advanced placement courses and guidance counselors encourage vocational work more than college admissions. Most students have at least one part-time job to help contribute to the family’s expenses. This community reflects the adversity of low-income, diverse students. These students must compete with students from well-resourced school districts, highly educated families, and access to many advanced placement college preparatory courses. Increasing diversity in medical school means increasing diversity at the college level. Diverse students from low-income communities are not on equal playing ground academically, when compared with students from higher socioeconomic classes. The pipeline of mentorship must begin at the elementary school level. After our yearlong outreach activity, we asked the students again, “What do you want to be when you grow up?” This time, they said, “A doctor.”
How do we address diversity in medical school? Though cultural sensitivity and patient communication classes exist, these workshops hold significantly less priority than the core medical science courses. Sessions are sporadically held at the end of a busy school day. At U.C. Davis, the Family and Community Medicine Department strongly supports educating students on underserved populations. Lunchtime electives are offered on underserved communities, or students may enroll in a clinical elective to spend time at the free clinics on weekends. In addition, weekend conferences and evening seminars provide an opportunity for students to learn more about diversity and disparities. However, most activities are optional and only attract interested students. Others continue their medical career with a strong emphasis in diagnosis and treatment instead of communication and advocacy. Through medical school, I have learned about health care disparities and the importance of diversity. The status quo is not good enough. As doctors, we can make a difference in addressing these health disparities through advocacy, community involvement, cultural competency, and diversity. Health care disparities will cease to exist when the migrant farmworker has access to healthful food, the Hmong grandfather can speak to his doctor, and the African American professor receives a kidney transplant. Tonantzin Rodriguez, MPH, is a second-year medical student at U.C. Davis Medical School and participated in the medical student panel during the 2009 Ethnic Physician Leadership Summit.
12 San Francisco Medicine November 2009
Improving Quality and Equality Continued from page 10 . . .
encounter, for example, Unequal Treatment tells us that poor cross-cultural communication between provider and patient (including due to language barriers), stereotyping of patients by providers, and patient mistrust all contribute to racial/ethnic disparities and lower quality care. Needless to say, disentangling and addressing the multifactorial and complex causes underlying racial and ethnic disparities is extremely challenging. The literature is expansive but, as one might expect, imperfect, given how difficult it is to study these issues in a clear and simple fashion. Actors within the health care system hold steadfast to their specific perspectives on the causes of disparities and strategies to eliminate them. Yet all agree that something must be done to address this national problem. Measurement of our progress to eliminate disparities is equally difficult and challenging, yet absolutely required if we are to chart our movement and document our successes. If true quality improvement in health care is our goal, the elimination of racial and ethnic disparities will surely follow. In this time of great debate about health care reform, we need to consider how we can make our health care system more equitable. Not only do we need to increase access to health care and provide stability to those who have health care coverage, but we also need to assure that everyone benefits equally from what we have to offer—thus truly achieving equity in health care. This is certainly no easy task, but as we approach this historic moment, we have the opportunity to rewire our health care system so that is responsive to the needs of all patients and truly delivers on its promise of quality. As health care providers, we can certainly make a difference through our words, activism, action, and deeds, helping create a new, equitable, efficient, and effective health care system for the next century. Joseph R. Betancourt, MD, MPH, is director of the Disparities Solutions Center at Massachusetts General Hospital and is assistant professor of medicine at Harvard Medical School. www.sfms.org
Diversity in Medicine
Minority Doctors in Short Supply A Report on California
Elizabeth Fernandez
A
study on physicians in California shows a glaring gap between the number of doctors of color compared with the state’s ethnically diverse population, especially among African Americans and Latinos. At the same time, the state has a disproportionate number of Asian and white doctors, according to the UCSF study, which focuses on doctor ethnicity and language fluency. It found that out of nearly 62,000 practicing doctors in California, only 5 percent are Latino even though Latinos comprise a third of the state’s total population. Only 3 percent of doctors in California are African American, compared with 7 percent of the state’s overall African American population. While Latinos and African Americans make up about 40 percent of the state’s residents, fewer than 10 percent of California’s doctors are African American or Latino. The disparity is particularly alarming because minority physicians are far more likely to practice primary care medicine and work with poor or uninsured patients in rural areas, inner cities, or other communities with a chronic shortage of physicians. “This is a critical public health issue,” said Dr. Kevin Grumbach, director of the UCSF Center for California Health Workforce Studies, which released the report Wednesday. “These patterns are real. The problem is even worse than we thought.” In a state with more than 35 million people, fewer than 3,300 Latino and only about 2,000 African American physicians are in “active patient care,” said Grumbach. “It brings the numbers home in a
“The disparity is alarming because minority physicians are far more likely to practice primary care medicine and work with poor or uninsured patients . . .” concrete and stark way,” he said. The health profession has long bemoaned the poor representation of minorities among physician ranks, a disparity wrought in part by a lamentable legacy of discrimination that included segregated educational practices. But this report is the first to analyze the physician workforce in California based on data compiled by the California Medical Board. The data was mandated by a 2001 state law requiring the board to gather information based on factors including doctor specialties, ethnicity, and languages spoken. The report found that whites make up 61 percent of the state’s doctors while the white population is just under 48 percent. Asian and Pacific Islander doctors comprise 26 percent of the physician workforce while the state’s Asian population is about 11 percent. That category includes doctors who say they are Chinese, Indian, or Filipino. “It is cultural,” said Dr. Satinder Swaroop, chair of the California Medical Association Foundation’s Network of Ethnic Physician Organizations, during a news conference Wednesday at the U.C. Davis School of Medicine.
