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D Racial Disparities in Healthcare: Highlights from Focus Group Findings Meredith Grady Tim Edgar Westat 1650 Research Boulevard Rockville, Maryland June 2001 STORIES OF RACIAL DISCRIMINATION IN HEALTHCARE PRACTICE Racial discrimination occurs on many levels, in a variety of contexts, intertwined with income, education level, and other sociodemographic factors. It can be subtle or disturbingly overt. During the eight focus groups, participants were asked to talk about their own personal experi- ences with racism in healthcare. When asked whether discrimination ex- ists in receiving quality healthcare, one African-American participant summed up the collective response in this way: “The medical world just reflects the real world.” Throughout the following section, participants’ stories and opinions are presented in their own words, providing evi- dence of healthcare inequity that participants attributed directly or indi- rectly to racial or ethnic discrimination, their lack of English-language proficiency, or both. Effect of Stereotyping Participants often felt that the quality of health care services they re- ceived stemmed from misperceptions and stereotypes, not the reality of who they are. They said they often feel that health care providers treat them differently and assume they are less educated, poor, or deserving of less respect because of their race or culture. A Hispanic physician, speak- ing of the perceptions of his colleagues, corroborated participants’ opin- ions that health care providers make assumptions about their patients based on race or ethnicity. “As soon as they look at the patient and see 392

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393 D: RACIAL DISPARITIES IN HEALTHCARE he’s African American or Latino, they assume automatically that he doesn’t have insurance at all.” The following quotes provide examples of encounters that partici- pants had with healthcare providers who made stereotypical assumptions about their education or culture. My name is . . . [a common Hispanic surname] and when they see that name, I think there is . . . some kind of a prejudice of the name. . . . We’re talking about on the phone, there’s a lack of respect. There’s a lack of acknowledging the person and making one feel welcome. All of the courtesies that go with the profession that they are paid to do are kind of put aside. They think they can get away with a lot because “Here’s another dumb Mexican.” (Hispanic participant) I’ve had both positive and negative experiences. I know the negative one was based on race. It was [with] a previous primary care physician when I discov- ered I had diabetes. He said, “I need to write this prescription for these pills, but you’ll never take them and you’ll come back and tell me you’re still eating pig’s feet and everything. . . . Then why do I still need to write this prescription.” And I’m like, “I don’t eat pig’s feet.” (African-American participant) My son broke my glasses so I needed to go get a prescription so I could go buy a pair of glasses. I get there and the optometrist was talking to me as if I was like 10 years old. As we were talking, they were saying, “What do you do,” and as soon as they found out what I did [professionally], the whole attitude of this person changed towards me. I don’t know if they come in there thinking, “Oh this poor Indian does not have a clue.” I definitely felt like I was being treated differently. (Native-American participant) One participant spoke about a relative who did not want to take her husband’s name after marriage for fear of being negatively stereotyped. My granddaughter, she’s a doctor herself. She graduated in Mexico and then she came here. She [studied here] so she could become a doctor here. She married a Mexican guy named [a common Hispanic surname]. You know what she did? She took off [a common Hispanic surname] and kept [another surname], her father’s name. (Hispanic participant) Language Barriers Many participants in the Chinese- and Spanish-speaking focus groups voiced concern about being treated unfairly because of their lack of English-language proficiency. As a result, they perceived that healthcare providers treat them differently and were concerned that they receive lower quality care. If you speak English well, then an American doctor, they will treat you better. If you speak Chinese and your English is not that good, they would also kind of look down on you. They would [be] kind of prejudiced. (Chinese participant)

