When is risk stratification by race or ethnicity justified in medical care?

The Ethics of Cancer Screening Based on Race and Ethnicity

Racial and ethnic disparities in incidence and mortality are well documented for many types of cancer. As a result, there is understandable policy and clinical interest in race- and ethnicity-based clinical screening guidelines to address cancer health disparities. Despite the theoretical benefits, such proposals do not typically address associated ethical considerations. Using the examples of gastric cancer and esophageal adenocarcinoma, which have demonstrated disparities according to race and ethnicity, this article examines relevant ethical arguments in considering screening based on race and ethnicity.

Race- and ethnicity-based clinical preventive care services have the potential to improve the balance of harms and benefits of screening. As a result, programs focused on high-risk racial or ethnic groups could offer a practical alternative to screening the general population, in which the screening yield may be too low to demonstrate sufficient effectiveness. However, designing screening according to socially based categorizations such as race or ethnicity is controversial and has the potential for intersectional stigma related to social identity or other structurally mediated environmental factors. Other ethical considerations include miscategorization, unintended negative effects on health disparities, disregard for underlying risk factors, and the psychological costs of being assigned higher risk.

Given the ethical considerations, the practical application of race and ethnicity in cancer screening is most relevant in multicultural countries if and only if alternative proxies are not available. Even in those instances, policymakers and clinicians should carefully address the ethical considerations within the historical and cultural context of the intended population. Further research on alternative proxies, such as social determinants of health and culturally based characteristics, could provide more adequate factors for risk stratification.

Cultural Factors Influencing Advance Care Planning in Progressive, Incurable Disease: A Systematic Review With Narrative Synthesis

CONTEXT

Advance care planning (ACP) can improve end-of-life outcomes, but low uptake indicates it is less acceptable to patients of some cultural backgrounds.

OBJECTIVES

The objectives of this study were to explore how cultural factors influence ACP for patients with progressive, incurable disease and how ACP might be made cross-culturally appropriate.

METHOD

We conducted a systematic literature review using narrative synthesis. Protocol was registered prospectively (PROSPERO CRD42017060441). Key words and subject headings of six databases (AMED, PsycINFO, Embase, Ovid MEDLINE, CINAHL, and Cochrane) were searched without time restrictions. Eligible studies reported original research published in full that included adult participants with progressive, incurable disease or their formal or informal caregivers. Study quality was assessed using the Mixed Methods Appraisal Tool.

RESULTS

Eight hundred and eighteen studies were screened. Twenty-seven were included: 20 quantitative, four qualitative, and three mixed methods. Most (20/30) studies were conducted in the U.S., where nonwhite ethnicity was associated with lower acceptability of formal, documented ACP processes. Cultural factors affecting ACP acceptability included religiosity, trust in the health care system, patient and clinician comfort discussing death, and patient attitudes regarding decision-making. Informal, communication-focused approaches to ACP appear more cross-culturally acceptable than formal processes. Clinician education in cultural competence is recommended. Study limitations included use of unvalidated tools and convenience samples and lack of reflexivity.

CONCLUSION

Many interconnected cultural factors influence the acceptability of ACP in progressive, incurable disease, although specific mechanisms remain unclear. A communication-focused approach to ACP may better meet the needs of culturally diverse populations.

Primary Care Physicians' Collection, Comfort, and Use of Race and Ethnicity in Clinical Practice in the United States

Purpose: The clinical utility of race and ethnicity has been debated. It is important to understand if and how race and ethnicity are communicated and collected in clinical settings. We investigated physicians' self-reported methods of collecting a patient's race and ethnicity in the clinical encounter, their comfort with collecting race and ethnicity, and associations with use of race in clinical decision-making.

Methods: A national cross-sectional study of 787 clinically active general internists in the United States. Physicians' self-reported comfort with collecting patient race and ethnicity, their collection practices, and use of race in clinical care were assessed. Bivariate and multivariable regression analyses were conducted to examine associations between comfort, collection practices, and use of race.