www.sfms.org 13 San Francisco Medicine November 2009
“Asian families push their children,” said Swaroop, who practices in Southern California. “Five people in my family are doctors. Part of it is we feel it is the field to go to.” Yet within the Asian-doctor category, there is a troubling shortage of Samoan, Cambodian, and Hmong doctors, the report found, decrying the overall pool of doctors statewide as inadequate. The ethnic gap is just as acute in the Bay Area, where a fifth of the general population is Latino, compared with less than 4 percent of the doctor population. The Bay Area’s African American population is just over 7 percent while the number of African American doctors is just under 3 percent. Besides English, Spanish is the language most commonly spoken by California’s doctors—about 18 percent said they speak Spanish fluently. Medical experts at the news conference stressed that ethnic diversity is directly tied to better access and quality of health care for disadvantaged patients. Dr. Henry Watson didn’t attend the session, but he has long known the lesson. A second-generation African American physician in Oakland, he has been an anomaly much of his life. So, too, was his father, James, who was refused medical privileges at some local hospitals when he first hung his shingle in Oakland in the mid-1950s. “I crawled on the floor of my father’s medical office when I was a baby,” said Watson. “It was my life’s dream to become a doctor and work with my father.” After graduating from medical school and completing his residency at UCSF,
Continued on page 15 . . .
November 2009 San Francisco Medicine 13 www.sfms.org
Diversity in Medicine
Ethnic Physician Leadership Summit 2009 Summit Focused on Health Care Reform and Strategies for Change
Satinder Swaroop, MD
H
ealth disparities and health policy, impact on quality care of health IT and the stimulus package, and inspiring messages of hope and determination from medical students. These are just some of the highlights from the California Medical Association (CMA) Foundation and Network of Ethnic Physician Organizations (NEPO) 2009 Ethnic Physician Leadership Summit, held September 26–27 in Santa Clara. In attendance were medical students, community health advocates, health care professionals, and policymakers such as Congressman Mike Honda of the Fifteenth Congressional District and Assemblywoman Fiona Ma of the Twelfth Assembly District of California. Joseph R. Betancourt, MD, MPH, director of the Disparities Solutions Center at Massachusetts General Hospital and assistant professor of medicine at Harvard Medical School, kicked off the summit by presenting an overview of the health disparities in minority populations in the United States. Dr. Betancourt stated, “My goal every day is to figure out how I can get everybody to take one step forward on this issue, to assure we can achieve equity in the health care system.” An Unprecedented Opportunity: Federal Stimulus Funds Advancing Health IT in California was presented by Mark Smith, MD, MBA, chief executive officer of the California Healthcare Foundation. Diversity in Clinical Trials addressed the gap that exists with communities of color in clinical trials, while Politics 101 reminded ethnic physicians about the importance of participating in public health policy efforts. Dr. Guillermo Valenzuela, MD, was
presented the 2009 Ethnic Physician Leadership Award for his outstanding leadership in efforts to send Inland Empire students to college. “I am so honored to receive this award,” said Valenzuela, chair of Women’s Health at Arrowhead Regional Medical Center in Colton. “It is my hope that this will bring attention to the need for greater investment in the futures of students across the state.” The California Medical Association Foundation, in conjunction with the Network of Ethnic Physician Organizations (NEPO), designed the Ethnic Physician Leadership Summit program to serve as a vehicle to continue the organizational development and strategic planning for NEPO; establish a process and structure for public policy advocacy for NEPO (inclusive of the development of the capacity to identify, analyze, track, and reach consensus on key public policy issues); to work with partner advocates, policy makers, and other coalitions; to serve as
15 San Francisco Medicine November 2009 14 San Francisco Medicine November
an information clearinghouse and communications conduit on policy issues for ethnic physicians and their organizations; and to facilitate the collaboration of ethnic physicians across projects within NEPO. The 2009 Ethnic Physician Leadership Summit is sponsored by the California Wellness Foundation, the California Endowment, United Health Foundation, Genentech, the Doctors Company Foundation, P&G, Pfizer, the Office of Minority Health, HealthNet, California Smoker’s Helpline, the Health Professions Education Foundation, and Fluency, Inc. A project of the CMA Foundation, NEPO is a coalition of more than forty-one ethnic physician organizations throughout California. As these leaders from the Chinese, Peruvian, Vietnamese, Latino, East Indian, Filipino, Korean, and African American medical associations coalesced around a unified message, the creation of NEPO was set in motion. No longer would ethnic physicians allow critical decisions www.sfms.org
that impact the health of their communities to be made without ethnic physicians at the table. The project, established in 2002, is designed to identify strategies for building the capacity of ethnic physician organizations. As a result, physicians are able to reduce health disparities and improve access to health care for their communities through increased collaboration with community organizations and through policy advocacy in both the public sector and in organized medicine, as well as addressing cultural competency and diversity in the health care workforce. For more information about NEPO or the Ethnic Physician Leadership Summit, visit www.ethnicphysicians.org or contact vberry@thecmafoundation.org. Satinder Swaroop, MD, is the steering committee chair of the Network of Ethnic Physician Organizations.
Minority Doctors in Short Supply Continued from page 13 . . .
Report’s recommendations
Watson achieved that dream, joining his father’s North Oakland practice in 1985. The elder Watson died last year, but his son continues his mission of providing quality medical care to many of Oakland’s poor residents. For a decade, he has traveled with a mobile clinic. “There are higher incidences of certain diseases in people of color,” he said. “Doctors of color work hard to screen for those kinds of diseases.” In two weeks, he plans to launch a special, county-sponsored program—on Fridays he’ll treat only indigent patients. “It took me twenty years to get it,” he said ruefully. “I could be in a high-rent district, but I believe in working in the community that needs me, in the community that brought me up. This is what I live for.”
