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Executive Vice President's ReportRacism, Sexism, Ageism -- Disparities
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As always, I am pleased to relinquish my Executive Vice President's Report page to Dr. Jeff Goldhagen, Director of the Duval County Health Department. He follows up on the challenge I presented in last month's issue of Jacksonville Medicine. Philip Gilbert, EVP Phil Gilbert's Report in April's Journal could be a turning-point for medicine in Northeast Florida. It documents the significant racial disparities in health outcomes that exist in our community. To suggest that these are the sole result of medical practice would be absurdly simplistic. However, to deny a degree of physician culpability and the impact of our current health care system would be incongruous with what is known about the relationships between medical practice and health outcomes. Evidence-based medicine has documented voluminous examples of such relationships and changes that could result in improved health outcomes for individuals and populations. Before such change can occur, there are several fundamental questions and issues that physicians, organized medicine and the health care system must resolve. Are physicians responsible for health outcomes of their patients and populations of people in a community? If so, what is the responsibility of physicians and the system to deal with health promotion, disease prevention and social determinants of health? Is there a different knowledge base and set of practice skills necessary to assume these responsibilities? If so, whose responsibility is it to reorient practicing physicians and train medical students and residents? How will physicians be reimbursed for interventions, both within and outside their practices, that will result in improved health outcomes? These are complex questions that will require dialog, time and commitment to resolve. In the meantime, there is an accumulation of evidence that there is much that physicians can do now, within the context of their current practice of medicine, to decrease disparities in health outcomes. It is important to note that we are not just dealing with racial disparities. Disparities exist in outcomes among races, sexes, ages, regions, etc. that can be tied directly to the practice of medicine. If you are black or female, you will receive major diagnostic or therapeutic procedures much less frequently than if you are white or male. Race and site of care affect physicians' use of corticosteroids to mitigate lung disease in premature infants. Race and sex impact the use of reperfusion therapy for acute myocardial infarction. Noncompliance with appointments contributes significantly to shorter breast cancer survival among black women. Depression is more likely to be diagnosed in women and more educated patients. Race influences hospitalization rates for asthma. Physicians vary widely in providing heart disease prevention services to their patients. Outcomes of knee replacement surgery for elderly patients are much improved when performed in more experienced hospitals. Elderly heart attack patients with multiple health problems do not receive thrombolytic medication as promptly as other patients. American hospitals vary greatly in their commitment to improvements in quality of care. Black Medicare patients hospitalized for heart failure or pneumonia may not receive the same care as white Medicare recipients. (Citations available upon request.) These are just a few examples from the medical literature of health care practices that result in outcome disparities. This is not to suggest these findings are the result of inherent bias or prejudice. When confronted with data on health outcomes, physicians do change their medical practices. The opportunity exists for the Medical Society and its membership to establish a "beachhead" and move forward deliberately in an assault on health outcome disparities. Evidence-based medicine can provide the template for changes in medical practice that physicians can effect now. Concurrently, physicians, the Medical Society, Health Department, hospitals, academic centers and other partners can begin the dialog and establish the strategies necessary to impact the more encompassing systems and societal issues that must be addressed to effect optimal health outcomes for all. These are issues of ethics and justice that physicians and organized medicine must address. Let's make Northeast Florida the epicenter of a national response to disparities in health outcomes. April, 2000/ Jacksonville MedicineWhat's New
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