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394 UNEQUAL TREATMENT When they see he can’t explain himself, they look at him as if [they are] belittling him. They treat him with a lot of inferiority… the doctor, nurses, receptionists. You can tell when the person is not liked by the doctors or the staff. I have seen a lot of discrimination in that manner. (Hispanic participant) I have a desire to improve my English so I can go to an American doctor and get better treatment. (Chinese participant) Healthcare providers were also concerned about not being able to communicate adequately with their patients because of a language bar- rier. One African-American nurse spoke of “seeing the fear in their eyes” and knowing how upset and frustrated patients were in trying to commu- nicate what was wrong with them. A Hispanic nurse acknowledged the language problem, stating that for “new immigrants that do not speak the language properly . . . it is the biggest obstacle they encounter.” Non-English-speaking participants, especially those in the Hispanic group, recounted many examples of personal situations in hospitals and other settings where they were forced to deal with serious health condi- tions without the benefit of interpreters or patient healthcare staff willing to assist them. They said they encountered healthcare staff who ignored them and avoided trying to help them. Others pointed out instances where they or their family members have received poor quality healthcare services and have been treated disrespectfully because they speak little or no English. A long time ago my husband was in pain. I had to call an ambulance and they took him to the hospital. We waited three hours. I would ask the nurse to please treat him because he could not stand the pain. She would say, “We’re going to call him, we’re going to call him.” I saw black people being called in, but they never called him back. I asked for some medication in the meantime. They never came out with the medicine. . . . Well, we left. [My husband] told me it must have been because we are Hispanic and don’t speak English. They would call and call in black people. . . . I think if we would’ve been black or American we would have been treated faster. (Hispanic participant) [My wife] was treated badly. They wouldn’t take care of her. They were chang- ing her IV and the nurse was very rough in the way she would take the needle out and put it back in. I felt bad. I had to go and tell them with the little English I speak what was happening. So, they changed the nurse. That’s the way it is. All the situations we are experiencing are because we can’t communicate in English. (Hispanic participant) My son was in a bed and another boy was with his mother. Of course, they didn’t speak English. The lady didn’t know . . . she wanted to know where they were taking the boy. She asked for the girl who was interpreting for her. One of the nurses said, “I don’t know why they send these people here without any- body to interpret for them. We’ll come back later,” and they left . . . but they

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395 D: RACIAL DISPARITIES IN HEALTHCARE didn’t do anything about finding out where the interpreter was. (Hispanic participant) I had eye surgery two or three years ago. The specialist was black. There were Hispanics out front. I told them I had an appointment with the doctor. They asked me if I spoke English . . . one said to the other in Spanish, “Go inside with her.” “No, you go.” I asked them who was going to go with me because the doctor was waiting for me. Once we were inside, he would speak [only to the interpreter] directly. I felt rejected. (Hispanic participant) Five years ago my son got double pneumonia. The doctors wanted to operate [on] him. . . . They called my husband and he said he had to talk with the special- ist who was treating my son to see what he had to say about the surgery. We called . . . and the specialist said my son would not be able to resist that type of surgery. My husband called the hospital and told me not to sign any papers. I didn’t speak English. I didn’t know anything. They put the paper in front of me to sign. They insisted I sign the paper. My husband told me not to sign anything and [that] he was on his way [to pick us up]. In the end my son didn’t have the surgery and he didn’t die like they said he would. Three days after they said he needed the surgery he got better. The surgery was not necessary. (Hispanic participant) I called a pharmacy to see if my daughter’s medicine was ready and they put me on hold. They put the phone down and said, “She’s a Spanish speaker,” and they put me on hold. She left me waiting a long time until I hung up. (Hispanic participant) The Role of Economics Oftentimes, participants noted, a person’s perceived or actual socio- economic status can be an obstacle to obtaining quality healthcare ser- vices. Participants were concerned that they may receive a lower stan- dard of care because healthcare providers make assumptions about the type of treatment or medication that they can afford because they are ra- cial or ethnic minorities. I know there have been a couple of times the doctor wanted to prescribe a certain medication but because of how much it was, he prescribed some- thing else. Not what was best, but what I could afford. (African-American participant) Often times, the system gets the concept of black people off the 6 o’clock news, and they treat us all the same way. Here’s a guy coming in here with no insur- ance. He’s low breed. (African-American participant) A lot of black people don’t have money so I guess you would say that it’s hard [to get quality healthcare.] A lot of black people don’t have any insurance. (African- American participant)