The UCSF report included the following recommendations for solving the ethnicity gap among doctors: • Invest in the educational pipeline preparing minority and disadvantaged students for careers in medicine and other health professions. • Promote diversity as a key part of expanding California medical education. • Hold health professions schools accountable for an institutional culture and environment that promotes diversity, recruitment, and retention of underrepresented minorities. • Increase incentives for physicians to work in underserved communities in California. Elizabeth Fernandez is a staff writer for the San Francisco Chronicle. This article, from April 2008, is reprinted with permission from the San Francisco Chronicle.
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Diversity in Medicine
Politics 101 Highlights from the Ethnic Physician Leadership Summit Politics 101 Workshop
Randal Pham, MD, FACS
D
uring the Politics 101 workshop at the Ethnic Physician Leadership Summit, physician attendees were asked to sit back and think of themselves as patients sitting in a doctor’s office. What would they want from their doctors? How would they want to be treated? What would they expect from their health providers as they are empowered with the tools to effect health care reforms? It was within this framework that I defined public policy and discussed how they can participate in the public policy process. The results of a 2009 public policy survey conducted by the Network of Ethnic Physician Organizations, a consortium of forty-one ethnic physician organizations, was presented. One hundred and one physicians responded to the survey. The survey revealed that access to health care is the number-one concern to both ethnic and nonethnic physicians. Health care reform was ranked second by the ethnic physicians, whereas health and health care disparities were second for the nonethnic physicians. Other issues of concern were cultural and linguistic competency, workforce diversity, obesity prevention, and physician workforce. Most responders came from two counties in California, Alameda and Los Angeles, but every county in California was represented. This survey was used to help prioritize public policies that are pertinent to physicians of color. I introduced the audience to the Ethnic Medical Organization Section (EMOS) of the CMA. In 1997, the California Medical Association established EMOS as a section to represent the ethnic physicians who are members of CMA. EMOS is dedicated
to representing the unique perspective of physicians of color and to facilitating communication and participation between physicians of the diverse ethnic groups in California. EMOS also provides a forum with CMA through which to resolve the unique concerns facing communities of color, promote nondiscrimination at all levels of medicine, and promote quality and culturally sensitive medical care. EMOS as an organization is represented in both the CMA House of Delegates and the CMA Board of Trustees to effect change within the house of medicine that benefits physicians of color. During the workshop I also described the process through which an issue of concern to ethnic physicians can be conceived and turned into concrete change in the form of legislation or legal action, as in the case of the injunction by a federal judge to stop the 10 percent MediCal cut in 2008. I urged ethnic physicians and nonethnic physicians who are interested in serving the ethnic communities to join EMOS and participate in the Annual Legislative Briefing, the CMA Legislative Day, and the NEPO/EMOS Legislative Day. Tom Riley, director of Government Relations of the California Academy of Family Physicians, also pointed out that we are living in a very exciting time. He stated that in his twenty-seven years as a lobbyist, he has never before encountered an opportunity to effect change in health care of this magnitude. Mr. Riley reported that, based on a survey he conducted, the public perceives the U.S. health care system as an automobile that is “very advanced,” “very expensive,” “not everybody can use it,” with “lots of moving parts,” and “if you get in a wreck, you die.” According
16 San Francisco Medicine November 2009 17 San Francisco Medicine November
to the public, the U.S. health care system is inaccessible, unsustainable, and of dubious quality. These are the reasons used by various groups in Washington to justify sweeping reforms of the health care system. Given the size and complexity of HR 3200, Mr. Riley suggested that the attendees pick three things from HR 3200 that they think that are of utmost importance and use advocacy strategies to voice their concerns. Mr. Riley highlighted the CMA’s support for coverage expansions, insurance market reforms, nearly $400 billion in physician payment fixes, and elimination of the current sustainable growth rate formula and MediCal rate increase. He also reasserted the CMA’s opposition to reduced payment for imaging services, the ban on physician-owned hospitals, provisions allowing nurse practitioners to run medical homes, and regulations forcing physicians to accept a public plan. Attendees were urged to be actively involved by contacting and maintaining relations with their senators and representatives in Congress. Randal Pham, MD, FACS is an oculoplastic surgeon practicing in San Jose and is the chair of the Ethnic Medical Organization Section (EMOS) of the California Medical Association. He is also a member of the Vietnamese Physician Association of Northern California.
www.sfms.org
Diversity in Medicine
Ethnic Minorities in Clinical Trials An Important Consideration
Owen Garrick, MD
P
harmaceutical and biotech companies are facing more stringent requirements surrounding efficacy and safety on new drug applications, particularly as they relate to minority populations and women. African Americans and Hispanics represent the largest minority subgroups in the United States, and they are disproportionately and more severely affected by disorders such as cardiovascular disease, diabetes, hyperlipidemia, HIV/AIDS, asthma, obesity, and cerebrovascular disease. Complying with the FDA guidelines regarding proportional inclusion of minorities and women in clinical trials has the potential for significant financial gain to pharmaceutical companies as new products receive quicker approval and are brought to market sooner. Further, the Center of Drug Evaluation and Research (CDER) notes that 4 percent or fewer of the participants in 2,500 clinical trials conducted between 1995 and 1999 were African American. This trend continues today, even though it has been well established that certain drugs are metabolized differently in African Americans and women. Thus, minority inclusion in clinical trials also serves to improve health care for all Americans.
Brief History
The randomized clinical trial has generally been accepted as the gold standard to test new clinical interventions. For many years, the predominant participant in clinical trials was an adult, Caucasian male. Over the years there has been a growing body of evidence demonstrating the need to include minorities and women in clinical trial research studies. During the Clinton administrations of the 1990s www.sfms.org
we saw the development of inclusion guidelines in clinical trials: In 1993, the NIH Revitalization Act established guidelines for inclusion of women and minorities in NIH-sponsored clinical research, and the FDA allowed a “Refusal to File” if clinical trial analyses on gender and race were not included. In 1997, the FDA Modernization Act directed development of gender and minority guidance. In 1998, the FDA amended its regulations for New Drug Applications (NDAs) to require that sponsors present efficacy and safety data on subpopulations based on race and gender. In 1999, population pharmacokinetic (PK) guidance recommended the collection of population PK data to help assess safety in minority populations and suggested that industry conduct clinical studies in subjects representative of the population to be treated by the drug. Interestingly, with a close read, one observes that there are actually divergent federal policies about the level of participation of racial and ethnic groups in government- and industry-sponsored clinical trials. The NIH guidelines have “teeth,” while the FDA policies are more suggestions for industry.