Results: Most physicians asked patients to self-report their race or ethnicity (26.5%) on an intake form or collected this information directly from patients (26.2%). Most physicians were comfortable collecting patient race and ethnicity (84.3%). Physicians who were more comfortable collecting patient race and ethnicity (β=1.65; [95% confidence interval; CI 0.03–3.28]) or who directly collected patients' race and ethnicity (β=1.24 [95% CI 0.07–2.41]) were more likely to use race in clinical decision-making than physicians who were uncomfortable.

Conclusions: This study documents variation in physician comfort level and practice patterns regarding patient race and ethnicity data collection. As the U.S. population becomes more diverse, future work should examine how physicians speak about race and ethnicity with patients and their use of race and ethnicity data impact patient–physician relationships, clinical decision-making, and patient outcomes.

Equity of access to elective surgery: reflections from NZ clinicians

Objectives

To explore factors potentially influencing equitable access to elective surgery in New Zealand by describing clinicians’ perceptions of equity and the factors they consider when prioritising patients for elective surgery.

Methods

A qualitative study in selected New Zealand localities. A purposive sample of 49 general practitioners, specialists and registrars were interviewed. Data were analysed thematically.

Results

General practitioners described unequal opportunities for patients to access primary and secondary care and, in particular, private sector elective surgery. They felt that socio-economically disadvantaged patients were less able to advocate for themselves and were more vulnerable to being lost to the elective surgical booking system as well as being less able to access private care. Both GPs and secondary care clinicians described situations where they would personally advocate for individual patients to improve their access. Advocacy was related to clinicians’ perceptions of the “value” that patients would receive from the surgery and patients” needs for public sector funding.

Conclusions

The structure of the health system contributes to inequities in access to elective care in New Zealand. Subjective decision making by clinicians has the potential to advantage or disadvantage patients through the weighting clinicians place on socio-demographic factors when making rationing decisions. Review of the potential structural barriers to equitable access, further public debate and guidance for clinicians on the relative importance of socio-demographic factors in deciding access to rationed services are required for allocation of services to be fair.

Shared Decision Making Among Clinicians and Asian American and Pacific Islander Sexual and Gender Minorities: An Intersectional Approach to Address a Critical Care Gap

Shared decision making (SDM) is a model of patient-provider communication. Little is known about the role of SDM in health disparities among Asian American and Pacific Islander (AAPI) sexual and gender minorities (SGM). We illustrate how issues at the intersection of AAPI and SGM identities affect SDM processes and health outcomes. We discuss experiences of AAPI SGM that are affected by AAPI heterogeneity, SGM stigma, multiple minority group identities, and sources of discrimination. Recommendations for clinical practice, research, policy, community development, and education are offered.

Is risk stratification ever the same as 'profiling'?

Physicians engage in risk stratification as a normative part of their professional duties. Risk stratification has the potential to be beneficial in many ways, and implicit recognition of this potential benefit underlies its acceptance as a cornerstone of the medical profession. However, risk stratification also has the potential to be harmful. We argue that 'profiling' is a term that corresponds to risk stratification strategies in which there is concern that ethical harms exceed likely or proven benefits. In the case of risk stratification for health goals, this would occur most frequently if benefits were obtained by threats to justice, autonomy or privacy. We discuss implications of the potential overlap between risk stratification and profiling for researchers and for clinicians, and we consider whether there are salient characteristics that make a particular risk stratification algorithm more or less likely to overlap with profiling, such as whether the risk stratification algorithm is based on voluntary versus non-voluntary characteristics, based on causal versus non-causal characteristics, or based on signifiers of historical disadvantage. We also discuss the ethical challenges created when a risk stratification scheme helps all subgroups but some more than others, or when risk stratification harms some subgroups but benefits the aggregate group.

