Disclosures ADDRESSING HEALTH CARE • NIH-NIDDK DISPARITIES • NIH-NIMHD AT THE BEDSIDE • NIH-NHLBI • PCORI BOG Alicia Fernandez, MD No conflicts of interest University of California, San Francisco Zuckerberg San Francisco General Goals for talk: Health care disparities: The evidence base • Connect Health Care Disparities (HCD) to daily clinical care • Robust literature with strengths and limitations • Provide skills to address HCD at the bedside • Studies can provide guidance when responding to clinical situations • Focus on the subset of HCD driven by provider behavior • Often, no single right answer even when guided by literature • Help expand our role as teachers about HCD 1
Overview of talk MD-driven HCD are subset of all HCD • Four cases • Commonly encountered clinical scenarios drawn from resident focus groups Health Care System Disparities • Illustrate role of provider-driven HCD in care • Each case includes: Structural disparities • Possible clinical outcomes Access disparities • Review (a little bit) of relevant evidence MD • Practical skills and teaching papers Driven • Revisit with possible responses • Engender thought and discussion about our role Case 1: “I speak Spanish” I speak Spanish: Options Get whatever history you can from the conversation The ER is very busy and you are very tired. A two year old A. between the MS-3 and the parent girl is there with lower abdominal pain and vomiting. The mother is clearly very concerned. She speaks only Spanish and there is no interpreter in sight. Make a note to get an interpreter in the morning B. Your medical student says he speaks “a little Spanish” and Try to use the AT&T operator while in the ED hallway C. begins to take a history. It is clear that there is communication difficulty. Ask a nurse or family member to interpret D. What do you do? 2
I speak Spanish: Possible outcomes “False fluency”: The evidence Unclear about the patient’s history but not wanting to 1. • False fluency: the inaccurate perception of miss anything, your team orders a full panel of studies. language competence The patient spends the next eight hours in the ED awaiting the results, all of which are normal. • False fluency is associated with increased medical errors, including major errors Unclear about the history, your team makes a 2. diagnosis of gastroenteritis and discharges the patient with reassurance and fluid precautions. She returns to • Limited English Proficiency (LEP) patients have: the ED four days later, worse, and found to have a a • Longer lengths of stay ruptured appendix. • Higher costs • More difficulty with medical comprehension • More medication errors Errors in Medical Interpretation and their Impact of Language Barriers on Documentation of Informed Consent at a Hospital with On-site Potential Clinical Consequences in Pediatric Interpreter Services Encounters • Study at SFGH: 75 LEP (Chinese- & Spanish-speaking) • Study design: Interviews using an interpreter were taped. patients matched with English-speaking patients • Findings: Errors in interpretation were common • Thoracentesis • averaging 31 per encounter, with 19 per encounter labeled as • Lumbar puncture clinically significant • Paracentesis • Examples of clinically significant errors include: • omitting questions about drug allergies • Patients excluded if procedure emergent, patient • adding that hydrocortisone cream must be applied to the entire body instead of only to facial rash incapable of informed consent, confusion, intubated • instructing a mother to put amoxicillin in both ears for treatment of otitis media • Ad hoc interpreters (staff, family) had higher error rates. Schenker/Fernandez, JGIM, 2007 Flores, 2003 3
Language is the only significant predictor Documentation of informed consent of documentation of informed consent LEP English P-value OR CI Adj OR CI N (%) N (%) Language 2.8 1.4-5.6 3.1 1.5-6.5 Full Informed Consent 21 (28) 39 (53) 0.003 (English vs. LEP) Age 1.0 0.9-1.0 1.0 1.0-1.1 Signed Consent Form - 52 (70) 63 (85) 0.03 any language Gender – ref men 0.7 0.3-1.5 0.7 0.3-1.5 Infection 1.0 0.5-2.0 0.9 0.4-2.1 Malignancy 1.4 0.5-4.0 1.5 0.5-4.7 Remember � informed consent is a legal LP 1.1 0.4-2.9 2.0 0.6-6.5 and ethical imperative. Paracentesis 1.0 0.3-2.9 1.1 0.3-3.4 LEP patients must have documentation of ED vs Wards 0.5 0.2-1.1 0.5 0.2-1.2 an interpretation in a discussion. Schenker/Fernandez, JGIM, 2007 Schenker/Fernandez, JGIM, 2007 Why Don’t We Use Interpreters? • Qualitative study IM “I Speak Spanish” residents SFGH/Yale- DOCTOR AND PATIENT When the Patient Gets Lost in Translation NH • Hassle factor vs What could you say? “Getting By” • Explicit decision making • Underuse of Sean Justice/Getty Images interpreters normalized By PAULINE W. CHEN, M.D. Published: April 23, 2009 TWITTER despite recognition of Diamond/Fernandez JGIM, 2009 impact on care 4