Racial/Ethnic Differences in Disease
Clinical trials have demonstrated racial and ethnic differences in the pharmacokinetics of certain drugs. Lim showed in 1996 the pharmacokinetic reasons for diversity of trials by examining the racial and ethnic variations in bioavailability for drugs that undergo gut or hepatic firstpass metabolism. Different ethnic and
racial groups have variations in protein binding, volume of distribution, hepatic metabolism, and renal tubular secretion. These differences can also determine the biologic course of certain diseases in the face of active treatment programs. In other words, diverse patient groups receiving the same and recommended treatment protocol could have vastly different health outcomes. Additionally, it has been well established that environmental factors lead to increased severity of disease at time of diagnosis as well as increased predisposition. These are underestimated contributors to differences in outcomes. From a policy perspective, one can choose to support either the environmental or genetic determinants of drug treatment outcomes. From a matter of course, what is relevant to your patients is that drugs work for them and their families.
Barriers to Overcome
It has also been determined that a major barrier to successful drug development has been finding appropriately trained and experienced clinical investigators who have access to specific patient populations required to adequately test a drug’s efficacy and safety. In this regard, African-American and Hispanic physicians represent an important source of new clinical investigators that have ready access to this highly valued clinical population. There is significant data that points to the strong connection between the principal investigator and the patient. Multiple published reports show that minority physicians are more likely to care
Continued on the following page . . .
November 2009 San Francisco Medicine 17
Ethnic Minorities in Clinical Trials Continued from the previous page . . .
for minority patients. Additionally, minority physicians provide a disproportionate amount of care to minorities, the poor, and Medicaid recipients. Nonetheless, recruiting ethnic populations can be successfully achieved by all physicians, just as all physicians are capable of providing care to all ethnicities. There have been many issues studied as to why ethnic minority patients have not participated more in clinical trials. From a practical perspective, I have found that the top two reasons that diverse patient populations do not participate in clinical trials are: They were not asked; They were not asked by their doctor. That is not to say that issues of mistrust, language, and economic constraints should be ignored. But the 80/20 rule likely applies in recruiting ethnic minority patients. I would surmise that the main reasons that most patients of any ethnicity participate in a study is that they were asked to in an appropriate way by the physician that they trust. Note: While your practice may not have a large minority patient population, partnering with ethnic minority physicians is a means to gain access to those targeted ethnic patients for clinical studies. I would not approach a colleague after you have received funding for a study to ask him or her to refer patients but rather would pursue a subinvestigator relationship that is more collaborative and begins in the early stages of study design or protocol review. Basic statistical concepts will show that underrepresentation of racial and ethnic minorities in clinical research limits the applicability of trial results to diverse subpopulations. Yet the pharmaceutical industry, policy makers, and providers continue to operate in a system that produces the disparity in clinical trial participation. There are proven ways to gain access to diverse patient populations. While it may not be as simple as the famous quote from the movie Field of Dreams, “If you build it, [they] will come,” with some effort and persistence more ethnic minorities will participate
perspectives. Psychopharmacol Bull. 1996; 32:205-17. National Vital Statistics System— Mortality (retrieved from DATA2010 at http://wonder.cdc.gov/data2010). NIDDK. Weight-Control Information Network. 2008. Saha S et al. Do patients choose physicians of their own race? Health Aff (Millwood) 2000; 19(4):76-83. Surveillance, Epidemiology, and End Results (SEER) Data. National Cancer Institute 2004. Thom T et al. Heart disease and stroke statistics: 2006 update. Circulation. Feb. 14, 2006; 113(6):e85–e151 Healing Our Village (HOV) Clinical Research has established a network of local clinical research alliances that provide training and support to investigators as they successfully deliver patients to drug company sponsors in clinical trials. For more information, contact Owen.Garrick@ hovclinical.com.
in clinical trials. As that happens, we will have a true sense of drug efficacy that may impact dosing regimens and potentially improve health outcomes for all of our patients.
References
Centers for Disease Control. MMWR Morb Mortal Wkly Rep. 2004; 53:121-125. Gray B et al. Patient-physician pairing: Does racial and ethnic congruity influence selection of a regular physician? J Comm Health. 1997; 22(4):247-59. Johnson JA. Influence of race or ethnicity on pharmacokinetics of certain drugs. J Pharm Sci. 1997; 86:1328-33. Kalow W. Interethnic variation of drug metabolism. Trends Pharmacol Sci. 1991; 12:102-107. Komaroumy M et al. The role of black and Hispanic physicians in providing healthcare for underserved populations. N Engl J Med. 1996; 334(20):1305-10. Lin KM et al. The evolving science of pharmacogenetics: Clinical and ethnic
18 San Francisco Medicine November 2009
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Diversity in Medicine
Diversity at UCSF Addressing Current and Future Health Disparities
J. Renee Navarro, Pharm D, MD
T
he University of California, San Francisco, sits at the center of one of the most densely populated and diverse U.S. cities. We are both a medical center and health sciences campus, so to effect true change in disparities in health care, we understand the importance of promoting diversity among faculty and staff who have direct patient contact as well as among our current and future scientists, clinical investigators, and educators. A diverse pool of scientists, for example, will provide perspectives that may increase our understanding of health and disease patterns in communities defined by race, ethnicity, gender, sexual orientation, or age. They also may facilitate more diverse participation in clinical trials and research.