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396 UNEQUAL TREATMENT Lack of Respect Many participants unequivocally believed that the lack of respect healthcare providers have for them leads to lower quality healthcare ser- vices than persons of other ethnicities, especially whites, receive. They spoke of instances where the office staff would not “look them in the eye” when they spoke to them or greeted other patients with a more pleasant attitude. Others felt a lack of respect when they were rushed during ap- pointments and sensed that providers or their staff did not want to take the time to help them, answer their questions, or explain medical proce- dures to them. They wouldn’t accept the appointment over the phone; they just put me on hold. I went in there and she looked at me and I told her I’d been calling trying to make an appointment. She said, “Well, you see this stack of paper, you think you’re the only one?” She either thought I was Mexican or she recognized I was Indian, but she would not make that appointment. She just got smart with me and all. I told my husband about it. He’s big and white. She got to him just like that. No problem. She got the appointment and got him through. She wouldn’t do it for me. (Native-American participant) I felt that because of my race that I wasn’t serviced as well as a Caucasian person was. The attitude that you would get. Information wasn’t given to me as it would have [been given to] a Caucasian. The attitude made me feel like I was less important. I could come to the desk and they would be real nonchalant and someone of Caucasian color would come behind me and they’d be like, “Hi, how was your day?” (African-American participant) I don’t have a problem with taking more time to be able to understand each other, but they get really annoyed when you don’t understand them. Basically, they get really annoyed if you talk too much because they know they don’t under- stand your language. When I go to the doctor I ask a lot of questions, so they can get really aggravated with me. I don’t know if they would do the same thing to a white person. (African-American participant) Others felt they must wait for long periods of time before receiving medications and other medical assistance, while whites are cared for first. I would call [for the nurse] when I was feeling pretty bad. They wouldn’t come until I finally had to yell, “Help me, I’m in pain! I need something to calm the pain!” They had to call someone and she gave it to me. There were American [patients] there. They would even close the curtains for them. (Hispanic par- ticipant) If your bell was on and the Caucasian lady, she doesn’t even have to have her bell on. She was being attended to because they knew they better . . . do a certain quality [of service]. Whereas the same quality should have been given to the

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397 D: RACIAL DISPARITIES IN HEALTHCARE black people, but their bell would be on and they still would have to wait. (African-American participant) Improper Diagnosis or Treatment More troubling are instances that participants mentioned where the quality of medical treatment was compromised by discriminatory atti- tudes or practices that participants believed led to either misdiagnosis or improper treatment. When I was growing up, my parents didn’t have health insurance. We would go to the Indian Health Service. You’d go there to the clinic and I think sometimes you wonder about the quality of the medical personnel that was examining you. My younger sister had appendicitis. It burst, and they told her she had a stom- ach flu. I don’t know how they were hiring the medical personnel at that time. It’s changed now, but back then I don’t think we had some of the best medical officers or nurses. (Native-American participant) Being in a group practice seeing predominantly African-American patients, I have patients who have seen mainly white physicians in the past. When they come in to visit with us and speak with us, something as simple as [asking them to] sit up on a table and they got a question. “What are you going to do?” “I’m going to examine you.” “Oh, my other doctor never did that.” (African- American physician) Of course, in psychiatry we see this [discrimination]. One area we see is in terms of diagnosis. Patients are inappropriately diagnosed and medications prescribed for the patients. We see errors in that. Minority patients will often be diagnosed inappropriately as being schizophrenic. (African-American physician) When I ask [my Hispanic patients] if the other doctor ever examines you, they say, “No, they give me a prescription.” It’s amazing. A lot of times these patients have these problems that are missed by the other doctors. (Hispanic physician) In some instances, participants noted, racial and ethnic minority pa- tients have difficulties gaining access to the specialists they need. One physician noted that specialists mistreat racial and ethnic minority pa- tients to avoid having to provide treatment for them. I’m in private practice and we refer a lot. We kind of know what specialists to avoid because we hear the patients coming back and telling about what type of treatment they’re getting from these specialists. A lot of the specialists in these institutions act like they don’t want to see the minority patient at all. When the minority patient ends up there maybe because they’re on [a particular] plan… they are mistreated. (African-American physician)

