Let's talk about cardiovascular disease differences.
Another form of health disparities.
I do applaud the cardiovascular community
because they've dig in a really hard look
at particularly race based differences on outcomes.
So for example we know that women
have a higher prevalence of cardiovascular disease versus men.
And it's also their cardiovascular disease among women
as associated with the higher mortality than among men as well.
Similarly, comparing black versus white adults.
Higher cardiovascular disease prevalence
and a higher cardiovascular disease mortality.
Now, given that information,
we know that percutaneous interventions
for acute myocardial events
so just acute myocardial infarction
have become a lot more commonly used.
Now, they're part of guidelines.
It's better care.
Patients do better with early PCI
within a month of their myocardial infarction.
But at the same time despite knowing
that this is now considered a standard of care,
we see that there's still a lot of folks who are left out from that model.
And the disparities that were there in 1992-1993
which are in the green, remain in 2009-2010.
While everybody has more access now to PCI.
And hospitals have certainly improve their access
it may have more of a model of care.
You can see that, you know, back in '92-'93,
the rates of using PCI were about double
in white men compared with black women.
And now it's slightly less than double.
So these disparities continue despite the broader use of this technology.
And that's the thing is that study after study showed,
even when these balance out things like socio-economic status
and geographical location, insurance status,
black patients are less likely to get things like PCI versus white patients.
So it really does come down to appearances
and an inherent racism within medicine.
It does certainly have a factor,
and social determinants of health as well
that some of the things I just mentioned.
I'm just gonna go through what are the major social determinants of health.
This list is not comprehensive.
But these are the major causes that I see in my practice.
It is also recommended by Federal Commission
to consider as the major social determinants.
So there's income, educational level, unemployment,
job security, employment and working conditions in particular.
I have a fair number of patients who are at risk for poor health outcomes
because of the type of work that they do.
Early childhood development.
Food insecurity in being in a food desert.
The housing situation.
Social exclusion and having a social safety network,
very, very important.
The access to health services of course.
Aboriginal status, gender, race and disability.
All importance social determinants of health.
As I said, the list is incomprehensive
but something to consider as you're going through patient care
to think about where your patients may have gaps in these areas.
Or where they maybe in a group that suffers disparities.
And then trying to address that as you move forward with their care.
How do you do that?
You know, what are some of the keys to cross cultural communication?
Because certainly not every patient is gonna share your background,
and you know, your values necessarily.
and I think that's actually a really rich and positive part of medicine.
It's being able to communicate
with people whose backgrounds aren't your own.
It starts of course with good listening skills.
So we talked about communication,
listening with empathy, and respect at all times.
Next is you do get a chance to explain your perspective.
Even if a patient really values some kind of care
that you don't necessarily provide or even believe in,
they're still come into you, it's your job to explain,
Well, this is the way my training
and what we would normally recommend using these treatment algorithms.
Here's what we would recommend to work for you.
You're gonna acknowledge the differences and the similarities there.
And so that's a great starting point.
Where do you have agreement with the patient,
and that's a good place to start in negotiating a plan of care.
Because you're gonna recommend treatment.
The patient did come to see you
to get the care that you can provide.
So it doesn't, so respecting a person's beliefs and their values
and what they wanna do with their own health,
doesn't mean that you have to be completely silent.
You still got to recommend a treatment
but you're not going to mandate the treatment.
They're gonna negotiate a plan of care.
So I really believed in this LEARN model
that the L, and the N are... they're critical parts
that negotiation is very, very important.
A couple of things about negotiating a plan of care.
It leads to greater adherence.
So therefore, because your patients more body in
and they understand that you heard them
and their needs and their limitations.
Therefore, I think you're gonna find
that they're more likely to follow through.
That leads to better outcomes and certainly more satisfaction.
Also when I'm negotiating a plan of care,
I also document in the chart that they were shared decision making going on.
And that's particularly important in cases
where patients refuse good evidence base care.
I'll make a special note to that.
Make sure it's clear on the chart, the electronic record that we use.
That way if any other provider sees the patient
it instantly recognizable to them.
And also just as a note to myself.
Because some patients maybe they go away
due to family crisis and don't come for two years,
I'll still have that front and center on their chart.
So it helps me to maintain that respectful relationship
and with their values in mind.