Campus-Wide Commitment
While there has been a history of supporting diversity at UCSF since the 1960s, leadership realized that establishing a culture of diversity must be embedded in every initiative across the campus, and it must start from the top. Nurturing diversity was adopted in 2007 as one of seven strategic directions outlined in the UCSF Strategic Plan, the product of extensive input from the campus community and community partners. The plan specifically calls on UCSF to “continue to improve diversity of faculty, staff, students, and trainees to effectively establish a culture of diversity on the UCSF campus.” The plan’s diversity goals include creating a more diverse campus community, ensuring that UCSF continues to attract the best and most diverse candidates for all educational programs, and improving diversity among senior leadership. In addition, UCSF’s newly appointed chancellor, www.sfms.org
Susan Desmond-Hellmann, has stated her ongoing commitment to perpetuating a climate that welcomes and respects the contributions of all faculty, staff, students, and trainees. In just two years, we’ve taken huge steps toward reaching our strategic goal. One major achievement has been empowering someone to lead and oversee initiatives to enhance diversity among faculty, students, and trainees; ensure the advancement and timely completion of academically related diversity activities; and coordinate with relevant system-wide committees. My position as director of Academic Diversity was created in 2007. Its other activities include: • Developing an academic database to track faculty searches, applicant pool demographics, national availability data, and current trends about existing faculty. • Introducing a leadership development program for staff in management positions to build the pipeline for future UCSF leaders. • Conducting an inventory of existing campus outreach programs designed to increase the pool of students, postdoctoral scholars, and faculty from diverse backgrounds. • Recommending improvements to UCSF outreach endeavors. • Launching a diversity website with information and video profiles to help foster appreciation for individual differences. We embrace an inclusive definition of diversity—one that refers to the variety of personal experiences, values, and world views that arises from differences in culture and individual circumstance. While UCSF reports on the number of women
and underrepresented minorities, the university and medical center are committed to increasing participation among all underrecognized groups irrespective of age, religion, language, abilities/disabilities, sexual orientation, socioeconomic status, and geographic origin.
Cultivating Future Leaders
In addition to efforts focused on current faculty, students, trainees, and staff, we’ve also charged each school at UCSF— the Schools of Dentistry, Medicine, Nursing, and Pharmacy—as well as the Graduate Division and UCSF Medical Center with identifying leaders who are responsible for addressing diversity opportunities unique to their schools while coordinating activities with the director of Academic Diversity. Each has developed outreach programs designed to expose potential students from diverse backgrounds to their specialties and to help them consider medical or research careers. The results have been measureable: an increase in the number of underrepresented minorities in the schools’ classes and improved accountability across the campus. In addition, programs such as the Medical Center’s School at Work focus on professional development for employees who are part of the UCSF community and encourage them to consider careers as allied health professionals. The long-term commitment of UCSF to enhancing, appreciating, and celebrating the diversity of our campus community is thriving. A diverse health care workforce is a significant part of the solution to ending health and health care disparities, and we are prepared to continue to lead this effort.
November 2009 San Francisco Medicine 19
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Hospital News Chinese
Joseph Woo, MD
We are very fortunate at Chinese Hospital to have signed a couple of our number-one draft choices. Joining our staff this fall are otolaryngologist Dr. Man-Kit Leung and urologist Dr. Wenwu Jin. In addition to being a skilled surgeon, Dr. Man-Kit Leung is also the son of our own renowned Dr. Martin Leung. He comes to us with incredible credentials, including graduating summa cum laude at Harvard College, a doctor of medicine from UCSF, ENT training at Stanford, and a rhinology and sinus surgery fellowship at Harvard Medical School. He will be splitting time in Chinatown and at his office near St. Francis Hospital. He is joining the practice of Drs. Dexter Louie and Clifford Chew. Dr. Wenwu Jin is another all-world physician. He holds a PhD in biophysics and bioengineering from Case Western University, where he also received his doctor of medicine. He completed his residency in urology at Baylor College of Medicine in Houston. His interests cover all major fields of adult urology, with special interests in minimally invasive laparoscopic and robotic surgeries. He is taking over the practice of Dr. Raymond Fay. Truly, “everything is bigger in Texas” applies to Dr. Jin.
www.sfms.org
CPMC
Saint Francis
Damian Augustyn, MD
Patricia Galamba, MD
ClearVision mask changes the face of patient care, literally: When Jeanne Hahne, RN, began working in a burn unit, she was frustrated because patients would come in badly burned and in need of treatment and comfort. But because they were dressed in cap, gown, and mask, she found it hard to create an emotional bond with patients, because the mask obscured the face and created a distance. So she invented the ClearVision mask. It’s made of clear plastic and works just like a regular mask but with several important advantages: Improved communication. Patients can see your lips as you talk, and see facial gestures more readily. Health. The mask could also prove to be a better barrier. Patient safety. Communication problems are the number-one cause of medical errors in hospitals. Patient anxiety. Being in the hospital is already scary enough. Health First, our specialized, multicultural health resource center at St. Luke’s, is being honored for its health education work. San Francisco Health Plan presented Health First with the Award for Dedication to Health Care Service Delivery during a ceremony at Fort Mason on October 29. Health First is an ambulatory health resource center that serves as a hub of prevention, education, and care coordination activities in the neighborhoods surrounding St. Luke’s. San Francisco Health Plan is a city-sponsored health plan providing health insurance to more than 55,000 low-income San Franciscans. Thanks to a generous sponsorship by CPMC Foundation, our Davies campus is now a member of Practice Greenhealth—a nonprofit organization dedicated to reducing the ecological footprint of the health care industry. Membership will give CPMC access to education, networking, support, and technical assistance, helping us improve our environmental stewardship. These services will be applied to all of our facilities as we work to “green” CPMC through initiatives such as waste minimization, reduction of toxic chemicals, and resource conservation.
