Understanding The Problem

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B. Waine Kong, PhD, JD: The United States is becoming more and more diverse… And physicians have many more challenges. It's not just business as usual anymore.

Troyen Brennan, MD, Aetna Chief Medical Officer: A health care provider can do a great deal about racial and ethnic disparities in health care.

Niurka C. Giron (patient): That's why we all prefer to have a doctor that understands our culture and our language.

Sampson Davis, MD: Hello, we're The Three Doctors. We've made it our mission, as a team, to create opportunities for communities through education, mentoring and health awareness.

Rameck Hunt, MD: Fifteen years ago, we were just three friends attending the same High School in Newark, New Jersey who had a pretty rough life. As African Americans coming from the inner city, we were determined to rise above any hardships and avoid becoming victims of our surroundings, so we made a pact to go to school together and become doctors.

George Jenkins, DMD: We want to examine the problem of racial and ethnic disparities in health care, a serious issue that Aetna is working very hard to address. Aetna realizes that its physicians and providers are the key to delivering quality health care to its members, and so today we want to look at what providers can do to better treat people from diverse cultures. By understanding the symptoms of the disparities problem, we can modify our treatment so that all people, regardless of their background, can receive quality health care.

Cheryl Pegus, MD, Aetna Clinical Product Head: Health disparities is an issue that really looks at: how is everyone in the country receiving health care? Is everyone getting the same quality of health care? Does everyone have the same access to health care?

Dr. Brennan: Most physicians believe that they're taking the same care of all of their patients, no matter what their race, their ethnicity, their creed, or what have you. (3.25) And so to find that some patients are receiving systematically worse care than others, and that it tends to be members of minorities who've been subject to discrimination in the past, it's something that indicts the entire health care system. Physicians want to do something about that.

John W. Rowe, MD, (former) Aetna Executive Chairman: The Institute of Medicine of the National Academy of Sciences, an elite group of policymakers and researchers and practicing physicians, conducted a very robust analysis of the issue of disparities, and they found that these were very durable, that they persisted across many different forms of disease, whether it's cancer or diabetes or high risk pregnancy, and it was something that was very clear in both the diagnosis of disease and the effective treatment of disease.

Dr. David Satcher, MD, PhD (former U.S. Surgeon General): We debate about what's the cause of that, whether it's culture, bias, or the system itself, but without question, studies show that people get different levels of quality of care. So we've got to attack quality of care. We have to attack lifestyle. We know that African Americans and Hispanics are much more likely to be obese, which means that we're at much greater risk for cardiovascular disease and diabetes and cancer, all the things that are associated with obesity.

Dr. Pegus: The ways that you reinforce someone to maintain a healthy lifestyle is you make sure that you're communicating with them regularly. For our Healthy Body Healthy Weight program at Aetna, we make sure that we have physical therapists, nutritionists, and weight loss therapists to assist someone on staying on track. Every three months, you're making sure that you're getting another incentive to stay with your healthy lifestyle but also finding out what may have changed in your work or your home life so we can adjust the plan to you.

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Targeted Solutions

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Dr. Hunt: The issue of health care disparities is immensely complex, but there are targeted solutions that can help us bridge the gap.

Dr. Jenkins: One of these solutions is improving communication between doctors and patients, so that cultural and language barriers are eliminated.

Joe Betancourt, MD, MPH: I have a patient who I see who's originally from the Dominican Republic. Prior to seeing me she had a lot of trouble communicating with her doctor. She's originally Spanish-speaking, speaks some English, so yes, language played a role, but I think clearly one of the other major issues was the fact that she couldn't communicate, she wasn't getting asked key questions about her condition, and I think she was very excited to get a chance to see somebody who would begin to ask these questions, begin to take her cultural perspective into account in the clinical encounter.

Giron: It took me more than 20 years to find a doctor to understand my culture!

Dr. Rowe: One of the things that we've done at Aetna that I'm very proud of is that we've launched a very significant effort in cultural competency training of all our clinical personnel, which is almost 1500 individuals, in our company.

Dr. Betancourt: So we developed an e-learning program: a 2-hour computer-based, web-based interactive program with patient cases so you, as a health care provider, you log on and you actually have to see these patients and, through that, we begin to teach you how you might take different things into consideration how you might use simple language, how you might negotiate with patients all towards getting a better outcome and addressing disparities.