Case 2: “I blew it” Summary As cross-cover at the public hospital you are called to see a • Law, ethics and effective clinical care all mandate patient for pain control after I&D of an abscess on his arm. interpreters Arriving at the bedside, you see a thin man in his thirties in obvious discomfort. He is African-American. • This can be difficult Remembering that your last patient with an abscess needed high doses of opiates to adequately control his pain, your first question to him is “how much heroin do you • Know the resources available to you use a day?” The patient explodes in anger, yelling that “all the doctors in • Advocate for your patients this hospital think all black men are addicts.” It becomes clear he has lymphoma and the abscess is a complication of a recent node extraction. I blew it: Possible outcomes I blew it: Options The patient declines additional doses of morphine, 1. Leave and let the nightfloat resident return without you. A. although clearly uncomfortable, and leaves the following day Explain to the patient that most abscess are caused by B. addict needles and you made an honest mistake The patient’s pain is better controlled over the next day 2. because you were trying to help him. and he is discharged, but fails to keep his follow-up appointment for chemotherapy Apologize. C. You apologize to the patient, who describes feeling 3. repeatedly mistreated. He accepts pain control. 5
Do house officers learn from their Facts about medical mistakes mistakes? • Stereotyping happens when we are stressed, tired or • Landmark study of UCSF IM trainees, reports of errors overwhelmed • Patients had serious outcomes in 90% of cases, including death in 31% • Communication is a procedure and is subject to mistakes, as are all procedures • House officers who accepted responsibility for the mistake and discussed it were more likely to report constructive changes in practice • Literature on how physicians handle mistakes shows Wu, JAMA, 1991 common responses are: • Cultural shift toward increased discussion of system • denial errors • concealment (from colleagues and patients) • Recent vignette study of PCPs indicates majority not fully • Patients want disclosure and clear discussion of errors disclose or apologize for delayed cancer diagnoses Errors: What can you say? Apologizing • Studies show that patients strongly desire error • Hard to do disclosure: • Embarrassing • An explicit statement that an error occurred • Fear of legal repercussions • What the error was • Keep it simple and focused on what you did • Why the error happened • “I am sorry” • How recurrences will be prevented • Name the error • A simple apology (resist the urge to justify) • “I made an assumption that was wrong” • Allow patient to continue to have an emotional response • Although disclosure is beneficial, it does create emotional distress for the doctor • Better in the long run, less malpractice? Gallagher, NEJM, 2007 Gallagher, NEJM, 2007; Kachalia, Ann Intern Med, 2010 Levinson, W; 2005 6
Summary Case 3: “Take two pills” • Subconscious stereotyping is common in medicine, as You are seeing a 5 year old patient in busy urgent care with pattern recognition informs much of our thinking possible pneumonia and asthma exacerbation before running to clinic. You give the mother discharge • Approximately 15% of patients feel disrespected due to instructions: “Take two of the antibiotic pills three times a race, ethnicity, and/or language day for the next seven days; take two prednisone pills daily for five days; use two puffs of inhaler four times daily and return if worse. The mother looks up at you, confused. • We all make mistakes • Learning to take responsibility and apologize is important Take two pills: Options Take two pills: Possible outcomes Assume the nurse will go over the medication A. The patient is leaves and returns to the ED two days 1. instructions also, and something will get through. later, having failed to take the prednisone. Make sure the family has clear written instructions in B. The patient’s mother is unable to follow the written 2. addition to the verbal ones. instructions provided and fails to keep the follow-up appointment in pediatrics clinic. Review again to make sure the parent understands C. how to give the meds. Ask your medical student to go over the patient’s meds D. while you move on. 7
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