Saint Francis Memorial Hospital can be described as a place where “cultures connect.” Our downtown location affords us the opportunity to serve every demographic, from the affluent on Nob Hill to the uninsured in the Tenderloin to the newly immigrated in Chinatown and Little Saigon. Our Emergency Department is often the first place an international tourist will turn to for medical care. When we opened our new ER in fall 2006, we made certain that patient rooms were predominantly private and that each room or bedside was installed with a CyraCom phone system so that we would have 24/7 translation services at our fingertips. We serve everyone side by side in our ER. It is striking to see how over the past several decades our workforce (doctors and hospital staff) have become as culturally diverse as our patient population. We rely heavily on our certified translators and our interdisciplinary team to assess cultural issues as they are related to the patient’s medical care, especially issues at end of life. Some challenges result from cultural differences between the patient’s beliefs and values and the practice of Western medicine. As practitioners we are wise to be aware of our own assumptions, beliefs, and values and know that they can impede our understanding of the patient’s needs. The most effective way to provide integrated care is to set aside our assumptions, seek to understand the patient, and meet them where they can understand the care that we can provide. We are fortunate to have the support of our Spiritual Care, Palliative Care, and Bioethics Departments in the accommodation of our beliefs and practices. On October 21, we happily celebrated the thirtieth anniversary of our Centers for Sports Medicine. At the celebration we unveiled the dedication of the Centers to honor sports pioneer and Medical Director Dr. James Garrick. The program is now called the James G. Garrick Centers for Sports Medicine. Congratulations to Dr. Garrick and his outstanding sports medicine team.
November 2009 San Francisco Medicine 21
Hospital News St. Mary’s
Veterans
Richard Podolin, MD
It is important for every physician to recognize the signs of abuse. Primary care physicians are often the first professionals with an opportunity to identify victims of violence. Patients who are abused may hide the cause of their injuries or emotional distress, and the physician must appreciate patients’ hesitancy in sharing this very private information. These patients may have been isolated by their abuser, and they may have told that no one but the abuser will love or help them. Patients may share their stories of abuse with their primary care physician but fear taking steps toward help. Furthermore, reporting abuse can have significant consequences in patients’ lives. It may affect their finances, their familes, and their children. As doctors, it is our duty to understand the anxieties our patients may encounter and then help empower them to make positive changes. When a physician is confronted with a possible case of violence or abuse, the first priority must be the patient’s safety. What resources are needed? Does this situation require counseling, social workers, police protection, or all of these? Psychiatric consultation can be invaluable, but unfortunately it may be necessary to help patients overcome barriers before they can receive this help. There is a common stigma associated with seeing a psychiatrist, and this may be particularly strong in some age groups and cultures. Once consulted, the psychiatrist can perform a risk assessment and can serve as a resource for primary care physicians, emergency physicians, and even the police, assessing a patient’s proximity to danger and helping patients help themselves. As physicians, we can be the bridge to community resources available to abuse victims. We need to be cognizant of the reporting requirements in some circumstances. First, however, we must be sensitive to the whole patient and see beyond the immediate presenting problem.
Diana Nicoll, MD, PhD, MPA
On September 14 the SFVAMC celebrated its seventy-fifth anniversary. A ceremony was held for patients and staff with Marvin Sleisenger, MD, distinguished physician and former chief of medicine; and Lloyd “Holly” Smith, professor emeritus, UCSF, providing remarks. Both are responsible for the establishment of the affiliation between the V.A. and UCSF. Also attending was Margaret Handlery, the greatgranddaughter of Lt. Colonel John D. Miley, the man for whom the V.A. property is named. Construction of the hospital began in 1933 on land known as Fort Miley, formerly used as a defense battery. The original plans called for twenty-one buildings and a 500-bed hospital. It was architecturally designed in a CaliforniaSpanish-Mayan style at a cost of $1.25 million. The hospital opened in 1934 with twenty-five staff doctors and a distinguished group of consultants. In 1941, the Japanese attack on Pearl Harbor on December 7 led to immediate reactivation of the Fort Miley batteries. More than 300 veterans were evacuated from the V.A. hospital due to the possibility of an air attack against San Francisco. Patients were returned to the hospital after the batteries were decommissioned and the hospital reopened in 1946. The Medical Center has a long history of being in the forefront of medical innovation and cutting-edge research. A fifty-year affiliation with the UCSF, has allowed the Medical Center to recruit outstanding clinicians, teachers, and researchers. This successful collaboration has facilitated advances in medicine and research and is the cornerstone of the Medical Center’s reputation for excellence. Today, the SFVAMC serves more than 50,000 veterans and provides ,more than 400,000 outpatient visits in fiscal year 2008. More than 700 UCSF trainees from thirty-four programs rotate through the Medical Center each year. It also has the number-one V.A. research program in the nation, with more than $77 million in expenditures in 2008.
