Health Care Disparities
Alana Dixson, MSII

We decided to include my comments on the importance of the MSII session on Health Care Disparities. I thought it might stir some thoughts also about recent events in the world that have put more people in desperate need of health care. We have also had a situation here at Keck that deals directly with issues of cultural competence that some of you may have submitted reflections on for this issue.

I have been a patient under a lot of different circumstances in my life, on a reservation in Arizona, in Russia, in Japan and Finland, in the inner cities of Portland, OR and NYC, and at some of the most "elite" medical institutions in the US...the experiences were all varied. I noticed different things about each setting and came away feeling differently about myself as a patient, as a woman of color, as someone of lower socioeconomic status, of higher socioeconomic status, educated and non-educated, etc. Now, it is important to note, that I am the same person today as I was in each of those experiences. Partly what made each encounter different was the age or circumstances of life that I brought to the clinic and partly just the intentions and background of my physician and the setting in which s/he practiced.

I left some encounters feeling very frustrated and marginalized, much like what was portrayed with some of the "insensitive" physicians. In other encounters, I felt as if I had been treated as a partner in my own health. My cultural background, educational attainment, and perceived socioeconomic status usually, in my opinion, made a difference in these more favorable encounters. I had one experience (I shared this last year in PPM) in which as a patient on the Hopi reservation in Arizona (a Native American reservation) I was treated very poorly until the physician found out that I was a student at Yale and that I was just visiting the reservation for the summer. Then he became attentive, enthusiastic and answered all of my questions. I got much better care, from what I could tell, than the other patients.

At first, the doctor thought that I was Apache, from a neighboring reservation. He had seen so many of "these" patients that he felt it was OK to treat me as though I had no interest in my own health and wouldn't listen to his counsel even if he bothered to give it to me. I was appalled and disheartened by this experience, I thought that it must be awful for American Indian people, living on their own lands, to be treated this way by health care providers who have the privilege of working with them. I vowed never to be such a provider and hoped that I would train with people who would want to learn how to avoid this behavior.

I know that many of us have not had the opportunity to be a patient in a place like LA County Hospital. Likewise, most of us probably identify, even now, more with the physicians in these scenarios than the patients. I don't think there is anything wrong with that. We all bring who we are to medical school and who we are is shaped by our experiences before this time and, certainly, during this time. I just hope that we don't discount that our professors are giving us a glimpse into some real experiences of patients.

These scenarios aren't made up to make people feel badly about being of one or another ethnic/SES/or other group, to say that all physicians are bad, or that everything in medicine is bad. Rather, they point out some real inequities, insensitivities and difficulties from both sides, the patient and the provider, that do exist. These issues are why NIH is spending millions of dollars on health disparities research. Especially in this climate of conservatism these must be real and important concerns if the current administration is willing to spend money on them! These problems between providers and patients are why the curriculums at medical schools are changing to include more topics. Having experienced these disparities in the way patients are perceived and its outcome on care myself, I can say that we need to be trained, as early as possible, to start examining our own prejudices and biases and learn to put them aside to take care of our patients and work well with our colleagues.

I am excited to hear that people are thinking about all of this. It's hard to learn, in my opinion, when people are too busy listening for cracking egg shells. I think we should be bold and honest in our discussions, let's hash out the issues. If you think all of this is stupid and irrelevant then say so. If you think it's important then say so. If you're offended, be offended, but I think we all need to then step back and say, "What can I learn from this?"

Sometimes the lesson may be that we have offended someone and even if we don't know why, we need to do everything in our power to rectify the wrong. Once rectified, we may just find that we can work better as health care providers and that our patients, or relationships with our colleagues, are actually healed.

It is impossible to become a physician, in every sense of the professional meaning, without training. I think these types of sessions in PPM and ICM are getting us there, even if we are too immature or inexperienced, or whatever, to know that. I know it has been uncomfortable for me this past year to confront some of my issues and even more difficult to change. But if it will help me be a better health care provider and researcher, then it's worth it. We are privileged to help people in their most difficult times of life. If gaining that privilege means that we have to go the extra mile to learn more about someone else's point of view, no matter how different that person is from us, and to overcome more personal, inner challenges, then we just have to do it. It's worthwhile. I'm excited to learn and grow more with you all over the next few months.