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398 UNEQUAL TREATMENT In contrast to situations described by participants in which healthcare providers sought to limit their access to healthcare services, two female participants described being pressured to have surgical procedures that, in retrospect, were deemed unnecessary by other doctors. The first thing they wanted to do was a hysterectomy. I was 36 years old and they never really examined me. I was just telling them the symptoms and it scared me and I left. . . . I guess they were trying to stop the population birth, whatever, because [the hospital] back then was for people who didn’t have insur- ance. (African-American participant) My Ob-Gyn is Caucasian. I have fibroid tumors and the doctor I’ve been going to, he’s been my Ob-Gyn for 14 years and for the last 2 years he told me I have to have this hysterectomy. I had a girlfriend at the office recommend me to a female African-American physician. . . . A week later she called me at home and said to me, “There’s nothing wrong with you. The fibroid is there but if it’s not bothering you, if it’s not broke, don’t fix it. You don’t need to have a hysterec- tomy.” (African-American participant) To overcome discriminatory attitudes from healthcare providers, one participant suggested that it is necessary for minorities to be “strong” and not “humble in your voice and tone” to have a better chance at getting the care they wanted. I believe that African Americans do get a lower quality of care. I think if you’re educated, if somebody’s not treating you right then you kind of push past some of the stuff, but for somebody that doesn’t have a good feeling about themselves, whether it’s because of race or literacy, that makes it very hard for them to get the care that they need. (African-American nurse) CHALLENGE OF IDENTIFYING RACIAL AND ETHNIC DISCRIMINATION Some participants found it difficult to identify obvious examples of discrimination they encountered in their healthcare experiences, although they were certain that discrimination exists in healthcare settings. As one African American participant aptly described, “It’s hard to identify dis- crimination because they don’t show it. They’ll be sweet and smooth, all the way through it.” Participants mentioned experiencing discrimination in many situations, but because of the subtleties often inherent in dis- crimination, it was challenging to identify overt examples. They often said, “You just know,” or “You can feel it” when describing incidences of discrimination. Overall, participants felt that racial discrimination could not easily be separated from other forms of discrimination. The quotes that appear in the following section illustrate participants’ concerns about not receiving

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399 D: RACIAL DISPARITIES IN HEALTHCARE appropriate healthcare services, but they also show that the link between one’s race or ethnicity and poor treatment can be very complex. While the underlying issues (e.g., economics, improper diagnosis) mentioned here parallel those discussed in an earlier section, the claims made in the fol- lowing quotes only suggest that a lower quality of healthcare stems from racial or ethnic discrimination. The evidence for this causal relationship tends to be circumstantial. Patients’ Appearance Some participants hinted that attention to appearance, (e.g., being well-dressed) might counteract discriminatory tendencies. One Hispanic participant said he felt it was important to “be presentable,” otherwise the healthcare staff would likely make him wait for hours before helping him. Another said: I’ve noticed that, outward appearance has a lot to do with the rapport that you have with your provider. They talk to you a little different, they treat you a bit differently. You can walk in, you’re all battered and crummy looking, and their whole personality changes. You walk in looking half-way decent, and they’re very pleasant, and they react and act completely different. (African-American participant) Patients’ Economic/Insurance Status Some participants provided examples of how they or their family members received poor healthcare services because of their lack of insur- ance or perceived inability to pay for these services. They believed that they were being treated differently by the healthcare system, although they did not make a direct link to race or ethnicity. I went back [to IHS] after I found out everything that needed to be done. I went back to the clinic and chewed out the doctor. Then she said, “Wait a minute. Wait a minute. Do you realize how much it’s going to cost you? It’s like buying a new car.” I said “I don’t care at this point. It’s my life. I don’t care how much money I have to pay out of my pocket.” Then she says, “Wait a minute. Let’s send you to a specialist.” I said, “Why didn’t you tell me this to begin with? Now that I’m making my move, now you’re telling me, OK, now you can do this and that for me?” I said, “No thank you. This is it.” (Native-American participant) My niece went to this hospital and they wouldn’t wait on her because she didn’t have insurance. They told her she would have to go to the county hos- pital. So I had to take her to the county hospital. She was bleeding all the way. It was just terrible, because she didn’t have insurance. (African-American participant)