22 San Francisco Medicine November 2009
UCSF
Elena Gates, MD
This issue includes an article describing UCSF’s efforts to promote a culture of diversity among faculty, staff, and students. Nurturing diversity is a university and medical center priority and one of the seven goals of UCSF’s strategic plan. These efforts are critically important; we also understand they are not an end in themselves. To improve care for all patients, respect for others’ differences must turn into actions that demonstrate appreciation of a group’s sensitivities, beliefs, or communication styles. One way to achieve that is by identifying local or global partners. UCSF launched a clinical trial to test culturally specific interventions for type II diabetes in Chinese immigrants. A study in Diabetes Care shows disease rates are 1.6 to 3 times higher for Chinese Americans than for European Americans. “Many standard recommendations for diabetes self-management don’t consider Asian orientations to health, including concerns for balance, or offer treatments sensitive to traditional Asian diets or exercise preferences,” said Catherine Chesla, RN, DNSc, principal investigator and School of Nursing professor. Chesla and UCSF researchers are collaborating with two respected Chinatown agencies, Donaldina Cameron House and North East Medical Services, in all research aspects. Study participants receive culturally specific training in managing complex social situations that arise during diabetes self-care, including tips on talking to doctors. Mt. Zion hospital historically has facilitated access to care for Russian-speaking people. The hospital began offering interpreters in the 1980s to address Jewish-Russian immigrants arriving in the city. Today, UCSF provides three full-time Russianspeaking interpreters and approximately 15,000 Russian interpretations annually. “Many Russian-speaking patients are elderly and need help with cancer, cardiology, or diabetes care,” said Tatyana Latushkin, interpreting services manager for Mt. Zion and Parnassus Medical Centers. The service offers 150 languages. www.sfms.org
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Report from the 2009 CMA Annual Meeting Stephen Follansbee, MD, and Steve Heilig, MPH
Policy and Progress at the CMA
D
emocracy is the worst form of government other than all the rest, or so the saying goes. The 300-plus elected physicians who constitute the House of Delegates (HOD) of the California Medical Association’s prove the point. Gathering annually, this year in the sometimes surreal environs of the Disneyland “resort” in Anaheim, the unwieldy group follows parliamentary procedure in arguing out dozens of policy proposals covering virtually all aspects of medical practice, science, regulation, ethics, finance, and more. It’s no mere academic exercise. The CMA’s political advocacy in Sacramento and elsewhere has a very good scorecard, and this is where the positions and priorities are set. Beyond that, some CMA policies are argued and adopted nationally by the AMA. And many of those, through the years, began here in San Francisco. The SFMS delegation, although relatively small, has by wide acclaim had an outsized impact on many issues throughout the years. Some have even called our group the “conscience” of the CMA, due perhaps to our continued focus on public health and ethical issues. This year was no exception. After three pre-HOD meetings locally, we brought a solid roster of resolutions to the meeting—and had virtually all of them adopted in some form. Some highlights, courtesy of your SFMS delegation (with names appended where special credit is due): Sugar taxes: CMA will now support increased taxes on sodas and other relevant sugar-sweetened beverages, with the revenues to be used for public health education efforts. (Shannon Udovic-Constant, MD) Pharmaceutical safety: CMA will advocate that the FDA be funded and staffed to adequately inspect and ensure the safety of all pharmaceuticals, including over-the-counter products, consumed in the United States, and that the FDA require labeling of all pharmaceuticals with their ingredients and their respective countries of origin. (Ann Myers, MD) Endocrine-disrupting chemicals: CMA will urge further collaboration among medical and scientific groups to identify ways to decrease exposure to endocrine-disrupting chemicals and that policy regarding EDCs be based on comprehensive data covering both low-level and high-level exposures. (Ann Myers, MD) Medical practice guidelines and conflicts of interest: CMA now holds that members of practice guideline development committees must disclose any possible conflict of interest; that medical and specialty associations should not receive from drug, device, or equipment manufacturers any money for practice guidelines; and that guidelines should be peer-reviewed by
24 San Francisco Medicine November 2009 25 San Francisco Medicine November
independent reviewers. (George Susens, MD) “Smart growth” and air pollution reduction: CMA supports regional targets for local governments to reduce greenhouse gas emissions and support land use and transportation strategies to meet those targets. (Thomas Addison, MD) Alcohol taxes: CMA now supports increased alcohol taxes and will advocate that any measure to increase alcohol taxes should allocate money to alcohol-related education, outreach, prevention, and treatment programs. (Gordon Fung, MD) Health system reform and palliative care: CMA will seek to improve access, training, discussion, and/or provision of good palliative care in any setting and respond to the scare tactics of those who distort the intent and impact of proposals to improve palliative care. (William Andereck, MD) These were just a few highlights. There were many more debates, including the annual one over “physician-assisted dying” (delegates Robert Liner and Follansbee strove to get CMA to take a ‘neutral” position but could not prevail). Your SFMS delegates even revised another delegation’s proposal and was able to get the CMA to now “consider the criminalization of marijuana to be a failed public health policy” (George Fouras, MD). For more information, visit the CMA website at CMAnet.org.