Paulina Jiminez, Nurse Consultant, Aetna Healthy Outlook Programs: I went through the cultural competency training at Aetna, and I learned how important it is for people to include other things into their care. For example, a lot of people do herbs, a lot of people do alternative medicine, like acupuncture, yoga, and a lot of people involve their families. So, through that training I was able to see that there were a lot of other things that were going to come into play when you think of a person and how they deal with disease and how they see their healing process.

Linda Mako, RN, Aetna Supervisor: When we speak with any member, we really want to get an appreciation for where they're coming from and their background. Dr. Betancourt's training really helped hone my skills as far as teaching people how to communicate in the best way over the phone in order to ask those open-ended questions, in order to understand what's going on with each member individually.

Jiminez: It is important to have a cultural understanding of these people, because, for example, in Hispanics, we like to involve our family in everything that we do. So a lot of times, they will have a family member listening in on the conversation or you can hear them in the background supplying information, or sometimes they take the role and they call you also with questions as they arise, so by understanding that, you are more aware that it's going to happen, and it's also easier for them.

Giron: It's very important for me and for all the Spanish-speaking to have a doctor that understands, you know, our language and our culture.

Victor Villagra, MD, FACP, President, Health and Technology Vector, Inc.: Physicians should also try to blend familiarity and friendliness with respect at the same time. It is important to keep in mind that health beliefs based on religious values or folk values may be a critical important part of the healing process, and they should be respectful and inclusive of those.

Ron Williams, Aetna Chairman, CEO and President: It's also important to understand the diet and the types of foods people typically eat. Because if a nutritionist, for example, is recommending a diet and doesn't take into account the types of foods typically prepared in that household, the member really doesn't stand much of a chance of being compliant with that diet. So the cultural context is the context against which health care will in fact be experienced by that member.

Dr. Villagra: It is important to respect the patient's traditional beliefs. They may want to carry an amulet to surgery for good fortune or good luck. Don't remove it. Encase it in a sterile bag and send the patient to surgery with it.

Kong: Learn, by travel. Learn, by participating in festivals, and go to ethnic restaurants. Become friends with people from those communities, outside of the health care system. Subscribe to lots of different cultural magazines.

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Closing The Gap

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Dr. Davis: Our road to becoming physicians was filled with bumps. Some of our obstacles were because of our culture and race.

Dr. Jenkins: If we can close the gap to provide people of different races and cultures the ability to go through training and education to become physicians- then those physicians and clinicians can better communicate and treat patients that share their same background.

Dr. Hunt: And so, moving towards a balanced medical representation of cultural diversity in the health care profession will be a very important step in eliminating health disparities.

Dr. Satcher: I'm worried about the pipeline for getting more African Americans and other minorities into the health professions, but I'm beginning to detect some momentum even in that direction. So hopefully, within five years, we'll see many more applicants to medical schools from minority communities, and many more being accepted.

Kong: One of the unfortunate things about American society and the history, you know, that we've had in this country, is that 70 percent of the cardiologists in this country are white men. And only 8 percent are women. Only 2 percent are African American. So it's not just being referred to a cardiologist- it's referred to what kind of cardiologist.

Williams: What we have learned is that physicians can be trained to always think about the cultural context. And in doing that, they really sit down with each patient regardless of their background and can really ask a set of questions and ask how does this individual's culture, how does their racial background, how does their ethnicity impact their ability to access quality health care services.

Kong: However you can communicate to patients that you care about them as an individual, and that you respect them, you will get good results. It is never going to help us if you just rush a patient in, spend two minutes, write a prescription, and say, "take this."

Dr. Betancourt: I think Aetna has set themselves apart as one of the industry leaders, and as such, they have a lot of people around the country looking at them and looking at their next steps, and so I think it's really incumbent around them to continue to be creative, to continue to be cutting-edge both around the education they provide internally and to their providers, around the initiatives they focus on for their employers who they work with, their efforts for educating their members.

Dr. Villagra: I am very impressed by the seriousness, the depth, and the breadth of Aetna's effort in eliminating disparities in health care.

Giron: When you have a doctor that understands your culture, and understands your language, it's easier for you to speak your mind, you know, so he could understand what you want.

Dr. Hunt: We all need to recognize that, unfortunately, health disparities exist and that they affect the entire health care system.

Dr. Davis: Only by acknowledging the problem can we begin to study it carefully and then turn our knowledge into action, truly treating all patients with the respect they deserve and expect.

Dr. Jenkins: After all, as health care providers, it is our responsibility to deliver the best possible care to people of all races, creeds, and cultures. When we do this every day, we can proudly say we are truly making progress towards closing the gap.

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