Racial and Ethnic Disparities in Health and Health Care: an Assessment and Analysis of the Awareness and Perceptions of Public Health Workers Implementing a Statewide Community Transformation Grant in Texas

INTRODUCTION

Little is known about the awareness of public health professionals regarding racial and ethnic disparities in health in the United States of America (USA). Our study objective was to assess the awareness and perceptions of a group of public health workers in Texas regarding racial health disparities and their chief contributing causes.

METHODS

We surveyed public health professionals working on a statewide grant in Texas, who were participants at health disparities' training workshops. Multivariable logistic regression was employed in examining the association between the participants' characteristics and their perceptions of the social determinants of health as principal causes of health disparities.

RESULTS

There were 106 respondents, of whom 38 and 35 % worked in health departments and non-profit organizations, respectively. The racial/ethnic groups with the highest incidence of HIV/AIDS and hypertension were correctly identified by 63 and 50 % of respondents, respectively, but only 17, and 32 % were knowledgeable regarding diabetes and cancer, respectively. Seventy-one percent of respondents perceived that health disparities are driven by the major axes of the social determinants of health. Exposure to information about racial/ethnic health disparities within the prior year was associated with a higher odds of perceiving that social determinants of health were causes of health disparities (OR 9.62; 95 % CI 2.77, 33.41).

CONCLUSION

Among public health workers, recent exposure to information regarding health disparities may be associated with their perceptions of health disparities. Further research is needed to investigate the impact of such exposure on their long-term perception of disparities, as well as the equity of services and programs they administer.

Physicians' anxiety due to uncertainty and use of race in medical decision making

BACKGROUND

The explicit use of race in medical decision making is contested. Researchers have hypothesized that physicians use race in care when they are uncertain.

OBJECTIVES

The aim of this study was to investigate whether physician anxiety due to uncertainty (ADU) is associated with a higher propensity to use race in medical decision making.

RESEARCH DESIGN

This study included a national cross-sectional survey of general internists.

SUBJECTS

A national sample of 1738 clinically active general internists drawn from the SK&A physician database were included in the study.

MEASURES

ADU is a 5-item measure of emotional reactions to clinical uncertainty. Bonham and Sellers Racial Attributes in Clinical Evaluation (RACE) scale includes 7 items that measure self-reported use of race in medical decision making. We used bivariate regression to test for associations between physician characteristics, ADU, and RACE. Multivariate linear regression was performed to test for associations between ADU and RACE while adjusting for potential confounders.

RESULTS

The mean score on ADU was 19.9 (SD=5.6). Mean score on RACE was 13.5 (SD=5.6). After adjusting for physician demographics, physicians with higher levels of ADU scored higher on RACE (+β=0.08 in RACE, P=0.04, for each 1-point increase in ADU), as did physicians who understood "race" to mean biological or genetic ancestral, rather than sociocultural, group. Physicians who graduated from a US medical school, completed fellowship, and had more white patients scored lower on RACE.

CONCLUSIONS

This study demonstrates positive associations between physicians' ADU, meanings attributed to race, and self-reported use of race in medical decision making. Future research should examine the potential impact of these associations on patient outcomes and health care disparities.

Genes, race, and culture in clinical care: racial profiling in the management of chronic illness

Race, although an unscientific concept, remains prominent in health research and clinical guidelines, and is routinely invoked in clinical practice. In interviews with 58 primary care clinicians we explored how they understand and apply concepts of racial difference. We found wide agreement that race is important to consider in clinical care. They explained the effect of race on health, drawing on common assumptions about the biological, class, and cultural characteristics of racial minorities. They identified specific race-based clinical strategies for only a handful of conditions and were inconsistent in the details of what they said should be done for minority patients. We conclude that using race in clinical medicine promotes and maintains the illusion of inherent racial differences and may result in minority patients receiving care aimed at presumed racial group characteristics, rather than care selected as specifically appropriate for them as individuals.

The measurement of spirituality in palliative care and the content of tools validated cross-culturally: a systematic review

CONTEXT

Despite the need to assess spiritual outcomes in palliative care, little is known about the properties of the tools currently used to do so. In addition, measures of spirituality have been criticized in the literature for cultural bias, and it is unclear which tools have been validated cross-culturally.

