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Audio included Social Disadvantage and General Practice 2013

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Geoffrey Spurling

on 16 March 2015

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Transcript of Audio included Social Disadvantage and General Practice 2013

Social Disadvantage in General Practice
2013. A hopeful journey

Neutral
Application to General Practice
Tag Clouds
Better Outcomes for patients
Self reflection
Resistance
Literature on Social Disadvantage/ Disparity and Medical Culture
Harvard Implicit
Not Seeing Privilege
Difference
Neutrality
At 3am in Emergency
Teaching Social and Cultural Awareness does not work
See treatment as futile

More than 50% saw obese patients as awkward, unattractive, ugly and noncompliant

30-45% saw obese patients weak-willed, sloppy or lazy

Physicians view obesity as a behavioural problem
Physicians and obesity treatment
Physicians and their negative attitude to obese patients
Doesn’t change their attitudes to their obese patients !
What about obese physicians?
Beagan on PPS
Foster
SES gradient and diet
For Women
Low SES associated with obesity
Especially for low education, occupation, area
For Men
Mostly studies show non-significant findings
However 50% of associations showed that obesity was associated with low SES and especially for low education
SES, Obesity and High Income Countries
Why women?
McLaren/ Foley
Establish cultural competence training
Multicultural understanding
Focussing on knowledge about particular groups
Cross-cultural interactions
Focussing on tools and skills
Previous Responses to Social Disparity Education
Social Scientists argue that
Medicine has a culture

The norms and values of the dominant society are embedded within it

Doctors are taught that their own personal background and patient characteristics should be excluded from consideration in formulating clinical decisions
What do social scientists say about us?
Beagan on harm
Neutrality is not possible
Try This: https://implicit.harvard.edu/implicit/
So, What is Medical Culture?
Everyday classism
Everyday classism
Everyday racism
Racism in medical school?
Everyday classism
Everyday racism
Everyday racism
Everyday classism
Beagan on race and class
Process of ongoing self-reflection and critiques of one’s pattern of behaviours
Cultural Humility
“We didn’t come to medical school to learn about soft social science type things”
Teaching social/ cultural competence may be a hard sell

Start with:
“Physician Know thyself”

Shared stylised dress code, doctor talk, shared language and communication between physicians
Overcoming resistance
Boutin-Foster
GP consultations with disadvantaged groups were

More likely to have the consult result in a prescription

They were less likely to have a long consultation,

Less likely to have a female GP,

Less likely to end in an investigation or referral.

(Harris et al, 2004. Matching care to need in general practice: A secondary analysis of Bettering the Evaluation and Care of Health (BEACH) data)

More benign skin lesions were excised by GPs per melanoma detected in the most disadvantaged group (NNT=60) compared to the least (NNT=20)
Australian
GP
Like prefer like (gender and race)
Physicians are inclined to prescribe higher doses of narcotic analgesics to patients of like gender
Predicts longer, more participatory visits
Patients less likely to delay care
Concordance
Male physicians less likely to offer cervical smears and screen for domestic violence
Female physicians may be more attentive to preventive health/ patient counselling and have longer visits (also shown in Australian data)
Male obstetricians more likely to perform caesarian sections
Male physicians more likely to perform cardiac catheterisation
Less likely to classify African American women as obese compared to white women
Psychiatrists were more likely to diagnose African Americans as paranoid schizophrenics
Diagnosis
Less likely to recommend weight loss to overweight female patients compared to overweight male patients
Less likely to counsel female tobacco users on smoking cessation
Less likely to monitor and treat hyperlipidemia in female patients compared to men
Less likely to recommend mammography and osteoporosis screening to African American patients
Prevention
Impact of patient demographics/ physician demographics and what happens when the consult is

concordant (white doctor/ white patient or black doctor/ black patient) and
discordant (white doctor/ black patient or black doctor/ white patient)
Withold opioid analgesia from minority patients compared to white ones
Less likely to prescribe anti-retroviral medication to African-Americans with HIV
Lower doses of chemotherapy to African-American breast cancer patients compared to white ones
African-American patients less likely to receive second generation anti-psychotic agents (assumed to be superior)
Fewer cardiac interventions for African-American patients – also true for Aboriginal Australian patients
Women less likely to receive antiretroviral therapy and less likely to be referred for angiography and receive thrombolysis
Treatment
Berger and Harris
Don't be neutral

Be self-reflective
- think about how your culture impacts on your explanations, your advice, your treatment, your referrals and the time you spend with your patient

Consider social prescribing
But is this Harmful?
GP v. overweight patient
Rebecca Onie
Final Video
Dr Geoffrey Spurling, DGP
g.spurling@uq.edu.au
Physician Characteristics
Everday Classism
Barry Schwartz
Ranatunga and Mutch, 2012
Ranatunga and Mutch, 2012
73.5% were experiencing at least one problem. Mean number of problems 3.74 +/- 2.4.

One in two (54%, n=47) reported that social problems affected their current health. Mean number of problems 4.66 +/- 2.58.

The mean number of problems reported by those who stated social concerns affect health was significantly higher than those whose health was not affected (t=4.5, df=85, P<0.05).
Socioeconomic problems in Brisbane
Inequality within countries and societies
Inequality between countries and societies
Health in childhood
Education
Socio-economic status
Employment conditions/unemployment
Access to health care and social support
Housing
Political empowerment: sense of inclusion
Social empowerment and isolation
Social determinants: associations with health outcomes and life expectancy

Why treat people…without changing what makes them sick?

The social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system.

These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices.
World Health Organisation

Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502

Benefits of primary care-oriented health systems:

Each additional general practitioner per 10,000 population (a 15 to 20 percent increase) is associated with about a 6 percent decrease in mortality
Heart disease, stroke, cancer, infant mortality

Lower mortality in countries with strong primary health care systems

Presence of primary care physicians offset the effect of low socio-economic status in economically deprived areas, resulting in fewer disparities in health across population subgroups
Making a difference in primary care
The golden age of primary care?
Ranatunga and Mutch, 2012
85% of patients indicated they were happy to discuss all social issues with the GP.

50% of patients had discussed social concerns with the GP in the past, but only 25% were planning to discuss these problems on the day of the survey.

Patients were the ones who generally raised social problems in the consultation, not the GPs.

Only 15% indicated that they did not want to discuss social problems with GPs.
But is this even our job?
http://www.abc.net.au/news/2012-05-16/salvation-army-releases-alarming-report/4015854?section=nsw

Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457-502

Serving as the first point of contact for all new health needs and problems

Delivering long-term, person-focused care

Comprehensively meeting all health needs except those whose rarity renders it impossible for a generalist to maintain competence in them

Coordinating care that must be received elsewhere
Important functions of primary care include:
Dr Rebecca Farley, DGP
Dr Allyson Mutch, SPH
Miriam Taylor, QCCID
m.taylor3@uq.edu.au
r.farley1@uq.edu.au
a.mutch@sph.uq.edu.au
Meeting the primary care needs of every person, especially those who belong to vulnerable and marginalised groups
Socioeconomic determinants of health, culture and our patients
How might some of the socioeconomic determinants of health be impacting on your patient?

How might culture, both your patient’s and your own, be impacting on your consultations?

What can you and primary health care offer?
What if Mr FS presents with chest pain?
Patients from minority groups are less likely to receive opioid analgesia
Doctors from a different cultural background more likely to give lower doses of analgesia
Fewer cardiac investigations and interventions for Aboriginal and Torres Strait Islander people once they get to hospital
But male cardiologists more likely to perform catheterization (male obstetricians more likely to perform caesarian)
Female patients less likely to receive counselling for smoking cessation
Full transcript