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400 UNEQUAL TREATMENT It’s almost like “Oh well, this person doesn’t have insurance. Let’s just give them the IHS treatment.” (Native-American participant) I have a son and he’s considered disabled. He had MediCal before. I got it before I got insurance through my job, and I had to wait 100 days before I got the insurance through my job. So I noticed there’s a longer waiting period… other people are coming in after me and have later appointments, but they have private insurance, so they’re seen before me and my son. And it wasn’t just the waiting period; the treatment was different. Now that I have private insurance, as soon as I get there, [they see me]. (Hispanic participant) An Ob/Gyn who had a large Medicaid population, not just black and Hispanic, but a large Medicaid population . . . they told the doctor they wanted him to have more deliveries at other hospitals. [He refused.] The hospital then, at that point, decided they would stop taking all Medicaid period because this doctor would not leave. For an entire year this hospital wouldn’t pay Medicaid just so this doctor wouldn’t deliver there anymore. (African-American physician) Healthcare Setting Native Americans, because of their unique access to healthcare through the Indian Health Service (IHS), spoke often about the poor quality of care at the IHS clinics. More than participants in the other groups, they defined their ability to get quality healthcare services by the setting in which they received care and not by their race. They did not blame poor healthcare on individual providers as much as they did on the IHS system. If you go into IHS for a problem, they don’t investigate your problem to the extent that a private place does. [Private offices] go through everything like an ultrasound, blood work, the whole nine yards, and they pinpoint the problem. IHS, they give you a temporary solution or shot and it comes back up a month later. (Native-American participant) I think the way that race plays into it is because we all go to the Indian Health Service because we’re Indian. That’s where we start out with our healthcare. (Native-American participant) I’ve had experiences where I had no choice but to go to the Indian Health Service. You go in there, they rush through you. They misdiagnosed several things with me, and you’re just rushed through. I’ve dealt with accidents, and to get your accidents paid for and stuff, IHS takes forever to get those reports through. It took like 2 years, and that’s a very long time. I don’t know where they get that, but I don’t think that’s right. (Native-American participant) Attitude of Healthcare Providers Some participants were surprised and disappointed by the uncaring attitude exhibited by some of their healthcare providers or administrative

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401 D: RACIAL DISPARITIES IN HEALTHCARE staff. In some cases, they felt staff were unwilling to help them, and infor- mation about their health was delayed or not provided to them. In other situations, doctors seemed more interested in insurance payment issues and less concerned with providing appropriate care for their patients. The doctor comes in and says, “Why is he on oxygen?” I was recovering from surgery. He’s looking at the chart and he says, “The insurance doesn’t cover it. Take it off.” Just like that. I’m right there, and I’m thinking “Wow, that’s pretty harsh if it comes from a doctor.” That was unfair I thought. (Hispanic participant) First of all, they didn’t send me back the results for 5-6 months. I can’t get an answer on the phone when I call. I have to call like 10 times and they put me on hold and say they’ll transfer me. They never transfer me. They hang up on me. (Hispanic participant) A few participants did not think their physicians took the time neces- sary to listen to them or examine them properly. They felt that their over- all health needs were being ignored. [The doctor] just walks in and has other patients to see, [she asks] “What’s wrong with you now?” and that’s it. Sometimes I will go into other things that I have felt and it’s like, “Oh, just take vitamins.” What if there’s something else wrong? They’re not trying to find out what’s wrong. Maybe I have cancer or something. (Hispanic participant) They just come in, look at the chart, say, “OK, are you taking your medications? See you in 3 months.” . . . if they find the chart. Sometimes they can’t even find mine. (Hispanic participant) Other Stories About Misdiagnosis or Improper Treatment Some participants spoke of going to the hospital or doctor and receiv- ing misinformation or improper service from healthcare providers. In some cases, participants said their healthcare providers misdiagnosed their condition or were too passive in their treatment approach. A few participants questioned whether some providers they went to were quali- fied to make an accurate diagnosis of their health problem. Again, the concerns expressed in these specific instances were linked to race and ethnicity by implication only. At the hospital, they sent me over to a doctor, who was not an [eye] specialist. He diagnosed me with cataracts and said I needed surgery the next day. Thanks to a miracle from God, I did not end up blind. [Afterwards] eight days went by that I was blind in that eye. . . . Jose took me to another doctor. The [second] doctor told us I needed surgery the next day. It’s a miracle from God that I can see. The other doctor left me with silicone. They put the entire amount that comes in the