OBJECTIVES

This systematic review aimed to identify and categorize spiritual outcome measures validated in advanced cancer, human immunodeficiency virus (HIV), or palliative care populations; to assess the tools' cross-cultural applicability; and for those measures validated cross-culturally, to determine and categorize the concepts used to measure spirituality.

METHODS

Eight databases were searched to identify relevant validation and research studies. An extensive search strategy included search terms in three categories: palliative care, spirituality, and outcome measurement. Tools were evaluated according to two criteria: 1) validation in advanced cancer, HIV, or palliative care and 2) validation in an ethnically diverse context. Tools that met Criterion 1 were categorized by type; tools that also met Criterion 2 were subjected to content analysis to identify and categorize the spiritual concepts they use.

RESULTS

One hundred ninety-one articles were identified, yielding 85 tools. Fifty different tools had been reported in research studies; however, 30 of these had not been validated in palliative care populations. Thirty-eight tools met Criterion 1: general multidimensional measures (n=21), functional measures (n=11), and substantive measures (n=6). Nine measures met Criterion 2; these used spiritual concepts relating to six themes: Beliefs, practices, and experiences; Relationships; Spiritual resources; Outlook on life/self; Outlook on death/dying; and Indicators of spiritual well-being. A conceptual model of spirituality is presented on the basis of the content analysis. Recommendations include consideration of both the clinical and cultural population in which spiritual instruments have been validated when selecting an appropriate measure for research purposes. Areas in need of further research are identified.

CONCLUSION

The nine tools identified in this review are those that have currently been validated in cross-cultural palliative care populations and, subject to appraisal of their psychometric properties, may be suitable for cross-cultural research.

Mentioning race at the beginning of clinical case presentations: a survey of US medical schools

OBJECTIVES

Medical students and doctors in the USA frequently mention the patient's race at the beginning of oral or written clinical case presentations. However, this practice is controversial. We aimed to determine whether US medical schools explicitly teach students to mention race at the beginning of case presentations, and to collect additional information on the schools' perspectives on this practice.

METHODS

An Internet-based questionnaire was submitted to directors of courses on history taking and physical examination at all US medical schools.

RESULTS

The response rate was 85%. Students are taught to mention race routinely at 11% of schools and selectively at 63% of schools; this practice is discouraged at 9% of schools and not addressed at 18% of schools. Most respondents noted that resident doctors at their institutions routinely mention race at the beginning of case presentations. Even at schools in which mentioning race is discouraged or not addressed, students tend to include race during their clinical rotations. Respondents were divided on whether a standardised approach to inclusion of race should exist at US schools.

CONCLUSIONS

Teaching about inclusion or exclusion of race in the opening statement of clinical case presentations varies across US medical schools. This variation presents an opportunity for medical educators to discuss tensions between stereotyping and cultural competence in medical education.

Understanding what residents want and what residents need: the challenge of cultural training in pediatrics

BACKGROUND

There is increasing recognition of the need for sophistication in the way culture is understood and taught in medicine.

METHOD

A two-phase study designed to understand how best to approach cultural training with pediatric residents was conducted. A needs assessment, consisting of resident and faculty focus groups, was carried out from which a workshop was developed for pediatric residents. The aims were to increase knowledge of local cultures and resources as well as to encourage self-reflection and awareness of cultural issues.

RESULTS

Focus group participants were consistent in identifying needs for training in: (1) a specific knowledge base of local cultural groups; (2) skills to better negotiate cultural encounters; (3) reconciling general cultural knowledge with an understanding of individual patient/family beliefs and practices. Analysis of focus group and workshop data suggests that culture is seen as both an obstacle and challenge. Cultural training in medicine uncovers a clash of epistemologies: the promotion of culturally-centered medicine is 'strange' to learners situated within a pedagogical tradition based on a 'familiar' reductionistic view of health.

