Leveling the caring field. In a follow-up to her 2001 study identifying racial disparities in the level of care cardiac patients receive, Nancy Kressin, an SPH associate professor of health services and a Veterans Administration research career scientist, found that physician assessments and perceptions, not patients’ beliefs, seem to be most significant in medical decisions about ordering invasive cardiac procedures such as cardiac catheterization.
Although it has been widely documented that African-American, Hispanic, and Asian patients are disproportionately less likely than European-Americans to undergo cardiac catheterization, Kressin’s research is the first to simultaneously assess how patient and physician attitudes play out in this area of medical decision-making.
Kressin and her colleagues administered questionnaires to 1,045 cardiac patients and their physicians at Department of Veterans Affairs Medical Centers in Houston, Pittsburgh, Atlanta, St. Louis, and Durham, N.C. They found that although African-Americans indicated a stronger reliance on religion, reported more racial and social-class discrimination, and were less likely to indicate a generalized trust in people, on the whole African-American and European-American patients had similar attitudes about illness and health care.
Physicians, on the other hand, evaluated the patients in each racial group very differently, rating the probability of coronary artery disease as well as the need for cardiac catheterization higher in European-American patients even though both populations had similar clinical characteristics. They also rated European-Americans as better communicators, of higher socioeconomic status, and as more likely to comply with medication treatment than African-American patients.
Kressin points out that since patients were cared for in VA facilities, ability to pay for care and financial incentives for physicians to recommend or deny procedures were not relevant in making decisions. In fact, demographic measures such as income and level of education were similar for all the patients in the study.
“Our findings also echo others regarding racial disparities in renal transplantation,” says Kressin, “where adjustment for patients’ preferences regarding transplantation did not account for the racial disparities in referral for the procedure.”
The researchers suggest that computerized decision aids at the point of care may help provide objective and accurate assessments of the seriousness of illness and the need for cardiac catheterization or other invasive procedures. Also, cultural competency training may help physicians become aware of how clinical stereotypes based on race may be biasing their medical decisions.
This research was reported in the December 2004 issue of the American Journal of Public Health.
Humanizing mental illness. Courtenay Harding, a SAR professor of rehabilitation counseling, a senior director of the Center for Psychiatric Rehabilitation, and director of the Institute for the Study of Human Resilience, works to see and understand the human being behind the mask of mental illness. Her most recent study, funded by Eli Lilly and Company, collected and analyzed the life stories of 884 people living with schizophrenia or schizoaffective disorders, the largest such collection documented to date.
The people Harding interviewed were part of a larger study known as the Schizophrenia Care and Assessment Program (SCAP), which included 2,400 people at six study sites. SCAP collected quantitative information about the patients’ quality of life, level of functioning, symptoms, and utilization and costs of services.
Harding and her colleagues used an interview instrument she developed known as LIFELINE©, which is based on the Life Chart developed by Adolf Meyer, one of the earliest and most influential American psychiatrists. It focuses on ways participants are able or unable to cope with schizophrenia-related symptoms and other problems and identifies external and internal resources that may help or hinder them in the recovery process.
Participants identified seven problems, in decreasing order of importance: symptoms, emotional abuse, physical abuse, substance abuse, medical problems, social isolation, and general stress or anxiety. The most helpful external coping mechanisms included treatment, support of friends and family, hobbies, faith or spiritual practice, work, sports, nature, and having a home. Effective internal coping mechanisms cited were emotional (repeating affirmations of self-worth and other methods of raising self-esteem and self-acceptance), cognitive (meditation, setting goals, scheduling their day), and focusing on the needs of others.
According to Harding, such qualitative research, originally developed by pioneers such as Margaret Mead to study people and cultures of distant lands, helps us look at the individual as a whole, not only in terms of his or her illness. It asks people how they got to where they are today, how they define their problems, what they do to help themselves cope, and what they do to make things worse. Using this type of instrument is in line with a new World Health Organization update of the International Classification of Functioning, a classification based on individual and social factors that can be used to understand and measure health outcomes, which has shifted from an old model of “impairment, disability, and handicap” to one that looks at human functioning as a continuum influenced by both environmental and personal factors.
For more information about Harding and the Institute for the Study of Human Resilience, visit http://www.bu.edu/resilience/.
Briefs" is written by Joan Schwartz in the Office of the Provost. To read
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