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402 UNEQUAL TREATMENT packet when they should have only put half. Why did the man who wasn’t an eye specialist tell me I had cataracts, when what I had was a detached retina? (His- panic participant) My daughter was young and I took her to the hospital. She had stomach pains… I went to this private doctor and hospital and they sent us home with some medicines. . . . The next day I sent her to school. The school called me up and said, “You [have] got to come pick up this child because she can’t even walk.” So I said, “OK, I’m going to County General because they will make sure this child’s taken care of.” I’m not going back playing with these people [at the private office]. I took her to County General. They had her in there for 5 hours checking everything. I found out that she had walking pneumonia. (African- American participant) In my country, if they find you have a fibroma they remove it. They don’t wait for it to grow. Maybe if they had taken them out this wouldn’t have happened to me. (Hispanic participant) INSTITUTIONAL DISCRIMINATION IN HEALTHCARE In discussions with African-American and Hispanic physicians and nurses, they spoke not only about the discrimination their patients experi- ence at the provider-patient level, but also cited examples of how health- care institutions perpetuate discrimination in their policies and methods of practice. Providers felt institutions mandate policies that have a sig- nificant negative impact on the provision or access to services for racial and ethnic minority patients. It’s very difficult to recruit Hispanics [for clinical trials] who cannot under- stand the consent form. I felt there was some resistance [to spending extra time counseling Spanish-speakers]. [I was told] it was just not really necessary, that I can just give them a synopsis of what is in that consent form. I said, “Wait a minute. This is a very important piece of paper. Why should it be different? You don’t give a synopsis to English-speakers.” So you can see sometimes the double standard there. (Hispanic nurse) They would not take certain doctors from certain ZIP codes, but we found out what was going on and that subsequently has changed a few years ago. Because they didn’t want [minority] patients, they just excluded people from certain ZIP codes, from certain sections of the city. (African-American physician) Providers also cited examples of discrimination that they have had to contend with personally during their medical training or professional career. There are those that don’t get promoted because of their race or whatever. The reason [may be because] they’re not well liked by administration or it may be just that they don’t want that person in that setting because of their race—that

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403 D: RACIAL DISPARITIES IN HEALTHCARE is out there. Racism is alive and well, and those of us who think that it’s not are living in some kind of dream world. (African-American nurse) The local medical society . . . it’s got the good old boy attitude. It’s the same old doctors that have been running it, and they’re still running it. The new guys kind of have trouble getting in. (Hispanic physician) I heard an Anglo doctor complaining that his daughter is having trouble getting into medical school. Then another doctor jumps in, another Anglo, “Oh, don’t worry about it. I know the admissions coordinator. . . I’ll get her in. I’ll give him a call and she’ll be in.” When does a Hispanic or black student have those advan- tages, the connections? I certainly didn’t have any connections, and I still don’t have any connections. I couldn’t get my son into medical school if I tried. (His- panic physician) INCLUSION OF AND RESPECT FOR CULTURE IN HEALTHCARE EXPERIENCES While some participants did not feel it was essential that providers and patients be of the same race or ethnic background, many participants felt that a cultural match between healthcare providers and patients is helpful in communicating more easily. One African-American physician summed up responses saying, “Basically, you’re comfortable with what you’re familiar with. That’s the bottom line.” Participants felt that it is easier to develop a rapport or discuss treatment options with healthcare providers of their own race who already understand their language and cultural idiosyncrasies. I don’t think necessarily you have to be an African American to provide good care to African Americans, but if you’re not you really need to be aware of the culture and some of the issues in that culture, and really look at how you feel about dealing with people from that culture. (African-American nurse) For me, my doctor is a thin doctor, but she knows that I like Mexican food so she knows it’s hard for me to lose weight. She understands the way my parents brought me up, the culture, the background, so she knows. In other words, we understand each other because we’re both Hispanic. (Hispanic participant) If someone, the doctor for example, is of the same ethnicity, Hispanic, he under- stands the idiosyncrasies more. For example, for women, in our country there are certain taboos. It is more difficult to talk about private things. So, a doctor of our same race will understand those things more. (Hispanic participant) I feel I could relate better to the African American [doctor]. He knows black folks better. If you’re talking about high blood pressure, diabetes, sometimes these are things that traditionally do not happen to white folks. To the extent with the ills that we suffer, I believe he would be better suited for me. (African-American participant)