CONCLUSION

Reconciling these divergent epistemologies requires a paradigm shift in how medicine understands culture and cultural training. These findings raise questions for consideration in other residency programs.

Applications and implications of advances in human genetics: perspectives from a group of Black Americans

OBJECTIVES

We explored the opinions of 40 Black Americans regarding: (1) what they thought most Blacks and Whites believe about genetic causes for perceived race differences in human traits, and (2) the impact of genetic science on them, their families, and Black people.

METHODS

We conducted in-depth telephone interviews with 40 self-identified Black men and women. Transcripts of the interviews were recorded and examined for common themes.

RESULTS

The majority of our respondents felt that most Whites, unlike most Blacks, attribute differences between these groups to genetic factors. Many in our sample felt that genetic advances may provide benefits in the area of health care, but many also recognized potential harm.

CONCLUSIONS

Our results provide a glimpse as to what some Blacks believe about genetic science in the context of racial issues.

Understanding the provider contribution to race/ethnicity disparities in pain treatment: insights from dual process models of stereotyping

OBJECTIVE

This article applied dual process models of stereotyping to illustrate how various psychological mechanisms may lead to unintentional provider bias in decisions about pain treatment. Stereotypes have been shown to influence judgments and behaviors by two distinct cognitive processes, automatic stereotyping and goal-modified stereotyping, which differ both in level of individual conscious control and how much they are influenced by the goals in an interaction. Although these two processes may occur simultaneously and are difficult to disentangle, the conceptual distinction is important because unintentional bias that results from goal-modified rather than automatic stereotyping requires different types of interventions. We proposed a series of hypotheses that showed how these different processes may lead providers to contribute to disparities in pain treatment: 1) indirectly, by influencing the content and affective tone of the clinical encounter; and 2) directly, by influencing provider decision making. We also highlighted situations that may increase the likelihood that stereotype-based bias will occur and suggested directions for future research and interventions.

How lay people respond to messages about genetics, health, and race

There is a growing movement in medical genetics to develop, implement, and promote a model of race-based medicine. Although race-based medicine may become a widely disseminated standard of care, messages that advocate race-based selection for diagnosing, screening and prescribing drugs may exacerbate health disparities. These messages are present in clinical genetic counseling sessions, mass media, and everyday talk. Messages promoting linkages among genes, race, and health and messages emphasizing genetic causation may promote both general racism and genetically based racism. This mini-review examines research in three areas: studies that address the effects of these messages about genetics on levels of genetic determinism and genetic discrimination; studies that address the effects of these messages on attitudes about race; and, studies of the impacts of race-specific genetic messages on recipients. Following an integration of this research, this mini-review suggests that the current literature appears fragmented because of methodological and measurement issues and offers strategies for future research. Finally, the authors offer a path model to help organize future research examining the effects of messages about genetics on socioculturally based racism, genetically based racism, and unaccounted for racism. Research in this area is needed to understand and mitigate the negative attitudinal effects of messages that link genes, race, and health and/or emphasize genetic causation.

Premigration exposure to political violence among independent immigrants and its association with emotional distress

Although the distinction between independent immigrants and refugees has an impact on policy, services, and public opinion because it implies differences in resettlement needs, few recent studies have documented the validity of this assumption. In this population-based survey of recent migrants in Quebec (N = 1871), immigration status (refugee, independent, or sponsored immigrant) is examined in relation to premigration exposure to political violence and refugees' emotional distress, assessed with the SCL-25. A higher percentage of refugees reported exposure to political violence in their homeland, but the percentages of exposed independent (48%) and sponsored (42%) immigrants were unexpectedly high. Emotional distress was significantly higher among Chinese respondents who had witnessed acts of violence and in subjects from Arab countries who reported persecution. These results suggest that service providers and policy makers should not assume that independent immigrants have not been exposed to political violence before their migration.