SFMS REPRESENTATIVES TO CMA Stephen E. Follansbee (Chair) Gordon L. Fung Rachel Shu E. Ann Myers Peter W. Sullivan Michael Rokeach George P. Susens Shannon UdovicConstant
John I. Umekubo H. Hugh Vincent Robert I. Liner Lawrence Cheung Rita Melkonian Peter J. Curran Rodman S. Rogers Roger Eng George A. Fouras Robert J. Margolin
William S. Andereck Richard A. Podolin Richard Bohannon Craig H. Kliger Andrew F. Calman Timothy Hamill Thomas E. Addison Eric Tabas Eric Denys Suketu Sanghvi
www.sfms.org
Health Policy Perspective Steve Heilig, MPH
Still Sick
A
s happens every generation or so, health care “reform” has become, at least in political terms, sexy. Traditionally seeing it as a “third rail” of policy making that few dared touch, officials, pundits, and experts of all stripes have been proposing remedies to the chronic issues of the cost, quality, and, especially, lack of access to care. Not since the Clintons’ well-intended but unsuccessful 1994 attempt at sweeping reform has the issue been so prominently discussed. In 2007, I reviewed for the San Francisco Chronicle a thennew book titled Sick: The Untold Story of America’s Health Care Crisis—and the People Who Pay the Price, by Jonathan Cohn, a senior editor at the New Republic. His book is now out in paperback and, unfortunately, as much or even more relevant than when it was first published. Perhaps the most notable aspect of Cohn’s book was that he focused less on the uninsured, and more on the majority who are ostensibly “covered.” Cohn illustrates his research with many real-life stories, albeit invariably sad ones. Consider Steven and Elizabeth Hilsabeck of Texas, whose son was born with cerebral palsy. Physical therapy is indicated to help people with this incurable condition, but the family’s insurers suddenly stop paying for it. A clerk informs them wrongly that they are only covered for sixty visits per lifetime; and then asks them “When is he getting over the cerebral palsy?” The couple considers divorce just so Elizabeth might become poor enough to qualify for Medicaid. Instead, they sell their home and move into a cramped trailer to afford care for their kids. Other unfortunate “insured” people profiled here wind up in other trailers, and some of their lives end with suicide, brought on by the despair of never getting the care they need. As should now be clear, even the insured often struggle with hassles, obstruction, misinformation, and worse from their “partners” in the health insurance industry. Cohn details how health insurance has evolved from well-meaning nonprofit efforts to large profitable companies and “managed care” in the 1990s, and how each step has brought more complaints. In President Obama’s August address on healthcare, he focused on insurance industry abuses more than any other problem, and Senator Dianne Feinstein has more recently added that the industry “has no moral compass.” The underlying dynamic, of course, is that so much of the health care industry remains a for-profit business. Even the founding figure of managed care, Paul Elwood, MD, came to lament it: “The idea was to have health care organizations compete on price and quality. The form it took, driven by employers, is www.sfms.org
competition on price alone.” Or, as Cohn observes, “When they’re not dealing with large groups of employees, insurers have no desire to protect those who most need protection.” In effect, Cohn concludes, “managed care hadn’t so much altered the evolution of American health insurance as reinforced it, moving toward a system that left the most medically vulnerable at even greater risk than before.” Cohn strives to be fair, giving some of the perspective of those charged with controlling costs as well. But it’s hard to reconcile a $500 million payout to HMO chiefs with the suffering some insured people endure—or cannot. And now even managed care is less viable than ever; Cohn notes that public and private insurance is faltering, and safety-net charitable clinics and emergency rooms and public hospitals are strained to the breaking point. “Sooner or later, something was going to give,” he writes. As in a newer and somewhat similar popular book, The Healing of America by T.R. Reid, Cohn sees solutions out there, sometimes in other nations. But neither author seems to feel that such “healing” is forthcoming anytime soon. So, with this depressing diagnosis, what is the cure? We now have a one-yearold federal administration that has focused mightily on health care “reform.” Multiple bills are grinding through committees in Washington, with the outcome unknown at press time. In his book, Cohn views previous attempts at reform under Presidents Clinton and Bush as largely political failures in the former or giveaways to powerful insurance and pharmaceutical interests in the latter. Massive lobbying and “donations” in recent months – on the order of $1million daily - are striving to repeat some version of those precedents. The much-discussed “public option” has been euthanized, then resuscitated, with the prognosis unknown, Other “reforms” are also being watered down, Yet in addition to whatever expanded coverage of uninsured people results from this round of reform, some progress might also be achieved in the form of restrictions on some of the insurance industry abuses Cohn documents. Limits on denial of coverage, including that for “preexisting conditions,” would be one major improvement. Such regulations will be far from the sweeping reform being proposed earlier this year,, but a worthy step along the way to a more humane health care “system.” Even with such incremental reforms, perhaps our national health care picture may not be quite so “sick.” And remember, as countless sports teams have been reminded—there’s always next season.
November 2009 San Francisco Medicine 25
Independent But Not Alone.
Richard Ward, M.D. Hill Physicians provider since 1994. Uses Ascender preventive health reminders and RelayHealth online communications for patient care and ePrescribing solutions.
Independence and strength are not mutually exclusive. Practices affiliated with Hill Physicians Medical Group retain independence while enjoying the strength that comes from being part of a large, well-integrated network of physicians. • Fast, accurate claims payments • Free electronic communication capabilities via RelayHealth • RN case management for complex, time-intensive cases • Preventive care and disease management reminders for patients • Deep discounts on EMR and EPM solutions That’s why Hill Physicians Medical Group is one of the country’s leading Independent Physician Associations. It’s a smart choice for providing better healthcare.
Your health. It’s our mission.
Learn more about Hill Physicians at www.HillPhysicians.com/Providers or contact: Bay area: Jennifer Willson, regional director, (925) 327-6759, Jennifer.Willson@hpmg.com Sacramento area: Doug Robertson, regional director, (916) 286-7048, Doug.Robertson@hpmg.com San Joaquin: Paula Schmit, regional director, (209) 762-5002, Paula.Schmit@hpmg.com Hill Physicians’ 3,000 healthcare providers accept many HMO plans including: Aetna, Alliance CompleteCare (Alameda County), Anthem, Blue Shield, CIGNA, Health Administrators (San Joaquin), Health Net, PacifiCare and Western Health Advantage.
26 San Francisco Medicine November 2009
www.sfms.org
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Let us show you how your membership in the Society can save you money. Social Security Administration, Fact Sheet January 31, 2007 Life and Health Insurance Foundation for Education, November 2005 3 ”Commissioners Disability Table, 1998,” Health Insurance Association of America, the New York Times, February 2000 1 2
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42612 (9/09) ©Seabury & Smith Insurance Program Management 2009 d/b/a in CA Seabury & Smith Insurance Program Management • CA License #0633005 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • CMACounty.Insurance@marsh.com • www.MarshAffinity.com Marsh is part of the family of MMC companies, including Kroll, Guy Carpenter, Mercer and the Oliver Wyman Group (including Lippincott and NERA Economic Consulting). Hartford Life and Accident Insurance Company, Simsbury, CT 06089. The Hartford® is The Hartford Financial Services Group, Inc., and its subsidiaries, including issuing company Hartford Life and Accident Insurance Company. All benefits are subject to the terms and conditions of the policy. Policies underwritten by Hartford Life and Accident Insurance Company detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued. (AGP-5719) • #3-924
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