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404 UNEQUAL TREATMENT I think there are just certain aspects of the culture that one may know a little bit more about by just being part of the culture. For example, with Hispanic pa- tients, it’s more of a touchy feely—especially my relationship with older women. There’s always a lot of hugging or kissing, whereas with the men—none of that— there’s only hand shaking. When it comes to my African-American women, there is some touchy feely stuff, but, again, there is more distance. I think just being aware of the cultural attitudes makes it slightly different. (Hispanic physician) In instances where healthcare providers or administrative staff are of a different race or ethnicity than the patients they are treating, partici- pants expressed a desire for more patience and respect from their provid- ers. They felt that doctors and nurses who are treating a high proportion of patients from a particular racial or ethnic group should be familiar with relevant customs that may impact patients’ healthcare decisions. One thing—the elders—they’re stubborn. You got to have a lot of patience with them because they think they’re all right and they don’t want to go to a doctor. It takes a lot just to get them to go. Have patience and be courteous towards them and respect them. (Native-American participant) A lot of Native Americans are shy. I think that would be good for a doctor to make sure the patient understands the treatment they’re going to provide or the cause of their illness and make sure they understand what’s going on. (Native- American participant) Our culture is very different. The Americans have a different way of treating people. We are more affectionate, sweet. We have a lot of time to give, they are very quick. (Hispanic participant) I think if [doctors] have a basic knowledge of the culture and are sensitive of that, culture is just the traditional part of healing. There was one doctor at IHS. My brother injured his leg, went in, had an x-ray. . . . I remember at the end of the visit, and this was the only time I heard one of the doctors there say, “If you want to go visit your medicine man, feel free to do that.”(Native-American participant) Yeah, I had to have surgery and also my mom. In both cases this is the same doctor, a specialist, and when he explained about my mom, for example, he even took me in the room. He showed her and me, he even on a piece of paper showed how the liver and all this, what they had to do and this and that, and explained in language that we understood and took the time. It took him maybe a little more than 20 minutes, and that counts for something in my book you know. (Hispanic participant) If they’re going to practice in a Native-American setting, they should under- stand how traditional medicine can lead to healing the patient. (Native- American participant)

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405 D: RACIAL DISPARITIES IN HEALTHCARE Understand what the past healthcare history has been to Native Americans. Maybe just having an understanding of how Native-American healthcare has been across the U.S., not just here in the Southwest, but everywhere. I think that would make [healthcare providers] effective because then they would know what’s happened in the past and not repeat the same mistakes. (Native-American participant) CONCLUSION The stories and recollections of participants across the eight focus groups provide supporting evidence for the concern that racial and ethnic minorities are less likely to receive appropriate medical services, and that they experience a lower quality of healthcare than do nonminorities. While racial and ethnic discrimination is not always easy to recognize or recall, participants offered many concrete examples of discriminatory situ- ations they encountered. This research adds to the growing body of lit- erature examining racial and ethnic disparities in healthcare and provides evidence of both interpersonal and institutional discrimination. Perhaps, through continued research and awareness, healthcare delivery will be- come more respectful and culturally appropriate for racial and ethnic mi- nority patients in the future.