Recruitment and retention strategies for longitudinal African American caregiving research: the Family Caregiving Project

OBJECTIVE

This article provides a detailed discussion, guided by a culturally competent approach, on recruitment and retention strategies used to study caregiving to older dependent elders in African American families.

METHODS

The study (lasting from 1995 through 2000) included collecting three waves of data, 9 months apart, among 202 caregiving units (containing a maximum of three caregivers per unit).

RESULTS

Four key strategies were identified as useful in recruiting and retaining the sample: (a) assigning the same interviewers to communicate with and interview study participants for each wave of data collection, (b) ensuring that all interviewers are knowledgeable of possible family dynamics and social issues within the African American community (e.g., access to health care, income and education issues, and discrimination), (c) providing a mechanism by way of a toll-free number for all participants to contact the project staff at the participant's convenience, and (d) allowing flexibility in scheduling and rescheduling interviews at the participant's convenience.

DISCUSSION

Researchers need to acquire knowledge and develop skills that will foster culturally competent approaches when studying diverse cultural groups, which involves incorporating the beliefs, values, and attitudes of a cultural group in every phase of the research project, from conceptualization to interpretation of findings. Additionally, a genuine interest in, knowledge of, and respect for the population are necessary to help improve participant involvement in longitudinal research among African American caregivers.

Medical decision-making and healthcare disparities: the physician's role

Widespread disparities in US healthcare have been documented with attendant speculation about their causes, including the potential role of the physician as a healthcare decision-maker. However, the current evidence on physician decision-making is inadequate to draw firm conclusions on how it relates to healthcare inequalities. In this article, we review the available evidence on physician decision-making as it relates to healthcare disparities, with an emphasis on its shortcomings, discuss potential sources of bias, including interpersonal factors and physician preferences, and make suggestions for further research in this area.

Patient expectations at a multicultural out-patient clinic in Switzerland

BACKGROUND

Recognizing patient expectation is considered as an important objective for primary care physicians. A number of studies suggest that failure to identify patient expectations can lead to patient dissatisfaction with care, lack of compliance and inappropriate use of medical resources. It has been suggested that identifying patient expectations in multicultural contexts can be especially challenging.

OBJECTIVES

The aim of the study was to compare health care expectations of Swiss and immigrant patients attending the out-patient clinic of a Swiss university hospital and to assess physicians' ability to identify their patients' expectations.

METHODS

Over a 3-month period, all patients attending the out-patient clinic at a Swiss university hospital were requested to complete pre-consultation surveys. Their physicians were requested to complete post-consultation surveys. Outcome measures were patients' self-rated health, resort to prior home treatment, patients' expectations of the consultation, physicians' perception of their patients' expectations and agreement between patients and physicians.

RESULTS

We analysed 343 questionnaires completed by patients prior to their consultation (> 50% immigrants) and 333 questionnaires completed by their physicians after the consultation. Most expectations were shared by all patients. Physicians had inaccurate perceptions of their patients' expectations, regardless of patients' origin.

CONCLUSIONS

Our study found no evidence that immigrant patients' expectations differed from those of Swiss patients, nor that physicians had more difficulty identifying expectations of immigrant patients. However, physicians in our study were generally poor at identifying patients' expectations, and therefore inter-group differences may be difficult to detect. Our results point to the need to strengthen physicians' general communication skills which should then serve as a foundation for more specific, cross-cultural communication training.

Paved with good intentions: do public health and human service providers contribute to racial/ethnic disparities in health?

There is extensive evidence of racial/ethnic disparities in receipt of health care. The potential contribution of provider behavior to such disparities has remained largely unexplored. Do health and human service providers behave in ways that contribute to systematic inequities in care and outcomes? If so, why does this occur? The authors build on existing evidence to provide an integrated, coherent, and sound approach to research on providers' contributions to racial/ethnic disparities. They review the evidence regarding provider contributions to disparities in outcomes and describe a causal model representing an integrated set of hypothesized mechanisms through which health care providers' behaviors may contribute to these disparities.